Endoscopic ligation,sclerotherapy and injection of tissue glue combined with medicine treatment have replaced surgical shunt and devascularization as the first-line treatment recommended by guidelines for esophagogastric variceal bleeding in patients with cirrhosis and portal hypertension.However,some of the variceal bleeding induced by non-cirrhotic portal hypertension.Comorbidities such as diabetes,portal vein thrombosis,liver tumors,and hepatic artery-portal vein fistulas have reduced the efficacy of endoscopic treatment,and have increased the rate of complication such as ectopic embolism.Traditional endoscopic techniques are facing substantial challenges.The urgent needs for precise injection techniques,complete variceal obliteration,and the prevention of ectopic embolism have become apparent.The era of precision medicine in variceal endoscopic treatment has been ushered in by advancements such as preoperative assessments using computed tomography(CT)and ultrasound endoscopy,ultrasound-guided tissue glue injection with spring coil assistance,and immediate postoperative ultrasound endoscopic evaluation.This progress is anticipated to overcome the diagnostic and therapeutic limitations associated with non-cirrhotic portal hypertension.Integrating CT imaging virtual simulation and other technological innovations,to surpass conventional interventional techniques,is helpful of achieving a comprehensive endoscopic approach to the diagnosis and treatment of portal hypertension.

Objective To evaluate the effect of para-esophageal and para-gastric vessels(PEPGV)on endoscopic secondary prophylaxis for varices.Methods The clinical data of patients with cirrhosis-related esophagogastric varices(EGV)who underwent endoscopic variceal ligation and/or obliteration,and had hepatic venous pressure gradient(HVPG)result between January 2020 and December 2020 in Zhongshan Hospital,Fudan University were retrospectively analyzed.Patients were divided into a group without PEPGV and a group with PEPGV based on CT imaging of the portal vein.The main outcome was 2-year re-bleeding.Results A total of 69 patients were included,and 27 of them had PEPGV.There was no statistical difference in baseline characteristics,blood indexes(included hemoglobin level,prothrombin time and albumin level),HVPG,and the secondary prophylactic endoscopic treatment ways between the two groups.A total of 25 patients experienced re-bleeding within 2 years after endoscopic treatment,including 15 in the group with PEPGV and 10 in the group without PEPGV.Kaplan-Meier analysis showed that the cumulative 2-year re-bleeding rate was significantly higher in the group with PEPGV than in the group without PEPGV(60.07％vs 32.79％,P=0.022).Further multivariate Cox analysis showed that PEPGV was an independent predictor of re-bleeding after endoscopic treatment in EGV patients(HR=2.33,95％CI 1.01-5.39,P=0.047).Conclusions The PEPGV is an independent predictor of re-bleeding after endoscopic treatment in EGV patients.It is suggested that when patients with EGV receive endoscopic treatment to prevent re-bleeding,portal vascular CT is suggested to evaluate PEPGV.For patients with giant extraluminal vascular masses,fully evaluating other treatment options such as transjugular intrahepatic portosystemic shunt,or adjusting endoscopic treatment ways is recommended.

Objective To explore the effects of anticoagulation treatment to postoperative bleeding events in liver cirrhosis patients with gastric varices and portal vein thrombosis.Methods Patients diagnosed with portal vein thrombosis and treated with endoscopic cyanoacrylate injection at Zhongshan Hospital,Fudan University due to gastric variceal bleeding from January 2023 to December 2023 were included.Clinical data of patients were collected,and patients were divided into anticoagulant group and non-anticoagulant group based on whether anticoagulant treatment was performed within 48 h after treatment.Re-bleeding in patients was evaluated in 6 weeks of follow-up.Cox regression was used for univariate and multivariate analysis of re-bleeding within 6 weeks after treatment.Results A total of 160 patients were included,of whom 65 patients received anticoagulation treatment within 48 h after endoscopic cyanoacrylate injection.There were no statistically significant differences in gender,etiology of liver cirrhosis,dosage of cyanoacrylate and sclerosing agents,and Child-Pugh grading between the two groups.There was no statistically significant difference in re-bleeding rate within 6 weeks after treatment between the two groups(1.54％vs 1.05％,P=0.795).Multivariate Cox regression analysis showed that the large amount of cyanoacrylate was a risk factor for re-bleeding within 6 weeks after endoscopic treatment(HR=5.862,P=0.015).Conclusions For patients with liver cirrhosis,gastric varices,and portal vein thrombosis,who receive endoscopic cyanoacrylate injection,early anticoagulation does not increase the risk of re-bleeding after treatment,while a large amount of cyanoacrylate injection may be a risk factor for re-bleeding.However,sample should be increased to verify.

Objective To compare the efficacy and safety of endoscopic ligation treatment and endoscopic tissue glue injection for secondary prevention of gastric variceal bleeding.Methods Patients with cirrhosis and esophagogastric variceal bleeding treated with gastric variceal ligation in Zhongshan Hospital,Fudan University,from January 2017 to December 2019 were screened(ligation group).And during the same period,patients underwent endoscopic cyanoacrylate treatment were also screened(tissue glue group).59 patients were included in the two groups after propensity score matching.Univariate and multivariate Cox proportional hazard regression models were used to anslyze risk factors for re-bleeding.Kaplan-Meier curves were plotted to analyze re-bleeding rate and mortality of the two treatment groups.Results There was no statistically significant difference in the eradication rate of esophagogastric varices between the ligation group and the tissue glue group(83.05％vs 79.66％,P=0.778);the ligation group required fewer median endoscopic treatments for variceal eradication(2 vs 3,P=0.017)and a lower average dosage of cyanoacrylate(0.70 mL vs 2.67 mL,P＜0.001).Multivariate Cox regression analysis showed that portal shunt was a risk factor for esophagogastric varices re-bleeding(HR=3.14,95％CI 1.02-9.68,P=0.046),endoscopic variceal ligation was a protective factor against re-bleeding(HR=0.25,95％CI 0.08-0.71,P=0.010).Compared with endoscopic cyanoacrylate injection,endoscopic ligation treatment did not significantly increase the 2-year risk of esophagogastric variceal re-bleeding(18.69％vs 36.29％,P=0.067)or risk of death(1.69％vs 3.39％,P=1.000);patients with GOV1 type had a significantly lower risk of re-bleeding after endoscopic ligation treatment(0 vs 40.27％,P=0.012)and there was a trend towards a lower re-bleeding risk in patients with GOV2 type after endoscopic ligation treatment(13.27％vs 34.16％,P=0.056).Conclusions Endoscopic ligation treatment has higher eradication rate for esophagogastric varices,and does not increase the risk of re-bleeding,death,or other adverse events.Therefore,it can be considered an effective secondary prevention way for patients with gastric varices.

In recent years, the etiology of portal hypertension has undergone many changes. In addition to the focus on viral and alcoholic liver diseases, obesity, hyperlipidemia and diabetes patients, all kinds of drugs, especially after chemotherapy with platinum drugs, bone marrow proliferative diseases, autoimmune liver disease patients, need to be included in the high-risk screening population. The change in etiology brings about complex pathological and physiological states. We need to conduct a comprehensive evaluation, understand past medical history, improve portal vein computed tomography (CT), liver elastography, gastroscopy and other examinations, clarify the etiology, and choose personalized treatment plans for patients. Through technological innovation, we aim to improve the efficacy of endoscopic therapy, combined with new concepts such as artificial intelligence, big data, and multi omics, so as to obtain more accurate prediction of portal vein pressure and clinical characteristics, refine risk stratification, and make more accurate personalized decisions for clinical diagnosis and treatment.

Objective:To explore the changes of iron metabolism in patients with hepatitis B cirrhosis and esophageal and gastric varices complicated with portal vein thrombosis.Methods:This study was a cross-sectional study. 253 patients with hepatitis B cirrhosis with esophageal and gastric varices who were hospitalized in the Zhongshan Hospital, Fudan University from January 1, 2020 to December 31, 2021 were included in this study. They were divided into portal vein thrombosis group ( n=57) and non portal vein thrombosis group ( n=196) according to the presence or absence of portal vein thrombosis. The iron metabolism characteristics of the two groups were compared, and subgroups were analyzed according to the presence or absence of ascites, platelet count level, D-dimer level, and Child grade. The factors related to portal vein thrombosis were screened through multivariate logistic regression analysis. Results:The ratio of Child pugh B/C, ascites, D-dimer and platelet count in patients with hepatitis B cirrhosis and esophageal and gastric varices complicated with portal vein thrombosis was higher (all P<0.05). Patients with portal vein thrombosis had higher levels of soluble transferrin receptor [2.4(1.8, 3.6)mg/L vs 1.8(1.3, 2.7)mg/L, P=0.006], and lower levels of ferritin [33.1(18.9, 63.3)ng/ml vs 57.7(19.4, 142.5)ng/ml, P=0.038]. Layered analysis showed that ascites, platelet count levels, D-dimer levels, and Child-pugh grade did not affect the negative correlation trend between ferritin and portal vein thrombosis, and the positive correlation trend between soluble transferrin receptors and portal vein thrombosis. Moreover, soluble transferrin receptors showed a statistically significant positive correlation with portal vein thrombosis in the absence of ascites, low D-dimer levels, and Child-pugh grade A. Multivariate analysis suggested that after weighing Child-pugh grading, platelet count, and D-dimer levels, ferritin ( OR=0.943, 95% CI: 0.904-0.983, P=0.006) and soluble transferrin receptor ( OR=1.034, 95% CI: 0.001-1.067, P=0.044) were independently associated with portal vein thrombosis. Conclusions:In patients with hepatitis B cirrhosis with esophageal and gastric varices, the characteristics of iron metabolism in patients with portal vein thrombosis are different from those in patients without thrombosis, with higher levels of soluble transferrin receptor and lower levels of ferritin.

Objective:To investigate whether discontinuation of previous targeted immunotherapy increases the risk of rebleeding in patients with advanced liver cancer complicated with esophageal and gastric variceal bleeding after endoscopic treatment.Methods:A retrospective cohort study was conducted to include advanced liver cancer patients who were diagnosed with esophageal and gastric variceal bleeding through endoscopic examination and treated under endoscopy at Zhongshan Hospital, Fudan University from March 1, 2020 to March 1, 2022, due to upper gastrointestinal bleeding. We collected clinical data from patients and divided them into targeted immunotherapy group and non targeted immunotherapy group based on whether they received targeted immunotherapy before bleeding; Follow up observation was conducted for 6 months to evaluate the patient′s re bleeding and survival status.Results:A total of 55 patients were included, of which 24 had previously received targeted immunotherapy and 31 had not received targeted immunotherapy. There was no significant difference between the two groups in gender distribution, etiology, hypertension and diabetes (all P>0.05). The age of the target immunotherapy group was younger than that of the non target immunotherapy group, and the level of fibrinogen was higher than that of the non target immunotherapy group, with statistical significance ( P=0.002, 0.017). There was no statistically significant difference in the 6-month re bleeding rate (20.83% vs 22.58%, P=0.269) and 6-month mortality rate (45.83% vs 29.03%, P=0.199) between the targeted and non targeted groups of patients. Further Cox regression multivariate analysis revealed that Child-pugh grading was an independent risk factor for 6-month survival in patients with advanced liver cancer with esophageal and gastric varices ( HR=2.64, P=0.009). Conclusions:Targeted immunotherapy does not increase the rate of rebleeding in patients with advanced unresectable liver cancer after endoscopic treatment of esophageal and gastric varices. Child-pugh grading is a factor that affects the 6-month survival of advanced liver cancer patients after bleeding, and the poorer the liver function, the shorter the survival period.

According to the pathophysiological characteristics, upper gastrointestinal bleeding can be divided into acid related disease bleeding and esophageal and gastric varices bleeding. Esophageal and gastric variceal bleeding is a common critical condition of Portal hypertension, with dangerous onset and high mortality. With the improvement of endoscopic treatment technology, endoscopy has become the first line treatment plan for esophageal and gastric variceal bleeding. The commonly used endoscopic management methods for varicose veins include variceal ligation, tissue glue combined with sclerosing agent embolization, ultrasound guided coil combined with tissue glue embolization, and other management measures. Early identification of gastrointestinal bleeding related to varicose veins, stratified diagnosis and treatment of high-risk patients, reasonable selection of endoscopic examination timing, and personalized decision-making of treatment choices are key to improving efficacy.

Objective:To evaluate the long-term risk of rebleeding in patients with acute esophageal and gastric variceal bleeding and portal vein thrombosis after endoscopic treatment in liver cirrhosis.Methods:From January to December 2022, 57 patients with acute esophageal and gastric variceal bleeding who were treated by endoscopy in the emergency department of the Zhongshan Hospital affiliated to the Fudan University were included in the study. According to the results of portal vein CT angiography (CTA), the patients were divided into thrombosis group and non thrombosis group. We compared the basic information and endoscopic treatment status of two groups of patients. All patients were followed up until 1 year after endoscopic treatment or April 15, 2023, and re bleeding and survival were recorded during the follow-up period. The influencing factors of rebleeding after 1 year of treatment were analyzed.Results:The patient′s age was (55.9±11.4)years old, mainly male [78.95%(45/57)]. The average time from initial bleeding to endoscopic treatment for all patients was (6.6±2.8)days. There was no statistically significant difference between the two groups in terms of age, sex, combined liver malignancy, Child-pugh score, first bleeding form, ascites, and first laboratory examination results (including hemoglobin, platelet, Prothrombin time, creatinine) (all P>0.05). There was no statistically significant difference in the history of endoscopic treatment, bleeding distance from endoscopic treatment, the proportion of patients with esophageal varices and gastric varices, the proportion of patients with esophageal varices treated with ligation, and the proportion of patients with gastric varices treated with tissue glue between the two groups (all P>0.05). A total of 2 patients died after surgery, and 12 patients experienced rebleeding, including 10 in the thrombotic group and 2 in the non thrombotic group. Kaplan Meier analysis showed that the 1-year rebleeding rate in the thrombotic group was significantly higher than that in the non thrombotic group (59.02% vs 24.71%, RR=6.002, 95% CI: 1.06-34.00, P=0.020 8). Cox multivariate regression analysis suggests that the presence of portal vein thrombosis ( HR=7.669, 95% CI: 1.453-40.472, P=0.016) was an independent risk factor for recurrent bleeding after endoscopic treatment of acute esophageal and gastric variceal bleeding for one year. Conclusions:Portal vein thrombosis in liver cirrhosis increases the risk of recurrent bleeding after endoscopic treatment for acute esophageal and gastric variceal bleeding for one year. For patients with acute Upper gastrointestinal bleeding complicated with portal vein thrombosis, regular endoscopic and ultrasonic follow-up, individualized endoscopic sequential and selective anticoagulation therapy should be carried out.

Humans ; Muscular Diseases/genetics* ; Cardiomyopathies/genetics* ; Lipid Metabolism, Inborn Errors/genetics* ; Mutation ; Lipids ; Muscle, Skeletal ; Acyltransferases/genetics* ; Lipase/genetics*