Recent studies suggest that liver cirrhosis is reversible after administering oral nucleos(t)ide analogue therapy to patients with hepatitis B virus (HBV) infection. However, few studies have addressed whether esophageal varices can regress after such therapy. We report a case of complete regression of esophageal varices during entecavir therapy in patients with HBV-related liver cirrhosis, suggesting that complications of liver cirrhosis such as esophageal varices can regress after the long-term suppression of HBV replication.
Abdomen/diagnostic imaging ; Antiviral Agents/*therapeutic use ; DNA, Viral/blood ; Esophageal and Gastric Varices/complications/prevention & control ; Guanine/*analogs & derivatives/therapeutic use ; Hepatitis B virus/genetics ; Hepatitis B, Chronic/complications/*drug therapy/virology ; Humans ; Liver Cirrhosis/*diagnosis/etiology ; Male ; Middle Aged ; Polymerase Chain Reaction ; Ultrasonography

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.
Aged ; Emergency Medical Services ; Endoscopy, Digestive System ; Esophageal and Gastric Varices/complications/*diagnosis ; Female ; Gastrointestinal Hemorrhage/mortality/*prevention & control ; Humans ; Kaplan-Meier Estimate ; Liver Cirrhosis/complications/*diagnosis ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Recurrence ; Risk Factors ; Severity of Illness Index ; Stomach/pathology ; Survival Rate ; Thrombosis

BACKGROUND/AIMS: To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC). METHODS: This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed. RESULTS: The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death. CONCLUSIONS: The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.
Adult ; Aged ; Aged, 80 and over ; Chi-Square Distribution ; Enbucrilate/*administration & dosage/adverse effects ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/complications/diagnosis/mortality/*therapy ; Female ; Gastrointestinal Hemorrhage/diagnosis/etiology/mortality/*therapy ; Hemostasis, Endoscopic/adverse effects/*methods/mortality ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Proton Pump Inhibitors/adverse effects/*therapeutic use ; Recurrence ; Retrospective Studies ; Risk Factors ; Sclerosing Solutions/*administration & dosage/adverse effects ; Sclerotherapy/adverse effects/*methods/mortality ; Time Factors ; Treatment Outcome ; Young Adult

Variceal bleeding occurs primarily in the esophagus or stomach in patients with liver cirrhosis, but can also occur rarely in the duodenum. Duodenal variceal bleeding has a high mortality and poor prognosis due to heavy blood flow originating from the portal vein (PV) and the technical difficulty of hemostatic procedures. Treatments including endoscopic sclerotherapy, endoscopic ligations, endoscopic clipping and transjugular intrahepatic portosystemic shunt have been tried, with only moderate and variable success. A percutaneous transsplenic approach offers another way of accessing the PV. Here we report a case of successfully treated duodenal variceal bleeding by percutaneous transsplenic embolization.
Aged ; Duodenum ; Embolization, Therapeutic ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/complications/*diagnosis ; Gastrointestinal Hemorrhage/*therapy ; Humans ; Liver Cirrhosis/complications/*diagnosis ; Male ; Portal Vein/diagnostic imaging ; *Portasystemic Shunt, Transjugular Intrahepatic ; Recurrence ; Tomography, X-Ray Computed

BACKGROUND/AIMS: To evaluate the long-term efficacy and safety of endoscopic injection of N-butyl-2-cyanoacrylate (NBC; Histoacryl) for treatment of bleeding gastric varices. METHODS: We retrospectively analyzed the records of 455 patients with gastric variceal hemorrhage (GVH) who were consecutively treated with NBC from January 2004 to July 2013, with a mean follow-up period of 582 days. The patients' endoscopic findings, initial hemostasis, complications, rebleeding rates, and bleeding-related death rates were reviewed. RESULTS: Hemostasis was achieved initially in 96.9% (441/455) of patients; rebleeding occurred in 35.2% (160/455), and the bleeding-related death rate was 6.8% (31/455) during follow-up. Complications included fever (6.8%), abdominal pain (3.7%), diarrhea (1.3%), spontaneous bacterial peritonitis (0.7%), bacteremia (0.4%), and embolism (0.2%). A red-color sign on concomitant esophageal varices (EVs) (p = 0.002) and previous history of variceal bleeding (p < 0.001) were significant risk factors for rebleeding within 1 year. The Child-Pugh score (p < 0.001), presence of hepatocellular carcinoma (p = 0.001), and failure of initial hemostasis (p < 0.001) were the risk factors most closely associated with bleeding-related death. CONCLUSIONS: This study provides a comprehensive overview of the outcomes and prognostic factors of patients with GVH. The results may help in the selection of effective treatment strategies for patients with GVH.
Adult ; Aged ; Aged, 80 and over ; Enbucrilate/adverse effects/*therapeutic use ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/complications/diagnosis/mortality/*therapy ; Female ; Gastrointestinal Hemorrhage/diagnosis/etiology/mortality/*therapy ; *Hemostatic Techniques/adverse effects/mortality ; Humans ; Male ; Middle Aged ; Recurrence ; Retrospective Studies ; Time Factors ; Treatment Outcome ; Young Adult

Esophageal and Gastric Varices ; diagnosis ; etiology ; pathology ; Hemorrhage ; Humans ; Liver Cirrhosis ; complications ; pathology

OBJECTIVETo investigate reliability of FibroScan (FS) in diagnosing size of oesophageal varices (OV) in patients with liver cirrhosis.

METHODSA total of 260 patients with liver cirrhosis were enrolled in the study. All patients underwent endoscopy to assess OV stage and FS to measure liver stiffness. Receiver operating characteristic (ROC) curves were generated to evaluate the diagnostic reliability of FS.

RESULTSThe FS values according to OV stage were 20.9 ± 10.3 kPa for patients without OV, 32.2 ± 13.5 kPa for patients with mild OV, 45.6 ± 18.3 kPa for patients with moderate OV, and 55.1 ± 15.6 kPa for patients with severe OV. Significant differences were found among the groups (P < 0.001) as well as between any two groups (t=6.574, 10.533, 13.247, 4.719, 7.072 and 2.171, P less than 0.05 respectively). ROC curves of FS for the diagnoses of patients with various OV stages showed the following:with vs. without OV, 0.824 (95% CI:77.5% to 87.4%); less than moderate vs. more than moderate OV, 0.849 (95% CI:79.6% to 90.2%); and less than severe vs. severe OV, 0.871 (95% CI:81.1% to 93.0%); the corresponding FS cut-off values were 22.8 kPa, 30.6 kPa, and 34.6 kPa.

CONCLUSIONLiver stiffness measurement by FibroScan allows prediction of the oesophageal varices stage in patients with liver cirrhosis.

Adult ; Elasticity Imaging Techniques ; Esophageal and Gastric Varices ; diagnosis ; etiology ; Female ; Humans ; Liver Cirrhosis ; complications ; diagnosis ; Male ; Middle Aged

While esophagogastric varices are common manifestations of portal hypertension, variceal bleeding from the jejunum is a rare complication of liver cirrhosis. In addition, ectopic variceal bleeding occurs in the duodenum and at sites of previous bowel surgery in most cases, including of stomas. We report a case of obscure overt gastrointestinal bleeding from jejunal varices in a 55-year-old woman who had not previously undergone abdominal surgery, who had liver cirrhosis induced by the hepatitis C virus. Emergency endoscopy revealed the presence of esophageal varices without stigmata of recent bleeding, and no bleeding focus was found at colonoscopy. She continued to produce recurrent melena with hematochezia and received up to 21 units of packed red blood cells. CT angiography revealed the presence of jejunal varices, but no active bleeding was found. Capsule endoscopy revealed fresh blood in the jejunum. The patient submitted to embolization of the jejunal varices via the portal vein, after which she had a stable hemoglobin level and no recurrence of the melena. This is a case of variceal bleeding from the jejunum in a liver cirrhosis patient without a prior history of abdominal surgery.
Angiography ; Capsule Endoscopy ; Embolization, Therapeutic ; Esophageal and Gastric Varices/complications/diagnosis ; Female ; *Gastrointestinal Hemorrhage ; Humans ; Hypertension, Portal ; Jejunal Diseases/*diagnosis/therapy ; Liver Cirrhosis/*diagnosis ; Melena/complications ; Middle Aged ; Tomography, X-Ray Computed

Systemic sclerosis (SSc) is a chronic systemic disease that affects the skin, lungs, heart, gastrointestinal tract, kidneys, and musculoskeletal system. Although up to 90% of patients with scleroderma have been estimated to have gastrointestinal involvement, liver disease has been reported only rarely. A 51-year-old woman was hospitalized due to esophageal variceal bleeding. Her serum was positive for anti-nuclear antibody and anti-centromere antibody. Sclerodactyly was noted on both hands, and she had recently developed Raynaud's syndrome. Punch biopsy of the hand showed hyperkeratosis, regular acanthosis, and increased basal pigmentation in the epidermis, and thick pale collagenous bundles in the dermis. Liver biopsy showed chronic active hepatitis with bridging fibrosis. Consequently, she was diagnosed with liver cirrhosis due to autoimmune hepatitis (AIH) combined with SSc. AIH had subsided after administration of prednisolone at 40 mg per day. She received 5-10 mg/day of prednisolone as an outpatient, and her condition has remained stable. Patients with either AIH or SSc should be monitored for further development of concurrent autoimmune diseases. The early diagnosis of AIH combined with SSc will be helpful in achieving optimal management.
Anti-Inflammatory Agents/therapeutic use ; Antibodies, Antinuclear/blood ; Esophageal and Gastric Varices ; Female ; Gastrointestinal Hemorrhage ; Hepatitis, Autoimmune/complications/*diagnosis/drug therapy ; Humans ; Liver Cirrhosis/*diagnosis/etiology/pathology ; Middle Aged ; Prednisolone/therapeutic use ; Raynaud Disease/diagnosis ; Scleroderma, Systemic/complications/*diagnosis ; Skin/pathology

BACKGROUND/AIMS: The aim of this study was to identify the parameters that could noninvasively predict the presence of esophageal/gastric varices and portal hypertensive gastropathy (PHG) in patients with chronic liver disease (CLD), and to determine the accuracy of those parameters. METHODS: We retrospectively analyzed 232 patients with CLD who underwent both upper endoscopy and liver CT within an interval of 3 months. The multidimensional index (M-Index) for spleen volume was obtained from the multiplication of splenic length, width, and thickness, as measured by computer tomography. RESULTS: The multivariate analysis revealed that platelet, albumin, and M-Index were independently associated with the presence of varices and PHG. We combined three independent parameters, and developed a varices and portal hypertensive gastropathy (VAP) scoring system (=[platelet count (/mm3)xalbumin (g/dL)]/[M-Index (cm3)]). The area under the receiver operating characteristic curve of the VAP score was 0.850 (95% confidence interval, 0.801-0.899). The VAP cut-off value of 861 had a sensitivity of 85.3%, a positive likelihood ratio of 3.17, and a negative predictive value of 86.4%. For predicting high-risk lesions for bleeding, with a cut-off value of 861 the sensitivity was 92.0%, the positive likelihood ratio was 2.20, and the negative predictive value was 96.4%. CONCLUSIONS: The VAP score can predict the presence of varices and PHG in patients with CLD and may increase the cost-benefit of screening endoscopy in the clinical practice setting. A prospective validation study is necessary in the future.
Adult ; Aged ; Chronic Disease ; Endoscopy, Gastrointestinal ; Esophageal and Gastric Varices/complications/*diagnosis ; Female ; Humans ; Hypertension, Portal/complications/*diagnosis ; Liver Diseases/complications/*diagnosis ; Male ; Middle Aged ; Platelet Count ; Predictive Value of Tests ; ROC Curve ; Retrospective Studies ; Risk Factors ; Serum Albumin/analysis ; Severity of Illness Index ; Spleen/physiology/radiography ; Tomography, X-Ray Computed