Gastric Varices
Gastric Varices. Massive Upper Gastrointestinal Bleeding.

Video Endoscopic Sequence 1 of 3.

Massive Upper Gastrointestinal Bleeding.

Gastric Varices.

In this video clip, you can observe one of the worst bleeding of the gastrointestinal track.

It is more difficult to stop bleeding from the gastric varices than from the esophageal varices. The rate of hemostasis by endoscopic management is higher with the Histoacryl than that with the other sclerosing agents such as 5% ethanolamine oleate.

After introducing N-butyl-2 -cyanoacrylate (Histoacryl) to the management of bleeding gastric varices, the hemostasis rate improves to almost 100% However, the rebleeding rate is still high if any further additional treatment has not been performed until the gastric varices have been eradicated. There is still a controversy regarding the management for the gastric varices.

Esophageal and gastric varices differ in their morphology, pathophysiology, and natural history. While gastric varices bleed less frequently than esophageal varices, the severity of bleeding and associated mortality is greater. Compared with esophageal varices, gastric varices are larger, more extensive, and lie deeper in the submucosa. As a result, standard endoscopic treatments for esophageal varices, including band ligation and sclerotherapy, are largely ineffective for gastric varices.

Gastric Varices.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 2 of 3.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Bleeding from gastric varices is a life-threatening complication of portal hypertension. Fundal and isolated gastric varices are at high risk for variceal bleeding.

The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate if those who survive.

Bleeding from gastric varices is generally more severe than bleeding from esophageal varices, although it occurs less frequently.

Gastrointestinal (GI) hemorrhage from portal hypertension is the most ominous form of bleeding. It carries the highest mortality, ranging from 30 to 40% and has an equally high rate of recurrence.

Vascular collaterals in the stomach, esophagus, small bowel and colon form as a consequence of portal hypertension,and these vessels have a high risk of rupture. The vascular congestion can also lead to mucosal bleeding throughout the GI tract from portal hypertensive gastropathy, enteropathy and colopathy.

Esophagus Gastric Varices


gastric varices.

Video Endoscopic Sequence 3 of 3.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Argon Plasma Coagulation was used as a emergency tool.

Gastric varices occur in about 20% of patients with portal hypertension and approxiamately 25% of gastric varices bleed during lifetime. Gastric variceal bleeding has a higher rate of recurrence than esophageal variceal bleeding, and is associated with decreased survival. The cumulative mortality of fundal varices reaches as high as 52% at the end of 1 year.


Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 1 of 7.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

This 66 year old female, presented with massive upper gastrointestinal bleeding. Endoscopy revealed spurting from a large varix in the gastric fundus.

Endoscopic appearance of actively bleeding gastric varices. Esophagogastroduodenoscopy in a cirrhotic patient with exsanguinating upper gastrointestinal hemorrhage reveals the characteristic endoscopic findings of superficial, purplish, serpiginous lesions in the very proximal stomach from fundal varices.

Active bleeding is evidenced by the spurting of blood from a varix and the adjacent pooling of bright red blood. In this retrofl exed view, the endoscopic shaft is seen adjacent to the fundal varices exiting from the gastroesophageal junction.

Bleeding from gastric varices is a life-threatening event that presents a therapeutic challenge for clinicians.


Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 2 of 7.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Active pulsatile bleeding from a gastric fundic, varix was seen at endoscopy

Gastric Varices are much less common cause of variceal hemorrhage than esophageal ones; but are important to recognize as the source of bleeding because their management is different. When gastric varices are prominent and associated with minimal to absent esophageal varices, one must consider splecnic vein thrombosis as the etiology of the increased venous pressures. Angiography may verify this diagnosis. These patients are best treated with simple splecnectomy, which adequately decompresses their varices. Such patients have an excellent prognosis because of the lack of underlying liver disease.
Splecnic vein thrombosis may occur as a complication of pancreatitis due to contiguous inflammation from the body and tail of the pancreas. Histoacryl (N-butyl-2-cyanocrylate) has been used in bleeding esophagogastric and ectopic varices.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 3 of 7.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Continuous flow of blood from the varix.

Gastric varices occur in about 20% of patients with portal hypertension and approximately 25% of gastric varices bleed during lifetime. Gastric variceal bleeding especially from isolated gastric varices usually is profuse, has a higher rate of recurrence than esophageal variceal bleeding and is associated with decreased survival (cumulativemortality of fundal varices reaching as high as 52% at the end of 1 year). The optimal treatment for gastric variceal bleeding is still controversial, primarily because ofthe apparent ineffectiveness of conventional antivariceal therapy and the inclusion of patients with gastric varices located at different sites.





Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 4 of 7.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Hemostasis was achieved using argon plasma coagulator APC.

Bleeding from gastric varices is often a serious medical emergency.

Although the incidence of bleeding from gastric varices is relatively low (10–36%), massive bleeding from gastric varices is life-threatening.


Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 5 of 7.

The video clip displays the APC stopping the hemorrhage.

Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. An adjuvant vasoactive agent is useful for the prevention of early rebleeding.

Follow-up endoscopic treatment is necessary in order to obliterate residual varices.


Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 6 of 7.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Status post coagulation with APC.

Gastric varices are most commonly located in the cardia in continuity with esophageal varices. Isolated gastric varices are most commonly located in the fundus and can be seen in patients with cirrhosis and portal hypertension, as well as in patients with splenic vein thrombosis (e.g., from pancreatic disease) or portal vein thrombosis. Bleeding from gastric varices is typically high volume in nature and can present with massive hematemesis.


Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 7 of 7.

Status post APC application seen with magnifying endoscope.

Endoscopic ultrasonography is useful in the prediction of recurrence of varices and facilitates visualization and guidance of further treatment of gastric varices.




Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 1 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Large multilobulated gastric varix in the fundus.

This 56 year-old lady with Esophagus-Gastric Varices.

Hemostatic methods that use standard therapy for esophageal varices have not been found effective for gastric varices.

 

 

Large Gastric Varices.

 

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 2 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Development of gastric varices is an important manifestation of portal hypertension. In segmental portal hypertension, gastric varices originate from short gastric nd gastroepiploic veins. In generalized portal hypertension, intrinsic veins at cardia participate in the formation of gastric varices. Endoscopy and/or splenoportovenography and a high index of suspicion are required for the diagnosis of gastric varices.

Gastric varices are classified depending on their relationship to esophageal varices and their location within the stomach. Gastroesophageal varices extend across the gastroesophageal junction either along the lesser curve or the greater curve. Isolated gastric varices lack continuity with esophageal varices and usually occur in the fundus. Morphologically, gastric varices can be further divided into three types based on their endoscopic appearance: single polyp-like structure; conglomerate of polypoid varices; and serpiginous rugae-like vessels. Typical fundal varices are large polypoid structures and pose the greatest challenge for treatment.



Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 3 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Sarin’s classification of gastric varices

 

Figura 1

Image1VG

 

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 4 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Sarin et al. defined four subtypes of gastric varices (Figure1). Gastro-esophageal varices (GOVs) are associated with esophageal varices along the lesser curve (type 1, GOV1), or along the fundus (type 2, GOV2).

Isolated gastric varices (IGVs) are present in isolation in the fundus (IGV1) or at ectopic sites in the stomach or the first part of the duodenum (IGV2). Gastric varices may be primary (at initial presentation) or secondary (appearing after obliteration of esophageal varices).

GOV1, the commonest at 70% of gastric varices, are also known as cardial varices. GOV2 and IGV1, at 21% and 7% of gastric varices, respectively, together referred to as fundal varices.

The incidence of bleeding is highest with IGV1 (78%), followed by GOV2 (55%), and much less for GOV1 and IGV2 at 10%. Although the mortality rate with GOV1 is high, endoscopic treatment of GOV1 is likely to be more successful than the other subtypes.


 

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 5 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

The natural history of bleeding gastric varices differs from that of esophageal varices. Although the risk of bleeding from gastric varices is half that of esophageal varices, the transfusion requirements and mortality once bleeding has occurred are greater particularly for IGV. It has been reported that patients with large gastric varices have a lower portal pressure than those with esophageal varices, which may be as a result of the development of gastrorenal porto-systemic shunts, or large size of the varices resulting in increased variceal wall tension.

Endoscopic controlling bleeding esophageal varices and gastric varices are totally different. Agents and techniques are not exactly the same. Gastric variceral obliteration requires a higher skill due to its awkward control of the scope. In addition, tissue glue to be used can cause scope damage if perform injection carelessly. Moreover, the most fearful complication form glue injection of gastric varices is systemic emboli. Therefore, endoscopist who would like to deal with this technique is mandatory required special training.


Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 6 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

8 months after the first endoscopy the patient began with her first hemorrhage presenting several episodes of hematemesis and melena.

This emergency endoscopy was carry out in the operation room under general anesthesia with endotracheal tube.




Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 7 of 25.

Identifying the Source of Bleeding

Irrigation and suction are helpful in removing old blood and blood clots from the stomach, it is not unusual to have residual clots obscuring the endoscopic view and preventing proper identification of the source of bleeding. A number of interventions have been described to help remove these clots and improve endoscopic visibility.

The irrigating hood is a device designed to be placed at the tip of the endoscope to allow forceful intragastric irrigation while maintaining an adequate intraluminal view of the bleeding site. Its use has been demonstrated to improve the endoscopic view and shorten procedure time.

 

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 8 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Multiple large gastric varices can be seen in the gastric cardia and fundus. The treatment chosen for this patient was intravariceal injection with cyanoacrylate.

After volume resuscitation and blood transfusion, urgent upper endoscopy was performed. The stomach and duodenum were clear of either fresh or old blood. There was an isolated cluster of gastric varices within the fundus, appreciated only on retroflexion. A red, flat spot was noted on one of the suspected varices.

 

 

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Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 9 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

In this video clips shows the exact site of the bleeding

Due to the rubbing of the injector with the surface of the varix, initiates the exact site of bleed varix was then noted to bleed actively.

3 ml of pure lipoidol was injected into the working channel of the endoscope to prevent occlusion of the channel by the glue. Endoscopic injection of tissue-adhesive agents has been shown to be very effective. Of these, the most successful has been N-butyl-cyanoacrylate (Histoacryl) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol.


Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Video Endoscopic Sequence 10 of 25.

Endoscopy of Gastrointestinal Bleeding from Gastric Varices

Glue for gastric varices

A mixture of Histoacryl with with Lipiodol (0.8 mL in 0.5 mL) will be injected intra-variceal.l.

Bleeding from FV. Bleeding was considered to arise from FV if one of the following criteria was present: active bleeding from the FV was seen, a clot or an ulcer was present over the FV, or (3) occurrence of bleeding in the context of distinct large FV in the absence of EV or other causes of upper GI bleeding.


Gastric Varices

Video Endoscopic Sequence 11 of 25.

Intravariceal injection Histoacryl with with Lipiodol

After the injection of the mixture, the syringe got stuck completely to the Luer Lock injector with the security knob. That is why the procedure itself was difficult. The needle had to be drawn out of the bleeding varicose vein without having obliterated it first, creating a larger bleeding area. Another injector of a different model had to be used. It is always advisable to have multiple syringes ready with the mixture.

In order to treat varices of the fundus with this mixture, injector probes of metallic Luer Lock must be used, and in this way sticking of the syringe is avoided.



Gastric Varices

Video Endoscopic Sequence 12 of 25.

Needle in gastric varix

Inmediately a new shot of the mixture of Histoacryl with with Lipiodol was injected with another injector, being successful with this.

In general, endoscopic therapy for the treatment of bleeding gastric varices has been less successful than for esophageal varices. Treatment options that have been studied in prospective trials include injection of cyanoacrylate-based tissue adhesives, alcohol, sclerosants, and the use of band ligation. Results from this limited number of small studies have had varying success rates and were uncontrolled, making it difficult to draw definitive conclusions about their efficacy or the superiority of one therapy over another. All techniques appear to be useful, but rebleeding and mortality rates in these studies were high. There are insufficient data to recommend repeat endoscopic procedures to achieve obliteration or secondary prophylaxis of isolated gastric varices.


Gastric Varices

Video Endoscopic Sequence 13 of 25.

Withdrawing the needle from the varix, washing it with saline solution to avoid be occluded by the glue and thus reuses it.

Gastric Varices

Video Endoscopic Sequence 14 of 25.

In this video clip, another shot of the mixture of glue is injected, after retiring the needle a slight bleeding of wall is observed.


Gastric Varices

Video Endoscopic Sequence 15 of 25.

After have applied histoacryl had been a slight bleeding which was handling with argon plasma.


Gastric Varices

Video Endoscopic Sequence 16 of 25.

The catheter of argon plasma is being coagulated the site of this bleed.


Gastric Varices

Video Endoscopic Sequence 17 of 25.

The hemorrhage has stopped.

 

Gastric Varices

Video Endoscopic Sequence 18 of 25.

The site of the last bleeding, besides of using glue and argon plasma, the hemostasis is reinforced with rubber bands.

Endoscopic injection with tissue adhesives such as histoacryl can effectively control active bleeding. However, gastric varices cannot disappear due to the unsatisfactory control of inflammation and fibrous organization caused by adhesives. Although endoscopic variceal ligation therapy (EVL) has shown its benefit for esophageal varices, it cannot achieve a similar success in the management of gastric varices.



Gastric Varices

Video Endoscopic Sequence 19 of 25.

Bleed has stopped completely.

Management for gastric varices usually include vasoactive agents, endoscopic therapy and surgery. Rupture of gastric fundal varices is often lethal because of massive bleeding.




Gastric Varices

Video Endoscopic Sequence 20 of 25.

Hemostasis was achieved

Hematemesis, melena, and hematochezia are symptoms of acute gastrointestinal bleeding. Bleeding that brings the patient to the physician is a potential emergency and must be considered as such until its seriousness can be evaluated. The goals in managing a major acute gastrointestinal hemorrhage are to treat hypovolemia by restoring the blood volume to normal, to make a diagnosis of the bleeding site and its underlying cause.


Gastric Varices

Video Endoscopic Sequence 21 of 25.

To avoid bronco aspiration the patient must be with endotracheal tube.

This image as well as the video clips show endotraqueal tube, there are a plenty of fresh blood in the oropharynx, that is the main reason to perform this procedure in the operation room. 

We can see the endotracheal tube that is placed to prevent aspiration. Every patient who has hematemesis should have an upper endoscopy practiced under general anesthesia, with placement of an endotracheal tube. In this example we can clearly see the amount of blood in the oropharynx. Orotracheal intubation is indicated when there is risk of aspiration because of continuous hematemesis.

The main complications associated with gastrointestinal bleeding in patients with hepatic cirrhosis include aspiration, hepatic encephalopathy, and renal failure. All of the complications mentioned cause rapid deterioration of the patient and are an important cause of death.

The major risk for aspiration occurs during hematemesis and upper endoscopy, as well as during esophageal tamponade, especially in patients with altered consciousness. Prevention of aspiration is obtained by orotracheal placement in patients with grade III-IV encephalopathy, as well as aspiration of gastric contents before the endoscopic procedure by means of a nasogastric tube.



Gastric Varices

Video Endoscopic Sequence 22 of 25.

The injector should have a Luer-lock metal fitting because, as Histoacryl is caustic to plastic and may crack a plastic hub.


Gastric Varices

Video Endoscopic Sequence 23 of 25.

Post Procedure Chest Radiograph.

In the thorax x-ray the mixture of histoacril with lipoidol is observed in the gastric bubble. Obtaining of this form the obliteración of varice that cause the bleed.

 

Video Endoscopic Sequence 24 of 25.


What is the role of radiographs in the documentation varix obliteration? Because Lipiodol is radioopaque, varices filled with the cyanoacrylate mixture are well visualized radiographically. However, the ability of radiographs to distinguish intra- and perivariceal injection or document varix obliteration has never been studied. Fluoroscopy is occasionally used to monitor the intravariceal injection of cyanoacrylate.

The use of a convex array echoendoscope to provide real-time monitoring of cyanoacrylate injection is technically possible but its benefit is questionable in comparison with endoscopy-guided injection.


Gastric Varices

Video Endoscopic Sequence 25 of 25.

The treatment of bleeding gastric varices is one of the final frontiers of flexible endoscopy—a chapter as yet incomplete in our textbooks.

 

Gastric Varix Endoscopic Ablation with Cyanoacrylate Glue

Video Endoscopic Sequence 1 of 18.

Endoscopic Ablation with Cyanoacrylate Glue

This 49 year-old female was hospitalized in a social security hospital in El Salvador, She was discharged from the hospital on day 10, after that visit us for a therapeutical endoscopy.

An upper endoscopy was practiced shows gastric varices of the fundus with a small quantity of blood emerging from the varix.

Acute Variceal Bleeding

 


Endoscopy of Gastric Varices

Video Endoscopic Sequence 2 of 18.

Endoscopy of Gastric Varices

Although gastric varices tend to bleed less frequently than esophageal varices, the morbidity and mortality associated with gastric variceal hemorrhage are substantial.

Gastric varices are dilated submucosal veins in the stomach, which can be a life-threatening cause of upper gastrointestinal hemorrhage. They are most commonly found in patients with portal hypertension, or elevated pressure in the portal vein system, which may be a complication of cirrhosis. Gastric varices may also be found in patients with thrombosis of the splenic vein, into which the short gastric veins which drain the fundus of the stomach flow. The latter may be a complication of acute pancreatitis, pancreatic cancer, or other abdominal tumours.


Endoscopy of Gastric Varices

Video Endoscopic Sequence 3 of 18.

Endoscopy of Gastric Varices

In the same day a therapeutic endoscopy a histoacryl injection is programed, under general anesthesia with endotracheal tube is achieved. Stigmata of recent bleeding is observed.

 

Gastric varices (GV) occur in 20% of patients with portal hypertension. GV located in the fundus (FV) tend to cause serious bleeding and are reported to be less responsive to endoscopic treatment. The risk of FV bleeding may range from 55% to 78%, with a bleeding-related mortality rate of 45%.

Video Endoscopic Sequence 4 of 18.

Gastric varices (GV) occur in 20% of patients with portal hypertension. GV located in the fundus (FV) tend to cause serious bleeding and are reported to be less responsive to endoscopic treatment. The risk of FV bleeding may range from 55% to 78%, with a bleeding-related mortality rate of 45%.


Endoscopy of Gastric Varices

Video Endoscopic Sequence 5 of 18.

Endoscopy of Gastric Varices

N-butyl-2-cyanoacrylate (Histoacryl) is a watery substance that polymerizes and hardens instantaneously when it comes into contact with blood. This unique property makes it attractive for use in obliterating varices. It is particularly useful in the treatment of fundic varices. Histoacryl is reconstituted with Lipiodol (0.8 mL in 0.5 mL), an oil-based radiopaque contrast agent). the therapeutic channel of the endoscope is first rinsed with 2mL of Lipiodol. The injection needle is then filled with 2mL of Lipiodol. The varix is punctured, and the Histoacryl-Lipiodol mixture is injected. Before retraction of the needle, residual glue is pushed into the varix with a further 2mL of Lipiodol. The needle is then retracted, and the catheter is rinsed with water. It is important at this juncture not to activate suction in the endoscope, and to continue irrigation to avoid contact between the glue and the lenses.

Endoscopy of Gastric Varices

Video Endoscopic Sequence 6 of 18.

The image and the video clip show the status of histoacryl injection. Glue extruding from the injection site.

When Histoacryl is mixed in a ratio of 0.5 cm3 (volume per tube of Histoacryl) to 0.8 cm' Lipiodol, hardening is delayed by approximately 20 seconds. The two components are drawn up together into a 2 ml syringe and then mixed by inverting the syringe several times. To help prevent Histoacryl from adhering to the catheter wall, several millilitres of Lipiodol are injected into the catheter.




Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 7 of 18.

The image and the video clips show the second shot of histoacryl.

Endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding was first reported in 1986. The tissue glue polymerizes on contact with blood, solidifying within the varix instantly, thus obliterating the varix and preventing bleeding. The glue cast will eventually slough off weeks to months later. Because of its excellent efficacy, N-butyl-2-cyanoacrylate is considered to be the optimal therapy for FV bleeding by many clinicians worldwide.



Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 8 of 18.

The image and the video clips show the third shot of histoacryl.

The dilution ratio increases if Lipiodol is used to flush the injector before injection. The rationale for diluting Histoacryl with Lipiodol is to delay the otherwise instantaneous polymerization reaction in order to complete the injection and remove the needle.


Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 9 of 18.

Hemostatic methods that use standard therapy for esophageal varices have not been found effective for gastric varices. Due to their large size and extensive distribution, it is difficult if not impossible to eradicate gastric varices with sclerotherapy or band ligation. More importantly, tissue necrosis resulting from these endoscopic interventions can cause significant and sometimes disastrous complications.

 



Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 10 of 18.

Conceptually, cyanoacrylate glue provides an ideal endoscopic treatment for gastric varices. Native cyanoacrylate is a liquid with a consistency similar to water and therefore lends itself to intravariceal injection. When added to a physiologic medium such as blood, the cyanoacrylate rapidly polymerizes, forming a hard substance. Thus, after injection into a varix, the cyanoacrylate plugs the lumen. This results not only in rapid hemostasis in cases of active bleeding, but it also prevents the recurrence of bleeding from the treated varix.



Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 11 of 18.

The patient has not had any further episodes of gastrointestinal bleeding in the months since her procedure.

Histoacryl is highly effective for the treatment of bleeding gastric varices. The treatment failure-related mortality rate was almost a result of malignancy or underlying liver disease. Serious adverse event may appear although under experienced endoscopist.

 

Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 12 of 18.

Successful obliteration with hardening of variceal bed. A follow up endoscopy one week later was performed. Glue extruding from the injection site.

It is essential to define the endpoint of treatment, as well as have a standardized protocol to achieve the endpoint. The goal of cyanoacrylate injection should be the obliteration of visible varices. The term “obliteration” more accurately describes the desired endpoint than “eradication,” because a varix occluded with cyanoacrylate may remain visible for many weeks. The completeness of obliterationdeserves special emphasis, as cyanoacrylates induce mucosal necrosis at the site of injection.

The amount of Histoacryl required to achieve obliteration will vary depending on varix size and extent. In general, Histoacryl is injected in aliquots of 0.5 mL (content of 1 ampoule), which translates to 1 to 2 mL after dilution with Lipiodol. Obliteration is tested by palpating the varix with the needle retracted. If “soft,” the varix is injected with an additional aliquot of Histoacryl.

 

Status post injection of histoacryl mixture.

Under normal circumstances blood from the fundus is drained by the short and posterior gastric veins into the splenic vein. In portal hypertension the direction of flow is reversed and blood drains from the spleen toward the stomach into FV. The majority of FVs drain into the inferior phrenic vein, which then joins with either the left renal vein to form the gastrorenal shunt (GRS) (80%-85%) or with the inferior vena cava just below the diaphragm to form the gastrocaval shunt (10%-15%).

Video Endoscopic Sequence 13 of 18.

Status post injection of histoacryl mixture.

Under normal circumstances blood from the fundus is drained by the short and posterior gastric veins into the splenic vein. In portal hypertension the direction of flow is reversed and blood drains from the spleen toward the stomach into FV. The majority of FVs drain into the inferior phrenic vein, which then joins with either the left renal vein to form the gastrorenal shunt (GRS) (80%-85%) or with the inferior vena cava just below the diaphragm to form the gastrocaval shunt (10%-15%).

 

 

 


Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 14 of 18.

Massive transfusions by nature lead to hemodilution, acidosis, hypothermia and ultimately coagulopathy. To minimize these complications it is recommended to replace plasma constituents and platelets with packed red blood cell infusions. A protocol with a replacement ratio of 5 PRBC, 5 FFP and 2 units of platelets minimizes bleeding, hemodilution and persistent thrombocytopenia.

Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 15 of 18.

Status post variceal ligation is observed at the cardias.

 

Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 16 of 18.

Fibrin and ulcers of post banding at the esophagus are displayed.

 

Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 17 of 18.

Follow up Endoscopy

After two year and a half it is observed complete obliteration of the varix.




Endoscopy of Gastric Varices histoacryl

Video Endoscopic Sequence 18 of 18.

Complete obliteration status

Gastric variceal obliteration was achieved

 

Endoscopy of Ulcerated Flat Gastric Varix

Endoscopy of Ulcerated Flat Gastric Varix

Image of ulcer with visble vassel

This is the case of 63 year-old male with alcoholic cirrhosis Child-Pugh Score C, with generalized anasarca, mild encephalopathy, jaundice; endoscopy shows varices of the esophagus and multiple gastric erosions at the gastric fundus display the image and the video clip here presented.

Large Gastric Varices.

Video Endoscopic Sequence 1 of 4.

Large Gastric Varices.

A large gastric varix (IGV1) with a recent nipple sign.

This 72 year old female with a recurrent episode of bleeding from gastric varices. Seen on retroflexion are pendulous varices in the gastric cardia and fundus.












Ulcerated Gastric Varix.

Video Endoscopic Sequence 2 of 4.

Ulcerated Gastric Varix.

A large gastric varix (IGV1) with a recent nipple sign.

Primary gastric varices are said to be detected in 20% patients with portal hypertensions. The data suggests that gastric varices bleed less frequently (14%-16%) , but once it bleeds it is torrential and severe.



Ulcerated Gastric Varix.

Video Endoscopic Sequence 3 of 4.

The patient underwent Cyanoacrylate glue injection for her gastric varices.

Variceal obstruction with cyanoacrylate tissue adhesive had beenused successfully and most studies have achieved control ofbleeding in almost 100% of patients.

 

Ulcerated Gastric Varix.

Video Endoscopic Sequence 4 of 4.

A large gastric varix (IGV1) with a recent nipple sign.

This image and the video clip was obtained with magnifying endoscope.

Gastric varices develop in patients with portal hypertension , including liver cirrhosis, idiopathic portal hypertension as well as left sided-local portal hypertension such as splenic vein thrombosis or splenic AV malformation. The inflow vein is the left gastric vein, posterior vein, or short gastric vein, while the outflow vein is the gastro-renal shunt in most of the patients with gastric varices. The form of the gastric varices is classified into three types of venous dilatation; tortuous type, notched type and tumor type according to the shape and size of the varices.

 

 

Fundus Gastric Varices.

Fundus Gastric Varices.

Fundus varices are observed in the maneuver of retroflexion, and the signs of recent bleeding are also observed.

Gastric varices usually accompany esophageal varices, although they may occur alone. They are located in the gastric fundus and are best appreciated endoscopically on retroflexed view.

 

Enormous Erosioned Gastric Varix.

Enormous Erosioned Gastric Varix.

Ulcerated Gastric Varix of the fundus that caused severe gastrointestinal hemorrhage.


Varices of the Gastric Fundus.

Varices of the Gastric Fundus.

More commonly, bleeding gastric varices are associated with large esophageal varices and are due to underlying liver disease. 

 

 

Gastric Varices

Varices of the Gastric Fundus.

More commonly, bleeding gastric varices are associated with large esophageal varices and are due to underlying liver disease. 

 

Gastric Varices Histoacryl was injected intravariceally.

Status Post Histoacryl

Histoacryl was injected intravariceally.

Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices, with rare complications occurring both acutely and long-term. Therefore, Histoacryl injection sclerotherapy is considered to be the first choice of treatment for bleeding gastric varices, but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding.

 

 

Gastric Varices

Video Endoscopic Sequence 1 of 3.

Linear Gastric Varices.

Linear varices in the gastric body of a 72 year-old man with abdominal pain and weight loss. There were no varices in the esophagus or gastric cardia. The woman was ultimately found to have pancreatic carcinoma, and was suspected to have splenic vein thrombosis.

 

Gastric Varices

Video Endoscopic Sequence 2 of 3.

Linear Gastric Varices.

Gastric variceal bleeding can be challenging to the clinician.

 

Linear Gastric Varices.

Video Endoscopic Sequence 3 of 3.

Linear Gastric Varices.

 

Gastroesophagic Varices

Video Endoscopic Sequence 1 of 7.

Gastroesophagic Varices.

This 72 year-old lady, 15 days previous it was hospitalized due to upper gastrointestinal bleeding in another hospital. At that time had an upper endoscopy revealing two ulcers one with visible vessel but they do not described varices of the esophagus, she was discharged from the hospital, two weeks after the patient present a severe re-bled and was hospitalized again, referred to our endoscopic unit, her hemoglobin was 5.7 g/dl.

 



Ulcerated Gastric Varix

Video Endoscopic Sequence 2 of 7.

Ulcerated Gastric Varix

An ulcer with a large visible vassel is seen, retroflexed image.


Ulcerated Gastric Varix

Video Endoscopic Sequence 3 of 7.

Ulcerated Gastric Varix

Due to the large vassel as well as the re-bled we decideany hemostatic maneuver to be used.



Ulcerated Gastric Varix.

Video Endoscopic Sequence 4 of 7.

Ulcerated Gastric Varix.


Ulcerated Gastric Varix.

Video Endoscopic Sequence 5 of 7.

In this image and video clip you can observe the small ulceration that was coagulated with argon plasma coagulator.


Ulcerated Gastric Varix.

Video Endoscopic Sequence 6 of 7.

The coagulation with argon plasma is observed.

 

Ulcerated Gastric Varix.

Video Endoscopic Sequence 7 of 7.

Gastric Ulcerated Varix

In order to perform a therapeutic hemostasis Argon plasma coagulation was used, but it caused an impressive bleeding to stop this hemorrhage a Sengstaken-Blakemore tube had to be placed using the gastric balloon..

Retrospectively, I would prefer using a rubber band ligation combining with histoacryl to obliterate this large vessel.





Gastroesophagic Varices.

Video Endoscopic Sequence 1 of 7.

Gastroesophagic Varices

This patient of 66 year-old male who has alcoholic hepatic cirrhosis had been hospitalized in a hospital of national insurance in San Salvador due to a massive bleeding of the upper digestive track a Sengstaken-Blakemore tube had been placed, after ten day of hospitalization the hemorrhage had been continuing, the physicians in that hospital wanted to performed a surgical procedure explained to the patient the high morbi-mortality, patient and his relatives declining that surgery. patient was preferred to our unit performing histoacryl injection in the operation room stopping the hemorrhage, tree shot of histoacryl injection was carry out.




Gastroesophagic Varices.

Video Endoscopic Sequence 2 of 7.

The patient was received from the other hospital with the Sengstaken-Blakemore tube.

The image and the video clip show the status post use the Sengstaken-Blakemore tube, showing the aspect of the mucosa that is edematized, the endoscopic anatomy, is deformed in the gastric fundus and the proximal body.


Gastric Varices

Video Endoscopic Sequence 3 of 7.

Through the cardia, one ulcerated gastric varix is observed, which was the exact site of the bleeding.

 

Gastric Varices

Video Endoscopic Sequence 4 of 7.

The cardias is found ulcerated due to the Sengstaken-Blakemore tube, patient had two more ulcers one in the middle third and upper third.

Balloon tamponade is used if sclerotherapy and vasoconstrictor therapy fail to control variceal bleeding or are contra-indicated. The usual tube is a Sengstaken-Blakemore which is passed into the stomach. The gastric balloon is inflated; the esophageal balloon is inflated only if bleeding is not controlled by the gastric balloon. The technique is successful in 90% of cases. Serious complications, with a 5% mortality, include aspiration pneumonia, esophageal rupture and mucosal ulceration. It is very unpleasant for the patient.

Note that balloon tamponade is a temporary measure and it may cause pressure necrosis after 48-72 hours. Thus sclerotherapy or some other means of control should be used after 12-24 hours.


Gastric Varices

Video Endoscopic Sequence 5 of 7.

In addition to the ablative therapy of the gastric varix, ten esophageal varices were ligated.

 

Gastric Varices

Video Endoscopic Sequence 6 of 7.

The upper esophageal sphincter was found ulcerated due to Sengstaken-Blakemore tube which found it misplaced.

 

Gastric Varices

Video Endoscopic Sequence 7 of 7.

A follow up endoscopy one month later was performed.

Status post injection of histoacryl mixture, tree shot of histoacryl injection was carry out.

 



Gastric Varices Rosettes formation

Video Endoscopic Sequence 1 of 22.

Gastric Varices Rosettes formation

65 year old woman referred to our endoscopic unit for evaluation and treatment of an upper GI bleeding. Recent history includes: 4 days previously, Surgical removal of giant ovarian tumor that compressed great abdominal vessels, also 2 previous episodes of upper GI bleeding, with placement of Sengstaken-Blakemore probe on one occasion.


Gastric Varices

Video Endoscopic Sequence 2 of 22.

Gastric Varices Rosettes formation

The first upper endoscopy was practiced in an outpatient setting with signs of recent bleeding. Abundant bloody secretions were aspirated, and the patient was admitted to the hospital for hemodynamic stabilization and monitoring.



Gastric Varices

Video Endoscopic Sequence 3 of 22.

Varices were found only in the gastric fundus. No varices were found in the esophagus. No other significant findings were recorded.


Gastric Varices

Video Endoscopic Sequence 4 of 22.

We can observe a small ulceration in one of the varices,
which could indicate a bleeding spot.

Therapeutic endoscopy was practiced in the operating
room with placement of an orotracheal tube to prevent
bronchoaspiration.


Gastric Varices

Video Endoscopic Sequence 5 of 22.

Another image of the varices located in the gastric fundus

 

Gastric Varices

Video Endoscopic Sequence 6 of 22.

Due to the gastric washing in order to look for the probable sites of bleeding acute bleeding is reactivated.

 

Gastric Varices

Video Endoscopic Sequence 7 of 22.

Bleeding has been sufficiently severe, we used the
therapeutic endoscopy of double channel.


Gastric Varices

Video Endoscopic Sequence 8 of 22.

Glue extruding from the injection site.

After to have washed and to have aspired abundant blood,
the image was partially clarified and seen through the
water and in a form of submarine swimming we managed
identify the varix and the probable site of bleeding.


Gastric Varices

Video Endoscopic Sequence 9 of 22.

Next step is that to inject a mixture of histoacryl with with lipiodol (0.8 mL in 0.5 mL) will be injected intra-variceal. 

 

Gastric Varices

Video Endoscopic Sequence 10 of 22.

It is observed when the mixture of the glue emerges through varix.


Gastric Varices

Video Endoscopic Sequence 11 of 22.

The glue emerging from the varix.

 

Gastric Varices

Video Endoscopic Sequence 12 of 22.

The glue in the middle of varix which has stopped the bleeding.

 

Gastric Varices

Video Endoscopic Sequence 13 of 22.

Glue extruding from the injection site.

Another image of varix with its glue

 

Gastric Varices

Video Endoscopic Sequence 14 of 22.

In the thorax x-ray the mixture of histoacryl with lipoidol is observed in the gastric bubble.

Gastric Varices

Video Endoscopic Sequence 15 of 22.

Another image of the glue, the lipoidol makes radio-opaque

 

Gastric Varices

Video Endoscopic Sequence 16 of 22.

3 weeks after a follow up endoscopy was performed

Showing the images and video clips of the 16 to 22 sequence, observing the glue (yellow) that emerges from the varix.

 

Gastric Varices

Video Endoscopic Sequence 17 of 22.

Approach by retroflexión to the varix.

 

Gastric Varices

Video Endoscopic Sequence 18 of 22.

Retroflexed image observing the varix with its glue.

 

Gastric Varices

Video Endoscopic Sequence 19 of 22.

Gastric varices have been increasingly recognized as a
major cause of gastrointestinal bleeding in patients with
portal hypertension. Compared with esophageal variceal
bleeding, hemorrhage caused by gastric varices is usually
more severe and hemostatic control is reported to be more
difficult.

 

Gastric Varices

Video Endoscopic Sequence 20 of 22.

Gastric Varices Rosettes formation.

 

 

Gastric Varices

Video Endoscopic Sequence 21 of 22.

 

Gastric Varices

Video Endoscopic Sequence 22 of 22.

Gastric Varices

Video Endoscopic Sequence 1 of 9.

Upper gastrointestinal bleeding due to gastric varices

This is a 58 year-old male with a history of abuse of
alcoholic beverages, iniciates with severe bleeding with
hematemesis and melena. Was transferred from
another hospital to our unit. He was stabilized
hemodynamically.

In the the operating room, therapeutic endoscopy was
performed under oropharyngeal intubation. At the moment
to enter to the operation room his hemoglobin was 3.5 g /dl.



Gastric Varices

Video Endoscopic Sequence 2 of 9.

Finding the exact site of bleeding

The possible sites of bleeding were revised, finding esophagogastric varices.

 

Gastric Varices

Video Endoscopic Sequence 3 of 9.

Gastric varices are seen with ulceration in the gastric fundus.

 

Gastric Varices

Video Endoscopic Sequence 4 of 9.

Ulcerated Gastric Varix

This is the view from the cardias, observing the site of this bleeding an ulcerated gastric varix, seen in this picture a small plug of fibrin, but had two more discretely hidden.

 

Gastric Varices

Video Endoscopic Sequence 5 of 9.

An ulcerated varix is barely seen in this retroflexed image (around 10 clockwise).

Gastric Varices

Video Endoscopic Sequence 6 of 9.

The therapeutic endoscopy is starting, performing hemostasis injecting Dermabond. (2-Octyl-cyanoacrylate). The technique of injecting this glue must consider an average by pass slowly 45 seconds. (different to histoacryl).


Gastric Varix

Video Endoscopic Sequence 7 of 9.

The glue was injected, and it came out from another hole The adhesive was detached. Some of the glue stayed inside the varix.

 

Gastric Varix

Video Endoscopic Sequence 8 of 9.

Endoscopic image after the injection of glue.

 

Gastric Varix

Video Endoscopic Sequence 9 of 9.

After satisfactory evolution, the patient was discharged 48 hours later.

 

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