Endoscopic Ultrasound (EUS) for Esophageal and Gastric Varices: How Can it Improve the Outcomes and Reduce Complications of Glue Injection

Abstract

Gastric varices (GV) have three major inflow tracts: (1) left gastric or coronary vein, (2) short gastric veins, and (3) posterior gastric veins. Most GV are formed by the left gastric or posterior gastric vein. 1,2The left gastric or coronary vein decompresses the portal vein directly via hepatofugal blood flow. Gastric varices of the left gastric vein are frequently located at the cardia and sometime extend cephalad to coalesce with the (para)esophageal varices.3 Hashizume et al showed that the anterior branch of the left gastric vein forms the gastroesophageal varices by directly communicating with the submucosal veins, while the posterior branch extends along the outside of the esophageal wall across the esophagogastric junction to drain into the para-esophageal collateral channels. 4 The other major inflow route is via the short gastric veins, which decompress the splenic vein at the splenic hilum ( Figure 1). Gastric varices of the posterior gastric and short gastric veins are frequently located at the fundus and drain into a major porto-systemic shunt. Iwase et al showed that the feeding vein for the junctional type of GV was mainly the left gastric vein, whereas the fundal type of GV was fed by short gastric veins.5 Varices of the gastroepiploic vein are rare but often occur after the treatment of other GV with surgery or coil embolization.The efferent tract of the GV can be upwards into the azygos system, or into one of the major porto-systemic shunt. The majority of varices located at the gastric fundus drain into the inferior phrenic vein, which later joins with the left renal vein to form the gastrorenal shunt (80-85% of cases) or with the inferior vena cava just below A large part of portal venous system and the paragastric and para-esophageal collateral circulation is within the reach of endoscopic ultrasound (EUS). The EUS is more sensitive than gastroscopy for the detection of gastric varices (GV), and can accurately distinguish GV from thickened gastric folds. Gastric varices are depicted by serpiginous, anechoic, Doppler-positive mural channels, with larger collateral channels visible outside the gastric wall. The EUS has also been used to monitor the completeness of GV obturation after glue injection. There are limited data that this strategy may be clinically beneficial to prevent GV re-bleed. The EUS has been used to deliver glue injections under real-time monitoring into the vascular channels, with or without steel coils as scaffolding for the glue. The potential advantages of this technique include a straight scope position, lack of hindrance from pooled blood in gastric fundus, smaller glue volume requirements, and precise intra-vascular placement of glue with avoidance of intramural injections, and reduced embolic complications. (J CLIN EXP HEPATOL 2012;2:70-74) Figure 1 Serpiginous anechoic elongated vascular channels along the upper splenic pole at the gastroesophageal junction and gastric fundus (arrow), suggestive of short gastric vein collaterals (arrowheads).

New Developments in Managing Variceal Bleeding

“…The synthetic fibers ("wool coils") covering the coils function as a scaffold to retain cyanoacrylate within the varix and may decrease the amount of glue injection needed to achieve obliteration. 52 A recent series was published regarding combining cyanoacrylate and coil for the treatment of gastric fundal varices with more than 150 patients. Technical success was 99%; the mean number of inserted coils was 1.4, and the mean amount of cyanoacrylate injected was 2 mL.…”

Endoscopic Ultrasound for the Hepatologist: A Comprehensive Review

“…1B), being connected to the larger peri-and paragastric collateral veins by perforating channels. 24 EUS can easily measure the size of the GVs, which was proven to strongly correlate with their flow volume. 25 Endoscopic ultrasound has been widely used to evaluate the response to endoscopic treatment.…”

“…The median of the maximum intact core tissue length obtained was 24 mm (18-35 mm). The median TSL was 60 mm (43-80 mm), with a median number of CPTs per TSL of 18 (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24). Nearly half of the patients had second stage of fibrosis (74/165, 44.8%), while 26 (15.8%) of them were found to have cirrhosis.…”

Pitfalls in histoacryl glue injection therapy for oesophageal, gastric and ectopic varices: A review

“…This is determined by probing with varix with an injection needle (needle withdrawn). The role of endoscopic ultrasound in facilitating injection when the view is obscured by blood in the stomach, or to provide a more accurate assessment of vascularity during and after injection, has been explored[18]. Real-time fluoroscopy to assess for possible embolisation has also been described, but this is better suited to elective re-injection of gastric varices and less achievable in the emergent scenario[19].…”