Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience.

BACKGROUND: Endoscopic injection of N-butyl-2-cyanoacrylate is the current recommended treatment for gastric variceal bleeding. Despite the extensive worldwide use, there are still differences related to the technique, safety, and long term-results. We retrospectively evaluated the efficacy and safety of cyanoacrylate in patients with gastric variceal bleeding. PATIENTS AND METHODS: Between January 1998 and January 2010, 97 patients with gastric variceal bleeding underwent endoscopic treatment with a mixture of N-butyl-2-cyanoacrylate and Lipiodol(TM). Ninety-one patients had cirrhosis and 6 had non-cirrhotic portal hypertension. Child-Pugh score at presentation for cirrhotic patients was A-12.1 %; B-53.8 %; C-34.1 % and median MELD score at admission was 13 (3-26). Successful hemostasis, rebleeding rate and complications were reviewed. Median time of follow up was 19 months (0.5-126). RESULTS: A median mixture volume of 1.5 mL (0.6 to 5 mL), in 1 to 8 injections, was used, with immediate hemostasis rate of 95.9 % and early rebleeding rate of 14.4 %. One or more complications occurred in 17.5 % and were associated with the use of Sengstaken-Blakemore tube before cyanoacrylate and very early rebleeding (p < 0.05). Hospital mortality rate during initial bleeding episode was 9.3 %. Very early rebleeding was a strong and independent predictor for in-hospital mortality (p < 0.001). Long-term mortality rate was 58.8 %, in most of the cases secondary to hepatic failure. CONCLUSION: N-butyl-2-cyanoacrylate is a rapid, easy and highly effective modality for immediate hemostasis of gastric variceal bleeding with an acceptable rebleeding rate. Patients with very early rebleeding are at higher risk of death.

Screening for pancreatic exocrine insufficiency in patients with diabetes mellitus.

OBJECTIVES: Fecal elastase 1 (E1) is a relatively sensitive and specific indirect test of pancreatic exocrine function. Despite the high functional reserve of the pancreas, it is recognized that a significant proportion of diabetic patients may also have a deficit of the exocrine function. The aim of this study was to screen patients with diabetes mellitus (DM) for pancreatic exocrine insufficiency. METHODS: A total of 80 patients were enrolled in this prospective study, including 42 patients with DM and 38 nondiabetic controls. Exclusion criteria were as follows: age >75 yr; alcohol intake >40 g/day; intake of orlistat or acarbose; and history of diarrhea, pancreatitis, GI surgery, immunodeficiency, or cancer. All patients underwent the same study protocol, which included clinical evaluation, determination of fecal E1, plain x-rays of the abdomen, and abdominal ultrasound. An immunoenzymatic method (ScheBoTech, Wettenburg, Germany) was used for E1 determination. Diagnosis of pancreatic insufficiency was established for a fecal E1 <200 microg/g. RESULTS: The DM and control groups were comparable regarding age (62 +/- 10 yr vs 56 +/- 10 yr), sex (18 men and 24 women vs 15 men and 23 women), and proportion of patients with excess weight (50% vs 42%). Patients had DM diagnosed for 11.5 +/- 8 yr, with structural changes of the pancreas detected on ultrasound in three cases and calcifications in one case. There was no relationship between E1 determination <200 microg/g and the duration or the type of therapy for DM. Fifteen patients (36%) in the DM group had a fecal E1 <200 microg/g, compared with two patients (5%) in the control group (p < 0.05). In the DM group (n = 42), 11 patients with excess weight presented a fecal E1 <200 microg/g, whereas four patients with a BMI <25 presented this result (p < 0.05). CONCLUSIONS: Pancreatic exocrine insufficiency occurs more frequently in diabetic patients than in controls. Diabetic individuals with excess weight (BMI >25) may be at increased risk for underlying exocrine pancreatic insufficiency.