Etiologies of Splenic Venous Hypertension: A Review.

Splenic venous hypertension or left-sided portal hypertension is a rare condition caused by an obstruction of the splenic vein. Usually, it presents with upper gastrointestinal bleeding in the absence of liver disease. Etiologies can be classified based on the mechanism of development of splenic vein hypertension: compression, stenosis, inflammation, thrombosis, and surgically decreased splenic venous flow. Diagnosis is established by various imaging modalities and should be suspected in patients with gastric varices in the absence of esophageal varices, splenomegaly, or cirrhosis. The management and prognosis vary depending on the underlying etiology but generally involve reducing splenic venous pressure. The aim of this review was to summarize the etiologies of splenic venous hypertension according to the mechanism of development.

Effect of diabetes on mortality and liver transplantation in alcoholic liver cirrhotic patients with acute decompensation.

BACKGROUND: Previous studies have investigated the influence of diabetes on alcoholic liver cirrhosis patients, leaving its impact unclear. Thus, we conducted a study to reveal the association of diabetes and clinical outcomes of such patients. MATERIALS AND METHODS: We prospectively collected data from multicenter pertaining to 965 patients diagnosed with alcoholic liver cirrhosis, all of whom were admitted due to acute decompensation between 2015 and 2019. Risk of major precipitating factors and incidences of death or liver transplantation in patients with and without diabetes was comparatively assessed. Propensity score (PS) matching was performed at a 1:2 ratio for accurate comparisons. RESULTS: The mean age was 53.4 years, and 81.0% of the patients were male. Diabetes was prevalent in 23.6% of the cohort and was positively correlated with hepatic encephalopathy and upper gastrointestinal bleeding, although not statistically significant. During a median follow-up of 903.5 person-years (PYs), 64 patients with and 171 without diabetes died or underwent liver transplantation, with annual incidence of 33.6/100 PYs and 24.0/100 PYs, respectively. In the PS-matched cohort, the incidence of death or liver transplantation was 36.8/100 PYs and 18.6/100 PYs in the diabetes and matched control group, respectively. After adjusting for various factors, coexisting diabetes significantly heightened the risk of death or liver transplantation in the short and long term, in addition to prolonged prothrombin time, low serum albumin, elevated total bilirubin and creatinine, and decreased serum sodium levels. CONCLUSIONS: Diabetes increases the risk of death or liver transplantation in patients with alcoholic liver cirrhosis.

Predicting early rebleeding and mortality after endoscopic hemostasis of esophagogastric varices: Diagnostic performance of aspartate aminotransferase-to-platelet ratio index and model for end-stage liver disease-Na score.

BACKGROUND: Endoscopic variceal ligation and sclerotherapy are recommended for esophagogastric variceal bleeding (EGVB) in cirrhosis but can be complicated by early rebleeding and death. This study aimed to identify noninvasive markers accurately predicting early rebleeding and mortality after endoscopic hemostasis for EGVB. METHODS: Among 116 patients with endoscopically confirmed EGVB and endoscopic hemostasis, various noninvasive markers were calculated, and their predictive accuracy was compared by receiver-operating characteristic curve analysis. Endpoints included 5-day rebleeding, 5-day mortality, 6-week rebleeding, and 6-week mortality. RESULTS: The median age was 63 years. Child-Pugh class B and C patients accounted for 40.5% and 34.5%, respectively. Only the aspartate aminotransferase-to-platelet ratio index (APRI) significantly predicted 5-day rebleeding, with an area under the curve (AUC) of 0.777 (95% confidence interval [CI]: 0.537-1). The model for end-stage liver disease-Na (MELD-Na) score showed good predictive accuracy for 5-day mortality (AUC: 0.839, 95% CI: 0.681-0.997), 6-week rebleeding (AUC: 0.797, 95% CI: 0.663-0.932), and 6-week mortality (AUC: 0.888, 95% CI: 0.797-0.979). CONCLUSIONS: Patients with cirrhosis with a high APRI and MELD-Na score were at high risk of early rebleeding and death after EGVB. Allocating appropriate monitoring and care for those patients is necessary.

EUS coil and glue for gastric varices-prevent, treat and rescue, one therapy to rule them all?

Background and Objectives: In portal hypertension, gastric varix-associated bleeding is known to have higher transfusion requirements, uncontrolled bleeding, rebleeding, intensive care unit requirements, and death. EUS-guided coil insertion is now an acceptable modality for endoscopic management in cases of gastric varices. With this study, we discuss our large single-center experience in the use of EUS for coil and glue injection in gastric varices. We also look into adverse events associated with and possibilities of using this modality as both primary prophylaxis and a rescue therapy. Methods: The study was conducted in a tertiary care center in India. A total of 86 patients were included in the study. The indication for EUS-guided coil and glue was divided into 3 clinical situations, namely, rebleed, rescue, and primary. The technical success and clinical success, that is, control of bleed in patients, were confirmed by absence of Doppler signal on EUS, endoscopic view, and stabilized hemoglobin with no need of blood product transfusion to maintain hemoglobin. Results: The mean Child-Turcotte-Pugh score and Model for End-Stage Liver Disease-Na score were 9.2 and 14.6, respectively. The mean size of the gastric varices was 18.9 mm. The mean number of coils used was 2.9, and the average quantity of glue required was 1.6 mL. The technical success was 100% across the patient group. Clinical success was seen in 90% of the patient group. Mean follow-up was seen for 175.2 days. Conclusions: EUS-guided coil and glue therapy has a role in different clinical settings, as primary therapy, rebleed, and rescue therapy. It has significant technical and clinical success. Its role in treatment algorithms needs to be further studied in prospective studies. It may offer a cost advantage in comparison to interventional radiology-led interventions.

Endoscopic glue injection versus glue plus BRTO or TIPSS for preventing gastric variceal bleeding: A randomized controlled trial.

BACKGROUND AND AIMS: To compare the efficacy of endoscopic injection sclerotherapy with N-butyl cyanoacrylate glue (EIS-CYA) vs EIS-CYA plus a radiologic intervention (either transjugular intrahepatic portosystemic shunt (TIPSS) or balloon-occluded retrograde transvenous obliteration (BRTO)) for secondary prophylaxis in patients with liver cirrhosis who presented with acute variceal bleeding (AVB) from cardiofundal varices. Primary outcome measure was gastric varix (GV) rebleed rates at 1 year. METHODS: Consecutive cirrhosis patients with AVB from cardiofundal varices were randomized into two arms (45 in each) after primary hemostasis by EIS-CYA. In the 'endoscopic intervention' (EI) arm, EIS-CYA was repeated at regular intervals (1, 3, 6 and 12 months), while in the 'radiological intervention' (RI) arm, patients underwent TIPSS or BRTO followed by endoscopic surveillance. RESULTS: GV rebleed rates at 1 year were higher in the EI arm compared to the RI arm: 11 (24·4%; 95% CI: 12·9%-39·5%) versus 1 (2·2%; 95% CI: 0·1%-11·8%); (p=0·004) [ARD: 22.2% (95% CI: 8.4%-36.6%)]. GV rebleed related mortality in the EI arm [8 (17·8%; 95% CI: 8·0%-32·1%)] was significantly higher than in the RI arm [1 (2·2%; 0·1%-11·8%)] (p=0.030) [ARD: 15.6 (95% CI: 2.9%-29.2%)], however, there was no difference in all-cause mortality between the two groups (12 [26·7%; 95% CI: 14·6 to 41·9] versus 7 [15·6%; 95% CI: 6·5 to 29·5]). Numbers needed to treat (NNT) to prevent one GV-related rebleed at 1 year was 4.5. CONCLUSION: Radiological intervention for secondary prophylaxis reduces rebleeding from gastric varices and GV rebleeding related mortality in patients with gastric variceal hemorrhage. (CTRI/2021/02/031396).

The Utility of the Platelet-Albumin-Bilirubin Score as a Non-invasive Predictor of Esophageal Varices and Variceal Hemorrhage in Patients With Liver Cirrhosis Compared to Child-Turcotte-Pugh and Model of End-Stage Liver Disease-Sodium Scores.

Introduction Research on non-invasive tools for detecting gastro-esophageal varices is underway. We investigated the Platelet-Albumin-Bilirubin (PALBI) score in comparison with the Child-Turcotte-Pugh (CTP) and MELD-Na (MELD-Na) scores in patients with liver cirrhosis. Methods Three hundred and twenty-three patients with liver cirrhosis were studied. The PALBI, CTP and MELD-Na scores were calculated and analyzed for gastroesophageal varices and their characteristics using SPSS version 26 (IBM Corp., Armonk, NY, USA). Results Two hundred and sixty-four patients had esophageal varices and 102 presented with variceal hemorrhage. Mean PALBI, CTP and MELD-Na scores were significantly higher for patients with varices versus without varices (p < 0.05). Unlike the mean MELD-Na score, the mean PALBI and CTP scores were significantly higher in patients with large high-risk varices as compared to patients with small low-risk varices (p < 0.05). The mean CTP scores were significantly higher in patients with variceal hemorrhage than those without hemorrhage (p < 0.05), while the difference between mean PALBI and MELD-Na was insignificant, in this regard. The PALBI score had better sensitivity than the CTP and MELD-Na scores in indicating the presence of varices but was similar to the CTP score in predicting high-risk varices. Conclusion The PALBI score proves to have good utility and efficiency in predicting varices in comparison to CTP and MELD-Na scores. It can determine high-risk stigmata of variceal hemorrhage with similar performance as the CTP Score.

Endoscopic band ligation or endoscopic tissue adhesive injection in the treatment of gastric varices: Which is better?

The combination of endoscopic ultrasound with endoscopic treatment of type 1 gastric variceal hemorrhage may improve the robustness and generalizability of the findings in future studies. Moreover, the esophageal varices should also be included in the evaluation of treatment efficacy in subsequent studies to reach a more convincing conclusion.

Bleeding Complications of Portal Hypertension.

In portal hypertension, acute variceal bleed is the cause of 2/3rd of all upper gastrointestinal bleeding episodes. It is a life-threatening emergency in patients with cirrhosis. Nonselective beta-blockers by decreasing the hepatic venous pressure gradient are the mainstay of medical therapy for the prevention of variceal bleeding and rebleeding. Evaluation of the severity of bleed, hemodynamic resuscitation, prophylactic antibiotic, and intravenous splanchnic vasoconstrictors should precede the endoscopy procedure. Endoscopic band ligation is the recommended endotherapy. Rescue transjugular intrahepatic port-systemic shunt (TIPS) is recommended for variceal bleed refractory to endotherapy. In patients with a high risk of failure of combined pharmacologic and endoscopic therapy, pre-emptive TIPS may improve the outcome. For gastric varices, "Sarin classification" is universally applied as it is simple and has therapeutic implication. For IGV1 and GOV2, injection cyanoacrylate glue is considered the endotherapy of choice. Endoscopic ultrasound is a useful modality in the management of gastric varices.

Risk Factors for Rebleeding After Endoscopic Injection of Cyanoacrylate Glue for Gastric Varices: A Systematic Review and Meta-Analysis.

BACKGROUND: Rebleeding is a significant complication of endoscopic injection of cyanoacrylate in gastric varices in cirrhotic patients. AIM: This systematic review and meta-analysis aimed to evaluate the efficiency of endoscopic cyanoacrylate injection and summarized the risk factors for rebleeding. METHODS: Databases were searched for articles published between January 2012 and December 2022. Studies evaluating the efficiency of endoscopic injection of cyanoacrylate glue for gastric varices and the risk factors for rebleeding were included. RESULTS: The final analysis included data from 24 studies. The hemostatic rates ranged from 65 to 100%. The pooled rate of gastric varices recurrence was 34% [95% CI 21-46, I2 = 61.4%], early rebleeding rate was 16% [95% CI 11-20, I2 = 37.4%], late rebleeding rate was 39% [95% CI 36-42, I2 = 90.9%], mild and moderate adverse events rate were 28% [95% CI 24-31, I2 = 91.6%], 3% [95% CI - 2 to 8, I2 = 15.3%], rebleeding-related mortality rate was 6% [95% CI 2-10, I2 = 0%], all-cause mortality rate was 17% [95% CI 12-22, I2 = 63.6%]. Independent risk factors for gastric variceal rebleeding included portal venous thrombosis, ascites, cyanoacrylate volume, fever/systemic inflammatory response syndrome, red Wale sign, previous history of variceal bleeding, active bleeding and paragastric veins. The use of proton pump inhibitors could be a protective factor. CONCLUSIONS: Endoscopic cyanoacrylate glue injection is an effective and safe treatment for gastric varices. Cirrhotic patients with the above risk factors may benefit from treatment aimed at reducing portal hypertension, antibiotic prophylaxis, and anticoagulation if they meet the indications.

Hipertensión portal no cirrótica por enfermedad vascular porto-sinusoidal: presentación de un caso y revisión de la literatura / Non-cirrhotic portal hypertension due to porto-sinusoidal vascular disease: Case presentation and literature review

La enfermedad vascular porto-sinusoidal es una causa infrecuente de hipertensión portal no cirrótica, fue descrita recientemente y es poco diagnosticada por el desconocimiento entre los médicos. Se considera en casos de hipertensión portal clínicamente significativa, en ausencia de cirrosis. El diagnóstico se basa en los hallazgos de la biopsia. El pronóstico de la enfermedad es mejor que el de los pacientes cirróticos, y el tratamiento es similar al de la hipertensión portal y al de las complicaciones que presentan los pacientes con cirrosis. Se presenta el caso de una paciente con várices esofágicas con estudios de imágenes no compatibles con cirrosis y hallazgos específicos en la biopsia de enfermedad vascular porto-sinusoidal. Este caso muestra el ejercicio diagnóstico en un caso de enfermedad vascular porto-sinusoidal de una paciente de Colombia, así como el resultado de las intervenciones terapéuticas y la evolución en el tiempo.

Porto-sinusoidal vascular disease is an uncommon cause of non-cirrhotic portal hypertension. It was recently described and is rarely diagnosed due to lack of knowledge among doctors. It is considered in cases of clinically significant portal hypertension in the absence of cirrhosis, and the diagnosis is based on biopsy findings. The prognosis of the disease is better than that of cirrhotic patients, and the treatment is similar to that of portal hypertension, including the management of complications associated with cirrhosis. We present the case of a patient with esophageal varices, whose imaging studies were not compatible with cirrhosis, alongside specific biopsy findings of porto-sinusoidal vascular disease. This case illustrates the diagnostic process in a patient from Colombia with portosinusoidal vascular disease, as well as the outcomes of therapeutic interventions and the patient´s evolution over time.

Visión general de las várices gástricas y su tratamiento / Overview of gastric varices and their treatment

Las várices gástricas (VG) son un complejo de colaterales vasculares entre la circulación portal y sistémica, condición que se desarrolla como resultado de la presión elevada en el sistema venoso portal. Se encuentran en el 20 % de los pacientes con cirrosis, y son menos frecuentes que las várices esofágicas. Según la clasificación de Sarin, las VG se dividen en cuatro tipos según su ubicación en el estómago y su relación con las várices esofágicas (GOV1, GOV2, IGV1 e IGV2). Entender su hemodinámica con respecto a las rutas de drenaje de las VG es importante para guiar su tratamiento.

Gastric varices (GV) are a complex of vascular collaterals between portal and systemic circulation, a condition that develops as a result of elevated pressure in the portal venous system. They are found in 20% of patients with cirrhosis, and are less common than esophageal varices. According to the Sarin classification, GV are divided into four types based on their location in the stomach and their relationship with esophageal varices (GOV1, GOV2, IGV1, and IGV2). Understanding their hemodynamics with respect to GV drainage routes is important to guide their treatment.

Propranolol can correct prolonged QT intervals in patients with cirrhosis.

Background: Prolonged QT intervals are extremely common in patients with cirrhosis and affect their treatment outcomes. Propranolol is often used to prevent gastroesophageal variceal hemorrhage in patients with cirrhosis; however, it is uncertain whether propranolol exerts a corrective effect on QT interval prolongation in patients with cirrhosis. Aim: The study aimed to investigate the therapeutic effects of propranolol on patients with cirrhosis and prolonged QT intervals. Methods: A retrospective cohort study approach was adopted. Patients with cirrhosis complicated by moderate-to-severe gastroesophageal varices, who were hospitalized at the Affiliated Hospital of Guangdong Medical University between 1 December 2020 and 31 November 2022, were included in the study. The patients were divided into the propranolol and control groups based on whether they had received propranolol. Upon admission, the patients underwent tests on liver and kidney functions, electrolytes, and coagulation function, as well as abdominal ultrasonography and electrocardiography. In addition to conventional treatment, the patients were followed up after the use or non-use of propranolol for treatment and subsequently underwent reexamination of the aforementioned tests. Results: The propranolol group (26 patients) had an average baseline corrected QT (QTc) interval of 450.23 ± 37.18 ms, of which 14 patients (53.8%) exhibited QTc interval prolongation. Follow-up was continued for a median duration of 7.00 days after the administration of propranolol and conventional treatment. Electrocardiographic reexamination revealed a decrease in the QTc interval to 431.04 ± 34.64 ms (p = 0.014), and the number of patients with QTc interval prolongation decreased to five (19.2%; p < 0.001). After treatment with propranolol and multimodal therapy, QTc interval normalization occurred in nine patients with QTc interval prolongation, leading to a normalization rate of 64.3% (9/14). The control group (n = 58) had an average baseline QTc interval of 453.74 ± 30.03 ms, of which 33 patients (56.9%) exhibited QTc interval prolongation. After follow-up for a median duration of 7.50 days, the QTc interval was 451.79 ± 34.56 ms (p = 0.482), and the number of patients with QTc interval prolongation decreased to 30 (51.7%; p = 0.457). The QTc interval normalization rate of patients in the control group with QTc interval prolongation was merely 10.0% (3/33), which was significantly lower than that in the propranolol group (p < 0.001). Conclusion: In patients with cirrhosis complicated by QT interval prolongation, the short-term use of propranolol aids in correction of a long QT interval and provides positive therapeutic value for cirrhotic cardiomyopathy.

Reinforcing the management of type 1 gastric esophageal varices.

Variceal bleed represents an important complication of cirrhosis, with its presence reflecting the severity of liver disease. Gastric varices, though less frequently seen than esophageal varices, present a distinct clinical challenge due to its higher intensity of bleeding and associated mortality. Based upon the Sarin classification, GOV1 is the most common subtype of gastric varices seen in clinical practice.

Computed tomography for the diagnosis of gastroesophageal varices and risk assessment in patients with cirrhosis: a systematic review and meta-analysis.

PURPOSE: This meta-analysis aimed to evaluate the diagnostic accuracy of computed tomography (CT) for gastroesophageal varices (GEVs) and identify high-risk GEVs in patients with cirrhosis. METHODS: A comprehensive search of databases identified 28 studies reporting on CT-based diagnosis for GEVs confirmed via endoscopy. Meta-analyses were conducted to calculate the pooled sensitivity (SEN) and pooled specificity (SPE), positive likelihood ratio (PLR) and negative likelihood ratio (NLR), diagnostic odds ratio (DOR), and the area under the curve (AUC). RESULTS: Based on the number of patients (or varices), the pooled SEN, SPE, PLR, NLR, DOR, and AUC of CT-based diagnosis were estimated at 0.91 (0.92), 0.81 (0.45), 4.82 (1.67), 0.11 (0.17), 42.47 (10.26), and 0.93 (0.94), respectively, for any GEV and at 0.89 (0.89), 0.90 (0.79), 8.86 (4.28), 0.12 (0.14), 75.71 (30.19), and 0.95 (0.85), respectively, for high-risk GEVs. Subgroup analyses indicated that CT had a higher diagnostic accuracy for esophageal varices compared with gastric varices (AUC: 0.93 vs. 0.89, P < 0.05), and the 64-slice CT yielded superior SEN compared with 16-slice and <16-slice CT (AUC: 0.97 vs. 0.92 and 0.82, respectively, P < 0.05). Prospective studies demonstrated higher diagnostic accuracy than retrospective studies (AUC: 0.95 vs. 0.90, P < 0.05). Regarding variceal size, a cut-off of 3 mm and 5 mm discriminated between low- and high-risk individuals, respectively, with high diagnostic accuracy (AUC: 0.992 vs. 0.997, P > 0.05). CONCLUSION: CT demonstrates promising diagnostic accuracy for identifying GEVs and distinguishing high-risk GEVs in patients with cirrhosis. Further research validating optimal variceal size cut-offs is warranted to enhance clinical utility. CLINICAL SIGNIFICANCE: Such a high diagnostic accuracy of CT scans for predicting varices is clinically meaningful for patients with cirrhosis accompanied by portal hypertension. If high-risk varices are identified at CT scans, early intervention would be helpful to reduce the risk of variceal bleeding.

Efficacy and safety of EUS-guided coil embolization in combination with cyanoacrylate injection versus conventional endoscopic cyanoacrylate injection in the treatment of gastric varices with spontaneous portosystemic shunts.

Background: Gastric varices (GV) with spontaneous portosystemic shunts (SPSS) pose considerable risks and challenges for administering endoscopic cyanoacrylate (CYA) injection. This study aimed to evaluate the efficacy and safety of EUS-guided coil embolization in combination with CYA injection compared to conventional endoscopic CYA injection for managing GV with SPSS. Methods: This retrospective analysis included patients with SPSS treated with either EUS-guided coil embolization in combination with CYA injection or conventional CYA injection for gastric variceal bleeding at Ningbo Medical Center Lihuili Hospital (Zhejiang, China) between January 2018 and March 2023. Patient demographics, procedural details, and follow-up results were reviewed. Results: The study evaluated 57 patients: 21 in the combined treatment group undergoing EUS-guided coil embolization in combination with CYA injection and 36 in the conventional group receiving conventional endoscopic CYA injection. Both cohorts achieved a 100% technical success rate. The mean volume of CYA used was significantly lower in the combined group (1.64 ± 0.67 mL) than in the conventional group (2.38 ± 0.72 mL; P < 0.001). Early GV rebleeding rates did not differ significantly between the groups; in contrast, the combined treatment group exhibited a considerably lower incidence of late GV rebleeding than the conventional group (4.8% vs 27.8%, P = 0.041). Conclusions: EUS-guided coil embolization in combination with CYA injection demonstrated superiority over conventional endoscopic CYA injection in reducing late GV rebleeding in treating GV with SPSS.

Isolated gastric varices associated with antiphospholipid syndrome and protein S deficiency: a case report and review of the literature.

The mortality rate of gastric varices bleeding can reach 20% within 6 weeks. Isolated gastric varices (IGVs) refer to gastric varices without esophageal varices and typically arise as a common complication of left portal hypertension. Although IGVs commonly form in the setting of splenic vein occlusion, the combination of antiphospholipid syndrome and protein S deficiency leading to splenic vein occlusion is rare. We herein present a case of a 28-year-old woman with intermittent epigastric pain and melena. She was diagnosed with antiphospholipid syndrome based on the triad of pregnancy morbidity, unexplained venous occlusion, and positive lupus anticoagulant. Laparoscopic splenectomy and pericardial devascularization were performed for the treatment of IGVs. During the 6-month postoperative follow-up, repeated endoscopy and contrast-enhanced computed tomography revealed disappearance of the IGVs. This is the first description of splenic vein occlusion associated with both antiphospholipid syndrome and protein S deficiency. We also provide a review of the etiology, clinical manifestations, diagnosis, and treatment methods of IGVs.

Is salvage Plug-Assisted Retrograde Transvenous Obliteration (PARTO) safe and effective for bleeding gastric varices ?- A preliminary single-center experience.

BACKGROUND: Vascular plug-assisted retrograde transvenous obliteration (PARTO) obliterates the gastric varices and portosystemic shunt, thus resulting in a lower rebleeding rate than endoscopic glue/sclerotherapy. AIMS: To evaluate the safety and efficacy of PARTO as salvage therapy in liver cirrhosis with gastric variceal bleed (GVB) after failed endotherapy. We assessed the clinical success rate and changes in liver function at 6- months. MATERIALS AND METHODS: Patients who underwent salvage PARTO after failed endotherapy for GVB (between December 2021 and November 2022) were searched and analyzed from the hospital database. Clinical success rate and rebleed rate were obtained at six months. Child-Pugh score (CTP) and Model for end-stage liver disease (MELD) score were calculated and compared between baseline and 6-month follow-up. RESULTS: Fourteen patients (n = 14, Child-Pugh class A/B) underwent salvage PARTO. Nine had GOV-2, and five had IGV-1 varices. The mean shunt diameter was 11.6 ± 1.6 mm. The clinical success rate of PARTO was 100% (no recurrent gastric variceal hemorrhage within six months). No significant deterioration in CTP (6.79 ± 0.98 vs. 6.21 ± 1.52; p = 0.12) and MELD scores (11.5 ± 4.05 vs. 10.21 ± 3.19; p = 0.36) was noted at 6 months. All patients were alive at 6 months. One patient (n = 1, 7.1%) bled from esophageal varices after three days of PARTO and was managed with variceal banding. 21.4% (3/14) patients had progression of esophageal varices at 6 months requiring prophylactic band ligation. Three patients (21.4%) had new onset or worsening ascites and responded to low-dose diuretics therapy. CONCLUSIONS: PARTO is a safe and effective procedure for bleeding gastric varices without any deterioration in liver function even after six months. Patient selection is critical to prevent complications. Further prospective studies with larger sample size are required to validate our findings.

Diagnostic and therapeutic role of endoscopic ultrasound in liver diseases: A systematic review and meta-analysis.

BACKGROUND: In hepatology, the clinical use of endoscopic ultrasound (EUS) has experienced a notable increase in recent times. These applications range from the diagnosis to the treatment of various liver diseases. Therefore, this systematic review summarizes the evidence for the diagnostic and therapeutic roles of EUS in liver diseases. AIM: To examine and summarize the current available evidence of the possible roles of the EUS in making a suitable diagnosis in liver diseases as well as the therapeutic accuracy and efficacy. METHODS: PubMed, Medline, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched until October 2023. The methodological quality of the eligible articles was assessed using the Newcastle-Ottawa scale or Cochrane Risk of Bias tool. In addition, statistical analyses were performed using the Comprehensive Meta-Analysis software. RESULTS: Overall, 45 articles on EUS were included (28 on diagnostic role and 17 on therapeutic role). Pooled analysis demonstrated that EUS diagnostic tests had an accuracy of 92.4% for focal liver lesions (FLL) and 96.6% for parenchymal liver diseases. EUS-guided liver biopsies with either fine needle aspiration or fine needle biopsy had low complication rates when sampling FLL and parenchymal liver diseases (3.1% and 8.7%, respectively). Analysis of data from four studies showed that EUS-guided liver abscess had high clinical (90.7%) and technical success (90.7%) without significant complications. Similarly, EUS-guided interventions for the treatment of gastric varices (GV) have high technical success (98%) and GV obliteration rate (84%) with few complications (15%) and rebleeding events (17%). CONCLUSION: EUS in liver diseases is a promising technique with the potential to be considered a first-line therapeutic and diagnostic option in selected cases.

Percutaneous Covered Stenting in Splenic Vein for Left-sided Portal Hypertension Caused by Chronic Splenic Vein Obstruction.

Left-sided portal hypertension (LSPH), an uncommon manifestation of portal hypertension, is characterized by conditions such as isolated gastric varices and splenomegaly, which result from impeded splenic venous drainage in the presence of pancreatic disease. We employed a percutaneous transhepatic technique to achieve regression of isolated gastric varices by implanting a covered stent within a blocked splenic vein and by embolizing the posterior gastric vein and varices using N-butyl-2-cyanoacrylate. We report the successful treatment of stenting for LSPH by the covered stent placement.

[Trends in endovascular treatment and prevention of portal bleeding]. / Tendentsii v rentgenendovaskulyarnom lechenii i profilaktike portal'nykh krovotechenii (obzor literatury).

Bleeding from esophageal and gastric varices is a major factor of mortality in patients with portal hypertension. The gold standard for diagnosis of portal hypertension is hepatic venous pressure gradient determining the treatment algorithms and risk of recurrent bleeding. Combination of endoscopic methods and therapy is limited by varix localization and not always effective. In these cases, endovascular bypass and decoupling techniques are preferred. Early endovascular treatment of portal bleeding is effective for hemostasis and higher transplantation-free survival of patients. Early transjugular intrahepatic portosystemic bypass should be associated with 8-mm covered stents of controlled dilation. Combination of endovascular techniques reduces the complications of each technique and potentiates their positive effect. Endovascular treatment and prevention of portal bleeding should be determined by anatomical features of portal venous system.