EGD pentru varice
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This mini-review addresses endoscopic management principles for gastric variceal bleeding, including limitations of ligation and sclerotherapy and merits of EGD pentru varice variceal obliteration. EGD pentru varice article article source discusses how emerging use of endoscopic ultrasound provides optimism of better diagnosis, improved classification, innovative management strategies and confirmatory tool for eradication of GVs.
This mini-review addresses endoscopic management principles for gastric variceal bleeding. Endoscopic tromboză și embolie pulmonară EGD pentru varice EVO with tissue adhesives is the currently accepted strategy for controlling bleeding and eradicating gastric varices GVs.
EVO is deemed better than both variceal ligation and sclerotherapy in randomized controlled trials. One unsettled issue with EVO is if routine reinjection is better than reinjection in case of rebleeding.
The experience with combination treatments is still premature. For secondary prophylaxis, EVO, transjugular intrahepatic portosystemic EGD pentru varice or beta-blocker use is recommended. Emerging use of EUS provides optimism of better diagnosis, improved classification, innovative management strategies and confirmatory tool for eradication of GVs. The natural history of gastric varices GVs is less understood than that of esophageal varices EVs.
They are also commonly seen in patients with non-cirrhotic portal hypertension NCPHTespecially with splenic vein thrombosis SVT. They are EGD pentru varice commonly associated with shunts than EVs, most commonly continue reading shunt, and their management is quite different from that of EVs.
IGV2 are the isolated gastric varices EGD pentru varice elsewhere other than the fundus, which drain visit web page a similar fashion into left renal vein but with multiple tributaries. The chance of variceal bleeding is driven by the pressure changes rather than EGD pentru varice forces. The pressures in the GVs are lower than the EGD pentru varice the Http://mutualcreative.co/vene-varicoase-fizioterapie.php because of their EGD pentru varice size and more frequent presence of the shunts like spleno-renal[ 7EGD pentru varice ].
Despite this, their rupture is more devastating because of the fact that the wall stress increases dramatically even with small rise in the portal pressures due to their larger radius. When there is increase in transmural pressure, the variceal size increases and wall thickness decreases, which leads to rupture[ 78 ].
The factors which predict hemorrhage in EVs also govern GVs: The plausible explanation is that after treatment the Sie încălcare a utero fluxului de sange placentar și articolul 1 von collaterals are not sufficient enough to decompress the portal pressure causing an increased incidence of fundic varices.
The preliminary management of bleeding GVs is the same as any other variceal bleeding[ 1 - 3 ]. Fluid resuscitation, airway protection, antibiotic administration for the bacterial peritonitis prophylaxis and use of vasoactive agents like octreotide and acid suppressant agents like proton pump inhibitors form cornerstone of initial management. Treatment options for acute GV bleeding are varied and include medical, surgical, endoscopic, and endovascular approaches[ 1 - 3 ].
Two general methods exist to deal with bleeding GVs: Once the patient is deemed stable from airway and circulation standpoint, an esophagogastroduodenoscopy EGD should be performed, which might show active bleeding or reveal stigmata of recent bleeding, in addition to qualify type of GVs and concomitant presence of EVs or PHG[ 1 - 3 ].
Several endoscopic techniques have been tested to control acute gastric variceal bleeding with varying successes. However, the universal phenomena is that majority of the methods used in controlling the bleeding EVs are difficult to practice in GVs and are inconsistently successful.
These include endoscopic injection sclerotherapy EIS and esophageal variceal ligation EVL. The varying success of these methods may be owing to different physiology and size of GVs which pose technical problems. The main indications for ligation in management of acute GV EGD pentru varice is banding of GOV1 varices, which are extensions of Click to see more into the stomach along the lesser curvature or as salvage strategy if other modalities are not available[ EGD pentru varice ].
Studies suggest good hemostasis efficacy and comparable re-bleeding rates of GOV1 ligation to EVL of EVs. There EGD pentru varice limited role for ligation in management of bleeding fundic varices[ 1 - 3 ].
In head-to-head studies, EVL was less effective than endoscopic obturation by injection of cyanoacrylate for hemostasis of large GVs[ 11 ], and had higher re-bleeding rates too[ 12 ]. Smaller studies have attempted improvisation of ligation methods to EGD pentru varice utero sanguin măsura în fetal care a încălcare 1a fluxului success in GV, like using detachable snares and elastic bands or in combination with sclerotherapy, however these experimental techniques are yet to be implemented varicelor Forum 1314 ].
Fundic varices IGV1 and IGV2 are wider and have larger volume, needing large quantity of sclerosant which is susceptible to being washed away, potentially leading to systemic esp.
Furthermore, the risk of complications including fever, retrosternal chest pain, temporary dysphagia and pleural effusions was EGD pentru varice higher EGD pentru varice EIS[ 15 ]. Overall, the success of EIS is questionable in management of acute GV EGD pentru varice 16 ] and hence is not the preferred method in any of the guidelines. Endoscopic variceal obturation EVO using tissue adhesives like glue, cyanoacrylate or histoacryl has provided a positive direction to management of fundic varices, which was always a challenge.
Cyanoacrylate is a polymer which upon coming in contact with blood polymerises instantly leading to obliteration of varices. EVO with N-butylcyanoacrylate has been the advocated first-line method in managing the gastric varices especially fundic varices[ 1 - 3 ]. Kang et al[ 17 ] performed EVO with cyanoacrylate in patients with GVs active bleeding and 27 prophylactically and reported a primary hemostasis rate of Several studies have compared EVO head-to-head with EIS or EVL to conclude the favorable outcomes of EVO in terms of initial hemostasis, and lesser re-bleeding and complications[ 111218 - 20 ].
Furthermore, re-bleeding rates after EVO were found to be comparable to transjugular intrahepatic porto-systemic shunt TIPS in EGD pentru varice with acute GV bleeding, suggesting this technique may be equally efficacious in secondary prevention and creating opportunity of therapy in patients in click here TIPS is contraindicated for encephalopathy reasons[ 21 ].
Few studies have advocated using dynamic CT scan prior to EVO read article increase the detection of EGD pentru varice vessels, assessment of direction of blood flow, presence of shunts, in an attempt to increase efficacy and minimize complications of EVO technique[ 22 ], although this is not universally practiced.
Although EVO is clearly a superior technique than EIS or EVL for bleeding GVs, it is not free of technical difficulties para-variceal injection, needle sticking in the varix, intra-peritoneal injection leading to peritonitis and adherence of the glue to the endoscope or complications fever, para-variceal injection with mucosal necrosis and bleeding, embolization into the renal vein, IVC, pulmonary or systemic vessels and retro-gastric abscesses [ 1218 - 20 ].
However, emerging literature supports preference of distilled water over saline to dilute cyanoacrylate to decrease coagulation and use of standardized techniques of tissue adhesive preparation and delivery to decrease rates of these complications[ 23 ].
In case of large gastric EGD pentru varice, it is advised to begin tissue adhesive injection from bottom to dome to minimize risk of bleeding if injected EGD pentru varice at high pressure-high flow dome area.
Liu et al[ 24 ] reported an interesting scenario which developed when EVO of GVs led to hemorrhage from EVs due to embolism of the glue into the EV thus increasing the pressure. This was click to see more amenable to EGD pentru varice ligation due to presence of foreign body glue and was managed with cyanoacrylate injection into EVs to achieve hemostasis and authors rightly cautioned endoscopists to treat EVs in the same setting as EVO of GVs to prevent such a complication[ 24 ].
Another major difference between EVO and other endoscopic techniques is that variceal obliteration of the GVs is not quite obvious after cyanoacrylate injection, and hence adequacy of EVO is controversial. Improved radiology use of CT portography [ 22 ] and newer endoscopic techniques have made this EVO adequacy assessment easier, as discussed later in this article. Notably, EVO has recently been shown to be superior to beta blocker therapy for primary prophylaxis of GVs and hence is continue reading advocated[ 25 ].
Evidence regarding efficacy of the glue in pregnant females and in children is still emerging and premature, and so is data on newer combination EVO-sclerotherapy modalities[ 26 ]. Endoscopists are trying several materials to achieve hemostasis in technically challenging situations, like successful use of hemostatic powder in situation with failed EVO with cyanoacrylate glue and contraindication to TIPS due to dilated cardiomyopathy[ 27 ].
Thrombin helps in clotting by converting fibrinogen to fibrin and promotes platelet aggregation as well. Although these studies were limited by their patient size 12 and 13 patients respectively [ 2829 ], and did not report any untoward thrombo-embolic events, the concern for thrombin leakage into systemic circulation and potentially causing disseminated intravascular coagulation DIC or systemic embolization still remains.
It is currently not being advocated due to lack of adequate data. Role of endoscopic ultrasound: It is common knowledge that endoscopic ultrasound EUS enables the visualization of esophago-gastric varices and other venous collaterals viz. The other EUS features of portal hypertension, in addition to EVs and GVs, may include dilatation of the azygos vein, splenic vein and portal vein, increased diameter of the thoracic duct, thickening of gastric mucosa and submucosa, presence of portal hypertensive gastropathy, and the presence of rectal varices[ 3032 ].
In addition, EUS combined with color Doppler imaging enabled visualization of shunts viz. Furthermore, EUS doppler helps characterize gastric submucosal lesions better than EGDs before proceeding to the biopsy of potential GV. Role of EUS in risk estimation for GV bleeding is a field of growing interest. EUS probes can be used to measure size of varices diameterand furthermore to estimate variceal wall thickness which is deemed as a better predictor of bleeding than varices diameter alone[ 34 ].
Intra-variceal pressure measurement may be a better EGD pentru varice for risk of bleeding, which can be accomplished by direct variceal puncture which is not practiced because of invasiveness. Although data is slim, there has EGD pentru varice an attempt looking at EUS guided EV pressure recording, to ciorapi elastici varice predict risk of bleeding, and http://mutualcreative.co/ingrijirea-pacientilor-cu-varice-2.php has been shown to have reasonable correlation with hepatic venous pressure gradient HVPG [ 35 ].
Finally, high risk stigmata like red hematocytic spot can be visualized with EUS[ 36 ]. EUS-assisted injection sclerotherapy for both gastric[ 37 ] and esophageal varices[ 38 EGD pentru varice is effective, achieving high eradication and low recurrence rates in long-term follow-up. In fact the risk of re-bleeding after EUS directed sclerotherapy is reportedly lower than endoscopic technique.
Recently additional attention has been diverted towards EUS delivered therapies to control bleeding in acute variceal bleeding patients, using unique agents like adhesive tissue histoacryl [ 39 ], thrombin[ 40 EGD pentru varice and EUS-guided coil injection for gastric[ 41 ] and ectopic duodenal varices[ 42 ].
Last but not EGD pentru varice least, EUS finds its utility in confirmation of adequacy EGD pentru varice EVO http://mutualcreative.co/varice-lkuvannya.php gastric varices, eliminating the need for inept endoscope probing assessment and thus increasing overall efficacy of EVO technique[ 43 medicamente tromboflebita si varice. A recent study from Taiwan used miniature ultrasound probe MUP sonography in 34 patients who underwent cyanoacrylate EVO therapy for acute GV bleeding, during follow-up endoscopy session to assess adequacy of EGD pentru varice and reinjection if necessary.
The authors demonstrated a significantly greater free-of-rebleeding rate and trend towards better survival for patients in MUP group compared with conventional endoscopy group[ 43 ]. Although these advances bring a sound of promise, EUS probe which has a larger diameter compared to conventional scope, in addition to GV intervention is certainly a high-risk procedure. Using a mini-probe may counter some of this added disadvantage but non-availability of pediatric sizes is still a limitation.
Furthermore, future studies need to compare radial and linear EUS scopes in diagnosis and management of varices. Decreasing portal pressure - either surgically or percutaneously by establishing a TIPS. Porto-systemic shunts such as TIPS are typically advocated as second-line acute therapy after endoscopic management to prevent re-bleeding of varices[ 1 - 3 ].
Although decreasing portal pressure is considered effective in reducing the bleeding rate of EVs, it is inconsistently effective for GVs, which tend to occur and bleed at lower portal pressures[ 2144 ]. Also there is discordance between decreased hepato-portal gradient with TIPS and actual decrease in GV re-bleeding. In addition, TIPS has its own limitations including worsening of encephalopathy or shunt occlusion, which can lead to recurrence of hemorrhage, and surveillance for patency.
Role of advanced radiological procedures: If all endoscopic techniques and TIPS fail or if TIPS is contraindicated, then the next step would be balloon-occluded retrograde transvenous obliteration BRTO [ 1 - 3 ], which is a popular technique in Japan, and allowing modulation of flow within the varices. BRTO was popularized and named by Kanagawa et al[ 45 ] inthis technique optimize the action of the sclerosing agent by inducing stagnation in the gastric varices, thereby allowing maximal sclerosant dwell time to cause endothelial sclerosis and vascular thrombosis.
The discussion of technique, advantages and complications of BRTO is beyond the scope of current mini-review, but one EGD pentru varice the emerging fronts in management EGD pentru varice acute GV bleeding. GVs are notorious to bleed massively and often difficult to manage with conventional techniques. EVO with cyanoacrylate glue injection is currently the most favored for being superior to variceal ligation or sclerotherapy in achieving EGD pentru varice in acute gastric variceal bleeding.
Endoscopists must remain cognizant about the possible complications of tissue adhesive injections and strive for standardization of EVO techniques to minimize them. Novel techniques like use of thrombin, coil embolization are under investigation as alternatives to cyanoacrylate aiming for improved outcomes. TIPS and BRTO are advanced radiological procedures available as salvage techniques in uncontrollable bleeding situations or when patients are not candidates or have failed endoscopic management.
The role of EUS in the therapeutic algorithm for GVs is still evolving. EUS is being used to confirm presence, size and location of GVs, EGD pentru varice stratify the risk of re-bleeding, as a therapeutic tool to perform sclerotherapy or EVO, and to confirm eradication of GVs after EVO.
Bayraktar Y, Harmanci O, Mesquita RA, Picchio M, Continue reading X S- EGD pentru varice Song XX L- Editor: National EGD pentru varice for Biotechnology InformationU. National Library of Medicine Rockville PikeBethesda MDUSA. NCBI Skip to main content Skip to navigation Resources How To About NCBI Accesskeys My NCBI Sign in to NCBI Sign Out. PMC US National Library of Medicine National Institutes of Health.
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Published online Mar Mohit GirotraSaikiran RaghavapuramEGD pentru varice R AbrahamMrinal PahwaArchna R Pahwaand Rayburn F Rego. Mohit Girotra, Rayburn F Rego, Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences UAMSLittle Rock, ARUnited States.
Saikiran Raghavapuram, Department of Medicine, University of Arkansas for Medical Sciences EGD pentru variceLittle Rock, ARUnited States. Rtika R Abraham, Department of Geriatrics, University of Arkansas for Medical Sciences UAMSLittle Rock, ARUnited States.
Mrinal Pahwa, Department of Surgery, Sir Ganga Ram Hospital, New DelhiIndia. Archna R Pahwa, Department of Pathology, Lady Hardinge Medical College LHMCNew DelhiIndia. All authors contributed to this work. Received Oct 29; Revised Feb 11; Accepted Feb This article has been cited by other articles in PMC.
Abstract Gastric varices GVs are notorious to bleed massively and often difficult to manage with conventional techniques. Gastric, Varices, Endoscopy, Ligation, Sclerotherapy, Management, Transjugular intrahepatic portosystemic shunt, Endoscopic ultrasound, Decât pentru tratarea ulcerului retrograde transvenous obliteration, Endoscopic variceal obliteration.
INTRODUCTION The natural history of gastric varices GVs is less understood than that of esophageal varices EVs. GENERAL PRINCIPLES OF MANAGEMENT OF BLEEDING GVS The preliminary management of bleeding GVs is the same as any other variceal bleeding[ 1 - 3 ]. Proposed management algorithm for gastric varices. Child Elimina umflarea picioarelor cu class B or C or endoscopic presence of red wale sign; Low Risk Patient: Child Pugh class A and no endoscopic high-risk features.
Direct approach Variceal management by direct endoscopy or endoscopic ultrasound. Endoscopic ultrasound classification of gastric varices: Proposed by Boustiere et al in Indirect approach Decreasing portal pressure - either surgically or percutaneously by establishing a TIPS.
CONCLUSION GVs are notorious to bleed massively and EGD pentru varice difficult to manage with conventional techniques. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.
Qureshi W, Adler DG, Davila R, EGD pentru varice J, Hirota W, Leighton J, Rajan E, Zuckerman MJ, Fanelli R, Wheeler-Harbaugh J, et al. Revising consensus in portal hypertension: Sarin SK, Kumar A. Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K. Endoscopic classification of gastric varices.
Polio J, Groszmann RJ. Hemodynamic factors involved in the development and rupture of esophageal varices: Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices. Effects of esophageal varice eradication on portal hypertensive gastropathy and fundal varices: Ryan BM, Stockbrugger RW, Ryan JM.
A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Lo GH, Lai KH, Cheng JS, Chen MH, Chiang EGD pentru varice. A prospective, randomized trial EGD pentru varice butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Tan PC, Hou MC, Lin HC, Liu TT, Lee FY, Chang FY, Lee SD. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butylcyanoacrylate injection versus band Tratamentul albine de varicelor. Lee MS, Cho EGD pentru varice, Cheon YK, Ryu CB, Moon JH, Cho YD, Kim JO, Kim YS, Lee JS, Shim CS.
Use of detachable snares and elastic bands for endoscopic control of bleeding from large gastric varices. Yoshida T, Harada T, Shigemitsu T, Takeo Y, Miyazaki S, Okita K. Endoscopic management of gastric varices using a detachable snare and simultaneous endoscopic sclerotherapy and O-ring ligation.
Schuman BM, Beckman JW, Tedesco FJ, EGD pentru varice JW, Assad RT. Complications of endoscopic injection sclerotherapy: Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices.
Kang EJ, Jeong SW, Jang JY, Cho JY, Lee SH, EGD pentru varice HG, Kim SG, Kim YS, Cheon YK, Cho YD, et al. Long-term result of endoscopic Histoacryl N-butylcyanoacrylate EGD pentru varice for treatment of gastric varices.
Sarin SK, Jain AK, Jain M, Gupta R. A randomized controlled click at this page of cyanoacrylate versus alcohol injection in patients with EGD pentru varice fundic varices. Mishra SR, Chander Sharma B, Kumar A, Sarin SK. Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: Eliminarea recenzii, varicelor PJ, Romagnuolo J, Hilsden RJ, Chen F, Kaplan B, Love J, Beck PL.
Endoscopic management of gastric varices: Lo GH, Liang HL, Chen WC, Chen MH, Lai KH, Hsu PI, Lin CK, Chan HH, Pan HB. Nocturne remedii piciorului crampe populare ale prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus EGD pentru varice injection in the prevention of gastric variceal rebleeding.
Rice JP, Lubner M, Taylor A, Spier BJ, Said A, Lucey MR, Musat A, Reichelderfer M, Pfau PR, Gopal DV. CT portography with gastric variceal volume measurements in the evaluation of endoscopic therapeutic efficacy of tissue adhesive injection into gastric varices: Seewald S, Ang TL, Imazu H, Naga M, Omar S, Source S, Seitz U, Zhong Y, Thonke F, Soehendra N.
A standardized injection technique and regimen ensures success and safety of N-butylcyanoacrylate injection for the treatment of gastric fundal varices with videos Gastrointest Endosc. Liu TT, Hou MC, Lin HC, Chang FY, Lee SD. Mishra SR, Sharma BC, Kumar A, Sarin SK.
Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: Shi B, Wu W, Zhu H, Wu YL. Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol. Holster IL, Poley JW, Kuipers EJ, Tjwa ET. Yang WL, Tripathi D, Therapondos G, Todd A, Hayes PC.
Endoscopic use of human thrombin in bleeding gastric varices. Ramesh J, Limdi JK, Sharma V, Makin AJ. The use of thrombin injections in the management of bleeding gastric varices: Caletti G, Brocchi E, Baraldini M, Ferrari A, Gibilaro M, Barbara L.
Assessment of portal hypertension by endoscopic ultrasonography. Endoscopic ultrasonography classification of gastric varices in patients with EGD pentru varice. Comparison with endoscopic findings. Faigel DO, Rosen HR, EGD pentru varice A, Flora K, Benner K. EGD pentru varice in cirrhotic patients with and without prior variceal hemorrhage in comparison with noncirrhotic control subjects. Kakutani H, Hino S, Ikeda K, Mashiko T, Sumiyama K, Uchiyama Y, Kuramochi A, Kitamura Y, Matsuda K, Kawamura M, et al.
Use of the curved linear-array echo endoscope to identify gastrorenal shunts EGD pentru varice patients with gastric fundal varices. Jackson FW, Adrain AL, Black M, Miller LS. Calculation of esophageal variceal wall tension by direct sonographic and manometric measurements. Endosonographic Doppler-guided manometry of esophageal varices: Schiano TD, Adrain AL, Vega KJ, Liu JB, Black M, Miller LS.
High-resolution endoluminal sonography assessment of the hematocystic spots of esophageal varices. Lee YT, Chan FK, Ng EK, Leung VK, Law KB, Yung MY, Chung SC, Sung JJ. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Treatment of esophageal varices: Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M, Marcos-Sanchez F, Caunedo-Alvarez A, Ortiz-Moyano C, Gomez-Parra M, Herrerias-Gutierrez JM.
EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: Krystallis C, McAvoy NC, Wilson J, Hayes PC, Plevris JN. EUS-assisted thrombin injection for ectopic bleeding EGD pentru varice case fonduri la varice în sarcinii and review of the literature.
Binmoeller KF, Weilert F, Shah JN, Kim J. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling click cyanoacrylate glue injection with videos Gastrointest Endosc. Levy MJ, Wong Kee EGD pentru varice LM, Kendrick ML, Misra S, Gostout CJ. EUS-guided coil embolization for refractory ectopic variceal bleeding with videos Gastrointest Endosc. Liao SC, Yang SS, Ko CW, Lien HC, Tung CF, Peng YC, Yeh HZ, Chang CS.
A miniature ultrasound probe is useful in reducing rebleeding after endoscopic cyanoacrylate injection for hemorrhagic gastric varices. Tripathi D, Therapondos G, Jackson E, Redhead DN, Hayes PC. The role of the transjugular intrahepatic portosystemic stent shunt TIPSS in the management of bleeding gastric varices: Kanagawa H, EGD pentru varice S, Kouyama H, Gotoh K, Uchida T, Okuda K.
Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. Articles from World Journal of Hepatology are provided here courtesy of Baishideng Publishing Group Inc. Article PubReader ePub beta PDF 1. EGD pentru varice Center Support Center. Please review our privacy EGD pentru varice. National Library of Medicine Rockville PikeBethesda MDUSA Policies and Guidelines Contact.
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