Clin Endosc.  2019 Sep;52(5):407-415. 10.5946/ce.2019.178.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding

Affiliations
  • 1Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea. kbs9225@cu.ac.kr

Abstract

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

Keyword

Esophageal and gastric varices; Hemorrhage; Endoscopy; Radiology; Interventional

MeSH Terms

Endoscopy
Esophageal and Gastric Varices*
Hemorrhage
Humans
Ligation
Liver Cirrhosis
Portasystemic Shunt, Surgical
Salvage Therapy
Varicose Veins

Figure

  • Fig. 1. Endoscopic diagnosis of esophageal variceal bleeding. (A) Large esophageal varix (EV) with a white nipple sign (arrow). (B) Active bleeding due to rupture of the esophageal varix. (C) Large EV with red wale marks.

  • Fig. 2. Endoscopic variceal ligation. (A) The “red-out” sign appears when the varix is fully sucked into the cap. (B) Successfully deployed band ligation on the varix.

  • Fig. 3. Transjugular intrahepatic portosystemic shunt (TIPS). (A) TIPS is a radiologic interventional technique that involves inserting a stent to connect the portal vein to the hepatic vein. It relieves portal hypertension, allowing the blood to flow directly from the portal vein to the systemic venous system. (B) Fluoroscopic image of TIPS. The portal venogram obtained after TIPS shows flow through the stent (arrowheads).

  • Fig. 4. Sarin classification of gastric varices. GEV, gastric epiploic vein; GOV, gastroesophageal varix; IGV, isolated gastric varix; LGV, left gastric vein; PGV, posterior gastric vein; PV, portal vein; SGV, short gastric vein; SV, splenic vein.

  • Fig. 5. Strategic approach for endoscopic variceal obturation of fundal varices. The top of the variceal dome (arrow) has high intravariceal pressure, which can cause immediate spurting of injected cyanoacrylate and massive hemorrhage. Thus, it is better to first inject cyanoacrylate at the side of the varix (arrowhead) where there is lower pressure.

  • Fig. 6. Retrograde transvenous obliteration. (A) Illustration of balloon-occluded retrograde transvenous obliteration of gastric varices. A balloon catheter is introduced through the femoral vein. Thereafter, the catheter is inserted into the gastrorenal shunt (GRS) via the left renal vein. The balloon is inflated to occlude the shunt, and a sclerosing agent is subsequently injected into the gastric varices for obliteration. (B) Fluoroscopic image of plug-assisted retrograde transvenous obliteration. Gelatin slurry is injected into the gastric varices (asterisk) and GRS (arrowhead) after deploying the vascular plug (arrow) at the GRS. GV, gastric varix; IVC, inferior vena cava; LGV, left gastric vein; LRV, left renal vein; PGV, posterior gastric vein; PV, portal vein; SGV, short gastric vein; SV, splenic vein.


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