Esophageal and gastric varices

Background/Aims: This study aimed to evaluate the efficacy and safety of emergency variceal ligation for the prevention of rebleeding in cirrhotic patients who are found on initial endoscopy to have blood clots in the stomach but no actively bleeding esophageal and gastric varices or stigmata. Methods: This study included 28 cirrhotic patients who underwent emergency prophylactic EVL and 41 who underwent an elective intervention between January 2009 and June 2014. Clinical outcomes were analyzed, including the rebleeding, 6-week mortality, and rebleeding-free survival rates. Results: The rebleeding rate was higher in the emergency than in the elective group (28.6% vs. 7.3%, P=0.041). Multivariate analysis showed that emergency prophylactic EVL (odds ratio [OR] = 7.4, 95% confidence interval [CI]=1.634.8, P=0.012) and Child-Pugh score C (OR=10.6, 95% CI=1.4-80.8, P=0.022) were associated with rebleeding. In the emergency group, the gastric varices were associated with rebleeding (OR=12.0, 95% CI=1.7-83.5, P=0.012). Conclusions: Emergency EVL may be associated with variceal rebleeding when blood clots are present in the stomach without active esophageal and gastric variceal bleeding or stigmata. Elective intervention should be considered as a safer strategy for preventing variceal rebleeding in this situation.

Introduction-It is well said and proven in literature that important causes of cirrhosis of liver include alcohol intake, metabolic associated fatty liver disease and chronic hepatitis B & C. Less important causes include autoimmune & congenital liver disease, Wilson's and alpha1 antitrypsin deficiency disease. There can occur gradual progression from chronic hepatitis to cirrhosis and in certain cases can further reach stage of hepatocellular carcinoma. Intracranial bleed is uncommon in cirrhotic patients.

Background: cirrhosis of liver is a diffuse process of fibrosis that converts the liver architecture into structurally abnormal nodules Portal hypertension leads to dilatation of portal vein, splenomegaly, and formation of portal systemic collaterals at different sites. Screening endoscopy is recommended for early detection of esophageal varices (EVs) in cirrhotic patients with portal hypertension. However, this approach is limited by its invasiveness and cost. The aim of the study was to determine if platelet count can predict the presence of EVs, especially large (grade III, IV) EVs in need of prophylactic therapy.Methods: Statistically 100 patients previously or newly diagnosed with cirrhosis of liver with portal hypertension without history of hepatic encephalopathy, variceal bleeding, EVL, use of beta blockers, were selected for the study. Ultrasonography was performed in all cases to note the spleen size. Routine blood testing including platelet count was done and UGI-Endoscop...

Background: Both drug therapy and banding ligation are widely used in the prevention of first variceal bleeding. This study compared the efficacy and safety of band ligation vs. combination of β-blocker and nitrate for the prevention of first bleeding in patients with cirrhosis and high-risk esophageal varices. Methods: A total of 61 patients with cirrhosis with moderate or severe esophageal varices associated with red color signs but without history of variceal bleeding were randomized to band ligation (30 patients) or treatment with nadolol plus isosorbide-5-mononitrate (ISMN) (31 patients). In the ligation group, multiband ligator with 4 elastic bands was applied during each session. Ligation was repeated at intervals of 4 weeks until variceal obliteration was achieved. In the combination group, the dose of nadolol was sufficient to reduce the pulse rate by 25%. ISMN 1 tablet 20 mg qd or bid was administered. Results: Both groups were similar in baseline characteristics. In the ligation group, variceal obliteration was achieved in 24 patients (80%), at a mean of 3.2 ± 0.9 ligation sessions and 11.7 ± 3.2 elastic bands. In the combination group, the mean daily doses of nadolol and ISMN administered were 40 ± 14 mg and 40 ± 12 mg, respectively. During a median follow-up of approximately 23 months, 5 patients (17%) in the ligation group and 8 patients (26%) in the combination group had upper-gastrointestinal bleeding (p = 0.53). Esophageal variceal bleeding occurred in 3 patients (10%) in the ligation group and 6 (19%) in the combination group (p = 0.42). By multivariate Cox analysis, presence of ascites was the only factor predictive of variceal bleeding. Minor complications were noted in 5 patients (17%) in the ligation group and 3 (10%) in the combination group (p = 0.47). Eight patients in the ligation group and 6 in the combination group died (p = 0.49). One (3%) patient in the ligation group and 3 (10%) in the combination group died of uncontrollable variceal bleeding. Conclusion: Our preliminary results suggest that endoscopic variceal ligation is similar to the combination of nadolol plus ISMN with regard to effectiveness and safety in the prevention of first variceal bleeding in patients with cirrhosis.

Endoscopic glue (N-butyl-2-cyanoacrylate) injection has emerged as promising therapy for bleeding gastric varices (GV). We evaluated safety and long term efficacy of this technique in patients with portal hypertension and large bleeding GV. 170 patients (mean age 40.9 +/- 14y; 132 male; 142 had cirrhosis, 40 Child A, 62 Child B, 40 Child C) underwent glue injection into GV (F3 140, F2 30; fundal 114) as emergency procedure for active bleeding in 62 and electively for prevention of rebleeding in 108. Glue was injected intra-variceally under endoscopic vision, 0.5-4 ml/aliquot, repeated at 3 weeks till varices were eradicated/solidified. The efficacy was assessed by hemostasis at 48 h, primary, secondary, definitive success and treatment failure. The overall hemostasis rate at 48h was 82.3% (51/62). Follow up was available in 158 patients for mean of 30.7 + 17.2 months. Repeat injections were performed in 76. The mean number of injections were 1.9 +/- 1.0 (1-4); total volume was 2.5 +...

Las várices gástricas se presentan en 20% de los pacientes con hipertensión portal. La clasificación más utilizada es la de Sarin. El tipo GOV1 es el más frecuente (74%). El desarrollo de shunt portosistémicos espontáneos, entre la vena esplénica y renal (shunt espleno-renal) son frecuentes en pacientes con VG (60% de los pacientes). Presentan un riesgo de sangrado de 25% a dos años, siendo éstos más graves por su localización submucosa. El riesgo es mayor para IGV1 y GOV2 (78 y 55%, respectivamente). El tratamiento de elección en el evento agudo y la prevención secundaria consiste en la inyección intravariceal de agentes tisulares adhesivos. Objetivo: Describir la prevalencia y manejo de las várices gástricas en el Servicio de Endoscopia del Hospital Juárez de México. Material y métodos: Se incluyeron a los pacientes de endoscopia del Hospital Juárez de México, con hipertensión portal y hepatopatía crónica de cualquier etiología, con diagnóstico endoscópico de várices gástricas de enero de 2006 a abril de 2010; a todos se les realizó panendoscopia, y la obliteración se realizó con cianocrilato a la dosis convencional. Resultados: Se obtuvieron 257 pacientes entre enero de 2006 a abril de 2010, 164 hombres (63.8%) y 93 mujeres (36.2%), con una edad promedio de 48. Las várices gástricas correspondieron a 194 con GOV1 (75.4%), 58 a GOV2 (22.5%), 4 IGV1 (1.6%) y 1 IGV2 (0.4%). Se obliteraron 40 (16%) várices gástricas. Con un éxito de 92.5%. Conclusiones: La oportuna clasificación trasciende en una adecuada toma de decisiones terapéuticas traducida a una alta tasa de éxito en pacientes con várices gástricas.

Background: Acute diffuse phlegmonous esophagitis is a relatively rare bacterial inflammation of the esophagus. It is characterized by an acute, diffuse, purulent infection involving the submucosal and serosal layers, resulting in phlegmonous-like features. There are only a few case reports in the medical literature, and early diagnosis of this condition presents challenges.
Case Presentation: This report presents a 73-year-old male patient with a history of type 2 diabetes, hypertension, gout, and chronic alcohol use, with poorly controlled blood glucose. The patient presented with upper abdominal pain, fever, shortness of breath, and dysphagia. Initial symptoms included severe upper abdominal pain, fever, and respiratory distress. Chest and abdominal enhanced CT scans revealed thickening and swelling along the entire esophagus, with narrowing of the lumen. After contrast enhancement, the esophagus showed ring-like enhancement. Upper gastrointestinal endoscopy showed mucosal swelling. There was no ulceration or perforation. The diagnosis of acute diffuse phlegmonous esophagitis was considered after excluding other common acute abdominal and chest pain conditions. The condition progressed rapidly, leading to septic shock. Next-Generation Sequencing of blood was positive for hypervirulent Klebsiella pneumoniae (hvKp). Despite active treatment, the patient’s condition was initially controlled; however, a follow-up chest CT showed multiple air pockets around the esophagus. The patient subsequently developed septic shock again and died despite active treatment.
Conclusion: Hypervirulent Klebsiella pneumoniae infection causing acute diffuse phlegmonous esophagitis involving the entire esophagus is a rapidly progressing condition that can quickly lead to septic shock. This report aims to alert clinicians to this rare disease and emphasizes the need for heightened awareness in cases of severe upper abdominal pain, where atypical abdominal pain may mask potentially fatal chest pain conditions. Early and accurate diagnosis and timely treatment are essential.

BACKGROUND: Several studies carried out to examine the growth of children with extra-hepatic portal vein obstruction and portal hypertension have reported a variety of findings. AIM: To assess anthropometric indices in children with portal hypertension due to extra-hepatic portal vein obstruction and who were treated by endoscopic variceal sclerotherapy. METHODS: Anthropometric data were obtained retrospectively from the medical records of 24 patients who had been followed for 3.8 ± 2.5 years at the Pediatric Gastroenterology Outpatient Clinic of the University Hospital, Campinas, SP, Brazil. The mean Z scores of weight for age, height for age and body mass index at diagnosis and at the last consultation were compared to reference data of the National Center for Health Statistics. The two recordings were compared to assess the long-term effect of the condition. RESULTS: The mean Z scores at diagnosis and at the last follow-up visit were all within normal ranges when compared to the ...

Background Liver disease is within the top five causes of premature death in adults. Deaths caused by complications of cirrhosis continue to rise, whilst deaths related to other non-liver disease areas are declining. Portal hypertension is the primary sequelae of cirrhosis and is associated with the development of variceal haemorrhage, ascites, hepatic encephalopathy and infection, collectively termed hepatic decompensation, which leads to hospitalisation and mortality. It remains uncertain whether administering a non-selective beta-blocker (NSBB), specifically carvedilol, at an earlier stage, i.e. when oesophageal varices are small, can prevent VH and reduce all-cause decompensation (ACD). The BOPPP trial is a pragmatic, multicentre, placebo-controlled, triple-blinded, randomised controlled trial (RCT) in England, Scotland, Wales and Northern Ireland. Patients aged 18 years or older with cirrhosis and small oesophageal varices that have never bled will be recruited, subject to exclusion criteria. The trial aims to enrol 740 patients across 55 hospitals in the UK. Patients are allocated randomly on a 1:1 ratio to receive either carvedilol 6.25 mg (a NSBB) or a matched placebo, once or twice daily, for 36 months, to attain adequate power to determine the effectiveness of carvedilol in preventing or reducing ACD. The primary outcome is the time to first decompensating event. It is a composite primary outcome made up of variceal haemorrhage (VH, new or worsening ascites, new or worsening hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), hepatorenal syndrome, an increase in Child-Pugh grade by 1 grade or MELD score by 5 points, and liver-related mortality. Secondary outcomes include progression to medium or large oesophageal varices, development of gastric, duodenal, or ectopic varices, participant quality of life, healthcare costs and transplant-free survival. The BOPPP trial aims to investigate the clinical and cost-effectiveness of carvedilol in patients with cirrhosis and small oesophageal varices to determine whether this non-selective beta-blocker can prevent or reduce hepatic decompensation. There is clinical equipoise on whether intervening in cirrhosis, at an earlier stage of portal †

Complications of portal hypertension are the Achilles heel of end-stage liver disease. Although initially developed in the 1960s, transjugular intrahepatic portosystemic shunts (TIPS) have recently gained popularity for decompressing the portal vein in patients with portal hypertension. The main indications for TIPS are the treatment of variceal hemorrhage unresponsive to endoscopic treatment and refractory ascites. Although several other applications for TIPS have been reported, they have not been tested in controlled trials. TIPS are not appropriate as initial therapy for variceal hemorrhage and ascites. Due to the virtually universal development of TIPS stenosis in the majority of patients, careful monitoring of stent patency is required. Several complications of TIPS are recognized, some of which are potentially fatal. Consequently, careful patient selection for TIPS is of paramount importance. Until further clinical trials become available, TIPS should be considered as a therap...

Tumours of the pancreas presenting as haematemesis are rare entities, with scarce documentation in literature. We report a 50-year-old woman who presented with haematemesis secondary to gastric fundal variceal bleeding due to splenic vein occlusion by a large mucinous cystadenoma of the pancreas. We also review the literature pertaining to unusual pathologies presenting as haematemesis.

Congenital combined immunodeficiency in association of acquired hypersplenism are uncommon lesions in pediatric patients and certainly poses several diagnostic and therapeutic challenges for successful and safe outcome of ideal treatment which has consequences of life long precautions. Herein, we report a case of combined immunodeficiency complicated by hypersplenism and pancytopenia in a 4-year-old female toddler who presented with hypogammaglobulinemia, low circulating B cells, and T cell lymphopenia, anemia and thrombocytopenia. The results of hematological investigations revealed pancytopenia with ongoing persistent anemia, thrombocytopenia and leukopenia. and bone marrow examination revealed adequate cellularity with normally functioning bone marrow and no circulating auto antibodies. A splenectomy using an innovative minimal invasive technique was performed for curative purposes. Any evidence of the recurrence of hypersplenism was not noted 30 months after the operation. Surgery is the most frequently performed treatment for hypersplenism with pancytopenia and normal bone marrow and no circulating antibodies. Pre-operative and post splenectomy vaccination record and post splenectomy status cards provide additional precautions for rare but life-threatening post splenectomy complications.

We electively compared the distal splenorenal ("selective") shunt with the end-to-side portacaval shunt in 80 prospectively randomized patients with variceal bleeding. Selective shunts required more operative time (3.9 vs. 2.8 h) and blood replacement (4.6 vs. 2.5 LJ) and postoperative mortality was slightly higher (5 of 38 selective vs. 0 of 40 portacaval). Postoperative complication rates were similar. After 65-mo mean follow-up, both shunts have protected well against late gastrointestinal bleeding (5 selective, 4 portacaval episodes). However, after selective shunts, spontaneous encephalopathy occurred less often (23% vs. 40% of patients), was severe in fewer patients (12% vs. 33%), and precipitated fewer hospital admissions (6 admissions in 4 selective patients vs. 26 admissions in 13 portacaval patients). Furthermore, selective shunt patients remained longer without functional disability (83% vs. 70% of postoperative patient months). Long-term survival was not significantly different in the two groups (5yr survival: selective 51% portacaval 56%). In 1967, Warren and colleagues (1) introduced the concept of selective decompression of esophagogas-

 Background and rationale. Portal hypertensive enteropathy (PHE) remains difficult to diagnose in patients with cirrhosis and portal hypertension. Limited test choices exist for the inspection of the small bowel in these patients. Small bowel capsule endoscopy (SBCE) is ideal in this situation but rarely performed. We aimed to determine the prevalence of PHE using SBCE in a cirrhotic patient population and correlate its presence with clinical and CT imaging findings. We retrospectively analysed data from cirrhotic patients who underwent SBCE at our unit. Studies were evaluated for the presence of cirrhosis-related findings in the oesophagus, stomach and small-bowel. The relationships between PHE and patients' clinical characteristics were evaluated. 53 patients with cirrhosis underwent SCBE. We used PillCam®SB on 36 patients and MiroCam® capsule on 17. Thirty patients were referred for iron deficiency anaemia, 15 for obscure gastrointestinal bleeding, and 4 for other indications...

Q.D.) for the varix model pressures was r = 0.97: 99% CI [0.95, 0.99]. Conclusion: The variceal pressure measuring device developed for this study measured intravariceal pressure in a model varix with a low percent error and high correlation to the actual pressures. Intraobserver and interobserver variability was low.

Variceal bleed is a severe complication of portal hypertension. We studied the predictors of failure to control variceal bleed and re-bleed in patients with cirrhosis. We reviewed the case records of 382 consecutive patients admitted with variceal bleed from January 2001 to December 2005. Diagnosis of cirrhosis was made on clinical, laboratory, and radiological parameters. Acute variceal bleeding, failure to control bleed, and re-bleeding were defined according to Baveno III consensus report. Failure to control bleed was observed in 39 (10.2%) patients while in hospital re-bleed occurred in 49 (12.8%) patients. Thirty-four patients died. Diabetes was present in 148 (39%) patients. On multivariate logistic regression analysis, predictors of failure to control bleed were presence of diabetes mellitus and active bleeding at the time of endoscopy; predictors of in-hospital re-bleed were diabetes mellitus and serum bilirubin >3 mg/dL. Diabetes mellitus, active bleeding at endoscopy and bilirubin >3 mg/dL are bad prognostic factors for initial control of variceal bleed, and recurrent bleed in patients with cirrhosis.

Variceal haemorrhage in cirrhotic patients carries a high early mortality even when balloon tamponade or emergency sclero- therapy are applied. The aim of this study to identify patients dying within six weeks of their first variceal haemorrhage. One hundred and twenty one patients with parenchymal cirrhosis presenting with the first variceal bleeding episode between June 1983 and December 1988 were studied. Nineteen patients were excluded for various reasons. Emergency sclerotherapy was carried out in cases of active bleeding or where there were endoscopic signs of recent bleeding, and then regularly repeated afterwards. Of the 24 vari- ables studied and included in a multivariate analysis using a logistic regression model, three had an independent prognostic value: encephalopathy, prothrombin time, and the number of blood units transfused within the 72 hours of time zero. The subsequent regression equation was able to predict 89% of the patients who will die and 97% of the patients who will still be alive six weeks after their first variceal haemorrhage treated by sclero- therapy. Pugh score was less discriminatory than these last three variables in terms of accuracy of adjustment, goodness of fit to the model, receiver operating characteristic curves, and percentage correct prediction. To measure the accuracy of the prediction rule, our model was applied to another series of 28 cirrhotic patients admitted with their first variceal bleeding during the next period (January 1989 to May 1990). Death and sur- vival were correctly predicted in respectively 82% and 94% ofthe cases. The use ofthis score is recommended for the selection of patients with high early mortality after variceal bleeding despite sclerotherapy, and for the design of new therapeutic trials. (Gut 1992; 33: 1381-1385) Variceal haemorrhage in cirrhotic patients carries high early mortality ranging from 31 61 to 63.3%,2 even when balloon tamponade, drugs or emergency scierotherapy are used as first line treatment. Death is mainly because of exsanguination or liver failure.3 Studies assessing the value of various risk factors and scoring systems in patients with acute variceal haemorrhage are important as they may offer a useful mean of selection for entry into clinical trials or they may identify a group of patients with a very high mortality. Endoscopic sclerotherapy, shunt

Background The combination of endoscopic band ligation (EBL) with either endoscopic injection sclerotherapy (EIS) or thermal therapy has been shown to reduce recurrence of esophageal varices compared to EBL alone. The aim of this prospective trial was twofold: 1) to evaluate the safety and efficacy of EBL used in association with microwave coagulation (MC), a thermal endoscopic therapy method, for treating esophageal varices and preventing recurrence; and 2) to compare these results to the joint application of EBL and EIS. Methods Seventy cirrhotic patients with bleeding esophageal varices were treated with EBL until only thin vessels remained. Thirty-six randomly selected patients received EIS (group A) and 34 received MC (group B) until complete eradication had been achieved. Endoscopic follow-up was performed to detect recurrence. The effectiveness of the treatment was measured using variceal recurrence, rebleeding, intervention complications, and recurrence factors. Results During follow-up evaluations averaging 34.9 ± 11.4 months, no significant differences were found between groups A and B in variceal recurrence (27.7 vs. 17.6%, P = 0.31) or rebleeding (8.3 vs. 0%, P = 0.23). Complications were rare, with no difference detected between groups. The presence of gastric varices influenced recurrence with an odds ratio of 3.9 (95% CI 1.14-13.1, P = 0.029). Conclusions Application of MC to esophageal varices after band ligation is safe. The post-MC recurrence rate may be comparable to that observed following the combined treatment of EBL and EIS. The presence of gastric varices increases the risk of esophageal variceal recurrence.

Endoscopic injection of N-Butyl-2-cyanoacrylate is a widely accepted treatment for esophagogastric varices. This procedure is commonly associated with minor complications which include transient pyrexia and abdominal discomfort. Serious vascular complications secondary to systemic embolization of cyanoacrylate have rarely been reported. We describe the CT findings of extensive splenic infarction in a patient following cyanoacrylate injection for gastric varices.

Esophageal variceal bleeding is the most dangerous complication in patients with liver cirrhosis, and it is accompanied by high mortality. Their treatment can be complex, and requires a multidisciplinary approach. This review examines current approaches to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding. PubMed, Google Scholar, and Cochrane Systematic Reviews were searched for articles published between 1987 and 2015. Relevant articles were identified using the following terms: 'esophageal variceal bleeding', 'portal hypertension' and 'complications of liver cirrhosis'. The reference lists of articles identified were also searched for other relevant publications. Inclusion criteria were restricted to the management of patients with liver cirrhosis who have acute esophageal variceal bleeding. It is currently recommended to combine vasoactive drugs (preferable somatostatin or terlipressin) and endoscopic therapies (endoscopic band ligation as first choice, sclerotherapy if endoscopic band ligation not feasible) for the initial treatment of acute variceal bleeding. Antibiotic prophylaxis must be regarded as an integral part of the treatment. The use of a Sengstaken-Blakemore tube is appropriate only in cases of refractory bleeding if the above methods cannot be used. An alternative to balloon tamponade may be the installation of self-expandable metal stents. The transjugular intrahepatic portosystemic shunt is an extremely useful technique for the treatment of acute bleeding from esophageal varices. Although most current clinical guidelines classify it as second-line therapy, the Baveno VI workshop recommends early transjugular intrahepatic portosystemic shunt with expanded polytetrafluoroethylene-covered stents within 72 h (ideally524 h) in patients with esophageal variceal bleeding at high risk of treatment failure (e.g. Child-Turcotte-Pugh class C514 points or Child-Turcotte-Pugh class B with active bleeding) after initial pharmacological and endoscopic therapy. Urgent surgical intervention is rarely performed and can be considered only in case of failure of conservative and/or endoscopic therapy and being unable to use a transjugular intrahepatic portosystemic shunt. Among surgical operations described in the literature are a variety of portocaval anastomosis and azygoportal disconnection procedures. To improve the results of treatment for patients with liver cirrhosis who develop acute esophageal variceal bleeding, it is important to stratify patients into risk groups, which will allow one to tailor therapeutic approaches to the expected results.

This work was designed to substantiate the necessity of estimating serum bacterial endotoxin levels in patients with liver cirrhosis (LC) for the prognostication of the risk of bleeding from oesophageal varices. The prospective cohort study included 90 patients with LC and clinical signs of portal hypertension. Total endotoxin of Gram-negative bacteria was measured by the activated particle method. The intensity of endotoxemia was estimated using the end-point turbidimetric test (variant of LAL test). Pronounced endotoxemia was associated with acute bleeding from oesophageal varices. Its severity in the patients with the history of hemorrhage was higher than in the absence of this complication. The endotoxin level in the range from 0 to 4 ng/ml suggested low probability of hemorrhage; its risk increased significantly at the endotoxin level in excess of 4.1 ng/ ml. It is concluded that the severity of endotoxemia in LC patients correlates with the degree of oesophageal vein dilation ...

All patients with liver cirrhosis and portal hypertension should be stratified by risk groups to individualize different therapeutic strategies to increase the effectiveness of treatment. In this regard, the development of primary prophylaxis of variceal bleeding and its management according to the severity of portal hypertension may be promising. This paper is to describe the modern principles of primary prophylaxis of esophageal variceal bleeding in patients with liver cirrhosis. The PubMed and EMbase databases, Web of Science, Google Scholar, and the Cochrane Database of Systematic Reviews were used to search for relevant publications from 1999 to 2019. The results suggested that depending on the severity of portal hypertension, patients with cirrhosis should be divided into those who need preprimary prophylaxis, which aims to prevent the formation of esophageal varices, and those who require measures that aim to prevent esophageal variceal bleeding. In subclinical portal hypertension, therapy should be etiological and pathogenetic. Cirrhosis with clinically significant portal hypertension should receive nonselective β-blockers if they have small esophageal varices and risk factors for variceal bleeding. Nonselective β-blockers are the first-line drugs for the primary prevention of bleeding from medium to large-sized esophageal varices. Endoscopic band ligation is indicated for the patients who are intolerant to nonselective β-blockers or in the case of contraindications to pharmacological therapy. In summary, the stratification of cirrhotic patients by the severity of portal hypertension and an individual approach to the choice of treatment may increase the effectiveness of therapy as well as improve survival rate of these patients.

position in commonly reported malignancies of the gastrointestinal tract. It occurs most commonly in the 6th decade of life having female predominance 2,3 of 4 to 5 times than male. Gallbladder malignancy presents vague symptoms such as abdominal pain, jaundice, pruritus, anorexia, and weight loss. This leads to the role of ultrasonography and contrastenhanced computed tomography in pointing towards the gross pathology of gallbladder carcinoma. It includes mass in gallbladder fossa replacing gallbladder, focal/intraluminal/polypoid gallbladder growth and asymmetrical/diffuse thickness of gallbladder. Although percutaneous ultrasonography is the first diagnostic modality

Background-The predictors for developing varices in patients with primary sclerosing cholangitis (PSC) have not been well studied prospectively. We sought to define the predictors for the presence of varices at baseline and for newly developing varices in patients with PSC. Methods-We used prospectively collected data from a multicenter randomized trial of high dose ursodeoxycholic acid for PSC. For the first aim, all 150 patients enrolled were reviewed and the second aim, we excluded 26 patients who had esophageal varices at baseline. Clinical examination, blood tests and upper endoscopy were done before randomization, at two years and after 5 years. Liver biopsy was performed at entry and at 5 years. Results-The median age (interquartile range; IQR) of patients was 45.9 years (35.8, 54.9). In a multivariable logistic regression, a higher Mayo risk score (>0.87) or a higher AST/ALT ratio (>1.12) were significantly associated with the presence of varices at initial endoscopy (OR=1.9 and 3.9). By the end of the study, 25 patients had new varices (20.2%). In a Cox model, after adjustment for baseline variables lower platelet count and higher total bilirubin at 2 years were significantly associated with the presence of new varices. The platelet count of 205 (× 10 9 /l) and the total bilirubin level of 1.7 mg/dL were the best cut off values for the detection of new varices. Conclusions-A higher Mayo risk score and higher AST/ALT ratio were significantly associated with the presence of varices at initial endoscopy. Lower platelet count and higher total bilirubin at 2 years were significantly associated with an increased risk of developing new varices in patients with PSC.

La hemorragia de vías digestivas altas por várices gástricas, aunque menos frecuente que la secundaria a las esofágicas, es una causa de alta mortalidad en los pacientes cirróticos. La ligadura es el tratamiento óptimo en las várices esofágicas, pero este tratamiento para las gástricas es todavía muy discutido. Presentamos el caso de una anciana, con antecedente de cirrosis hepática secundaria a esteatosis hepática no alcohólica (NASH), que ingresa, con hemorragia de vías digestivas altas, evidenciándose en la esofagogastroduodenoscopia una várice fúndica subcardial con sangrado activo, para la cual se decide manejo con ligadura con banda de caucho con resultado exitoso y desaparición de la várice en control posterior.

The coexistence of pregnancy and liver disease represents a complex clinical situation. Pregnancy develops hypervolemic state due to increased splachnic blood flow, which contributes to increased portal pressure transmitted to collateral veins that increase the risk of variceal bleeding in these patients. We report the case of a 39 years old patient in the sixth pregnancy and without any previous medical history that presented pre-sinusoidal portal hypertension, and thanks to appropriate multidisciplinary management had an uncomplicated delivery. We review the literature relevant to the case.

Background/Aim. Esophageal variceal bleeding is one of the most frequent and gravest complications of liver cirrhosis, directly life-threatening. By monitoring certain clinical and laboratory hepatocellular insufficiency parameters (Child-Pugh score), it is possible to determine prognosis in patients who are bleeding and evaluate further therapy. Recently, the Model for the End-Stage Liver Disease (MELD) has been proposed as a tool to predict mortality risk in cirrhotic patients. The aim of the study was to evaluate survival prognosis of cirrhotic patients by the MELD and Child-Pugh scores and to analyze the MELD score prognostic value in patients with both liver cirrhosis and variceal bleeding. Methods. We retrospectively evaluated the survival rate of a group of 100 cirrhotic patients of a median age of 57 years. The Child-Pugh score was calculated and the MELD score was computed according to the original formula for each patient. We also analyzed clinical and laboratory hepatocel...

Background The Rockall risk scoring system uses clinical criteria and endoscopy to identify patients at risk of adverse outcomes after acute upper gastrointestinal haemorrhage. A clinical Rockall score obtained using only the clinical criteria may be able to predict outcome without endoscopy. Aim To validate the clinical Rockall Score in predicting outcome after acute non-variceal upper gastrointestinal haemorrhage. Methods A retrospective observational study of consecutive patients who were admitted with non-variceal acute upper gastrointestinal haemorrhage was undertaken. Medical records were abstracted using a standardised form. Results 102 cases were identified (51 men and 51 women; mean age 59 years). 38 (37%) patients considered to be at low risk of adverse outcomes (clinical Rockall Score 0) had no adverse outcomes and did not require transfusion. Patients with a clinical Rockall Score of 1–3 had no adverse outcomes, although 13 of 45 (29%) patients required blood transfusion...

Background/Aims: The purpose of this study was to evaluate the technical/hemodynamic success, complications, and biochemical/ hematologic consequences of transjugular intrahepatic portosystemic shunt (TIPS) created with 10-mm bare stents in our patients. Materials and Methods: Data of 27 cirrhotic patients (18 men and 9 women; mean age, 39.7±18.7 years) with a median MELD score 14 (range 7-31) treated with TIPS between January 2000 and August 2010 were evaluated retrospectively. Results: The indications were refractory bleeding varices in 48.2%, refractory ascites in 22.2%, and Budd-Chiari syndrome in 29.6% of the patients. Technical and hemodynamic success rates were 96.3% and 92.3%, respectively. Mean portosystemic pressure gradient decreased from 21.5±5.3 mm Hg to 9±2.7 mm Hg (p<0.05). The rate of primary stent patency was 76.9% 1 year after the procedure. No statistically significant difference in shunt dysfunction was found between the groups of patients treated for Budd-Chiari syndrome and other indications (p>0.05). One patient (3.7%) had shunt dysfunction due to thrombosis within 24 hours. New and/or worsening hepatic encephalopathy occurred in 34.6% of patients. Increased age (≥40 years) was significantly related to hepatic encephalopathy in both univariate and multivariate analyses (p<0.05). Thirty-day mortality rate and 1-year transplant-free survival rate were 0% and 80.7%, respectively. Conclusion: Transjugular intrahepatic portosystemic shunt procedure is a safe treatment for many patients with cirrhosis, but post-procedure hepatic encephalopathy and shunt dysfunction are still problems. Especially, patient age should be taken into consideration in predicting hepatic encephalopathy risk.

Background-Endoscopic sclerotherapy (EST) is an established method for controlling and preventing bleeding from oesophageal varices. However, oeso- phageal varices sclerose easily and require less sessions of EST in some patients while few fail to respond. This study therefore looked at changes in the vascular anatomy of the lower oesoph- agus and upper stomach that accompany successful sclerotherapy of oesophageal varices. was performed in 50 patients with cirrhotic portal hypertension before (control, 20 patients) and after successful obliteration ofvarices with endoscopic sclerotherapy in a group ofresponders (EST-R, 20 patients) and in a group of non-responders (EST- NR, 10 patients). Results-The median number and size of submucosal veins at the gastro- oesophageal junction and in the lower oesophagus were significantly less in the EST-R group compared with control and EST-NR groups (p values between <0*00001 and <0.000001). Concomitantly, the number and size of paraoesophageal collaterals were significantly less in the EST-R group compared with the other two groups (p values between 0.02 and 0.00007). Perforating veins were identified in 14 (70Gb) patients in the control group, nine (900/o) in the EST-NR group and in none in the EST-R group (p<0 001 for both controls v EST-R and EST-R v EST- NR, and p=NS, control v EST-NR). Conclusion-Oesophageal variceal sclero- sis is associated with significant reduction in the number and size of paraoeso- phageal collaterals and disappearance of perforating veins in the lower oesophagus.

One of the rare presentations of superior vena cava syndrome is bleeding of &quot;downhill&quot; esophageal varices (DEV) and different approaches have been used to control it. This is a case report whose DEV was eradicated by band ligation for the first time. We report a 42-year-old man who is a known case of Behcet&#39;s disease. The patient&#39;s first presentation was superior vena cava syndrome due to thrombosis followed by bipolar ulcers and arthralgia. He received warfarin, prednisolone and azathioprine. The clinical course of the patient was complicated by one episode of hematemesis without abdominal pain when the patient&#39;s PT was in therapeutic range. After resuscitation and correction of PT with fresh frozen plasma transfusion, upper gastrointestinal endoscopy was done. Prominent varices were seen in the upper third of the esophagus, tapering to the middle part without acute bleeding. Stomach and duodenum were normal. Color ultrasonography evaluation of the portal, hep...

As compared with a liberal transfusion strategy, a restrictive strategy significantly improved outcomes in patients with acute upper gastrointestinal bleeding. (Funded by Fundació Investigació Sant Pau; ClinicalTrials.gov number, NCT00414713.

Carvedilol is effective in the primary prophylaxis for large oesophageal varices. We investigated its use in preventing progression of small to large oesophageal varices. Consecutive cirrhotics with small oesophageal varices were prospectively randomised to either carvedilol (n=70) or placebo (n=70) and followed up for a minimum of 24 months. Endoscopy was done at baseline and six monthly intervals. Hepatic vein pressure gradient (HVPG) was measured at baseline and at 12 months. The primary endpoint was development of large varices. Baseline characteristics in two groups were comparable. The predominant aetiology of cirrhosis was non-alcoholic fatty liver disease in both the groups. The mean dose of carvedilol administered was 12±1.67 mg/day and the target heart rate achieved was 58±3 bpm. A higher proportion of patients in carvedilol group had non-progression to large varices than placebo (79.4% vs 61.4%; p=0.04); the mean time of non-progression to large varices was 20.8 months (9...

and hepatitis B virus (HBV) cause acute and often also chronic hepatitis. The mechanisms underliing the different stages and outcomes of liver disease, e.g. hepatic injury or viral clearance, are not well understood. According to a model of a cytokine-mediated immunopathology for virus-induced hepatitis we analyzed the expression of IFN-g and TNFa both in serum on the protein level by an enzyme linked immunoassay and in peripheral blood mononuclear cells (PBMC) and polymorphonuclear leukocytes (PMN) on the transcriptional level by a quantitative RT-PCR technique in patients chronically infected with HCV. IFN-g gene expression by PBMC, but not IFN-g serum concentration, was found to be elevated in HCV-infected patients with enhanced serum transaminase activities (e.g. GPT>50u/I) when compared to patients exhibiting enzyme activities below or healthy individuals, respectively. No IFN-g gene expression was detectable in PMN. In contrast, TNFa gene expression by PBMC was not significantly different between patients and healthy donors. However, PMN from HCV-infected individuals were found to be transcriptionally active when compared to healthy blood donors and express TNFcc independently from the degree of inflammationl Also serum TNFc~ concentrations were found to be elevated in patients when compared to healthy individuals. IFN-g gene expression by PBMC declined in patients responding to IFNa therapy with decreasing serum transaminase activity. Furthermore, in patients treated with IFNcr a correlation between virus disappearance and the degree of TNFa expression by PBMC rather than TNFa expression by PMN or TNFa serum concentrations was observed. Provided that data obtained from studiing blood components are representative for the situation within the liver our data suggest a role for IFN-g as a mediator of the inflammatory process and an involvement of PBMC-derived TNFa in virus elimination. They are thus in line with a proposed model of a cytokine-mediated immunopathogenesis for virus-induced hepatitis.