Clin Endosc.  2023 Jan;56(1):65-74. 10.5946/ce.2021.119.

Endoscopic ultrasound-guided coiling and glue is safe and superior to endoscopic glue injection in gastric varices with severe liver disease: a retrospective case control study

• Jamwal KD
• Padhan RK
• Sharma A
• Sharma MK

• KMID: 2538753
• DOI: http://doi.org/10.5946/ce.2021.119

Abstract

Background/Aims
Gastric varices (GV) are present in 25% of cirrhotic patients with high rates of rebleeding and mortality. Data on endoscopic ultrasound (EUS)-guided treatment in severe liver disease (model for end stage liver disease sodium [MELD-Na] >18 and Child-Turcotte-Pugh [CTP] C with GV) are scarce. Thus, we performed a retrospective comparison of endoscopic glue injection with EUS-guided therapy in cirrhotic patients with large GV.
Methods
A retrospective study was performed in the tertiary hospitals of India. A total of 80 patients were recruited. The inclusion criteria were gastroesophageal varices type 2, isolated gastric varices type 1, bleeding within 6 weeks, size of GV >10 mm, and a MELD-Na >18. Treatment outcomes and complications of endoscopic glue injection and EUS-guided GV therapy were compared.
Results
In this study, the patients’ age, sex, liver disease severity (CTP, MELD-Na) and clinical parameters were comparable. The median number of procedures, injected glue volume, complications, and GV obturation were better in the EUS group, respectively. On subgroup analysis of the EUS method (e.g., direct gastric fundus vs. paragastric collateral [PGC] coil placement), PGC coil placement showed decreased coil requirement, less injected glue volume, decreased luminal coil extrusion, and increased successful GV obturation.
Conclusions
EUS-guided treatment is more efficient and safer, and requires a smaller number of treatment sessions, as compared to endoscopic treatment in severe liver disease patients with large GV. Furthermore, PGC coil placement increases the complete obliteration of GV.

Keyword

Endoscopic ultrasound; Gastric varices; Liver dysfunction; Portal hypertension

Figure

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  Fig. 1. Flow chart of the included patients. GV, gastric varices; PVT, portal vein thrombosis; HCC, hepatocelluar carcinoma; SVT, superior mesenteric vein thrombosis; BRTO, balloon occlusion with retrograde transvenous obliteration; MELD-Na, model for end stage liver disease sodium; TIPS, trans­jugular intrahepatic portosystemic shunt; EUS, endoscopic ultrasound.

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  Fig. 2. Endosonographic images for the mucosal component of the gastric varices and connecting collateral (A), the large perisplenic collateral (B), an embolization coil deployed into the gastric varices (C), and after the coil has been deployed inside the gastric varices (D).

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  Fig. 3. The image shows the combination of a cartoon (A, D) showing various components (mucosal, shunt, and paragastric collateral) of the gastric varices (GV). (B) The coronal computed tomography scan section shows that the gastrorenal shunt (GRS) drains the GV. The red arrow points to the submucosal portion (paragastric collateral), and the white arrow points to the mucosal portion of the GV. (C) Endoscopic appearance of the same GV. (E) EUS appearance of the same GV, with the mucosal GV and collateral. LR, lienorenal; PEP, phrenic esophageal pericardiac vein; PGC, paragastric collateral; PV, portal vein; SGV, short gastric vein; SV, splenic vein.

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  Fig. 4. Images showing isolated gastric varices type 1 (IGV1). (A) Endoscopic appearance of a large IGV1 with stigmata of recent hemorrhage. (B) The coronal computed tomography scan section shows the portovenous phase and the draining veins of IGV1. (C) A coil is deployed in the gastric fundus of the IGV1, and the collateral is seen distant to the coil. (D) A non-contrast coronal computed tomography scan shows the coil in the same IGV1. PV, portal vein; SV, splenic vein.

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