Therapeutic strategy for patients with bleeding rectal varices complicating liver cirrhosis.

AIM: Although rupture of rectal varices is rarely encountered, it may provoke massive and fatal hemorrhage in patients with liver cirrhosis. We examined the clinical features of patients showing bleeding from rectal varices to establish a suitable therapeutic strategy for the lesions. METHODS: Twelve cirrhotic patients with bleeding rectal varices were enrolled. Surgical suture, endoscopic variceal ligation (EVL) or balloon tamponade was performed to achieve the initial hemostasis. Then, the feeding and drainage vessels of the varices were evaluated by computed tomography, and additional procedures were undertaken: EVL was performed when the sizes of the varices and feeding vessels were small. In contrast, in patients with varices of large sizes, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed when single or two drainage vessels were identified, while endoscopic injection sclerotherapy (EIS) using ethanolamine oleate was carried out for varices with three or more drainage vessels. RESULTS: The Child-Pugh class was grade A in four, B in six and C in two patients. Eleven patients had received previous therapy for esophageal varices. Initial hemostasis was achieved by surgical suture in three patients, EVL in one patient and balloon tamponade in two patients. EVL, EIS and B-RTO were carried out as additional procedures in seven, three and one patient, respectively. Rebleeding from the rectal varices occurred in only one patient who underwent EVL as an additional procedure. CONCLUSION: Bleeding from rectal varices was controlled satisfactorily by the therapeutic strategy of selecting EVL, EIS or B-RTO as an additional therapy according to the size and hemodynamics of the varices.

Long-term efficacy of endoscopic coagulation for different types of gastric vascular ectasia.

AIM: To examine the long-term therapeutic efficacies of endoscopic cauterization for gastric vascular ectasia, according to the type of lesion. METHODS: Thirty-eight patients with hemorrhagic gastric vascular ectasia (VE) were treated by endoscopic cauterization: 13 by heater probe coagulationand 25 by argon plasma coagulation. Depending on the number of lesions, 14 and 24 patients were classified into localized VE (≤ 10; LVE) and extensive VE (> 10; EVE), respectively. The patients were followed-up by repeated endoscopic examinations after the therapy, and the incidences of VE recurrence and re-bleeding from the lesions were evaluated. RESULTS: Although the VE lesions disappeared initially in all the patients after the therapy, the recurrence of VE developed in 25 patients (66%) over a mid-term observation period of 32 mo, and re-bleeding occurred in 15 patients (39%). The recurrence of VE was found in all patients with EVE, with re-bleeding occurring in 14 patients (58%). In contrast, only 1 patient (7%) with LVE showed recurrence of the lesions and complicating hemorrhage. Both the cumulative recurrence-free rates and cumulative re-bleeding-free rates were significantly lower in the EVE group than in the LVE group (P < 0.001 and P < 0.001, respectively). Moreover, the cumulative re-bleeding-free rate in the EVE group was 47.6% at 1 year and 25.4% at 2 years in patients with chronic renal failure, which were significantly lower than the rates in the patients without chronic renal failure (83.3% and 74.1%, respectively) (P < 0.05). CONCLUSION: The recurrence of VE and re-bleeding from the lesions was more frequent in the patients with EVE, especially in those with complicating renal failure.

Usefulness of miriplatin as an anticancer agent for transcatheter arterial chemoembolization in patients with unresectable hepatocellular carcinoma.

BACKGROUND: Injection of a suspension of miriplatin into the hepatic artery has been employed for the treatment of hepatocellular carcinoma (HCC). The efficacy and safety of transcatheter arterial chemoembolization (TACE) using miriplatin were evaluated. METHODS: A total of 236 patients with unresectable HCC received miriplatin administration through the hepatic artery, followed by embolization with porous gelatin particles. The efficacy of this treatment modality was evaluated by contrast-enhanced computed tomography performed 1 month later and its safety based on the Common Terminology Criteria for Adverse Events (CTCAE). RESULTS: Miriplatin was used at a median dose of 66 mg. The therapeutic efficacy was evaluated in 130 patients, and the overall and complete response rates were 70.0 and 37.7%, respectively. The efficacies differed depending on the staging and Japan integrated staging (JIS) scores of the HCCs, with the overall and complete response rates being 87.7 and 66.7% for stage I and stage II HCC, and 56.2 and 15.1% for stage III and stage IV HCC, respectively; the corresponding rates were 93.2 and 70.5%, respectively, for HCCs with score 0 and score 1, and 58.1 and 20.9%, respectively, for those with scores 2-4. The stage of HCC was a significant independent factor associated with curative effects of TACE using miriplatin. Grade 3 elevation of serum transaminase levels was found in 23.4% of the patients; however, the values returned to the baseline levels. CONCLUSIONS: Miriplatin is a useful and safe agent for TACE in patients with HCC stage I or II and/or JIS score 0 or 1 only when radiofrequency ablation and liver resection cannot be performed.

Usefulness of anti-ulcer drugs for the prevention and treatment of peptic ulcers induced by low doses of aspirin.

AIM: To investigate the usefulness of anti-ulcer drugs for the prevention and treatment of low-dose aspirin-induced peptic ulcer. METHODS: Upper gastrointestinal endoscopy was performed in 68 patients receiving daily low-dose aspirin (81 or 100 mg/day). The endoscopic findings were classified according to the Lanza score, and the scores were compared between groups categorized according to the concomitant use of anti-ulcer drugs and the types of drugs used. In another study, 31 hemorrhagic peptic ulcer patients who had been receiving low-dose aspirin were enrolled. The patients were randomly classified into the proton pump inhibitor (PPI)-treated group and the H2 receptor antagonist (H2RA)-treated group. The administration of low-dose aspirin was continued concomitantly, and endoscopic examinations were performed 8 wk later. RESULTS: The Lanza scores (mean +/- SD) of the gastro-mucosal lesions were 1.0 +/- 1.9 and 1.9 +/- 2.3 in 8 and 16 patients receiving prevention therapy with a PPI and an H2RA, respectively. Both scores were significantly smaller than the scores in 34 patients who were not receiving prevention therapy (4.7 +/- 1.0) and in 10 patients receiving cytoprotective anti-ulcer drugs (4.3 +/- 1.6). In the prospective study, 18 and 13 patients received a PPI and an H2RA, respectively. Endoscopic examinations revealed that the tissue in the region of the gastro-mucosal lesions had reverted to normal in all patients in the PPI-treated group and in 12 patients (92%) in the H2RA-treated group; no significant differences were observed between the groups. CONCLUSION: H2RA therapy was effective for both the prevention and treatment of low-dose aspirin-induced peptic ulcer, similar to the effects of PPIs, while cytoprotective anti-ulcer drugs were ineffective in preventing ulceration.