Venous anatomy of the lower oesophagus in portal hypertension: Practical implications

Kitano, Seigo; Terblanche, J.; Kahn, Delawir; Bornman, P. C.

doi:10.1002/bjs.1800730704

Cited by 113 publications

(34 citation statements)

References 11 publications

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“…The portal circulation is complex, and in the presence of patients received sclerotherapy when ligation alone was un-portal hypertension the flow often is bidirectional. 17 Patterns successful in the face of rebleeding. In addition, one patient of venous drainage are variable and unpredictable.…”

Section: Failures Of Therapy and Loss To Follow-upmentioning

confidence: 99%

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: A multicenter prospective randomized trial

et al. 1997

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rate could be lowered [3][4][5][6][7][8] and survival prolonged. 4,6,9,10 Studies Patients who have bled from varices remain at risk with rubber band ligation have shown that in addition to for rebleeding. There is interest in methods that would being safer than sclerotherapy, 11-14 ligation can further lower enable rapid eradication of varices. The present trial the rebleeding rate 12,13 and further improve survival. 11 Howwas designed to study whether combining ligation with ever, the problem of rebleeding has not been eliminated. Besclerotherapy will allow quicker eradication of varices cause most episodes of rebleeding occur early, methods that than either modality alone. Patients with bleeding eradicate varices more rapidly by reducing the ''period at esophageal varices were randomized into ligation or risk'' might further improve outcome. combination therapy groups. Patients in the ligationIn our first multicenter trial, an average of five sessions group were treated with endoscopic rubber band ligawere required to eradicate varices with sclerotherapy, tion alone. In combination group patients, each variceal whereas four sessions were required with ligation. 11 To furcolumn was ligated distally and 1 mL of ethanolamine ther optimize efficiency, we asked whether a lower dose of was injected proximal to each ligated site. Subsequent sclerotherapy in conjunction with ligation would eradicate treatment sessions were at 7-to 14-day intervals until esophageal varices more quickly than either modality alone, varices were eradicated. The clinical and endoscopic while maintaining the lower complication rate associated characteristics of 25 patients in the ligation group were with ligation. In an initial single-arm study, we ligated each similar to those of 22 patients in the combination group.variceal column distally and injected 1 mL of sclerosing soluFollow-up was up to 30 months. Active bleeding was contion proximal to each ligated site. With this approach, varices trolled in 100% of patients in the ligation group and 75%were eradicated with an average of approximately three sesof those in combination group (P Å NS). It took 3.3 { .4sions. 15 The aim of the present prospective randomized trial (range, 1-7) sessions to eradicate varices with ligation was to determine whether combination therapy would eradiand 4.1 { .6 (1-7) with combination therapy (P Å NS).cate varices more quickly than ligation alone. The rebleeding rate in patients who survive an episode of geal varices with red color signs, and absence of other lesions such as variceal hemorrhage is higher than that associated with any ulcers, erosions, vascular malformations, or mucosal tears. Exclusion other cause of upper gastrointestinal hemorrhage.1 An early criteria were (1) previous endoscopic or operative treatment, i.e., study of the ''natural history'' of variceal bleeding showed rubber band ligation, sclerotherapy, or shunt; (2) gastric varices more that approximately one third of patients who survived the than 2 cm from the gastroesophageal jun...

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Section: Failures Of Therapy and Loss To Follow-upmentioning

confidence: 99%

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: A multicenter prospective randomized trial

et al. 1997

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“…Previous reports on the portal collateral system have resulted from postmortem examinations [10, 11, 12]or angiographic analyses [13, 14, 15, 16]. However, these descriptions were not precise enough to be useful in variceal treatments.…”

Section: Introductionmentioning

confidence: 99%

Correlation between Endoscopic and Angiographic Findings in Patients with Esophageal and Isolated Gastric Varices

Chikamori¹,

Kuniyoshi²,

Shibuya

et al. 2001

Dig Surg

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Background/Aim: The correlation between angiographic vascular patterns and endoscopic findings in portal hypertension is not sufficiently known, and knowledge of the vascular anatomy may contribute to an improvement in endoscopic embolization and transjugular retrograde obliteration procedures. We propose a new vascular map that should prove useful for this purpose. Methods: Between April 1985 and December 1997 we performed percutaneous transhepatic portography in a selected group of 75 patients (16 women and 59 men), aged 43–71 years, from whom informed consent was obtained. All patients had been diagnosed endoscopically as having either esophageal or isolated gastric varices. According to the Child-Pugh classification, class A, B, and C cirrhosis was seen in 19, 40, and 16 patients, respectively. We created a vascular map of esophageal and isolated gastric varices, based on the opacification of the portal venous collaterals on percutaneous transhepatic portography. We compared the patients in both variceal groups in terms of portal venous pressure, main blood supply, and drainage routes. Results: We found that the portal collateral system was divided into two systems: the portoazygos venous system and the portophrenic venous system. The former contributed to the formation of esophageal and cardiac varices and the latter to the formation of isolated gastric varices located at the fundus or at both the cardia and fundus. The left gastric vein participated as blood supply in 70% of the isolated gastric varices and in 100% of the esophageal varices (p < 0.01). The posterior gastric vein participated as blood supply in 70% of the isolated gastric varices and in 24% of the esophageal varices (p < 0.01). We classified the main blood drainage routes of isolated gastric varices functionally into three types: gastrorenal shunt (85%), gastrophrenic shunt (10%), and gastropericardiac shunt (5%). The portal venous pressure in patients with esophageal varices was 358 ± 66 mm H₂O, whereas in patients with isolated gastric varices it was 262 ± 44 mm H₂O (p < 0.01). Conclusion: We suggest that this new vascular map will be useful in endoscopic embolization and transjugular retrograde obliteration procedures for esophageal and isolated gastric varices.

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“…These collaterals -mainly located with-DOI: 10.1159/000492076 in the mucosa and submucosa [1,2] of the distal oesophagus, the gastroesophageal junction or the gastric fundus -may rupture and cause life threatening bleeding. It is assumed that once the portal pressure surpasses 10 mm Hg, varices develop.…”

Section: Formation Of Varices and Occurrence Of Variceal Bleedingmentioning

confidence: 99%

“…The potential of bleeding occurs beyond a threshold of 12 mm Hg. Besides the blood pressure within the vessel, the risk of bleeding is determined by morphological parameters (variceal size and location) [1,2,4]. In compensated cirrhosis without oesophageal varices, such collaterals develop at a rate of 7-8% per year [5].…”

Section: Formation Of Varices and Occurrence Of Variceal Bleedingmentioning

confidence: 99%

Treatment of Oesophageal Varices in Liver Cirrhosis

Sauerbruch

2018

Digestion

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Background: The development of cirrhosis with resultant portal hypertension can lead to oesophageal varices at a rate of 7% per annum. Bleeding from varices happens when the portal pressure is ≥12 mm Hg and can threaten life. Summary: Eliminating the aetiology of cirrhosis is a pivotal step to prevent the formation of varices. In patients with established varices, primary prophylaxis with non-selective beta blockers (NSBB) may slow down the progression of varices and prevent the first variceal bleed. NSBB, similar to other agents such as renin/angiotensin blockers, statins, and rifaximin, may have the additional advantage of blunting inflammatory stimuli, which can contribute to the progression of varices. Variceal band ligation is an alternative for primary bleeding prophylaxis with excellent results. Any acute variceal bleed should be managed with band ligation after careful resuscitation. Early pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) in decompensated cirrhotic patients is very effective in controlling the bleeding and improves survival. Secondary prophylaxis against further variceal bleeding using NSBB and band ligation is recommended in most other patients. TIPS may be considered in appropriate patients as a secondary prophylaxis against recurrent variceal bleed. Future research should be directed towards the prevention of varices and targeting inflammation to reduce cirrhotic complications. Key Messages: Treatment strategies depend on the stage the patient is at along the natural history of varices: NSBB or band ligation for primary prophylaxis; band ligation or early TIPS for acute bleed; and a combination of NSBB + band ligation or TIPS for secondary prophylaxis (Fig. 1).

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Venous anatomy of the lower oesophagus in portal hypertension: Practical implications

Cited by 113 publications

References 11 publications

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: A multicenter prospective randomized trial

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: A multicenter prospective randomized trial

Correlation between Endoscopic and Angiographic Findings in Patients with Esophageal and Isolated Gastric Varices

Treatment of Oesophageal Varices in Liver Cirrhosis

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