Gastric Varices in Cirrhosis versus Extrahepatic Portal Venous Obstruction and Response to Endoscopic N-Butyl-2-cyanoacrylate Injection

Abstract

Background: Gastric varices are found in patients with portal hypertension. Incidence of bleeding from gastric varices is relatively low, but tends to be more severe, and is associated with higher mortality than esophageal variceal bleeding. Aims and objectives: To compare the prevalence and types of gastric varices in cirrhosis versus extrahepatic portal venous obstruction (EHPVO) and the results of endoscopic N-butyl-2-cyanoacrylate (NBC, glue) injection. Methods: Eighty six patients presenting with bleeding from gastric varices between August 2010 and August 2011 were retrospectively analyzed. Results: Of 86 patients, 65% (n = 56) were cirrhotics and 35% (n = 30) had EHPVO. Distribution of types of gastric varices showed GOV1 in 14% (n = 8) of cirrhotics vs. 7% (n = 2) of EHPVO, GOV2 in 80% (n = 45) of cirrhotics vs. 53% (n = 16) of EHPVO, IGV1 in 40% (n = 12) of patients with EHPVO vs. 4% (n = 2) cirrhotics. The patients were treated with NBC injections. The mean volume of glue injected was 3.7 ± 2.58 ml over a median of 1 session (range: 1-8). The total volume of glue required was lower in cirrhotics (3.2 ± 2 ml vs. 4.7 ± 3.1 ml, p < 0.05) than in EHPVO patients. Twenty (36%) of cirrhotics required >1 sessions of glue injection as compared to 17 (57%) of EHPVO patients. Over mean follow up of 12 months, rebleeding (9% vs. 10%) and mortality (11% vs. 3%) were similar in patients with cirrhosis and EHPVO. Conclusions: In patients with bleeding from gastric varices, GOV2 is more common in cirrhotics and IGV1 in patients with EHPVO. Patients with EHPVO required higher total volume of glue and more glue sessions for gastric varix obturation. ( J CLIN EXP HEPATOL 2013;3:19-23)

Overview of Complications in Cirrhosis

“…Non-selective beta blockers Propranolol (40-80 mg orally two times per day) Carvedilol (3.125 mg twice daily, titrate up to 25 mg qd) 75,87 Hepatorenal syndrome (HRS) Terlipressin Midodrine and octreotide Dopamine Noradrenaline infusion 0.5-1 mg q 6h as bolus IV with doubling of dose every 2 days to a maximum of 12 mg/day of creatinine does not decrease by >25%. 59 Treatment can be given for up to 2 weeks, but can be stopped early after complete reversal of HRS.…”

“…69,74 Injection of glues like cyanoacrylate or N-butyl-cyanoacrylate in gastric AVB has been reported in studies from India. [75][76][77] Endoscopic ultrasound assisted coil and glue injection is another technique used to control gastric variceal bleeding. 78 Early TIPS placement (within 72 of hemorrhage) as a pre-emptive procedure can prevent rebleeding-related mortality in a selected group of patients at a high risk of failure or rebleeding (HVPG > 20 mmHg, CTP class C cirrhosis, or CTP class B with active bleeding on endoscopy) who have no contraindications for TIPS.…”

Hepatobiliary Quiz-6 (2013)

“…GOV2 was present in 80% of cirrhotics as compared to 53% of EHPVO patients while IGV1 was seen in only 4% cirrhotics compared to 40% of patients with EHPVO. 47 Endoscopic glue injection and transjugular intrahepatic portosystemic shunts (TIPS) are equivalent in the control of acute bleeding, with a similar rate of rebleeding but compared with glue but TIPS is associated with higher morbidity because of an increased incidence of encephalopathy. Glue injection is also significantly cheaper and available at many more centres than TIPS.…”