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Endoscopic Variceal Ligation: a to Z

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Endoscopic Variceal Ligation: a to Z Endoscopic Variceal Ligation: A to Z Division of Gastroenterology and Hepatology, Liver Clinic Department of Internal Medicine Soon Chun Hyang University School of Medicine, Soon Chun Hyang University Bucheon Hospital, Bucheon, Korea 김 상 균 Agenda 1. Endoscopic classification of esophageal varices 2. Endoscopic ultrasound for the management of esophageal varices 3. Endoscopic treatment of esophageal varices 1) Endoscopic injection sclerotherapy (EIS) vs. Endoscopic variceal ligation (EVL) 2) Primary prophylaxis for esophageal varices 3) Acute esophageal bleeding 4) Secondary prophylaxis after variceal bleeding 4. Procedure of endoscopic band ligation 5. Recurrence of esophageal varices after band ligation 6. Conclusions Case • 52/M, Chronic alcoholism • C/C : Abdominal distension, 1 month ago • MELD score:22, Child-Pugh class C with ascites • endoscopy What should be recorded? 1. F2, Lm, Cb, red wale marking, hematocystic spots 2. F3, Lm, Cb, RC (++), 3. F2, Lm, RC (++) 4. F3, RC (++) 5. F1, RC Endoscopic Classification According to Form F0: No varicose appearance F1: Straight, small-caliber varices F2: Moderately enlarged, beady varices F3: Markedly enlarged, nodular or tumor-shaped varices The Japanese Research Society for Portal Hypertension. Dig Endosc 2010;22:1-229 Endoscopic Classification According to Color • Cw: White varices Cb: Blue varices • Cw-Th: Thrombosed white varices • Cb-Th: Thrombosed blue varices Endoscopic Classification According to Location • Ls: Locus superior • Lm: Locus medialis • Li: Locus inferior • Lg-c: Adjacent to the cardiac orifice • Lg-cf: Extension from the cardiac orifice to the fornix • Lg-f: Isolated in the fornix • Lg-b: Located in the gastric body • Lg-a: Located in the gastric antrum Modified from Sohendra N, et al. Therapeutic Endoscopy Endoscopic Classification According to Red Color Sign • Red wale markings, Cherry red spots, Hematocystic spots, • RC0: absent, RC1: small in No & localized, RC2: RC1 - RC 3, RC3: large in No and circurmferential Endoscopic findings and scoring system predicting variceal bleeding • By Japansese Research Society for Portal Hypertension; • Validated by North Italian Endoscopic Club Rate of Bleeding(%) Risk Beppu’s No.Who Class Score Bled/Total Expected Observed 1yr 2yr 1 >+1.14 7/61 0.0 3.4 9.2 2 0.38 to 1.14 35/146 20.6 14.9 22.1 3 <0.38 to 0.0 6/12 40.0 25.1 33.3 4 0.0 to >-0.38 13/50 64.5 16.7 29.0 5 -0.38 to >-1.14 11/25 90.2 36.8 41.0 6 <-1.14 13/23 100.0 42.9 51.7 NIEC, N Engl J Med 1988;319:983-9 Beppu K, Gastrointest Endoscopy, 1981;27:213-8 Agreement of endoscopic findings Agreement (%) Kappa indexb Endoscopic Frequency features (%) Overall Single class p valueª Overall Single class Esophageal varices Size 82±18 0.59 0 19 79±18 0.59 1 36 75±20 <0.01 0.45 2 38 86±16 [1-3] 0.60 3 7 100±0 0.84 Extent 75±19 0.37 1/3 24 66±22 0.28 2/3 67 78±17 <0.05 0.30 3/3 9 82±24 0.58 color 77±19 0.28 white 28 78±18 NS Blue 72 75±18 Red sign 88±17 0.58 Yes 32c 86±19 NS No 68 89±17 Gastroenterology 1990;98:156-162 Valuable findings to be noted Factors related to bleeding of esophageal varices Transmural Pressure x Radius Variceal Wall Tension = Variceal Wall Thickness Transmural P = (Variceal P – Luminal P) High HVPG Transmural pressure Luminal Variceal size RadiusPressure of the varix Variceal Variceal Pressure Wall Red color signs R Wall thickness Size of varix and RC sign are most important risk factors • To assess the risk of bleeding-NIEC index Size of varices Points to add NIEC index Rate of Bleeding (%) Small 8.7 6 months 12 months Medium 13.0 <20 0 1.6 Large 17.4 ~25 5.4 11.0 Red wale markings ~30 8.0 14.8 Absent 3.2 ~35 13.1 23.3 Mild 6.4 ~40 21.8 37.8 Moderate 9.6 >40 58.5 68.9 Severe 12.8 N Engl J Med 1988;319:983-9 Child-Pugh class A 6.5 This multicenter Italian prospective study showed the Beppu score significantly B 13.0 overestimated the probability of first C 19.5 esophageal varix hemorrhage. How to measure the varix size? 1. Naked-eye 2. Specific size marker 3. Computed tomography 4. Balloon assisted endoscopic ultrasound 5. Endoscopic ultrasound with mini-probe The issue for measuring the varix size F1: small-caliber varices, not disappear with insufflation. F2: Moderately enlarged, beady varices, less than 1/3 of the esophageal lumen F3: Markedly enlarged, nodular or tumor-shaped varices, more than 1/3 of the esophageal lumen World J. Surg 1995;19:420-423 On EGD, esophageal varices should be graded as small or large (>5 mm) with the latter classification encompassing medium-sized varices when 3 grades are used (small, medium, large). (Class IIa, Level C). AASLD practice guideline Hepatology 2007;46:922-938 How to measure the varix size Esophageal varices were graded from 1 to 4 grade 1 : ≤3 mm in diameter; grade 2 : 4-6 mm, grade 3, 7-10 mm, grade 4, ≥11 mm Gastrointest Endosc 2005;61:58-66 Baveno III consensus workshop J Hepatology 1992;15:256-261 GASTROENTEROLOGY 1997;113:1640–1646 Varix size: Sum of Esophageal Variceal Cross-Sectional Surface Area? • Risk of Esophageal Variceal Bleeding Based on Endoscopic Ultrasound evaluation of the Sum of Esophageal Variceal CSA The grade of the esophageal varices by endoscopy was not a significant predictor of future variceal bleeding in this study. Using a cutoff value for the CSA of 0.45 cm2, the sensitivity and specificity for future variceal bleeding above and below this point is 83% and 75%. Am J Gastroenterol 2003;98:454–459. The objectiveness of EUS measurement The intraobserver and interobserver correlations reflecting the objectiveness of the EUS measurement were excellent. Intraobserver Interobserver correlations correlations Variceal radius 0.98 0.97 Wall thickness 0.92 0.91 Variceal radius was not correlated with wall thickness (r=-0.08) Gastrointest Endosc 1996;44:425-8 Measurement of varix size with endoscopic ultrasound 6.5mm 0% 30% 60% 100% • Measure the radius of varix by 20MHz IVUS • Grade I~V • Interobserver correlation r=0.88 Miller LS et al. HEPATOLOGY 1996;24:552-555 Endoscopic ultrasound for the management of esophageal varices Peri-, Para-EV & Perforating vein Muscularis externa Muscular Peri-esophageal layer collateral veins Mucosa & (peri-ECVs) Submucosal layer Lumen Perforating vein (connected with Perforating vein para-ECVs) (connectedLarge Paraesophageal with collateral vein and perforating vein are peri-ECVs) Para-esophageal considered as an important risk factor for varicealcollateral recurrence veins Gastrointest(para Endosc-ECVs) 2001;53:77 -84 Modified from El-Saadany, M. et al. Endoscopy 2008;40:690-696 How to deal with it? 1. Nonselective β-blocker (NSBB) 2. Endoscopic injection sclerotherapy (EIS) 3. Endoscopic variceal ligation (EVL) 4. Combination of EIS+EVL 5. Combination of NSBB + EVL Nonselective β-blocker for the primary prevention of bleeding • Small varices & Not bled – High risk of hemorrhage (Child B/C or red wale markings), • Nonselective ß-blockers should be used for (IIA) – No increased risk of hemorrhage • Nonselective ß-blockers can be used. • Medium/large varices & Not bled – High risk of hemorrhage (Child B/C or red wale markings) • Nonselective ß-blockers or EVL may be recommended (IA). – No high risk of hemorrhage • Nonselective ß-blockers are preferred • EVL: CIx, intolerance or non-compliance to ß-blockers (IA) 2005 ASGE guideline, Gastrointest Endosc 2005;62:651-655 2007 AASLD and ACG Practise guideline Beta-blockers in patients with end- stage cirrhosis needs to be cautioned. The use of beta-blockers may be associated with a high risk of paracentesis-induced circulatory dysfunction in patients with cirrhosis and refractory ascites. J Hepatol 2011;55:794-9 The use of beta-blockers is associated with poor survival in patients with refractory ascites. patients not patients taking b-blocker taking b- blocker Median 20.2 months 5.0 months survival (4.8-35.2) (3.5-6.5) HEPATOLOGY 2010;52:1017-1022 The effect of long-term use of non-selective beta-blocker on the development of acute kidney injury in patients with liver cirrhosis 208 patients developed AKI from 2,250 liver transplantation waitlist registrants. Median follow-up duration : 20.3 (range:3~201) months. 4.27 1.53 1.00 Hazard ratio AKI of ratio Hazard Probability of being free of AKI of free beingof Probability 0.19 Ascites(-) & Ascites(-) & Ascites(+) & Ascites(+) & NSBB(-) NSBB(+) NSBB(-) NSBB(+) Kim SG et al. 2014 KASL Endoscopic injection sclerotherapy (EIS) Injection of 5% ethanolamine oleate in the varix Endoscopic injection sclerotherapy (EIS) vs. Endoscopic variceal ligation (EVL) Randomized trials showed that EVL is more effective than EIS in controlling esophageal variceal bleeding. 1. makes less complications 2. requires fewer treatment sessions to achieve eradication 3. improves the survival of patients Authors Treatment N Complications, Eradication, Recurrence, Rebleed,% % % % Stiegmann et al. EIS 65 22 56 50 48 EVL 64 2 55 33 36 Gimson et al. EIS 49 57 71 - 53 EVL 54 67 82 - 30 Laine et al. EIS 39 56 69 - 44 EVL 38 24 59 - 26 Lo et al. EIS 59 19 63 - 51 EVL 61 3 74 - 33 Hou et al. EIS 67 22 79 30 33 EVL 67 5 87 48 18 Lo et al EIS 34 29 - - 33 EVL 37 5 - - 17 Baroncini et al. EIS 54 31 92 13 19 EVL 57 11 93 30 16 Avgerinos et al.
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