Downhill esophageal varices: unusual cause of hematemesis.
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ABSTRACT:
SUBMITTER: Raghavapuram S
PROVIDER: S-EPMC5991938 | biostudies-literature | 2017 Sep
REPOSITORIES: biostudies-literature
Publications
Downhill esophageal varices: unusual cause of hematemesis.
Raghavapuram Saikiran S George Nayana N Girotra Mohit M Siddique Sameer S Tharian Benjamin B
VideoGIE : an official video journal of the American Society for Gastrointestinal Endoscopy 20170407 9
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Project description:Our patient with primary biliary cholangitis, previously termed as primary biliary cirrhosis, presented with an unexpected and unusual cause of hematemesis in the form of multiple esophageal ulcers in-between variceal columns. Given that upon endoscopic examination, the esophageal ulcers were found to bleeding instead of the varices; they should be considered in the differential in the etiology of hematemesis in primary biliary cholangitis and thoroughly searched for during an endoscopic procedure for early treatment and subsequent secondary prevention.
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Project description:Video 1EGD revealing 1 column of nonbleeding grade 2 varices in the middle third of the esophagus at the anterior wall; absent red wale sign and 3 columns of nonbleeding grade 3 varices in the upper third of the esophagus in the anterior and posterior wall. Stigmata of recent bleeding evident, red wale signs present, and 1 white nipple sign identified in the anterior wall, in the same column coming from the middle esophagus. Successful variceal banding ligation was performed, and there was no recurrence of bleeding.
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Project description:Pancreaticoduodenectomy (PD) is one of the most complex surgeries and is associated with a high rate of complications, including bleeding, delayed gastric emptying (DGE), and pancreatic fistula. Although the frequency of postoperative hemorrhage is not high, this complication results in severe adverse outcomes. A 67-year-old man was diagnosed with pancreatic cancer and underwent PD. On the tenth day after surgery, he developed hypovolemic shock with hematemesis. Urgent digital subtraction angiography identified the bleeding artery as the jejunal mesenteric artery at the afferent loop, and the bleeding artery was embolized with two coils. After digital subtraction angiography, the patient had an uneventful recovery with no further complications. Therefore, we concluded that it is possible that bleeding may occur in the afferent loop when hemorrhage occurs after PD.
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Project description:PurposeEndoscopy is recommended to screen for esophageal varices in patients with cirrhosis. The objective of this study was to identify features on abdominal CT imaging associated variceal hemorrhage (VH).MethodsA case-control study was performed among patients with cirrhosis who had a CT scan. Consecutive patients who experienced VH were included as cases, and patients without VH served as controls. Two radiologists recorded the maximal esophageal varix diameter in addition to other measures of portal hypertension at CT.ResultsThe most powerful CT parameter associated with VH was the esophageal varix diameter (5.8 vs. 2.7 mm, p < 0.001; adjusted OR 1.84 per mm, p = 0.009). 63% of individuals with VH had a maximal varix diameter ≥5 mm compared to 7.5% of cirrhotic patients without VH (p < 0.001). In contrast, the proportion of individuals whose largest varix was <3 mm was 7.4% among VH cases compared to 54.7% among controls (p = 0.001). The varix diameter powerfully discriminated those with and without VH (C-statistic 0.84).ConclusionsA large esophageal varix diameter is strongly associated with subsequent VH. A threshold of <3 and ≥5 mm appears to identify patients with cirrhosis at low and high risk for hemorrhage.
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Project description:The safety and efficacy of endoscopic submucosal dissection (ESD) and radiofrequency ablation for early esophageal cancer (EEC) in cirrhotic patients has not been thoroughly investigated to date. The present study aimed to establish a standard treatment strategy for EEC in cirrhotic patients with esophageal varices. Six cirrhotic patients with early flat-type EECs (high-grade intraepithelial neoplasia) on or adjacent to esophageal varices were enrolled. Esophageal varix ligation (EVL) or transjugular intrahepatic portosystemic shunt (TIPS) were used for the initial management of esophageal varices. Follow-up endoscopy was performed two months following the initial procedure. The mean longitudinal length of the lesions was 4.3 cm (range, 2-6 cm). The average procedure time was 72.8 min (range, 34-135 min) and the average longitudinal length of the resected specimens was 45.6 mm (range, 30-90 mm). One case had a tumor-positive lateral margin with lymphovascular infiltration. Both complete and curative resection rates were 80% (4/5 lesions). Large intraoperative bleeding was detected in patients undergoing EVL compared with TIPS prior to the ESD procedure. No severe complications or mortality-associated events, including massive postoperative bleeding, perforation or hepatic failure, were observed. No recurrence and metastasis were observed during the follow-up period. The current study suggested a novel treatment strategy for EECs complicated by esophageal varices in cirrhosis with good treatment results, no neoplastic progression and an acceptable adverse event profile.
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Project description:Currently, endoscopic variceal ligation (EVL) monotherapy is the standard therapy for managing esophageal variceal hemorrhage. Patients generally need several sessions of endoscopy to achieve optimal variceal ablation, and the varices can recur afterward. Endoscopic injection sclerotherapy (EIS) is an older technique, associated with certain complications. This study aimed to evaluate the clinical efficacy of EVL alone versus combined EVL and EIS in the treatment of esophageal varices. This retrospective study included 84 patients, of which 40 patients were treated with EVL monotherapy and 44 patients were treated with combined EVL + EIS. The main outcomes were rebleeding rates, recurrence at six months, number of treatment sessions, length of hospital stay, cost of hospitalization, and procedural complications. At six months, the rebleeding rate and recurrence were significantly lower in the EVL + EIS group compared to the EVL group (2.3% versus 15.0%; and 9.1% versus 27.5%, respectively). The number of treatment sessions, length of hospital stay, and cost of hospitalization were significantly lower in the EVL + EIS group compared to those in the EVL group (2.3 ± 0.6 versus 3.2 ± 0.8 times; 14.5 ± 3.4 versus 23.5 ± 5.9 days; and 23918.6 ± 4220.4 versus 26165.2 ± 4765.1 renminbi, respectively). Chest pain was significantly lower in the EVL + EIS group compared to that in the EVL group (15.9% versus 45.0%). There were no statistically significant differences in the presence of fever or esophageal stricture in both groups. In conclusion, combined EVL + EIS showed less rebleeding rates and recurrence at six months and less chest pain and was more cost effective compared to EVL alone in the treatment of gastroesophageal varices.
| S-EPMC8024074 | biostudies-literature
Project description:Previous reports of simultaneous presence of esophageal varices (EV) and achalasia suggest placement of a transjugular intrahepatic portosystemic shunt (TIPS) and surgical myotomy or endoscopic therapy. We report the case of a 64-year-old man who received anticoagulant therapy for a myeloproliferative disorder with extensive portal thrombosis which was a contraindication to placement of a TIPS. .
| S-EPMC4831925 | biostudies-other
Project description:Background/aimEsophageal varices (EVs) are a serious consequence of portal hypertension in patients with liver diseases. Several studies have evaluated possible noninvasive markers of EVs to reduce the number of unnecessary endoscopies in patients with cirrhosis but without varices. This prospective study was conducted to evaluate noninvasive predictors of large varices (LV).Patients and methodsThe study analyzed 106 patients with liver diseases from January 2007 to March 2008. Relevant clinical parameters assessed included Child-Pugh class, ascites and splenomegaly. Laboratory parameters like hemoglobin level, platelet count, prothrombin time, serum bilirubin, albumin and ultrasonographic characteristics like splenic size, splenic vein size, portal vein diameter were assessed. Univariate and multivariate analysis was done on the data for predictors of large EVs.ResultsIncidence of large varices was seen in 41%. On multivariate analysis, independent predictors for the presence of LV were palpable spleen, low platelet count, spleen size> 13.8 mm, portal vein> 13 mm, splenic vein> 11.5 mm. The receiver operating characteristic (ROC) curve showed 0.883 area under curve. Platelet spleen diameter ratio 909 had a sensitivity and specificity of 88.5%, 83% respectively.ConclusionThrombocytopenia, large spleen size, portal vein size and platelet spleen diameter ratio strongly predicts large number of EVs.
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Project description:Video 1Balloon-compression endoscopic injection sclerotherapy for the treatment of esophageal varices. A 50-year-old man with schistosomiasis-induced liver fibrosis presented with melena and hematemesis. The bleeding stopped after intravenous administration of somatostatin and ceftriaxone for 4 days. Balloon-compression endoscopic injection sclerotherapy (bc-EIS) was performed with the patient under general anesthesia to prevent rebleeding. The novel device for bc-EIS is composed of a syringe, a stopcock, a catheter, and an inflatable balloon. In the majority of patients with cirrhosis, the blood flow from the coronary vein drains into the azygos and hemiazygos venous system through esophageal and para-esophageal varices, and eventually back to the inferior vena cava. With compression of proximal esophageal and para-esophageal varices via an inflated balloon, sclerosant can be retained at the injection site, rather than flowing back to the inferior vena cava. Endoscopy revealed the presence of moderately enlarged, beady esophageal varices with red wale signs in the middle and lower esophagus. An inflatable balloon was fixed to an endoscope at a distance of 3 cm from its distal end. When the end of the endoscope was introduced to the target varices, 20 mL of air was injected into the balloon through a thin catheter, making its outer diameter expand to 3.5 cm. A disposable endoscopic injection needle then entered the base of the variceal columns near the cardia. When blood flowed back into the needle, a mixture of Lauromacrogol and methylene blue was intravariceally administered. Minor bleeding at the injection site was stopped through brief compression with the needle sheath. The second injection was performed following the aforementioned procedure. Follow-up endoscopy at 1 month, 4 months, and 7 months revealed the progression from thrombosed blue varices to complete eradication of esophageal varices. Endoscopic ultrasonography also showed the absence of blood flow in the varices after treatment. To date, bc-EIS has been performed successfully on 28 patients with esophageal varices. Variceal eradication was obtained in 17 patients with 1 session, 10 patients with 2 sessions, and 1 patient with 3 sessions. Two patients showed recurrence of esophageal varices on routine follow-up endoscopy and were re-treated with bc-EIS successfully. There were no severe complications during the follow-up period. With the sclerosant retained at injection sites after balloon compression, bc-EIS enables complete eradication of esophageal varices and lowers the risk of recurrence. The blockade of sclerosant also decreases the incidence of complications related to large-volume injection of sclerosant, such as embolization, ulceration, and perforation. In conclusion, bc-EIS appears to be an effective and safe approach for the treatment of esophaeal varices. Further research is underway to determine its suitability for large-scale clinical application.
| S-EPMC8755456 | biostudies-literature
Project description:BackgroundEsophageal varices, dilated submucosal veins in the lower esophagus, are commonly associated with portal hypertension, particularly due to liver cirrhosis. The high morbidity and mortality linked to variceal hemorrhage underscore the need for accurate diagnosis and effective management. The traditional method of assessing esophageal varices is esophagogastroduodenoscopy (EGD), which, despite its diagnostic and therapeutic capabilities, presents limitations such as interobserver variability and invasiveness. This review aims to explore the role of artificial intelligence (AI) in enhancing the management of esophageal varices, focusing on its applications in diagnosis, risk stratification, and treatment optimization.MethodsThis systematic review focuses on the capabilities of AI algorithms to analyze clinical scores, laboratory data, endoscopic images, and imaging modalities like CT scans.ResultsAI-based systems, particularly machine learning (ML) and deep learning (DL) algorithms, have demonstrated the ability to improve risk stratification and diagnosis of esophageal varices, analyzing vast amounts of data, identifying patterns, and providing individualized recommendations. However, despite these advancements, clinical scores based on laboratory data still show low specificity for esophageal varices, often requiring confirmatory endoscopic or imaging studies.ConclusionsAI integration in managing esophageal varices offers significant potential for advancing diagnosis, risk assessment, and treatment strategies. While promising, AI systems should complement rather than replace traditional methods, ensuring comprehensive patient evaluation. Further research is needed to refine these technologies and validate their efficacy in clinical practice.
| S-EPMC11433421 | biostudies-literature