Asunto(s)

Cianoacrilatos , Embolización Terapéutica , Várices Esofágicas y Gástricas , Embolia Pulmonar , Humanos , Persona de Mediana Edad , Cianoacrilatos/uso terapéutico , Embolización Terapéutica/métodos , Várices Esofágicas y Gástricas/terapia , Várices Esofágicas y Gástricas/diagnóstico por imagen , Embolia Pulmonar/etiología , Embolia Pulmonar/diagnóstico por imagen , Resultado del Tratamiento , Várices/terapia , Várices/diagnóstico por imagen

RESUMEN

Acute gastric variceal bleeding is a life-threatening condition that could be effectively treated with endoscopic cyanoacrylate injection diluted with lipiodol. The mixture acts as a tissue adhesive that polymerizes when in contact with blood in a gastric varix. This work reports a patient that presented to the emergency department with upper gastrointestinal bleeding due to acute variceal bleeding, who developed systemic embolization following cyanoacrylate injection therapy. This complication culminated in cerebral, splenic and renal infarctions with a fatal outcome. Systemic embolization is a very rare, but the most severe complication associated with endoscopic cyanoacrylate injection and should be considered in patients undergoing this treatment.

Asunto(s)

Cianoacrilatos , Várices Esofágicas y Gástricas , Hemorragia Gastrointestinal , Adhesivos Tisulares , Humanos , Cianoacrilatos/uso terapéutico , Cianoacrilatos/administración & dosificación , Cianoacrilatos/efectos adversos , Embolia/etiología , Embolia/terapia , Embolización Terapéutica/métodos , Várices Esofágicas y Gástricas/terapia , Várices Esofágicas y Gástricas/etiología , Resultado Fatal , Hemorragia Gastrointestinal/terapia , Hemorragia Gastrointestinal/etiología , Adhesivos Tisulares/uso terapéutico , Adhesivos Tisulares/administración & dosificación

RESUMEN

INTRODUCTION AND OBJECTIVES: Congenital hepatic fibrosis (CHF) is a rare condition characterized by biliary tract changes and a geographic pattern of liver fibrosis. Liver biopsy is essential to confirm its diagnosis. The absence of specific clinical indicators in adults often leads to delays in diagnosis and management, while the natural history has not been well described. We sought to define the presentation and outcomes of adults with biopsy-proven CHF. MATERIALS AND METHODS: A retrospective chart review was conducted of patients diagnosed with CHF by liver biopsy. Continuous variables were summarized with the sample median and range. Categorical variables were summarized with number and percentage of patients. RESULTS: We identified 24 patients evaluated over a 20-year period, with a median age of 51 years (range 22-72 years) at initial presentation; 14 were male. The most common imaging findings were renal cysts (91.3%), splenomegaly (69.6%), and a cirrhotic-appearing liver (60.9%). The most commonly treated liver-related complications were cholangitis (45.8%), varices (45.8%), and hepatic encephalopathy (25%). Two patients died with a median length of follow-up of 2.9 years (range: 0.0-20.0 years). Two patients underwent transjugular intrahepatic portosystemic shunt (TIPS) placement to manage bleeding esophageal varices. Eight patients underwent liver transplantation (LT), the most common indication being decompensated disease (50%). CONCLUSIONS: CHF should be considered when patients present with cholangitis and/or complications of portal hypertension and have a cirrhotic appearing liver and renal cysts on imaging. Depending upon the disease severity, interventions such as TIPS or LT may be required.

Asunto(s)

Cirrosis Hepática , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Colangitis , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/etiología , Enfermedades Renales Quísticas/complicaciones , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/etiología , Cirrosis Hepática/terapia , Estudios Retrospectivos

RESUMEN

The Baveno VII consensus workshop has provided several novel recommendations regarding the management of patients with clinically significant portal hypertension (CSPH). The expert panel summarized the existing data into simple clinical rules to aid clinicians in their clinical practice. The use of non-invasive tests (NITs), especially liver stiffness measurement (LSM), have gain an important role in daily practice. The use of LSM alone or in combination with platelet count can be used to rule-in and rule-out compensated advanced chronic liver disease (cACLD) and CSPH. Further decompensation events were defined as a prognostic stage associated with an even higher mortality than that associated with first decompensation. Moreover, the term hepatic recompensation was introduced in Baveno VII consensus implying a partial or complete regression of the functional and structural changes of cirrhosis after the removal of the underlying etiology. This review will summarize the reader main aspects of Baveno VII consensus regarding the use of NITs in cACLD, analyze further decompensation events, and evaluate recent recommendations for prophylaxis and management of liver decompensation events.

Asunto(s)

Diagnóstico por Imagen de Elasticidad , Várices Esofágicas y Gástricas , Hipertensión Portal , Humanos , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/terapia , Hipertensión Portal/complicaciones , Hipertensión Portal/diagnóstico , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/terapia , Pronóstico

RESUMEN

Cirrhosis is the end-stage of chronic liver disease and constitutes a leading cause of potential years of working life lost, especially in the Americas and Europe. Its natural history is characterized by an asymptomatic phase called compensated cirrhosis, followed by a rapidly progressive phase characterized by liver-related complications termed decompensated cirrhosis. Complications could be related to portal hypertension and/or liver dysfunction, including ascites, portal hypertensive gastrointestinal bleeding, encephalopathy, and jaundice. This review will discuss some of the most important precipitants of hepatic decompensation, including acute variceal bleeding, spontaneous bacterial peritonitis, and hepatic encephalopathy.

Asunto(s)

Várices Esofágicas y Gástricas , Gastroenterología , Encefalopatía Hepática , Humanos , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Pacientes Internos , Cirrosis Hepática/complicaciones , Cirrosis Hepática/diagnóstico , Cirrosis Hepática/terapia , Encefalopatía Hepática/diagnóstico , Encefalopatía Hepática/terapia , Ascitis/etiología , Ascitis/terapia

RESUMEN

BACKGROUND: In natural history of cirrhosis, variceal bleeding is one of the earliest decompensations to happen, and, if adequately managed, survival is improved. Gastric varices have challenges in management due to their location, size and propensity to bleed. The N-butyl 2-cyanoacrylate (NBC) glue application has emerged as definitive therapy in bleeding gastric varices. Here we present our experience with use of NBC in management of gastric and difficult cases of esophageal varices. METHODS: A total of 75 patients underwent NBC glue application for varices which included 69 patients with gastric varices and six patients with esophageal varices. All the procedures were done with flexible endoscope and sclerotherapy needle after due precautionary measures. RESULTS: Hemostasis was varices in all patients after endotherapy. The average quantity of glue used was 2.75±0.95 mL. Complete obliteration with single session of NBC application was achieved in 55 patients. Re-bleeding occurred in five patients within 5 days of index event. 20 patients had in-hospital mortality but none was related to gastrointestinal bleeding. 6-week all-cause mortality was 26 (35%). CONCLUSION: Glue therapy with NBC is a life saving therapy in patients with bleeding gastric varices and esophageal varices not amenable to endoscopic variceal ligation or sclerotherapy.

Asunto(s)

Enbucrilato , Várices Esofágicas y Gástricas , Várices , Cianoacrilatos/uso terapéutico , Enbucrilato/uso terapéutico , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Humanos , India , Resultado del Tratamiento , Várices/complicaciones

RESUMEN

OBJECTIVE: To evaluate efficacy and safety between dual angiotherapy (endocoil plus N-butyl-cyanoacrylate) guided by endoscopic ultrasound) versus N-butyl-cyanoacrylate in the secondary prophylaxis of gastroesophageal varices (GOV). METHOD: Prospective non-inferiority study comparing two gastric variceal eradication techniques. We evaluated technical and clinical success, GOV occlusion and eradication, rebleeding, reoperation, GOV-free period, complications, and mortality. Chi square for categorical variables and Student's t for numerical variables with a significance level of 0.05. RESULTS: There were 68 patients (average age 55.5 ± 10 years, women 44 (64.7%) and average body mass index 25.7 ± 3.5 kg/m2). The most frequent cause was alcoholic steatohepatitis (58%). Dual therapy had greater technical (100% vs. 94.3%) and clinical (100% vs. 85%) success. Obliteration was faster (100 vs. 79.2%). This group only required one session. The GOV size was 24 ± 14 mm and 1-2 endocoils were placed. The median follow-up was 221 days. The reoperation-free rate was high (100% vs. 94%; p = 0.9). CONCLUSIONS: Dual angiotherapy guided by endoscopic ultrasound and cyanoacrylate injection are effective for the eradication of GOV without differences in adverse event rates.

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OBJETIVO: Evaluar la eficacia y la seguridad de la angioterapia dual (endo-coil más N-butil-cianoacrilato) guiada por ultrasonido endoscópico) frente a N-butil-cianoacrilato solo en la profilaxis secundaria de várices gásctricas. MÉTODO: Estudio prospectivo de no inferioridad comparando dos técnicas de erradicación de várices gástricas. Se evalúan el éxito técnico y clínico, la oclusión y la erradicación de GOV, el resangrado, la reintervención, el período libre de GOV, las complicaciones y la mortalidad. Análisis estadístico mediante prueba de χ2 para variables categóricas y t de Student para las numéricas, con nivel de significancia de 0.05. RESULTADOS: Fueron 68 pacientes (edad promedio 55.5 ± 10 años, mujeres 44 (64.7%) e índice de masa corporal promedio 25.7 ± 3.5 kg/m2). La causa más frecuente fue esteatohepatitis alcohólica (58%). La terapia dual tuvo mayor éxito técnico (100% vs. 94.3%) y clínico (100% vs. 85%), y la obliteración fue más rápida (100 vs. 79.2%); este grupo solo requirió una sesión. El tamaño de las GOV fue de 24 ± 14 mm y se colocaron uno o dos endo-coils. La mediana de seguimiento fue de 221 días. La tasa de libres de reintervención fue alta (100% vs. 94%; p = 0.9). CONCLUSIONES: La angioterapia dual guiada por ultrasonido y la inyección de cianoacrilato son efectivas para la erradicación de las GOV, sin diferencias en las tasas de eventos adversos.

Asunto(s)

Enbucrilato , Várices Esofágicas y Gástricas , Anciano , Enbucrilato/efectos adversos , Enbucrilato/uso terapéutico , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/terapia , Femenino , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Humanos , Persona de Mediana Edad , Estudios Prospectivos , Recurrencia , Estudios Retrospectivos , Resultado del Tratamiento , Ultrasonografía Intervencional

RESUMEN

Gastric variceal bleeding has a high mortality. Endoscopic cyanoacrylate injection is the standard therapy; however, rebleeding and unexpected adverse events, such as injection sites ulcers and distal glue embolisms, are pitfalls of this therapy. Endoscopic ultrasound (EUS)-guided endovascular therapies offer a safer and more practical alternative for the treatment of gastric varices. EUS-guided combined therapy with coiling and cyanoacrylate injection is the most promising alternative with high obliteration rates and fewer adverse events reported. The authors reviewed the latest available data for all endoscopic therapies proposed for the management of gastric varices in patients with chronic liver disease.

Asunto(s)

Várices Esofágicas y Gástricas , Hemostasis Endoscópica , Várices , Cianoacrilatos , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Humanos , Recurrencia , Resultado del Tratamiento , Várices/diagnóstico por imagen , Várices/terapia

Asunto(s)

Endoscopía del Sistema Digestivo/métodos , Várices Esofágicas y Gástricas/terapia , Escleroterapia/métodos , Anciano , Dolor en el Pecho/etiología , Cianoacrilatos/administración & dosificación , Disnea/etiología , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Aceite Etiodizado , Humanos , Masculino , Polietilenglicoles/uso terapéutico , Embolia Pulmonar/etiología , Soluciones Esclerosantes/efectos adversos , Soluciones Esclerosantes/uso terapéutico , Escleroterapia/efectos adversos , Tomografía Computarizada por Rayos X

RESUMEN

INTRODUCTION: gastric varices hemorrhage is a severe complication of portal hypertension, with high mortality rates and few management alternatives, especially when there is a contraindication to transjugular intrahepatic portosystemic shunts (TIPS). The usual therapeutic options are the injection of cyanoacrylate, the insertion of coils or both. Hydrocoils are special coils coated with different types of expandable hydrogel polymers conventionally used in neurovascular interventionism. They allow rapid occlusion of vessel, forming a mesh that favors the local formation of thrombus and the development of a neointima on the gel cover. We consider the use of endoscopic ultrasound (EUS) guided hydrocoil insertion in gastric varices, without using cyanoacrylate. OBJECTIVE: this study aimed to evaluate the safety and effectivity of the application of EUS-guided hydrocoils in patients with gastric varices hemorrhage with TIPS contraindication. MATERIAL AND METHODS: this was a retrospective case series of four patients with TIPS contraindication after interventional radiologist evaluation. Linear echoendoscopes, fluoroscopy, 19G needles and hydrocoils (Azur®, Terumo) and Progreat® 3 Fr microcatheters were used. An interventional radiologist expert advised the procedures and endoscopic ultrasound confirmed the varix obliteration. RESULTS: technical and clinical success occurred in all patients involved in this study. There were no adverse effects related to the procedure or endoscopic equipment damage. CONCLUSIONS: the application of EUS-guided hydrocoils can be a safe and effective method in the short term for gastric varices bleeding in patients who are not candidates for TIPS. Besides, a complete obliteration of the vascular lumen could occur and thus, dispense with the use of cyanoacrylate. Further studies are needed to corroborate these preliminary results.

Asunto(s)

Várices Esofágicas y Gástricas , Endoscopía , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/diagnóstico por imagen , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/diagnóstico por imagen , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Humanos , Hidrogeles , Polímeros , Estudios Retrospectivos , Resultado del Tratamiento

Asunto(s)

Humanos , Masculino , Anciano , Várices Esofágicas y Gástricas/terapia , Escleroterapia/métodos , Endoscopía del Sistema Digestivo/métodos , Polietilenglicoles/uso terapéutico , Embolia Pulmonar/etiología , Soluciones Esclerosantes/efectos adversos , Soluciones Esclerosantes/uso terapéutico , Dolor en el Pecho/etiología , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Tomografía Computarizada por Rayos X , Escleroterapia/efectos adversos , Aceite Etiodizado , Cianoacrilatos/administración & dosificación , Disnea/etiología

RESUMEN

BACKGROUND: Gastric variceal bleeding is a life-threating condition with challenging management. We aimed to compare the efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization and cyanoacrylate injection versus EUS-guided coil embolization alone in the management of gastric varices. METHODS: A single-center, parallel-randomized controlled trial involving 60 participants with gastric varices (GOV II and IGV I) who were randomly allocated to EUS-guided coil embolization and cyanoacrylate injection (n = 30) or EUS-guided coil embolization alone (n = 30). The primary end points were the technical and clinical success rates of both procedures. The secondary end points were the reappearance of gastric varices during follow-up, along with rebleeding, the need for reintervention, and complication and survival rates. RESULTS: The technical success rate was 100 % in both groups. Immediate disappearance of varices was observed in 86.7 % of patients treated with coils and cyanoacrylate, versus 13.3 % of patients treated with coils alone (P < 0.001). Median survival time was 16.4 months with coils and cyanoacrylate versus 14.2 months with coils alone (P = 0.90). Rebleeding occurred in 3.3 % of patients treated with combined treatment and 20 % of those treated with coils alone (P = 0.04). With combined treatment, 83.3 % of patients were free from reintervention versus 60 % with coils alone (hazard ratio 0.27; 95 % confidence interval 0.095 - 0.797; P = 0.01). CONCLUSIONS: EUS-guided coil embolization with cyanoacrylate injection achieved excellent clinical success, with lower rates of rebleeding and reintervention than coil treatment alone. Multicenter studies are required to define the most appropriate technique for gastric variceal obliteration.

Asunto(s)

Várices Esofágicas y Gástricas , Hemostasis Endoscópica , Cianoacrilatos/efectos adversos , Endosonografía , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Humanos , Recurrencia Local de Neoplasia , Resultado del Tratamiento

RESUMEN

BACKGROUND: Portal hypertension commonly accompanies advanced liver disease and often gives rise to life-threatening complications, including bleeding (haemorrhage) from oesophageal and gastrointestinal varices. Variceal bleeding commonly occurs in children with chronic liver disease or portal vein obstruction. Prevention is therefore important. Primary prophylaxis of variceal bleeding in adults is the established standard of care because of the results of numerous randomised clinical trials demonstrating the efficacy of non-selective beta-blockers or endoscopic variceal ligation in decreasing the incidence of variceal bleeding. However, sclerotherapy is the only endoscopic prophylactic option currently available in infants weighing less than 10 kg of bodyweight due to the size of the endoscopic ligator. OBJECTIVES: To assess the benefits and harms of sclerotherapy versus any type of beta-blocker for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. SEARCH METHODS: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, PubMed, Embase Elsevier, LILACS (Bireme), and Science Citation Index Expanded (Web of Science) in February 2019. We scrutinised the reference lists of the retrieved publications and performed a manual search from the main paediatric gastroenterology and hepatology conferences (NASPGHAN and ESPGHAN) abstract books from January 2008 to December 2018. We searched ClinicalTrials.gov, FDA, EMA, and WHO, for ongoing clinical trials. There were no language or document type restrictions. SELECTION CRITERIA: We planned to include randomised clinical trials irrespective of blinding, language, or publication status, assessing sclerotherapy versus any type of beta-blocker for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. We planned to include quasi-randomised and other observational studies retrieved with the searches for randomised clinical trials for report of harm. DATA COLLECTION AND ANALYSIS: We planned to collect and summarise data from randomised clinical trials as described in our protocol, using standard Cochrane methodologies. MAIN RESULTS: We found no randomised clinical trials assessing sclerotherapy versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis. AUTHORS' CONCLUSIONS: Randomised clinical trials assessing the benefits or harms of sclerotherapy versus beta-blockers for primary prophylaxis of oesophageal variceal bleeding in children and adolescents with chronic liver disease or portal vein thrombosis are lacking. Therefore, trials with adequate power and proper design, assessing the benefits and harms of sclerotherapy versus beta-blockers on patient-relevant clinical outcomes such as mortality, failure to control bleeding, and adverse events are needed. Unless such trials are conducted and the results become published, we cannot make any conclusions regarding the benefits or harms of the two interventions.

Asunto(s)

Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/prevención & control , Escleroterapia , Adolescente , Antagonistas Adrenérgicos beta/uso terapéutico , Niño , Femenino , Humanos , Ligadura , Cirrosis Hepática/complicaciones , Masculino , Vena Porta , Prevención Primaria , Ensayos Clínicos Controlados Aleatorios como Asunto , Trombosis de la Vena/complicaciones

RESUMEN

Acute portomesenteric vein thrombosis is potentially lethal. In the present paper, a cirrhotic patient with a previous history of esophageal variceal bleeding presented with acute occlusive portomesenteric vein thrombosis, but achieved complete recanalization by low-molecular-weight heparin followed by rivaroxaban. Notably, no bleeding episode occurred during anticoagulation therapy. This case supported early initiation of anticoagulation in such patients.

Asunto(s)

Várices Esofágicas y Gástricas/terapia , Inhibidores del Factor Xa/uso terapéutico , Hemorragia Gastrointestinal/terapia , Hemostasis Endoscópica , Heparina de Bajo-Peso-Molecular/uso terapéutico , Cirrosis Hepática Alcohólica/complicaciones , Venas Mesentéricas , Vena Porta , Rivaroxabán/uso terapéutico , Trombosis de la Vena/tratamiento farmacológico , Enfermedad Aguda , Várices Esofágicas y Gástricas/diagnóstico , Várices Esofágicas y Gástricas/etiología , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/etiología , Hemostasis Endoscópica/efectos adversos , Humanos , Cirrosis Hepática Alcohólica/diagnóstico , Masculino , Venas Mesentéricas/diagnóstico por imagen , Persona de Mediana Edad , Vena Porta/diagnóstico por imagen , Resultado del Tratamiento , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiología

RESUMEN

INTRODUCTION AND OBJECTIVES: The Baveno VI criteria to rule out varices needing treatment (VNT) was introduced in 2015. Soon after, the expanded Baveno VI and stepwise platelet-MELD criteria were proposed to be equal/more accurate in ruling out VNT; however, neither has been widely validated. We aimed to validate all 3 criteria in compensated cirrhosis from assorted causes. MATERIALS AND METHODS: We conducted a cross-sectional study including all adult compensated cirrhotic patients who underwent endoscopic surveillance at our center from 2014 to 2018 and had transient elastography (TE), and laboratory data for criteria calculation within 6 months of endoscopies. Exclusion criteria were previous decompensation, unreliable/invalid TE results, and liver cancer. The diagnostic performances of all criteria were evaluated. RESULTS: A total of 128 patients were included. The major cirrhosis etiologies were hepatitis C and B (37.5% and 32.8%, respectively). VNT was observed in 7.8%. All criteria yielded high negative predictive values (NPVs)>95%, missed VNT was observed in 2%, 2.7%, and 2.8% in the original, expanded Baveno VI, and platelet-MELD criteria, respectively. The expanded Baveno VI and the platelet-MELD criteria yielded significantly better specificities and could spare more endoscopies than the original Baveno VI criteria. CONCLUSIONS: All 3 criteria showed satisfactorily high NPVs in ruling out VNT in compensated cirrhosis from various causes. The expanded Baveno VI and the platelet-MELD criteria could spare more endoscopies than the original Baveno VI criteria. From a public health standpoint, the platelet-MELD criteria might be useful in a resource-limited setting where TE is not widely available.

Asunto(s)

Várices Esofágicas y Gástricas/diagnóstico , Hemorragia Gastrointestinal/prevención & control , Cirrosis Hepática/sangre , Cirrosis Hepática/diagnóstico por imagen , Adulto , Anciano , Diagnóstico por Imagen de Elasticidad , Enfermedad Hepática en Estado Terminal , Endoscopía del Sistema Digestivo , Várices Esofágicas y Gástricas/etiología , Várices Esofágicas y Gástricas/terapia , Femenino , Hemorragia Gastrointestinal/etiología , Hepatitis B Crónica/complicaciones , Hepatitis C Crónica/complicaciones , Humanos , Cirrosis Hepática/complicaciones , Cirrosis Hepática Alcohólica/sangre , Cirrosis Hepática Alcohólica/complicaciones , Cirrosis Hepática Alcohólica/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Recuento de Plaquetas , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Medición de Riesgo , Índice de Severidad de la Enfermedad

Asunto(s)

Várices Esofágicas y Gástricas , Derivación Portosistémica Intrahepática Transyugular , Várices , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/etiología , Hemorragia Gastrointestinal/terapia , Humanos

Asunto(s)

Várices Esofágicas y Gástricas/terapia , Hemorragia Gastrointestinal/prevención & control , Gastropatías/terapia , Toma de Decisiones Clínicas/métodos , Várices Esofágicas y Gástricas/complicaciones , Hemorragia Gastrointestinal/etiología , Humanos , Prevención Primaria/métodos , Prevención Secundaria/métodos , Gastropatías/complicaciones

RESUMEN

BACKGROUND: One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques. OBJECTIVE: This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone. DESIGN: A pilot randomized controlled trial. METHODS: Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure. RESULTS: A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed. CONCLUSION: There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

Asunto(s)

Cianoacrilatos/administración & dosificación , Várices Esofágicas y Gástricas/terapia , Adulto , Anciano , Endosonografía/métodos , Várices Esofágicas y Gástricas/diagnóstico por imagen , Aceite Etiodizado/administración & dosificación , Femenino , Hemostasis Endoscópica/métodos , Humanos , Inyecciones Intralesiones/efectos adversos , Inyecciones Intralesiones/métodos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Embolia Pulmonar/etiología , Resultado del Tratamiento

RESUMEN

ABSTRACT BACKGROUND: The gastroesophageal reflux disease (GERD) is the most common esophageal disease in medical practice, and it is suspected according to patients' symptoms. GERD can be classified in erosive esophagitis (EE) according to the presence of upper gastrointestinal endoscopy findings. OBJECTIVE: To evaluate endoscopic findings in patients with symptoms suggestive of GERD comparing epicemiological and risk factors. METHODS: Upper endoscopy reports were examined retrospectively from patients with symptoms of GERD such as heartburn, regurgitation, cough, throat clearing, globus and chest pain. EE was determined based on Los Angeles classification. Comparisons between risk factors in EE and non-EE groups were done with statistical analysis. RESULTS: A total of 984 endoscopic reports were examined and 676 selected for analysis (281 with EE and 395 with non-EE form). Most were female 381 (56.36%) with a mean age of 44.01±15.40 years. Hiatal hernia was present in 47(6.96%) and smoking in 41(6.07%). Univariate logistic regression showed that male (OR=2.24, CI 95%, 1.63-3.06) and hiatal hernia (OR=4.52, CI 95%, 2.30-8.89) were independent predictors of erosions in the EE group. The presence of hiatal hernia (OR=12.04, CI 95%, 3.57-40.62), smoking (OR=8.46, CI 95%, 3.28-31.32) and aged patients (OR=8.01, CI 95%, 2.42-26.49) were also indicated as a risk factor for severe EE (grades C and D of Los Angeles). CONCLUSION Male gender and hiatal hernia were associated with EE. Aged patients, smoking and hiatal hernia were related to severe EE. It is suggested that the risk factors for EE and non-EE types are different. Cohort studies are necessary to identify the exact mechanisms involved in each disease form.

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RESUMO CONTEXTO: A doença do refluxo gastroesofágico (DRGE) é uma das doenças digestivas mais comuns na prática médica e deve ser suspeitada de acordo com os seus sintomas clínicos, podendo ser classificada em esofagite erosiva (EE) de acordo com os achados de endoscopia. OBJETIVO: Avaliar os achados endoscópicos em pacientes com sintomas sugestivos de DGRE comparando fatores de risco e epidemiológicos. MÉTODOS: Resultados de endoscopias digestiva foram examinados retrospectivamente de pacientes com sintomas relacionados com DRGE como pirose, regurgitação, tosse, pigarro, globus e dor torácica. EE foi determinada de acordo com a classificação de Los Angeles. Comparação de fatores de risco entre os grupos EE e não-EE foram feitos com análise estatística. RESULTADOS: Um total de 984 endoscopias foram examinadas e 676 endoscopias selecionadas para análise (281 com EE e 395 sem EE). A maioria dos pacientes era do sexo feminino 381 (56,36%) com uma idade média de 44,01±15,40 anos. Hérnia hiatal esteve presente em 47 (6,96%) e tabagismo em 41 (6,07%). Regressão logística uni variada mostrou que sexo masculino (OR=2,24 - IC 95%: 1,63-3,06) e hérnia hiatal (OR=4,52 - CI 95%: 2,30-8,89) foram fatores de risco independentes de EE. A presença de hérnia hiatal (OR=12,04 - CI 95%: 3,57-40,62), tabagismo (OR=8,46 - CI 95%: 3,28-31,32) e pacientes idosos (OR=8,01 - CI 95%, 2,42-26,49) foram fatores de risco no grupo de EE grave (classes C e D de Los Angeles). CONCLUSÃO: Sexo masculino e hérnia hiatal foram associados com EE. Idade avançada, tabagismo e hérnia hiatal foram relacionados à forma grave de EE. É sugerido que os fatores de risco de pacientes com e sem EE sejam diferentes. Estudos de coorte são necessários para identificar os mecanismos exatos envolvidos em cada forma da doença.

Asunto(s)

Humanos , Masculino , Femenino , Adulto , Anciano , Várices Esofágicas y Gástricas/terapia , Cianoacrilatos/administración & dosificación , Embolia Pulmonar/etiología , Várices Esofágicas y Gástricas/diagnóstico por imagen , Inyecciones Intralesiones/efectos adversos , Inyecciones Intralesiones/métodos , Proyectos Piloto , Resultado del Tratamiento , Hemostasis Endoscópica/métodos , Aceite Etiodizado/administración & dosificación , Endosonografía/métodos , Persona de Mediana Edad

RESUMEN

ABSTRACT BACKGROUND: One of the most feared complications with the use of cyanoacrylate for treatment of gastric varices is the occurrence of potentially life-threatening systemic embolism. Thus, endoscopists are turning towards new techniques, including endoscopic coiling, as a potentially safer and more effective treatment option. However, no studies have been performed comparing the two techniques. OBJECTIVE: This study aims to compare the safety and efficacy of endoscopic ultrasound guided coil and cyanoacrylate injection versus the conventional technique of injection of cyanoacrylate alone. DESIGN: A pilot randomized controlled trial. METHODS: Patients randomized into group I were treated with coil and cyanoacrylate, and those in group II with cyanoacrylate alone. Flow within the varix was evaluated immediately after the treatment session and one month following initial treatment. If thrombosis was confirmed, additional follow-up was performed 4 and 10 months following initial treatment. All patients underwent a thoracic computerized tomography scan after the procedure. RESULTS: A total of 32 patients, 16 in each group, were followed for an average of 9.9 months (range 1-26 months). Immediately after the procedure, 6 (37.5%) group-I patients and 8 (50%) group-II patients presented total flow reduction in the treated vessel (P=0.476). After 30 days, 11 (73.3%) group-I patients and 12 (75%) group-II patients were found to have varix thrombosis. In both groups, the majority of patients required only one single session for varix obliteration (73.3% in group I versus 80% in group II). Asymptomatic pulmonary embolism occurred in 4 (25%) group-I patients and 8 (50%) group-II patients (P=0.144). No significant difference between the groups was observed. CONCLUSION: There is no statistical difference between endoscopic ultrasound guided coils plus cyanoacrylate versus conventional cyanoacrylate technique in relation to the incidence of embolism. However, a greater tendency towards embolism was observed in the group treated using the conventional technique. Both techniques have similar efficacy in the obliteration of varices. Given the small sample size of our pilot data, our results are insufficient to prove the clinical benefit of the combined technique, and do not yet justify its use, especially in light of higher cost. Further studies with larger sample size are warranted.

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RESUMO CONTEXTO: Uma das complicações mais temidas com o uso de cianoacrilato para tratamento de varizes gástricas é a ocorrência de embolia sistêmica potencialmente fatal. Assim, os endoscopistas estão se aprimorando com novas técnicas, incluindo o uso de coils endoscópico, como uma opção de tratamento potencialmente mais segura e eficaz. No entanto, nenhum estudo foi realizado comparando as duas técnicas. OBJETIVO: Este estudo tem como objetivo comparar a segurança e eficácia da injeção de coil com cianoacrilato guiados por ultrassom endoscópico versus a técnica convencional de injeção de cianoacrilato. DESIGN: Um ensaio piloto controlado aleatoriamente. MÉTODOS: Os pacientes randomizados para o grupo I foram tratados com coil + cianoacrilato e os do grupo II apenas com cianoacrilato. O fluxo dentro da variz foi avaliado imediatamente após a sessão de tratamento e um mês após o tratamento inicial. Se a trombose foi confirmada, o acompanhamento adicional era realizado em 4 e 10 meses após o tratamento inicial. Todos os pacientes foram submetidos a uma tomografia computadorizada torácica após o procedimento. RESULTADOS: Um total de 32 pacientes, 16 em cada grupo, foram acompanhados por uma média de 9,9 meses (variação de 1-26 meses). Imediatamente após o procedimento, 6 (37,5%) pacientes do grupo I e 8 (50%) pacientes do grupo II apresentaram redução total do fluxo no vaso tratado (P=0,476). Após 30 dias, 11 (73,3%) pacientes do grupo I e 12 (75%) pacientes do grupo II apresentaram trombose da variz. Em ambos os grupos, a maioria dos pacientes necessitou de apenas uma única sessão para obliteração da variz (73,3% no grupo I versus 80% no grupo II). Embolia pulmonar assintomática ocorreu em 4 (25%) pacientes do grupo I e em 8 (50%) pacientes no grupo II (P=0,144). Nenhuma diferença significativa entre os grupos foi observada. CONCLUSÃO Apesar de não haver diferença estatística entre os dois grupos em relação à incidência de embolia neste estudo piloto, observou-se maior tendência de embolia no grupo tratado pela técnica convencional.

Asunto(s)

Humanos , Masculino , Femenino , Adulto , Anciano , Várices Esofágicas y Gástricas/terapia , Cianoacrilatos/administración & dosificación , Embolia Pulmonar/etiología , Várices Esofágicas y Gástricas/diagnóstico por imagen , Inyecciones Intralesiones/efectos adversos , Inyecciones Intralesiones/métodos , Proyectos Piloto , Resultado del Tratamiento , Hemostasis Endoscópica/métodos , Aceite Etiodizado/administración & dosificación , Endosonografía/métodos , Persona de Mediana Edad