The Role of Endoscopic Ultrasound (EUS) in the Management of Gastric Varices

Abstract

Purpose of Review Gastric varices (GV) are an important complication of portal hypertension, and the current recommendation for management is beta-blocker therapy for primary prophylaxis and transjugular intrahepatic portosystemic shunt (TIPS) for active bleeding or secondary prophylaxis. Direct endoscopic injection of cyanoacrylate (CYA) glue has been investigated but has drawbacks including limited endoscopic characterization of GV and possible distal glue embolism. To this end, endoscopic ultrasound (EUS) has been pursued to help in characterization of GV, visualization of treatment in real time, and confirmation of obliteration with Doppler. Recent Findings In this paper, we review treatments for GV involving EUS, including EUS-guided injection of CYA and coils, either alone or in combination. We also discuss less common methods, including EUS-guided injection of thrombin and absorbable gelatin sponge. We then review literature comparing EUS-guided methods with direct endoscopic therapy and comparing individual EUS-guided methods with one another. We conclude by highlighting drawbacks of EUS in this field, including the unproven benefit over conventional therapy, lack of a standardized approach, and limited availability of expertise and necessary materials. Summary Novel EUS-based methods offer a unique opportunity to directly visualize and access gastric varices for treatment and obliteration. This may provide key advantages over current endoscopic or angiographic treatments. Comparative studies investigating the benefit of EUS over conventional therapy are needed.

Paracetamol: A Review of Guideline Recommendations

“…Almost all RCTs and meta-analyses reported numbers of adverse events from paracetamol that were inferior to those of NSAIDs and comparable to those of placebo. However, reviews on long-term observational data reported increased cardiovascular, gastrointestinal, and renal adverse events during therapy with paracetamol, especially in the high dose range; cases of acute liver failure have been reported after accidental and unintentional overdose of paracetamol [ 10 , 131 , 132 , 133 , 134 , 135 , 136 , 137 , 138 , 139 , 140 , 141 , 142 , 143 , 144 ]. Acute liver failure is infrequent with an approximate incidence for all causes of 1/million/year and is declining [ 134 ].…”

“…Furthermore, drug-induced liver injury is a diagnosis of exclusion that has been ascribed almost only to paracetamol [ 143 ]. However, a recent review indicates that a drug-induced liver injury is idiosyncratic, unpredictable, and related to herbal and dietary supplements and to a number of many potentially toxic drugs to the liver [ 144 ].…”

Role of Endoscopic Ultrasound in Liver Disease: Where Do We Stand?

“…According to some authors, EUS can evaluate ectopic duodenal varices [77], easily distinguish thickened gastric folds from small GV [78], and help in the diagnosis of portal gastropathy, showing diffuse thickening of the gastric wall with dilated paragastric veins (differential diagnosis to "watermelon stomach") [7]. EUS also has an important role in the characterization of GV, visualization of treatment in progress, and confirmation of obliteration using Doppler [79,80]. Furthermore, EUS can easily measure the size of GV, which directly correlates with their flow volume [81].…”

Nonadhesive massive coiling endoscopic ultrasound-guided embolization in a single session for treatment of gastric varices: learning points of a technical variant

“…Published online: 2021-05-31 nique [2][3][4][5]. This technique is feasible, simple, and may reduce the reported risk of reintervention compared with the combined (coil plus adhesive) strategy, avoiding the potential risks of using glue.…”