Endosonography as a predictive tool for first esophagogastric variceal bleeding

The development of portosystemic collaterals is the central pathophysiological event that leads to variceal bleeding in patients with liver cirrhosis. Endosonography [EUS] is useful to evaluate the fine details of the vascular structures at the gastroesophageal junction. EUS may give a promising chance for predicting upper gastrointestinal bleeding in cirrhotic patients. To evaluate the value of extraluminal gastroesophageal vascular collaterals as predictors of first variceal bleeding. A total of 50 cirrhotic patients with no history of previous upper GI bleeding were recruited into this cohort study. After thorough history taking and clinical examination, they were subjected to upper endoscopy and EUS for assessing the number and size of peri- and para-mural collaterals and perforating vessels. All participants were followed up for 24 months for upper gastrointestinal bleeding. Eighteen out of 50 patients [36%] had at least one attack of upper GI bleeding during the follow up period. All patients had one or more type of extraluminal venous collaterals. Gastric varices [P = 0.02], perigastric collaterals [P = 0.03] and perforators [P = 0.02] were independent risk factors for first variceal bleeding. The presence of 3 or more paraesophageat collaterals and the presence of perforators were significantly higher in bleeders compared to non-bleeders [P = 0.034]. Perigastric and paragastric collateral size were significantly larger in bleeders than non bleeders [P = 0.019 and 0.038 respectively]. Perigastric and paragastric collaterals size more than or equal to 2 mm and 6.20 mm respectively were associated with significantly increased risk of first variceal bleeding. Peri-esophageal and para-esophageal collaterals although present in large diameters in all bleeders than non bleeders, did not reach a statistical significant level EUS may be a promising tool for predicting first variceal bleeding in cirrhotic patients thus justifying primary prevention by band ligation or sclerotherapy

Comparative study between variceal ligation by detachable snare versus banding in bleeding esophageal varices

Varcial bleeding is a very serious complication with a reported mortality rate of 20-50%. Patients who have had a vatriceal hemorrhage are usually treated by endoscopic injection sclerotherapy or band ligation to eradicate the varices. Endoloop ligation is a new technique invented to achieve hemostatis and variceal eradiation. This work included fifty patients with acute esophageal ariceal bleeding, 25 patients were managed by band ligation and the other 25 patients were managed by endoloop ligation. The number of patients who rebelled during the follow-up was smaller in the endoloop group [12%] compared to the band group [28%], yet, this difference did not reach statistical significance. Also, no statistically significant difference was found between the two groups regarding the number of patients who showed complete varicea eradication, the number of active sessions needed to reach variceal eradiation or the incidence of variceal recurrence by the end of follow-up period of six months. It was found that the total cost of endoloop sessions' needed for variceal obliteration was 1163.9 l.e for erach patient, while it was 12.9.9 l.e for band ligaion. Also, the endoloop showed technical advanced over band application including better field of vision, more tight application, good results on junctional varices, and no strain exerted by the device on the endoscope. We can conclude that endoloop ligation is a new promising technique for managing bleeding esophageal varices