The Clinical Role of Endoscopic Ultrasound for Management of Bleeding Esophageal Varices in Liver Cirrhosis

Abstract

Bleeding esophageal varices (BEV) is a serious clinical condition and can potentially be life-threatening. Esophageal varices are caused by abnormal dilated submucosal and collateral veins in the esophagus wall as a result of portal hypertension due to liver cirrhosis. Consequently, it is important to administer appropriate preventive treatment for the disease in order to decrease morbidity and mortality rates. The current gold standard to identify esophageal varices is the use of esophagogastroduodenoscopy (EGD). However, EGD has limitations due to its inability in observing detailed information of varices morphology and esophagogastric hemodynamics. This report shares the potential role of endoscopic ultrasound (EUS) to overcome the limitation of EGD in clinical practices. Two cases of BEV in hepatitis B liver cirrhosis patients were described in the report. In case 1, large esophageal varices were found through EGD, and large paraesophageal varices were found through EUS. In case 2, small esophageal varices were found through EGD, and submucosal varices with a large periesophageal collateral vein and perforating vein in the distal esophagus were found through EUS. Cyanoacrylate injection guided by EUS was performed in both cases, and no rebleeding occurred after the procedure. In these cases, we showed that EUS is proven to be a potential tool in diagnosis and management of BEV in liver cirrhosis. EUS provides more accurate diagnostic aspects to find varices, assess bleeding risk, and predict bleeding recurrence. EUS also provides more beneficial treatment aspects to guide the treatment procedure and to monitor post treatment response.

Characteristics of liver cirrhosis patients: A literature review

“…The risk of bias assessment tool used is the JBI (Joanna Briggs Institute) critical appraisal with prevalence studies. The following is a table for assessing the risk of bias in data from eight pieces of literature [8], [15], [12], [1], [9], [14], [2], [6]:…”

Transparent cap adjusted the stent placed for stenosis after endoscopic injection of esophageal varices: A case report

“…Endoscopic sclerotherapy was considered the main treatment for esophageal varices[ 2 ]. In recent years cyanoacrylate injection was performed successfully for esophageal varices without any bleeding recurrence[ 3 ]. Esophageal stricture is one of the complication after endoscopic injection cyanoacrylate and/or sclerotherapy esophageal varices.…”

Endoscopic ultrasound-guided portal pressure gradient measurement in managing portal hypertension

“…Second, EUS-PPG measurement can be performed together with EUS-guided liver biopsy; however, EUS-guided liver biopsy is not considered as a routine procedure yet in clinical practice due to the unavailability of standard training, limited experience and availability, and high cost when compared to percutaneous liver biopsy[ 44 , 45 ]. Last but not least, EUS-PPG measurement can be performed and then followed by EUS-guided cyanoacrylate injection for large or deep gastroesophageal varices as well as isolated gastric varices[ 37 , 46 ]. However, the need of EUS approach in acute variceal bleeding and the impact of interventional radiology procedures, such as transjugular intrahepatic porto-systemic shunt or balloon-occluded retrograde transvenous obliteration, are still becoming a long way discussion for managing PH complications[ 30 , 47 ].…”