Usefulness of antegrade foam sclerotherapy for portal hypertensive variceal bleeding.

PURPOSE: This study investigates the usefulness of antegrade variceal embolization using sclerosant foam to evaluate technical success and clinical outcomes in cases of hypertensive variceal bleeding. METHODS: A total of 16 patients underwent percutaneous antegrade variceal embolization using foam sclerotherapy from August 2019 to January 2022. Among the patients, 12 cases were of gastroesophageal varices, two were rectal varices, and one case each was duodenal and jejunal varices, respectively. Sodium tetradecyl sulfate (STS) foam was used as a detergent for variceal bleeding sclerotherapy at various anatomical locations. The detergent was used in a foam form to promote clinical outcomes and enable the effective embolization of the entire blood vessel wall, including the ventral side, against gravity. Furthermore, STS foam could be used to help sufficiently deliver the drug to distal segments. A balloon catheter was also used to block the antegrade flow and prevent the dilution of the sclerosant. Technical success was defined as the completion of sclerotherapy for variceal bleeding as planned before the procedure to achieve the disappearance of variceal bleeding. Clinical success was defined as the complete obliteration of varices without recurrent bleeding during the follow-up period after the procedure. RESULTS: Technical success was 81.3%, and clinical success was 84.6%. Additionally, 15/16 of the procedures were emergencies, and there were no complications related to the procedure. CONCLUSION: Antegrade foam sclerotherapy using 3% STS for variceal bleeding is clinically safe and effective. Moreover, antegrade foam sclerotherapy can be a useful treatment option for patients with active variceal bleeding in emergency cases.

Comparison of carvedilol and propranolol for primary prophylaxis of esophageal variceal bleed in cirrhotic patients.

Cirrhosis continues to claim the lives of people worldwide every year. Esophageal variceal bleeding due to portal hypertension is one of the dreadful complications. We compared carvedilol with propranolol to find better drug that can prevent index variceal bleed in cirrhotic patients. 220 patients with known esophageal varices on upper GI endoscopy and no previous history of GI bleed were randomized to group A (Carvedilol) and group B (Propranolol). Bleeding occurred in 37.14% and 59.04% of the patients in group A (carvedilol) and B (propranolol) respectively (p=0.02). Bleeding was more common among patients with large as compared to small varices (67.04% versus 35.48% respectively). Among patients with large varices bleeding occurred in 58.13% and 75.55% of patients in group A and B respectively while in small varices, bleeding rate was 25% and 46.66% respectively (p=0.03). Regarding the response of beta blockers, mean pulse rate dropped from 85.15±5.49 to 59.8±2.39 per minute in Group A while in Group B it was reduced to 60.5±4.21 from 83.8±5.33 per minute at 3 years follow up. No significant difference found in the side effect profile. Our study showed that carvedilol was more effective than propranolol in primary prevention of variceal hemorrhage.

Positive effects of Pycnogenol®-Centellicum® on venous elasticity: an ex-vivo concept study.

BACKGROUND: The aim of this ex-vivo study was to evaluate the efficacy of Pycnogenol®-Centellicum® oral supplementation on vein segments, retrieved from graft harvesting or from vein surgery. The parameters assessed were elasticity and recovery after dynamic tests: 1) an enlargement stress; 2) an elongation stress; and 3) elasticity after torsion. The tests were made in standardized conditions, less than 3 hours after explant, at 22 °C by the same operator with surgical and microsurgical experience. METHODS: Veins of 59 subjects were included in the study: 17 subjects with normal veins with a planned bypass graft and 42 subjects with varicose veins. Of the subjects with normal veins, 8 subjects followed standard management (group 1) and 9 took Pycnogenol®-Centellicum® for 4 weeks before surgery (group 2). In the group with varicose veins, 22 subjects served as controls (group 3) and 20 were supplemented with Pycnogenol®-Centellicum® for 4 weeks before surgery (group 4). No side effects or tolerability problems were observed in the supplementation period before surgery and veins harvesting. The full return to initial shape/sizes after dynamic stress was evaluated in 1 min after removing the stress. RESULTS: In group 1, 4 out of 8 vein segments recovered their size after forced enlargement vs. 7/9 in the Pycnogenol®-Centellicum® group 2 (P<0.05). In the elongation test, 3/8 normal control vein segments recovered their length (group 1) vs. 7/9 in the supplement group (group 2) (P<0.05). In the torsion test, 4/8 (group 1) veins recovered their shape after torsion vs. 9/9 veins in Pycnogenol®-Centellicum®-pretreated segments (group 2) (P<0.05). Only 45.8% of normal, control vein segments (group 1) recovered their shape/size in comparison with 85.2% of normal vein segments in the supplement group (group 2) (P<0.05). In group 3 and 4 (segments of varicose veins), the proportion of vein segments with enlargements, elongation and torsion were significantly lower at the end of the test (P<0.05) in the Pycnogenol®-Centellicum® group 4 with 51.7% of the vein segments recovering their shape in the Pycnogenol®-Centellicum® vs. 16.6% of the vein segments recovering their shape in control segments (P<0.05). Results show that Pycnogenol®-Centellicum® supplementation allows vein segments to better return to their original shape/size after a morphological alteration of shape (in different directions). This could be an expression of an improved wall tone and elasticity of the veins. No vein was teared or damaged during the 59 tests indicating that all stresses were well within the normal wall tensile characteristics of the veins. CONCLUSIONS: In this study, Pycnogenol®-Centellicum® improved vein elasticity in subjects with normal and varicose veins as vein segments were more elastic (able to recover length and shape) and less passively dilated by high pressure or dynamic stresses. This study indicates that the protective effects of Pycnogenol®-Centellicum® may partially stop passive dilatation of veins to varicose veins over time by improving vein elasticity. Pycnogenol®-Centellicum® managed vein segments return more rapidly back to the initial dimensions, shapes and diameters after a dynamic stress.

Beta-adrenergic blockade in cirrhosis - harmful or helpful?

INTRODUCTION: Portal hypertension exacerbates the disease course of cirrhosis and is responsible for major complications, including bleeding from esophageal varices, ascites, and encephalopathy. More than 40 years ago, Lebrec and colleagues introduced beta-blockers to prevent esophageal bleeding. However, evidence now suggests that beta-blockers may cause adverse reactions in patients with advanced cirrhosis. AREAS COVERED: This review addresses current evidence for the pathophysiology of portal hypertension, focusing on the pharmacological effects of treatment with beta-blockers, indications for preventing variceal bleeding, their effects on decompensated cirrhosis, and the risk of treating patients suffering from decompensated ascites and renal dysfunction with beta-blockers. EXPERT OPINION: The diagnosis of portal hypertension should be based on direct measurements of portal pressure. Carvedilol or nonselective beta-blockers are the first-line treatment for patients with medium-to-large varices as primary or secondary prophylaxis, in Child C patients with small varices, and sometimes for patients with clinically significant portal hypertension (HVPG ≥ 10 mm Hg, irrespective of the presence of varices) to prevent decompensation. Caution should be used when treating decompensated patients who are suspected of imminent cardiac and renal dysfunction. Future strategies for managing patients with portal hypertension should aim for more personalized treatment that takes into account the disease stage.

Survival outcomes of patients with concomitant acute variceal bleeding and acute coronary syndrome, and the role of antiplatelet agents: an institutional experience from a lower middle-income Country.

BACKGROUND: There is strong evidence demonstrating the incidence of Acute Coronary Syndrome (ACS) among patients with cirrhosis, with the initiation of antiplatelet therapy being subject to debate due to an increased risk of bleeding. This study aimed to determine mortality among patients presenting with concomitant Acute Variceal Bleeding (AVB) and ACS at Index admission. Furthermore, the recurrence of AVB and ACS among patients discharged with or without antiplatelet therapy was determined. METHODS: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan on patients ≥ 18 years of age admitted to our ER with concomitant ACS and AVB between January 2002 to December 2017. Follow-up for 6 months or till death (if < 6 months), was observed, to help determine the incidence of recurrent AVB and ACS. The incidence of AVB and ACS was then compared amongst patient groups based on the usage of anti-platelet drugs on discharge. RESULTS: A total of 29 patients were included, with a mean age of 58.7 ± 11.0 years. Seven patients died on admission, having worse underlying liver disease. No mortality was reported among the remaining 22 patients. All 22 patients underwent surveillance endoscopy with variceal band ligation until obliteration, as needed. Only 7 patients from the surviving cohort received antiplatelet therapy. After 6.05 ± 1.1 months of follow-up, 1/22 (4.5%) developed recurrent AVB and 2/22 (9.1%) developed cardiovascular events. Importantly, there was no significant difference in the incidence of recurrent AVB (P = 1.000) and ACS (P = 0.091), depending on the use of antiplatelet therapy. CONCLUSION: Concomitant AVB and ACS is a severe disorder with increased mortality among cirrhotic patients at presentation. The incidence of AVB does not seem to exacerbate with the use of antiplatelet agents, provided successful obliteration of varices is achieved using elective band ligation.

Factors influencing superficial and deep vein thrombosis after foam sclerotherapy in varicose veins.

BACKGROUND: Side effects of foam sclerotherapy for varicose veins can include both deep (DVT) and superficial leg vein thrombosis (SVT). The risk factors that favor the development of SVT or DVT after foam sclerotherapy are still largely unclear. The aim of our retrospective analysis was to use a larger group of patients with thromboembolic complications to identify both patient-related and procedure-related risk factors for thromboembolic complications from foam sclerotherapy. PATIENTS AND METHODS: A total of 170 patients who received foam sclerotherapy were examined. With reference to a cut-off date, March 17th, 2020, the 85 most recent patients with thromboembolic complications (study group A) were included and compared to the most recent 85 patients without thromboembolic complications (control group B), after sclerotherapy with foamed sclerosant. RESULTS: Patients with a thromboembolic complication were more likely to have thrombophilia (11/85 vs. 3/85). The mean BMI values in group A (25.9 ± 5.1) were significantly lower than in group B (28.0 ± 7.2) (P = 0.034). Thromboembolic complications were more likely to appear after foam sclerotherapy on the lower leg (61/105) than on the thigh (1/13) (P < 0.001), particularly after dorsal than after ventral foam sclerotherapy (39 of 47 vs. 5 of 40, P < 0.001). Of the 39 thromboembolic complications on the dorsal lower leg, 23 were muscle vein thromboses. CONCLUSION: The risk of muscle vein thrombosis after foam sclerotherapy is especially increased in slender patients with sclerosed, dorsal lower legs.

Risk of Postoperative Thromboembolism in Men Undergoing Urological Prosthetic Surgery: An Assessment of 21,413 Men.

PURPOSE: We assessed venous thromboembolism (VTE) and associated risk factors following artificial urinary sphincter (AUS) and inflatable penile prosthesis (IPP) surgery. MATERIALS AND METHODS: Using IBM® MarketScan, a commercial claims database, patients undergoing AUS and IPP surgery were identified using CPT® and ICD (International Classification of Diseases)-10 procedure codes between 2008 and 2017. ICD-9 and -10 codes were used to identify health care visits associated with lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) within 90 days of surgery. Covariates were assessed using a multivariable model to determine association with outcome of DVT and/or PE. RESULTS: A total of 21,413 men underwent AUS (4,870) or IPP (16,543) surgery between 2008 and 2017 with a median age of 62 years and 68 years, respectively. DVT and PE events following AUS and IPP surgery occurred in 1.54% and 1.04%, respectively. A history of varicose veins (HR 2.76; 95% CI 1.11-6.79), prior history of DVT (HR 13.65; 95% CI 7.4-25.19), or PE (HR 7.65; 95% CI 4.01-14.6) in those undergoing AUS surgery was highly associated with development of postoperative VTE. Likewise, prior history of DVT (HR 12.6; 95% CI 7.99-19.93) and PE (HR 8.9; 95% CI 5.6-14.13) was strongly associated with a VTE event following IPP surgery. CONCLUSIONS: In a large cohort of men undergoing AUS and IPP surgery, 1.54% and 1.04% of men experienced a VTE event within 90 days of surgery, respectively. Prior history of varicose veins, DVT, and PE was associated with an increased likelihood of developing a postoperative DVT or PE.

Applying spectrochemical analyses on venous disease patients treated by N-Butyl Cyanoacrylate Ablation Surgery.

BACKGROUND: The venous disease of the legs is a common disease among adults that may lead to a deterioration in the structure and concentration of biomolecules. N-Butyl Cyanoacrylate Ablation Surgery (NBCA) or cyanoacrylate embolization (CAE) technique to adhesive the saphenous vein is an alternative method for the treatment of venous disease. OBJECTIVE: We aimed to show what kind of changes occurs after CAE surgery using FTIR spectroscopy combined chemometrics. We compared before and after surgery blood sera of patients to find whether a correlation between spectral data and laboratory indexes. We studied the blood sera of those who suffered from varicose veins and treated them by CAE technique. METHODS: In order to examine the molecular profiles in blood sera who underwent the CAE technique of the great saphenous vein for the treatment we used Fourier Transform InfraRed spectroscopy (FTIR) spectroscopy of blood samples of patients before and after surgery as a fast diagnostic technique. To obtain information about the spectra variation among the types of samples Principal component analysis (PCA) was performed for fingerprint, amide II with amide I regions. To find normality among variations Partial Least Square P-P plot of residual was performed. RESULTS: Absorbance values were statistically significant only in amide II, amide I, and OH vibrations. In the blood collected before surgery, higher peaks area of α-helix and ß-harmonica were noticed. However, in both groups of samples, a higher amount of ß-harmonica was visible. Pearson correlation analysis showed that the value of white blood cells (WBC) correlate with absorbance at 2858 cm-1 wavenumber. Moreover, a correlation between neutrophil (NEU) and OH vibrations, and between hematocrit (HCT) and 1082 cm-1, were found. Furthermore, a high correlation Platelets (PLT) and FTIR peak at 1165 cm-1, was noticed. CONCLUSIONS: This methodology suggests with PCA analysis CAE caused structural and quantitative chemical changes in blood samples of patients.

Exendin-4 attenuates inflammation-mediated endothelial cell apoptosis in varicose veins through inhibiting the MAPK-JNK signaling pathway.

Context: Inflammation response has been found to be associated with endothelial cell death in the progression of varicose veins. Exendin-4 is able to reduce inflammation and thus attenuate cell apoptosis.Aim: The aim of our study is to explore the influence of Exendin-4 on LPS-treated endothelial cells.Methods: Cells were treated with LPS. Exendin-4 was added into the medium of cells. Western blots, qPCR, and ELISA were used to analyze the role of Exendin-4 in LPS-mediated cell death.Results: We found that LPS treatment caused significantly cell death. Whereas this trend could be attenuated by Exendin-4. After treatment with Exendin-4, inflammation factors upregulation and oxidative stress activation were significantly repressed, an effect that was followed by a drop in the levels of glucose production and lactic acid generation. At the molecular levels, Exendin-4 treatment inhibited the activity of MAPK-JNK signaling pathway in the presence of LPS treatment.Conclusions: LPS causes cell apoptosis through inducing inflammation response, oxidative stress and energy stress. Exendin-4 treatment enhances cell survival, reduces inflammation, and improves energy stress through inhibiting the MAPK-JNK signaling pathway.

A case of severe stenosis of hepatic veins and inferior vena cava with stomal variceal bleeding induced by oxaliplatin-based chemotherapy.

A 27-year-old woman with colon cancer and liver metastasis was referred to our hospital. Colectomy and colostomy were performed to improve her ileus. Following 13 sessions of oxaliplatin-based chemotherapy (OC) with mFOLFOX6 + bevacizumab, thrombocytopenia and frequent peristomal bleeding occurred. Computed tomography showed severe ascites, splenomegaly, significant collateral veins around the stoma, and severe stenosis of the hepatic veins (HV) and inferior vena cava (IVC). Ultrasound elastography showed high liver (and spleen) stiffness values. Repeated OC appeared to cause IVC stenosis as a result of worsening sinusoidal obstruction syndrome (SOS), and peristomal variceal bleeding. After ultrasound-guided percutaneous embolization, bleeding did not recur. Unfortunately, the patient died of liver dysfunction caused by severe SOS. The incidence of OC-induced SOS is reported to be about 50%; however, there is apparently no report of OC-induced HV and IVC stenosis, and in most cases, portal hypertension is improved after OC cessation. This is the first report of OC-induced severe HV and IVC stenosis resulting in refractory peristomal variceal bleeding and eventual death.

[A case of bleeding stomal varices during the course of oxaliplatin-based chemotherapy for recurrent rectal cancer].

A 51-year-old man with a history of an abdominoperineal resection of the rectum and colostomy for rectal cancer underwent chemotherapy for multiple liver metastases.Twenty -two courses of the folinic acid, 5-fluorouracil(5-FU)and oxaliplatin(FOLFOX4)/bevacizumab(BEV)regimen and 39 courses of 5-FU/Leucovorin/BEV were administered.Progressive splenomegaly and stomal varices were observed during the course of chemotherapy.The patient was admitted due to excessive bleeding after colostomy.Angiography revealed bleeding stomal varices secondary to portal hypertension.Splenectomy was performed with subsequent reduction in the size of the stomal varices and no rebleeding was observed.Oxaliplatin -based chemotherapy could lead to hepatic sinusoidal dilation and induce splenomegaly and varix formation secondary to portal hypertension.Our experience with this case suggests that careful attention should be paid to stomal varices in colostomy patients receiving oxaliplatin-based chemotherapy.

The effects of vasopressin and its analogues on the liver and its disorders in the critically ill.

PURPOSE OF REVIEW: Vasopressin and terlipressin, a long-acting V1a analogue, are increasingly used in intensive care. The main clinical indications are the treatment of patients with septic shock and of patients with cirrhosis, who develop variceal bleeding, the hepatorenal syndrome or both. In this review, we summarize the effects of these drugs on splanchnic hemodynamics and organ function. RECENT FINDINGS: A recent systematic meta-analysis of randomized trials suggests that terlipressin may improve renal function in hepatorenal syndrome and thereby reduce mortality by 34%. Moreover, a recent study reported that association of terlipressin and albumin was more effective than terlipressin alone. In patients with variceal bleeding, the bleeding control is significantly improved by early administration of terlipressin. The place of vasopressin in the treatment of patients with septic shock is still discussed, but compared with norepinephrine, vasopressin showed at least an equal efficacy. SUMMARY: The use of vasopressin and its synthetic analogues has shown beneficial effects in the management of patients with cirrhosis, especially in the context of variceal bleeding, the hepatorenal syndrome or both. In both cases, the use of terlipressin improved survival. Therefore, in these clinical indications, terlipressin is a part of recommendations. The role of vasopressin in patients with septic shock remains to be precisely evaluated.

[Colonic varices: an unusual cause of occult blood loss]. / Colonvarices: een zeldzame oorzaak van occult bloedverlies.

A man aged 81 known to suffer from atrial fibrillation - the treatment for which included acetylsalicylic acid - and chronic obstructive pulmonary disease, was hospitalized because of a respiratory infection. Since he had iron deficiency anaemia and the case history mentioned "intestinal bleeding', supplementary examinations were carried out. Endoscopy revealed colonic varices; because of the absence of portal hypertension and other disorders related to colonic varices, the varices were classified as idiopathic. In view of the extensiveness of the lesions, it was decided to refrain from endoscopic sclerotherapy and to adopt an expectative policy.

[Venous insufficiency and oral contraception]. / Insuffisance veineuse et contraception orale.

Varicose veins are commoner in women than in men. The recrudescence of venous symptoms during pregnancy or premenstrual syndrome indicate the preponderant role of sex hormones in their etiology. Oral contraception may thus have effects on the veins. These effects can be broadly divided into two groups: risks of thromboembolism (clotting disorders, venous wall changes and hemodynamic abnormalities). These risks are rare but serious, venous pathology (loss of venous tone, slowing of blood flow, valve insufficiency, trophic lesions, etc.) Since the availability of low dose oral contraceptives, and since improved knowledge of contraindications, vascular repercussions have almost disappeared except when there is a vascular past history which must be routinely sought.