[Efficacy Evaluation of Three Endoscopic Therapies of Isolated Gastric Varices with Modified Tissue Adhesive].

Objective: To evaluate the efficacy of three endoscopic therapies of isolated gastric varices (IGV) with modified tissue adhesive. Methods: A retrospective analysis was conducted with the clinical data of 73 IGV patients who were treated between January 2008 and December 2019 at Beijing Ditan Hospital. Patient clinical data on age, sex, etiology, biochemistry findings, Child-Pugh classification, the type of spontaneous shunt, preoperative bleeding history, and the presence or absence of liver cancer were collected. The three therapies evaluated were endoscopic intravenous injection of tissue glue combined with lauromacrogol, endoscopic clip-assisted intravenous injection of tissue glue combined with lauromacrogol, and endoscopic clip and LOOP-assisted intravenous injection of tissue glue combined with lauromacrogol. Their respective clinical treatment outcomes, including ectopic embolism rate, survival rate, rebleeding rate, amount of lauromacrogol and tissue glue used, the number of endoscopic clips used, and the number of times of the procedure the patient underwent, were evaluated. Results: In the patient baseline data, Child-Pugh grade, preoperative thrombus formation, and the presence or absence of liver cancer, showed significant difference between the three therapies ( P<0.05). There was no significant difference in the rates of ectopic embolism among the three methods ( P>0.05), but no ectopic embolism occurred after endoscopic clip-assisted intravenous injection of tissue glue combined with lauromacrogol, or after endoscopic clip and LOOP-assisted intravenous injection of tissue glue combined with lauromacrogol. There was no significant difference in the survival rate, the rebleeding rate, amount of lauromacrogol and tissue glue used for the three therapies, but there was significant difference in the number of endoscopic clips used and the number of times the procedure was conducted within one year ( P<0.05). Conclusion: The two endoscopic therapies of intravenous injection of modified tissue glue, one assisted by clip and the other assisted by clip and LOOP, can help reduce the number of procedures IGV patients undergo within one year.

Risk of rebleeding from gastroesophageal varices after initial treatment with cyanoacrylate; a systematic review and pooled analysis.

BACKGROUND: Cyanoacrylate alone or in combination with other interventions, can be used to achieve variable rates of success in preventing rebleeding. Our study aims to assess the pooled risk of gastric and esophageal varices rebleeding after an initial treatment with cyanoacrylate alone and/or in combination with other treatments, by a systematic review of the literature and pooled analysis. METHODS: PubMed, EMBASE, SCOPUS, and the Cochrane library were searched for studies that reported the risk of rebleeding during the follow-up period after treatment of gastric or esophageal varices with either cyanoacrylate alone or in combination with other treatments. Standard error, upper and lower confidence intervals at 95% confidence interval for the risk were obtained using STATA Version 15 which was also used to generate forest plots for pooled analysis. The random or fixed effect model was applied depending on the heterogeneity (I2). RESULTS: A total of 39 studies were found to report treatment of either gastric or esophageal varices with either cyanoacrylate alone or in combination with other treatments. When gastric varices are treated with cyanoacrylate alone, the risk of rebleeding during the follow-up period is 0.15(Confidence Interval: 0.11-0.18). When combined with lipiodol; polidocanol or sclerotherapy the rebleeding risks are 0.13 (CI:0.03-0.22), 0.10(CI:0.02-0.19), and 0.10(CI:0.05-0.18), respectively. When combined with percutaneous transhepatic variceal embolization; percutaneous transhepatic variceal embolization; endoscopic ultrasound guided coils; or with ethanolamine, the rebleeding risk are 0.10(CI:0.03-0.17), 0.10(CI:0.03-0.17), 0.07(CI:0.03-0.11) and 0.08(CI:0.02-0.14), respectively. When esophageal varices are treated with cyanoacrylate alone, the risk of rebleeding is 0.29(CI:0.11-0.47). When combined with percutaneous transhepatic variceal embolization; sclerotherapy; or band ligation, the risks of rebleeding are 0.16(CI:0.10-0.22), 0.12(CI:0.04-0.20) and 0.10(CI:0.04-0.24), respectively. When combined with a transjugular intrahepatic portosystemic shunt; or ethanolamine, the risks of rebleeding are 0.06(CI: - 0.01-0.12) and 0.02 (CI: - 0.02-0.05), respectively. CONCLUSION: In treating both gastric and esophageal varices, cyanoacrylate produces better results in terms of lower risk of rebleeding when combined with other treatments than when used alone. The combination of cyanoacrylate with ethanolamine or with endoscopic ultrasound guided coils produces the lowest risk of rebleeding in esophageal and gastric varices, respectively. We call upon randomized trials to test these hypotheses.

[Use of cyanoacrylate as a treatment of gastric varices in a public hospital in Lima - Peru]. / Uso de cianoacrilato como tratamiento de várices gástricas en un hospitalp úblico nivel III en Lima - Per ú.

OBJECTIVE: To evaluate the therapeutic success of endoscopic therapy with N-butyl-2-cyanoacrylate and to determine the re- bleeding and mortality rates. MATERIALS AND METHODS: Prospective analytical observational study of 47 cases of patients with gastric varices who were treated with N-butyl-2-cyanoacrylate, using a 1: 1 mixture with lipiodol between 2013 and 2017 in a level III public hospital in Lima - Peru. The therapeutic indication was active hemorrhage, primary or secondary prophylaxis. RESULTS: Of the 47 patients, 5 (10.6%) had active hemorrhage, control was obtained in all cases, 24 (51.1%) had stigmas of recent bleeding during endoscopy. Secondary prophylaxis was performed in 16 (34%) patients and primary prophylaxis in 2 (4.7%). 59.6% required a single session with a total volume of cyanoacrylate (ml / patient) of 1.28 ± 0.44. The endoscopic finding was GOV-2 in 78.7% of the cases, IGV-1 in 12.8% and GOV-1 in 8.5%. Seven patients (14.8%) presented late re- bleeding, with successful new therapy in 6 of them, one dying due to therapy failure. Of the six (12.76%) patients who died in total, 5 (83.3%) were due to other causes. No adverse events related to the therapy were reported. No adverse events were reported. Variceal obturation was observed in 28 (59.5%) patients. CONCLUSIONS: Endoscopic management of gastric varices with cyanoacrylate is a safe and effective treatment, with low recurrence and mortality rates.

[Application of multi-slice spiral CT to assess vascular volume for the diagnosis and treatment of gastric varices].

Objective: To differentiate the inflow and outflow channels of gastric varices in cirrhotic portal hypertension patients using multi-slice spiral CT (MSCT), and to assess the relationship between calculable CT volume of gastric varices and the amount of tissue adhesive. Methods: 97 cases with cirrhotic gastric varices who were admitted from November 2013 to August 2017 were selected. The type and shape of gastric varices were observed before tissue glue injection treatment by MSCT. The correlation between CT volume of gastric varices and the amount of tissue adhesive was evaluated by Spearman rank correlation coefficient and Univariate linear regression analysis. Results: MSCT showed that Le, g type had the highest proportion (54.6%), followed by Le, g, Lg (20.6%). Le, Lg and Lgf type accounted for 17.5%, and 5.2%, respectively, while Lgf+b accounted for 2.1%. On MSCT, varices of the gastric fundus were in the direction from bottom to top, and 75% of the fundus had a large curved side varices combined with gastric and renal shunt. Under the gastroscopy, varices in the small curved side of the gastric fundus from near to far were formless. In addition, varices in the large curved side of the gastric fundus when observed from different angles to the direction of blood flow (reverse gastroscope) were 72.7% (near and far) or 20.5 % (far and near). There was a positive correlation between CT volume (R = 0.97, P < 0.001) and the amount of tissue adhesive (Y(1) = 0.35 + 0.65X1, Univariate linear regression equation; ρ = 0.89, P < 0.001, Spearman correlation analysis). Conclusion: MSCT can recognize the vascular shape and inflow and outflow channels of gastric varices. A positive correlation between CT volume and the amount of tissue adhesive, suggested that the CT volume measurement before treatment could be used as one of the method to predict the amount of tissue adhesive.

Endoscopic cyanoacrylate injection with or without lauromacrogol for gastric varices: A randomized pilot study.

BACKGROUND AND AIM: Current guidelines recommend injection of cyanoacrylate as first-line therapy to prevent gastric variceal rebleeding. The method still poses a risk of ectopic embolism, which possibly correlates with the volume of cyanoacrylate used. In this trial, we evaluated the short-term efficacy and safety of tissue adhesive injection combined with lauromacrogol for treating gastric varices. METHODS: Patients admitted to our hospital for variceal hemorrhage were enrolled and blindly randomized into two treatment groups: lauromacrogol group (lauromacrogol-cyanoacrylate-lauromacrogol) and lipiodol group (lipiodol-cyanoacrylate-lipiodol). Patient follow-up was 6 months. Primary outcome was rebleeds, and secondary outcomes were mortality, gastric varices eradication, and treatment-related adverse events. RESULTS: Between March 6, 2013 and October 16, 2013, 96 patients met the criteria. Two cases were lost to follow-up, and all treated cases were successful. No procedural-related adverse events were observed in either group. Cyanoacrylate volumes used in the lauromacrogol group were significantly less than those of the lipiodol group (0.9 ± 0.5 vs 2.0 ± 1.2 mL, P = 0.000). Eleven patients developed upper gastrointestinal rebleeding, which did not show significant difference between groups. On multivaritate analysis, portal venous thrombosis and fever were potential risk factors of rebleeding. Treatment failure, complications, gastric varices obturation, and survival did not differ between the two groups. CONCLUSION: Tissue adhesives combined with lauromacrogol is a safe therapeutic option for gastric varices, with comparably less cyanoacrylate volume used. Because of the small number of study patients, it cannot be proven to have better efficacy than without lauromacrogol. Multicenter studies with larger patient groups are necessary.

Management of gastric varices.

According to their location, gastric varices (GV) are classified as gastroesophageal varices and isolated gastric varices. This review will mainly focus on those GV located in the fundus of the stomach (isolated gastric varices 1 and gastroesophageal varices 2). The 1-year risk of GV bleeding has been reported to be around 10%-16%. Size of GV, presence of red signs, and the degree of liver dysfunction are independent predictors of bleeding. Limited data suggest that tissue adhesives, mainly cyanoacrylate (CA), may be effective and better than propranolol in preventing bleeding from GV. General management of acute GV bleeding must be similar to that of esophageal variceal bleeding, including prophylactic antibiotics, a careful replacement of volemia, and early administration of vasoactive drugs. Small sample-sized randomized controlled trials have shown that tissue adhesives are the therapy of choice for acute GV bleeding. In treatment failures, transjugular intrahepatic portosystemic shunt (TIPS) is considered the treatment of choice. After initial hemostasis, repeated sessions with CA injections along with nonselective beta-blockers are recommended as secondary prophylaxis; whether CA is superior to TIPS in this scenario is not completely clear. Balloon-occluded retrograde transvenous obliteration (BRTO) has been introduced as a new method to treat GV. BRTO is also effective and has the potential benefit of increasing portal hepatic blood flow and therefore may be an alternative for patients who may not tolerate TIPS. However, BRTO obliterates spontaneous portosystemic shunts, potentially aggravating portal hypertension and its related complications. The role of BRTO in the management of acute GV bleeding is promising but merits further evaluation.

Comparison of endoscopic ultrasound-guided coil deployment with and without cyanoacrylate injection for gastric varices.

BACKGROUND AND STUDY AIMS: Gastric variceal bleeding is more severe than esophageal variceal bleeding, and is associated with higher rebleeding and mortality rates. The benefits of endoscopic ultrasound-guided coil deployment alone for treating gastric varices, compared with concomitant cyanoacrylate injection, remain unclear. Therefore, this study aimed to compare the outcomes of both modalities. PATIENTS AND METHODS: Data of patients who underwent endoscopic ultrasound-guided coil deployment with/without concomitant cyanoacrylate injection for gastric varices between 2010 and 2021 were reviewed. The rates of rebleeding, reintervention, and survival were assessed. RESULTS: Twenty-eight patients (mean age, 55.9 ± 12.9 years; 17 men) underwent endoscopic ultrasound-guided coil deployment, either alone (EUS-coil) (n = 19) or with cyanoacrylate injection (EUS-coil/CYA) (n = 9), to treat cardiofundal varices. Among the 20 patients treated for secondary prophylaxis, including 3 actively bleeding patients (11 via EUS-coil, 9 with EUS-coil/CYA), no significant differences were observed in the rates of rebleeding (1 vs. 2), reintervention (1 vs. 0) or adverse events (1 vs. 1) (all P > 0.05). The 6-month, 1-year, and 3-year overall survival rates did not differ between the treatment groups (crude survival ratio: 76.9% vs. 77.8%; survival rates: 0.923, 0.682, and 0.615 vs. 0.778 for each year; log-rank = 0.227; P = 0.633). In patients treated for primary prophylaxis (n = 8; all via EUS-coil alone), no bleeding episodes were observed after 433 days of follow-up; however, one patient required reintervention for the reappearance of varices without bleeding. CONCLUSION: EUS-coil alone was not inferior to EUS-coil/CYA combination concerning rebleeding, reintervention, or survival.

Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: a randomized controlled trial.

BACKGROUND & AIMS: Gastric variceal bleeding is severe and is associated with high mortality. We compared the efficacy of cyanoacrylate injection and beta-blockers in primary prophylaxis of gastric variceal bleeding. METHODS: Cirrhotics with large gastroesophageal varices type 2 with eradicated esophageal varices or large isolated gastric varix type 1, who had never bled from gastric varix, were randomised to cyanoacrylate injection (Group I, n=30), beta-blockers (Group II, n=29) or no treatment (Group III, n=30). Primary end-points were bleeding from gastric varix or death. RESULTS: The actuarial probability of bleeding from gastric varices over a median follow-up of 26 months was 13% in Group I, 28% in Group II (p=0.039), and 45% in Group III (p=0.003). The actuarial probability of survival was higher in the cyanoacrylate compared to the no-treatment group (90% vs. 72%, p=0.048). The median hepatic venous pressure gradient (HVPG) was increased in Group I (14-15 mm Hg, p=0.001) and III (14-16 mm Hg, p=0.001) but decreased in Group II (14 to 12 mm Hg, p=0.001) during follow-up. Size of gastric varix >20 mm, a MELD score ≥17, and presence of portal hypertensive gastropathy predicted 'high risk' of first bleeding from gastric varices. CONCLUSIONS: Primary prophylaxis is recommended in patients with large and high risk gastric varices to reduce the risk of first bleeding and mortality. Cyanoacrylate injection is more effective than beta-blocker therapy in preventing first gastric variceal bleeding.

CT portography with gastric variceal volume measurements in the evaluation of endoscopic therapeutic efficacy of tissue adhesive injection into gastric varices: a pilot study.

BACKGROUND: N-butyl-2-cyanoacrylate (NBCA) injection is used for treating gastric varices (GV). Determining the degree of obliteration of GV is not readily evident at endoscopy. AIMS: The aim of this study was to evaluate CT portography with gastric variceal volume calculations to assess endoscopic therapeutic efficacy of NBCA injection. METHODS: The study design is a retrospective series pilot study. The setting is a single, tertiary care academic medical center. Ten patients underwent esophagogastroduodenoscopy (EGD) with NBCA injection of GV and had biphasic CT scans performed before and after injection therapy. Based on portal venous images, 3D reconstruction and semi-automated volume calculations of GV were performed. Pre and post injection GV volume calculations were compared. RESULTS: The mean pre-procedure GV volume was 89.84 cm3. Eight patients had significant improvement in GV volume from pre-treatment versus post-treatment (95.65 cm3 vs. 49.65 cm3, P-value 0.04). Pre-procedure GV volume was not significantly different in patients treated for active hemorrhage versus no hemorrhage (101.66 cm3 vs. 72.11 cm3, P-value 0.33). Two patients had a subsequent GV hemorrhage after NBCA injection. The mean residual GV volume in these patients versus those that did not re-bleed was significantly more (127.77 cm3 vs. 38.00 cm3, P-value 0.005). CONCLUSIONS: CT portography with measurement of GV volume is a potentially useful tool in determining the therapeutic efficacy NBCA injection of GV. Patients with higher residual GV volumes are at increased risk of hemorrhage and may benefit from repeat injection to reach ideal GV volumes.

Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding.

BACKGROUND: Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. N-butyl cyanoacrylate (NBC), mixed with lipiodol, has been shown to be effective in controlling bleeding, but is associated with the risk of distal embolization. OBJECTIVE: To study the efficacy and safety of undiluted NBC in the management of gastric varices (GV). DESIGN: Prospective cohort study. SETTING: Single tertiary care center. PATIENTS: 170 consecutive patients with GV. INTERVENTION: Standardized technique of undiluted NBC injection for management of GV. MAIN OUTCOME MEASUREMENTS: Achievement of initial hemostasis, rate of rebleeding, procedure-related complications, and mortality. RESULTS: GV were identified in 170 patients, 87 of whom were treated with 261 injections of undiluted NBC. Among 46 patients with active bleeding of GV, initial hemostasis was achieved in 84.8%. Rebleeding was seen in 23.4% patients over a mean follow-up of 16 months. No case of clinical distal embolization was seen. Large GV size, fundal location, and large esophageal variceal size were predictive of GV bleed. The mortality was 8.8% for all patients with GV; 10.3% for patients with GV treated with NBC, and 7.2% for those with GV not treated with NBC. Child-Pugh status was the only predictor of mortality. LIMITATION: Only 1 intervention group. CONCLUSION: Undiluted NBC is safe and effective in the management of gastric variceal bleeding.

Long-term outcomes of prophylactic endoscopic histoacryl injection for gastric varices with a high risk of bleeding.

PURPOSE: Endoscopic histoacryl injection (EHI) is reported to be an effective treatment modality for bleeding gastric varices (GVs) but controversial as a prophylactic treatment for non-bleeding GVs because efficacy and safety have yet to be determined. The aim of this study was to evaluate safety and long-term outcomes of prophylactic EHI for non-bleeding GVs with a high risk of bleeding. METHODS: Thirty-three patients (23 males/10 females, mean age 56.6 years old) with a high risk of gastric variceal bleeding (large tumorous (27), red color sign (14) or rapidly growing in size (1)) underwent EHI. According to the grade of GVs, 25 patients belonged to F3, seven to F2, and one to F1. In terms of the locations of GVs, four patients belonged to type IGV1, 21 to type GOV2, and eight to type GOV1. RESULTS: Obliteration of GVs was achieved in all of the treated patients. Twenty-three patients required one session and ten needed more than two sessions to obliterate their GVs. A mean volume of histoacryl used per session was 2.0 ml. Complications related to the procedure included immediate bleeding in two patients and bacteremia in one patient. The mean duration of follow-up was 12.2 months and eradication of GVs was achieved in 21 (95%) of 22 patients who were followed-up more than 3 months. Index GVs recurred in three of 21 patients (14%) and re-bleeding in index GVs after EHI occurred in two of 26 patients (8%). CONCLUSIONS: Prophylactic EHI can be a promising procedure for eradication of non-bleeding GVs in case with a high risk of bleeding.

A randomized trial of endoscopic cyanoacrylate injection for acute gastric variceal bleeding: 0.5 mL versus 1.0 mL.

BACKGROUND: Endoscopic injection of N-butyl-2-cyanoacrylate is the preferred method to treat acute gastric variceal bleeding (GVB). However, its rebleeding rate remains high. OBJECTIVE: To compare an injection containing 0.5 mL of cyanoacrylate (group A) with an injection containing 1.0 mL of cyanoacrylate (group B). DESIGN: A single-center, randomized, controlled trial. SETTING: A tertiary referral center. MAIN OUTCOME MEASUREMENT: Occurrence of rebleeding. PATIENTS: Patients with acute gastric variceal bleeding. RESULTS: Forty-four patients in group A and 47 patients in group B were studied; their clinical characteristics were similar. The treatment stopped active bleeding in approximately 90% of cases in both groups. The rebleeding rate was 29.8% (14/47) in group B compared with 38.6% (17/44) in group A (P = .504; 95% CI, -10.592 to 28.280). On multivariate analysis, concomitant hepatocellular carcinoma, infection, and the size of the gastric varices were independent determinants of rebleeding. More patients in group B than in group A had postinjection fever (>37.5 degrees C) (23/47 vs 12/44, P = .059). Treatment failure, complications, 30-day mortality, and survival did not differ between the 2 groups. CONCLUSIONS: Due to the small number of study patients, a double dose of cyanoacrylate injection for GVB cannot be proven to have better hemostatic efficacy than a single dose. Multicenter studies with larger patient numbers are necessary to determine whether a double dose is in fact more efficacious.

Current endoscopic therapy of variceal bleeding.

Variceal ligation has proved more effective and safer than sclerotherapy and is currently the endoscopic treatment of choice for oesophageal varices. In acute bleeding, vasoactive drugs should be started before endoscopy and maintained for 2-5 days. The efficacy of drugs is improved when associated with emergency endoscopic therapy. Antibiotic prophylaxis should also be used. To prevent rebleeding, both endoscopic ligation and the combination of beta-blockers and nitrates may be used. Adding beta-blockers improves the efficacy of ligation. Haemodynamic responders to beta-blockers+/-nitrates (those with a decrease in portal pressure gradient HVPG to <12 mmHg or by >20% of baseline) have a marked reduction in the risk of haemorrhage and will not need further treatment. Beta-blockers significantly reduce the risk of a first haemorrhage in patients with large varices, and they improve survival. As compared to beta-blockers, endoscopic ligation reduces the risk of first bleeding without affecting mortality, and should be used in patients with contraindications or intolerance to beta-blockers.

Risk of bacteremia in bleeding and nonbleeding gastric varices after endoscopic injection of cyanoacrylate.

BACKGROUND AND STUDY AIM: Bacteremia is common in cirrhosis with gastrointestinal bleeding, including variceal bleeding. Elective esophageal sclerotherapy and banding have been reported to cause bacteremia. The risk associated with therapeutic endoscopy in patients with gastric varices has not yet been reported. This study was conducted to compare the risk of bacteremia between patients with active gastric variceal bleeding and those with gastric varices that were not actively bleeding who underwent N-butyl-2-cyanoacrylate injection. PATIENTS AND METHODS: Patients were categorized into three groups: group I, patients with bleeding gastric varices who underwent cyanoacrylate injection for hemostasis (n = 20); group II, patients who underwent elective cyanoacrylate injection for further obliteration of gastric varices (n = 18); and group III, patients with cirrhosis who underwent endoscopic surveillance for varices, and patients with gastric varices who presented for a follow-up endoscopy without a requirement for treatment (n = 17). Blood culture was obtained before and 5 minutes and 3 hours after endoscopy. Needle tips were also sent for culture. RESULTS: Before procedures, blood cultures were positive in 4 patients (20 %) from group I. The number of positive blood cultures in group I at 5 minutes and 3 hours after the procedure were 3 (15 %) and 2 (10 %) respectively. The identified organisms were: Klebsiella pneumoniae (2), Escherichia coli (1), Vibrio cholerae non-O1 (1). No patient from group II had a positive culture at any point of blood drawn. Only one in group III had a positive culture, for Streptococcus mitis at 5 minutes. No clinical evidence of infections occurred in any patient. Needle-tip cultures grew mainly organisms from the oral and gastrointestinal tracts. CONCLUSIONS: Elective cyanoacrylate injection for nonbleeding gastric varices is not associated with significant bacteremia or infection. For this reason, prophylactic antibiotics may not be needed in this patient group. By contrast, prophylactic antibiotics are strongly recommended for patients with bleeding gastric varices undergoing cyanoacrylate injection.

Enbucrilate for gastric varices: extended experience in 92 patients.

AIM: We assessed N-2-butyl-cyanoacrylate (enbucrilate) in 92 patients with gastric variceal bleeding under an FDA-approved investigation. These results extend our prior report of the first 44 patients. METHOD: Injection was performed with enbucrilate and ethiodol (1:1). Eighty patients had portal hypertension and 12 had splenic vein thrombosis. RESULTS: In the portal hypertensive group, re-bleeding from gastric varices was seen in 4 of 80 (5%) from 0 to 72 h, 5 of 76 (6.5%) from > 72 h to 3 months and 9 of 51 (17%) from > 3 months to 1 year. Re-bleeding and survival were significantly related to the Child-Pugh class. In the splenic vein thrombosis group (n = 12), there was early rebleeding in 2 (17%) patients from 0 to 72 h, 1 (8%) from > 72 h to 3 months and none in the chronic phase (> 3 months to 1 year) although 1-year survival in this group was only 6 (50%) due to the underlying malignancy in most. Serious embolization was suspected in 2 patients (2%). CONCLUSION: Enbucrilate offers an important intervention in gastric variceal bleeding which should be further studied in the US. A randomized trial is warranted to compare this intervention to radiological therapy.

Improvement of tissue-adhesive obliteration of bleeding gastric varices using adjuvant hypertonic glucose injection: a prospective randomized trial.

BACKGROUND AND STUDY AIMS: Rebleeding can occur after endoscopic injection of gastric varices with tissue adhesive. The aim of this study was to evaluate whether adjuvant hypertonic glucose solution injections enhance the effects of Histoacryl after successful initial variceal obliteration. PATIENTS AND METHODS: A total of 67 patients (37 men, 30 women; mean age +/- standard deviation [SD] 60 +/- 17 years) with initially successful Histoacryl obliteration of bleeding gastric varices were included in the study and randomly divided into two groups: a "combined" group of patients who had adjuvant injection of hypertonic glucose solutions in cases of residual gastric varices (F1 or less) and a "control" group of patients who did not receive such therapy. End points were either variceal recurrence/progression (F2 or more) requiring Histoacryl reinjection or rebleeding. RESULTS: Residual small varices were found in 56% of patients in the combined group and in 60% of patients in the control group. Adjuvant therapy was only performed in the combined group. During the follow-up period (mean duration +/- SD 37.9 +/- 18.5 months, range 19-56 months), two patients in the combined group showed gastric variceal progression, compared with nine patients showing progression in the control group, with two cases of rebleeding, both occurring in the control group. Two years after the first Histoacryl injection, the cumulative proportion of patients who did not have gastric variceal progression was significantly higher in the combined group than it was in the control group (92.8% vs. 71.4%, P = 0.029). There was no significant difference between the two groups with respect to their survival curves (P = 0.12). No marked immediate or delayed symptoms or complications were observed in the patients given hypertonic glucose injections. CONCLUSIONS: Adjuvant treatment with hypertonic glucose solution for residual small gastric varices is a safe and simple method. It helps reduce the recurrence or progression of gastric varices after tissue adhesive injections and can therefore reduce the risk of rebleeding.

Cyanoacrylate therapy for the treatment of gastric varices: a new method.

OBJECTIVE: Cyanoacrylate (CYA) injection is recommended for bleeding gastric varices (GV) but with significant adverse effects. Transesophageal endoscopic ultrasound-guided therapy of large GV with a combined coil and CYA injection has shown promising results. However, it is expensive and requires technical expertise. In this study, we aimed to compare the safety and efficacy of a new method with UCYA [undiluated CYA (UCYA) followed by lipiodol-diluated CYA (DCYA)] in the management of large bleeding GV. METHODS: Fifteen consecutive patients with bleeding from large GV (>1 cm) were prospectively treated with DCYA and another 15 patients treated with UCYA retrospectively. All patients in the DCYA group underwent thoracic computed tomography scan to identify glue embolism. RESULTS: Baseline characteristics were similar between the two groups. Rates of GV obliteration and rebleeding were 100% vs 93.3% (P = 0.309) and 6.7% vs 33.3% (P = 0.06) in the DCYA and UCYA groups, respectively. One patient in the UCYA group had needle fixation which led to fatal bleeding after forceful needle extraction. In DCYA group none had glue embolism. CONCLUSIONS: Both UCYA and DCYA are effective in treating bleeding from large GV. DCYA has lower rebleeding rates and tends to have fewer adverse events than UCYA injection, although the differences are not statistically significant. Large-sample-sized prospective randomized trials are required.

Anticoagulation in the treatment of portovenous emboli after cyanoacrylate injection for a bleeding gastric varix.

We herein report the use of endoscopic n-butyl-2-cyanoacrylate injections to obliterate a gastric varix, which led to cyanoacrylate embolisation in the splenic and portal veins in a single patient. Cyanoacrylate embolisation is a known but uncommonly reported complication of endoscopic sclerotherapy. This case report illustrates the successful management of this complication (i.e. cyanoacrylate embolisation in the splenic and portal veins) with anticoagulation and analyses the presentation and management of other cases of cyanoacrylate embolisation reported in the literature.