Progression of gastric variceal hemorrhage (GVH) is poorer than esophageal variceal bleeding. However, data on its optimal treatment are limited. We designed a prospective study to compare the efficacy of endoscopic band ligation (GVL) and endoscopic N-butyl-2-cyanoacrylate injection (GVO). Liver patients with cirrhosis with or without concomitant hepatocellular carcinoma (HCC) and patients presenting with acute GVH were randomized into two treatment groups. Forty-eight patients received GVL, and another 49 patients received GVO. Both treatments were equally successful in controlling active bleeding (14/15 vs. 14/15, P ‫؍‬ 1.000). More of the patients who underwent GVL had GV rebleeding (GVL vs. GVO, 21/48 vs. 11/49; P ‫؍‬ .044). The 2-year and 3-year cumulative rate of GV rebleeding were 63.1% and 72.3% for GVL, and 26.8% for both periods with GVO; P ‫؍‬ .0143, log-rank test. The rebleeding risk of GVL was sustained throughout the entire follow-up period. Multivariate Cox regression indicated that concomitance with HCC (relative hazard: 2.453, 95% CI: 1.036-5.806, P ‫؍‬ .041) and the treatment method (GVL vs. GVO, relative hazard: 2.660, 95% CI: 1.167-6.061, P ‫؍‬ .020) were independent factors predictive of GV rebleeding. There was no difference in survival between the two groups. Severe complications attributable to these two treatments were rare. In conclusion, the efficacy of GVL to control active GVH appears not different to GVO, but GVO is associated with a lower GV rebleeding rate. (HEPATOLOGY 2006;43:690-697.) A lthough the outcome of variceal hemorrhage has improved over the past two decades, variceal hemorrhage is still the most serious complication of portal hypertension and chronic liver disease. 1 Although bleeding occurs less often from gastric varices (GV) than from esophageal varices (EV) (esophageal variceal hemorrhage [EVH] accounts for 70% to 80% of variceal hemorrhage), it has a poorer prognosis and is associated with more severe blood loss, a higher rebleeding rate, and a higher mortality rate. 1-3 However, limited data exist on the best treatment for GV hemorrhage (GVH). Endoscopic treatment is an alternative in the management of GVH and includes endoscopic injection of sclerosants or thrombin, 4,5 endoscopic band ligation, 6,7 and others. The success rate in controlling GVH by endoscopic injection of N-butyl-2-cyanoacrylate (GVO) appears higher than for other sclerosants according to previous non-randomized trials. 8,9 Though endoscopic variceal ligation is regarded as the optimal endoscopic treatment for EVH, 10 its safety and efficacy for the treatment of GVH is uncertain. 7,11 The rebleeding rate of GVO is variable and ranges from 10% to 42%. 12 At the time we started this trial, there were no randomized control trials, and even now, there is only one relatively small randomized clinical trial, 13 which was conducted to compare these two potential treatment modalities (endoscopic band ligation [GVL] vs. GVO) on the GVH; it showed results in favor of GVO for the treatment of GVH. We...

Bacterial infection may adversely affect the hemostasis of patients with gastroesophageal variceal bleeding (GEVB). Antibiotic prophylaxis can prevent bacterial infection in such patients, but its role in preventing rebleeding is unclear. Over a 25-month period, patients with acute GEVB but without evidence of bacterial infection were randomized to receive prophylactic antibiotics (ofloxacin 200 mg i.v. q12h for 2 days followed by oral ofloxacin 200 mg q12h for 5 days) or receive antibiotics only when infection became evident (on-demand group). Endoscopic therapy for the GEVB was performed immediately after infection work-up and randomization. Fifty-nine patients in the prophylactic group and 61 patients in the on-demand group were analyzed. Clinical and endoscopic characteristics of the gastroesophageal varices, time to endoscopic treatment, and period of follow-up were not different between the two groups. Antibiotic prophylaxis decreased infections (2/59 vs. 16/61; P < .002). The actuarial probability of rebleeding was higher in patients without prophylactic antibiotics (P ‫؍‬ .0029). The difference of rebleeding was mostly due to early rebleeding within 7 days (4/12 vs. 21/27, P ‫؍‬ .0221). The relative hazard of rebleeding within 7 days was 5.078 (95% CI: 1.854 -13.908, P < .0001). The multivariate Cox regression indicated bacterial infection (relative hazard: 3.85, 95% CI: 1.85-13.90) and association with hepatocellular carcinoma (relative hazard: 2.46, 95% CI: 1.30 -4.63) as independent factors predictive of rebleeding. Blood transfusion for rebleeding was also reduced in the prophylactic group (1.40 ؎ 0.89 vs. 2.81 ؎ 2.29 units, P < .05). There was no difference in survival between the two groups. In conclusion, antibiotic prophylaxis can prevent infection and rebleeding as well as decrease the amount of blood transfused for patients with acute GEVB following endoscopic treatment. (HEPATOLOGY 2004;39:746 -753.)

No abstract

Hemobilia is one of the causes of obscure gastrointestinal haemorrhage. Most cases of hemobilia are of iatrogenic or traumatic origin. Hemobilia caused by a hepatic artery pseudoaneurysm due to ascending cholangitis is very rare and its mechanism is unclear. We report a 74-year-old woman with a history of surgery for choledocholithiasis 30 years ago, suffering from a protracted course of life-threatening gastrointestinal bleeding. A small intestines series and endoscopic retrograde cholangiopancreatography revealed a chronic cholangitis with marked contrast reflux into the biliary tree. Angiography confirmed the bleeding from a pseudoaneurysm of the middle hepatic artery. Coil embolization achieved successful hemostasis. We discussed the mechanism and reviewed the literature.Liu TT, Hou MC, Lin HC, Chang FY, Lee SD. Life-threatening hemobilia caused by hepatic artery pseudoaneurysm: A rare complication of chronic cholangitis. World J Gastroenterol 2003; 9(12): 2883-2884