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At least 91 records · Page 5Linked to original sources
PubMed2001

Transjugular intrahepatic portosystemic shunt (TIPS) versus endoscopic variceal ligation in the prevention of variceal rebleeding in patients with cirrhosis: a randomised trial.

BACKGROUND AND AIMS: The transjugular intrahepatic portosystemic shunt (TIPS) is a new therapeutic modality for variceal bleeding. In this study we compared the two year survival and rebleeding rates in cirrhotic patients treated by either variceal band ligation or TIPS for variceal bleeding. METHODS: Eighty cirrhotic patients (Pugh score 7-12) with variceal bleeding were randomly allocated to TIPS (n=41) or ligation (n=39), 24 hours after control of bleeding. RESULTS: Mean follow up was 581 days in the ligation group and 678 days in the TIPS group. The two year survival rate was 57% in the TIPS group and 56% in the ligation group (NS); the incidence of variceal rebleeding after two years was 18% in the TIPS group and 66% in the ligation group (p<0.001). Uncontrolled rebleeding occurred in 11 patients in the ligation group (eight were rescued by emergency TIPS) but in none of the TIPS group. The incidence of encephalopathy at two years was 47% in the TIPS group and 44% in the ligation group (NS). CONCLUSIONS: TIPS did not increase the two year survival rate compared with variceal band ligation after variceal bleeding in cirrhotic patients with moderate or severe liver failure. It significantly reduced the incidence of variceal rebleeding without increasing the rate of encephalopathy.

Adolescent↗
PubMed2002

Appearance of rectal varices in extrahepatic portal obstruction after treatment for esophago-gastric varices: a case report.

We report a case of rectal varices that developed after endoscopic injection sclerotherapy (EIS) and Hassab's operation for esophageal varices with extrahepatic portal obstruction. A 54-year-old woman was admitted to our hospital in September 1997 for treatment of hematochezia. Emergent colonoscopy revealed tortuous rectal varices with a white plug. Angiography revealed that rectal varices were provided with backward blood flow by the inferior mesenteric vein due to extrahepatic portal obstruction. In this case, previous treatment, EIS and Hassab's operation, for esophago-gastric varices might have inhibited the development of collaterals apart from surface of gastrointestinal tract, such as para-esophageal collateral veins or spleno-renal shunt. Since the thrombus in the extrahepatic portal vein causes strong pressure on inferior mesenteric vein which is connected to the inferior vena cava via the inferior rectal vein, rectal varices might be developed. In this case, it was considered that rectal varices were not treated enough by endoscopic therapy because of regurgitant hyper blood flow against portal venous pressure. Therefore, rectal transection was performed. After the treatment, the patient suffered no further episodes of bleeding from rectal varices.

Esophageal and Gastric Varices↗
PubMed1997

The portal pressure response to beta-blockade is greater in cirrhotic patients without varices than in those with varices.

BACKGROUND & AIMS: Nonselective beta-blockers are effective in reducing portal pressure in cirrhotic patients. However, this beneficial effect is highly variable and may depend on the extent of portal system collateralization. The aim of this study was to compare portal pressure response with timolol, a nonselective beta-blocker, in cirrhotic patients with and without varices. METHODS: Portal and systemic hemodynamics were measured before and after a single oral dose of 10 mg of timolol in 50 patients with cirrhosis and portal hypertension, 15 with and 35 without esophageal varices. RESULTS: Timolol significantly decreased portal pressure in all patients (mean reduction, 20% +/- 13%; P < 0.0001). The reduction in hepatic venous pressure gradient was greater in patients without varices (-24% +/- 14%) than in those with varices (-12% +/- 8%) (P < 0.01). A decrease in the hepatic venous pressure gradient of <12 mm Hg was achieved in 7 of 12 (58%) patients without varices and a baseline pressure gradient of <12 mm Hg, but only in 3 of 15 patients with varices (20%) (P < 0.01). CONCLUSIONS: Timolol is effective in reducing portal pressure in cirrhotic patients, more so in patients without varices, suggesting that nonselective beta-blockers will be more effective in the treatment of portal hypertension when administered at early stages, before the development of varices.

Aged↗
PubMed1997

A novel therapeutic approach for rectal varices: a case report of rectal varices treated with double balloon-occluded embolotherapy.

We present a patient with continuous melena, diagnosed as rectal varices bleeding. She had a history of esophageal varices, which was treated by endoscopic ligation therapy. Eight years after the treatment of esophageal varices, the continuous melena began. Colonoscopic examination showed that the melena was caused by rectal varices, which were so severe that they could not be treated by either endoscopic sclerotherapy or surgical devascularization. Taking into considering the overall risk of treating rectal varices, we chose the approach of double balloon-occluded embolotherapy (DBOE) with 5% ethanolamine oleate with iopamodol as a liquid embolic material. DBOE is one of the interventional radiology techniques (Morita et al., Acta Hepatol Jpn 1994;35:109-120), but in this case was a completely new and novel clinical procedure for rectal varices. After the DBOE therapy, the condition of rectal varices was markedly improved. Thus, DBOE might be a new tool for treating inoperable rectal varices.

Aged↗
PubMed1997

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: a multicenter prospective randomized trial.

Patients who have bled from varices remain at risk for rebleeding. There is interest in methods that would enable rapid eradication of varices. The present trial was designed to study whether combining ligation with sclerotherapy will allow quicker eradication of varices than either modality alone. Patients with bleeding esophageal varices were randomized into ligation or combination therapy groups. Patients in the ligation group were treated with endoscopic rubber band ligation alone. In combination group patients, each variceal column was ligated distally and 1 mL of ethanolamine was injected proximal to each ligated site. Subsequent treatment sessions were at 7- to 14-day intervals until varices were eradicated. The clinical and endoscopic characteristics of 25 patients in the ligation group were similar to those of 22 patients in the combination group. Follow-up was up to 30 months. Active bleeding was controlled in 100% of patients in the ligation group and 75% of those in combination group (P = NS). It took 3.3 +/- .4 (range, 1-7) sessions to eradicate varices with ligation and 4.1 +/- .6 (1-7) with combination therapy (P = NS). Survival (four deaths in ligation group, 8 in combination group), rebleeding rate (25% vs. 36%), and varix recurrence (16% vs. 23%) also were similar. There were more complications with combination therapy, including deep ulcers (65% vs. 20%; P < .05); dysphagia (30% vs. 0%; P < .05), with three strictures requiring dilation; and pain (30% vs. 10%; P = NS). Our results show that sclerotherapy combined with ligation offers no benefit over ligation alone. The higher complication rate with combination therapy does not warrant this approach.

Adult↗
PubMed2005

Transjugular intrahepatic porto-systemic shunt and variceal embolisation in the management of bleeding stomal varices.

BACKGROUND AND AIMS: Bleeding from stomal varices is uncommon. Local measures to control the bleeding offer short-lived control. Our experience with transjugular intrahepatic porto-systemic shunt (TIPS) and variceal embolisation is presented and appraised. PATIENT AND METHODS: Three patients presented with bleeding from stomal varices (Child-Pugh class B, n=2 and class C, n=1) in association with primary sclerosing cholangitis, autoimmune hepatitis and alcoholic liver disease. Local treatment measures including suture ligation, sclerotherapy and re-siting of the stoma achieved short-lived control. TIPS were inserted in all 3 patients, with embolisation of the stomal varices in 2. RESULTS/FINDINGS: The radiological interventions were uncomplicated and resulted in cessation of the bleeding in all patients. One of the patients has had no further bleeding at 12 months' follow-up post-TIPS insertion. The other two patients re-bled at 5 and 6 months post-TIPS insertion and were successfully managed by insertion of a second TIPS in one patient and by balloon dilatation of the TIPS in another. The former patient has had no re-bleeding at a further 8 months' follow-up, while the latter had re-bleeding at 12 months post-TIPS insertion and underwent liver transplantation. INTERPRETATION/CONCLUSION: Transjugular intrahepatic porto-systemic shunt with variceal embolisation offers an effective, minimally invasive management option in patients with bleeding stomal varices, and may be used as the primary mode of intervention in conjunction with medical therapy, and as the definitive therapy in patients unfit for surgery. TIPS and variceal embolisation do not preclude subsequent liver transplantation, and may be used during the acute situation as a bridge to transplantation.

Adult↗
PubMed1998

Randomized controlled trial of sclerotherapy versus somatostatin infusion in the prevention of early rebleeding following acute variceal hemorrhage in patients with cirrhosis. Variceal Bleeding Study Group.

BACKGROUND/AIMS: Early rebleeding is a very frequent complication of variceal hemorrhage. Sclerotherapy effectively controls variceal hemorrhage and prevents early rebleeding. Somatostatin infusion is as effective as sclerotherapy in controlling variceal hemorrhage, but no study has evaluated the efficacy of 5-day somatostatin infusion in preventing early rebleeding after the initial control of bleeding. The aim of the study was to compare the efficacy and safety of somatostatin and sclerotherapy in the prevention of early variceal rebleeding in cirrhotic patients. METHODS: The study included 169 patients with acute variceal hemorrhage who were randomized within 24 h of controlling the acute bleeding to receive either sclerotherapy (n=79) or continuous somatostatin infusion for 5 days (250 microg/h after a 250-microg bolus, repeated every 24 h, n=90). Success of therapy was defined by absence of rebleeding during the 5 days following randomization. RESULTS: Early (5 days) rebleeding occurred in 12/79 patients treated with sclerotherapy vs 14/90 of those receiving somatostatin (NS). The treatment was equally effective in Child's C patients (sclerotherapy: 18/20; somatostatin: 17/20; NS) and Child's A+B patients (sclerotherapy: 49/59; somatostatin: 59/70; NS). Complications occurred in 19/79 patients receiving sclerotherapy vs 4/90 in the somatostatin group (p= 0.00019), being severe in 6 vs 0 patients (p=0.0094). There were no differences between the two groups in the incidence of 6-week rebleeding (14% vs 15%, NS) and mortality (9% vs 9%). CONCLUSIONS: Continuous somatostatin infusion is as effective as sclerotherapy in preventing early variceal rebleeding and maintaining low mortality following acute variceal hemorrhage. Somatostatin is associated with a lower rate of complications than sclerotherapy.

Aged↗
PubMed1999

Endoscopic variceal ligation is a sufficient procedure for the treatment of oesophageal varices in patients with hepatitis C liver cirrhosis: comparison with injection sclerotherapy.

AIMS: Endoscopic variceal ligation (EVL) is a recently developed alternative to endoscopic injection sclerotherapy (EIS) for the treatment of oesophageal varices. Endoscopic variceal ligation and EIS were compared in an attempt to clarify the efficacy and safety of EVL for patients with cirrhosis due to hepatitis C. METHODS: Endoscopic variceal ligation was performed in 60 patients and EIS in 30. Varices were eradicated in all patients by EVL and 87% (26 out of 30) by EIS. RESULTS: There was no significant difference between EVL and EIS in relation to the incidence of bleeding and the 5 year survival rate after treatment. There were no severe complications except mild substernal pain after EVL, while pulmonary embolism occurred in one patient receiving EIS. CONCLUSIONS: Endoscopic variceal ligation is a safe and effective technique for eradicating oesophageal varices in patients with hepatitis C cirrhosis.

Esophageal and Gastric Varices↗
PubMed2001

A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal variceal bleeding.

Despite publication of several randomized trials of prophylactic variceal ligation, the effect on bleeding-related outcomes is unclear. We performed a meta-analysis of the trials, as identified by electronic database searching and cross-referencing. Both investigators independently applied inclusion and exclusion criteria, and abstracted data from each trial. Standard meta-analytic techniques were used to compute relative risks and the number needed to treat (NNT) for first variceal bleed, bleed-related mortality, and all-cause mortality. Among 601 patients in 5 homogeneous trials comparing prophylactic ligation with untreated controls, relative risks of first variceal bleed, bleed-related mortality, and all-cause mortality were 0.36 (0.26-0.50), 0.20 (0.11-0.39), and 0.55 (0.43-0.71), with respective NNTs of 4.1, 6.7, and 5.3. Among 283 subjects from 4 trials comparing ligation with beta-blocker therapy, the relative risk of first variceal bleed was 0.48 (0.24-0.96), with NNT of 13; however, there was no effect on either bleed-related mortality (relative risk [RR], 0.61; confidence interval [CI], 0.20-1.88) or all-cause mortality (RR, 0.95; CI, 0.56-1.62). In conclusion, compared with untreated controls, prophylactic ligation reduces the risks of variceal bleeding and mortality. Compared with beta-blockers, ligation reduces the risk for first variceal bleed but has no effect on mortality. Prophylactic ligation should be considered for patients with large esophageal varices who cannot tolerate beta-blockers. Subsequent research should further compare ligation and beta-blockers to determine the effect on mortality, and measure ligation's cost-effectiveness.

Esophageal and Gastric Varices↗
PubMed1999

Effect of esophageal variceal sclerotherapy on hemorrhoids, anorectal varices and portal colopathy.

BACKGROUND AND STUDY AIMS: Endoscopic sclerotherapy (EST) results in an increase in the prevalence of portal hypertensive gastropathy (PHG). However, the effects of sclerotherapy on hemorrhoids, anorectal or colonic varices and portal hypertensive colopathy are not known. The aim of this study was to investigate these effects. PATIENTS AND METHODS: A total of 39 patients with portal hypertension were studied. Upper gastrointestinal endoscopy and full-length colonoscopy were carried out before the patients underwent EST for esophageal varices, and after obliteration of the varices following sclerotherapy. RESULTS: The obliteration of esophageal varices by EST did not significantly affect the prevalence of hemorrhoids (32 % before and after), anorectal varices (45% before and after) or portal hypertensive colopathy (60.5 % before and 66 % after, P > 0.05). CONCLUSION: Obliteration of esophageal varices does not affect the prevalence of hemorrhoids, anorectal varices, or portal hypertensive colopathy.

Adult↗
PubMed1989

Endoscopic variceal sclerotherapy as primary treatment for bleeding esophageal varices.

In this study of 75 patients with bleeding esophageal varices we confirm not only the ability of endoscopic variceal sclerotherapy (EVS) to control acute bleeding episodes but to effect variceal obliteration that confers a significant survival advantage, regardless of initial Child's classification. Survival correlates directly with the degree of hepatic dysfunction, although all patients regardless of Child's status have a statistically significant survival advantage when treated until esophageal variceal obliteration is achieved. All patients treated with EVS should be followed for life, but virtually all follow-up can be done on an outpatient basis. Shunt surgery should be reserved for: (a) patients whose acute bleeding cannot be controlled with EVS at the time of index bleed; and (b) patients who rebleed repeatedly or uncontrollably from gastric or duodenal varices. EVS is more cost-effective than other available treatments. It also effectively stabilizes potential candidates for orthotopic liver transplantation. Despite a progressive increase in the admissions for bleeding varices at our institution, the introduction of EVS has been associated with a significant decline in portosystemic shunt therapy. We believe that EVS is now the first-line treatment for all patients with bleeding esophageal varices.

Endoscopy↗
PubMed2006

Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding.

INTRODUCTION: Endoscopic obliteration of esophageal varices by endoscopic variceal ligation (EVL) is an effective form of secondary prophylaxis. However, there is no consensus regarding the technical aspects of EVL for secondary prophylaxis. The present study compares the technical aspects of EVL (frequency of sessions, number of sessions and number of bands used) in patients who rebled following secondary prophylaxis of esophageal varices by EVL compared to those who did not rebleed. METHODS: All patients who underwent EVL for treatment of acute variceal bleeding followed by EVL for secondary prophylaxis and who subsequently developed recurrent variceal bleeding at Mayo Clinic, Rochester between January 1995 and May 2003 were identified. A control group of patients undergoing EVL for secondary prophylaxis who did not rebleed was identified. RESULTS: During the study period, 216 patients with acute esophageal variceal hemorrhage underwent emergent EVL treatment with follow-up EVL for secondary prophylaxis, of whom 20 (9.3%) subsequently rebled. Both rebleeding and non-rebleeding patient groups were well-matched with respect to liver function (Child-Pugh class), number and size of variceal trunks, endoscopic stigmata of hemorrhage and beta-blocker usage. The median interval between EVL sessions in the rebleeding group (2 weeks, interquartile range 0-2 weeks) was significantly shorter compared to the non-rebleeding group (5 weeks, interquartile range 3-7 weeks; P = 0.004). Adjusting for age, gender, and Child-Pugh class, interbanding interval >/= 3 weeks was associated with increased likelihood of not rebleeding, hazard ratio 3.84 (95% confidence interval: 1.69-11.79; P = 0.0007). CONCLUSIONS: These findings demonstrate the importance of technical aspects of EVL on patient outcome, suggesting the benefit of longer interbanding intervals. Future prospective studies are required to define the optimal intersession interval. Standardizing procedural aspects of EVL will aid in objectively evaluating the benefit of this procedure when compared to other modalities such as medical treatment.

Acute Disease↗
PubMed2001

Usefulness of endoscopic ultrasonographic analysis of variceal hemodynamics for the treatment of esophageal varices.

The correlation of between the endoscopic findings of esophageal varices and endoscopic ultrasound findings of the collaterals outside the esophageal wall in patients with portal hypertension remains unclear. We investigated the relationship between esophageal varices and the collaterals by endoscopy and endoscopic ultrasound. Moreover, we investigated the correlation between the collaterals around the esophagus and recurrence of esophageal varices in patients with portal hypertension who had undergone endoscopic injection sclerotherapy. The collaterals were divided into two groups: 1; those with peri-esophageal collateral veins (peri-ECVs) adjacent to the muscularis externa of the esophagus, and 2; those with para-esophageal collateral veins (para-ECVs) distal to the esophageal wall without contact with the muscularis externa. Peri- and para-ECVs were scored as mild or severe according to the stage of development. According to endoscopy, the varix form was significantly larger in severe peri-ECVs group than in mild peri-ECVs group. In contrast, the varix form did not differ significantly between the mild and severe para-ECVs group. The prevalence of perforating veins increased according to the varix form. With regard to variceal recurrence, in patients with variceal recurrences, EUS findings included a significantly higher incidence of severe-type peri-ECVs, a significantly larger number of perforating veins, and a significantly larger diameter of perforating veins compared with patients without recurrence. Moreover, when EUS found the abnormalities when no endoscopic recurrence was found, the results were the almost same as the findings when EUS was performed at the same time when endoscopic recurrence was found. In conclusion, the presence of severe peri-ECVs and large perforating veins in the esophageal wall strongly correlates with occurrence and recurrence of esophageal varices in patients with portal hypertension. An understanding of these EUS abnormalities on the basis of hemodynamics around the esophagus is thought to be important for management of esophageal varices in patients with portal hypertension.

Collateral Circulation↗
PubMed2001

Endoscopic variceal ligation for intractable esophageal variceal bleeding in children with idiopathic extrahepatic portal vein occlusion: report of three cases.

Extrahepatic portal vein occlusion (EPVO) is an important cause of extrahepatic portal hypertension and variceal hemorrhage in children. We report 3 children with a diagnosis of EPVO and intractable esophageal variceal bleeding who underwent scheduled endoscopic variceal ligation (EVL) and prophylactic propranolol therapy for eradication of esophageal varices. Complete variceal obliteration was achieved in all 3 children following 3-4 treatment sessions. There were no significant complications or gastrointestinal hemorrhage during a follow-up period of 9 to 31 months after variceal eradication. In conclusion, EVL and long-term propranolol prophylaxis is safe and effective in eradicating bleeding esophageal varices in children with EPVO.

Child↗
PubMed1997

An improved endoscopic variceal ligation for esophageal and solitary gastric varices--three-O-band-shooter.

We have reported a 16.0 mm long new type of instrument with the inner diameter of inner cylinder of 10.3 mm for endoscopic variceal ligation which could shoot 3 elastic O bands continuously in short period of time without removing the endoscope. The suction volume of new instrument is larger than that of the Stiegmann's ligator. We performed endoscopic variceal ligation (EVL) in 17 cases of the esophageal varix and 8 cases of the solitary gastric varix. EVL was performed as prophylaxis as all the cases. The esophageal varices were eliminated in all the cases after ulcer formation. The procedure was performed one time in 15 cases and two times in the remaining 2 cases. Three patients died one to hepatic failure during the follow-up period between 4 and 16 months. Six and twelve months cumulative recurrence rates were 30% and 48% respectively. On the other hand all the gastric varices disappeared after one sitting of the treatment. There was one variceal recurrence during the follow-up period. Computed tomography and/or arterioportography performed before had showed patent gastro-renal shunt in five cases. No change in the shunt was observed after the treatment. No serious complications due to EVL was encountered in all the cases. Therefore, it is thought that this method can be used for the treatment of not only esophageal varices but also gastric varices.

Endoscopes↗
PubMed1984

Angioarchitectural study of esophageal varices. With special reference to variceal rupture.

Pathomorphological and angioarchitectural characteristics of esophageal varices, mainly of ruptured varices, were studied in autopsy cases. Contrast medium was injected into the esophageal vein in 25 among 75 cases with varices, and in 4 cases without varices as a control. Out of the 75 cases with varices, rupture was confirmed in 8 cases. Ruptured points were recognized at the oral end of the longitudinal veins (these veins were called "sudare-like veins" in this study) in the lamina propria at the lower end of the esophagus in all of the 8 cases. This ruptured area was called the "critical area". By morphometric examination, dilatation of these sudare-like veins was the most obvious in severe varices, and these veins were observed to penetrate the muscularis mucosae to connect to the submucosal veins at the critical area. This area seemed to be of the greatest significance in the pathogenesis of spontaneous variceal rupture.

Endoscopy↗
PubMed1988

Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study.

We conducted a prospective study of 321 patients with cirrhosis of the liver and esophageal varices with no history of bleeding to see whether a comprehensive analysis of their clinical features and of the endoscopic appearances of their varices could help to identify those at highest risk for bleeding. Varices were classified endoscopically as suggested by the Japanese Research Society for Portal Hypertension. Patients were followed for 1 to 38 months (median, 23), during which 85 patients (26.5 percent) bled. Multiple regression analysis (Cox's model) revealed that the risk of bleeding was significantly related to the patient's modified Child class (an index of liver dysfunction based on serum albumin concentration, bilirubin level, prothrombin time, and the presence of ascites and encephalopathy), the size of the varices, and the presence of red wale markings (longitudinal dilated venules resembling whip marks) on the varices. A prognostic index based on these variables was devised that enabled us to identify a subset of patients with a one-year incidence of bleeding exceeding 65 percent. The index was prospectively validated on an independent sample of 75 patients with varices and no history of bleeding. We conclude that our prognostic index, which identifies groups of patients with one-year probabilities of bleeding ranging from 6 to 76 percent, can be used to identify candidates for prophylactic treatment.

Esophageal and Gastric Varices↗
PubMed1997

A randomized trial comparing transjugular intrahepatic portosystemic stent-shunt with variceal band ligation in the prevention of rebleeding from esophageal varices.

The aim of this study was to compare transjugular intrahepatic portosystemic stent-shunt (TIPSS) with variceal band ligation (VBL) in the secondary prophylaxis of esophageal variceal hemorrhage in patients with cirrhosis. Fifty-eight patients with cirrhosis who presented with the first episode of esophageal variceal hemorrhage were randomized to TIPSS (31) or VBL (27), 24 hours after control of bleeding. Shunt function was assessed after 1 month and then at 6 monthly intervals thereafter. VBL was performed weekly until variceal eradication, and then at 3 months, 6 months, and yearly thereafter. Mean follow-up in the TIPSS group was 15.7 (+/-10.2) months; in the VBL group, it was 16.8 (+/-10.9) months. Results for rebleeding and mortality were analyzed on an intention-to-treat basis and using the Kaplan-Meier method. The frequency and the severity of variceal rebleeding was significantly lower in the TIPSS group (9.8%), compared with the VBL group (51.9%) (P < .0006). Although mortality rates were not significantly different, 8 of the patients who rebled in the VBL group required TIPSS therapy for uncontrolled bleeding. No significant differences were found in the frequency of other complications such as encephalopathy and sepsis. Patients in the VBL group required significantly greater time in the intensive care unit during the period of this study (<0.03). The total direct cost of treatment incurred was pound sterling 1,373 ($2,200) per patient, the cost being less in the patients treated with TIPSS compared with VBL. The results of this study show that TIPSS is superior to VBL for the secondary prophylaxis of variceal hemorrhage in patients with cirrhosis.

Adolescent↗