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The Role of Endoscopic Ultrasound for Esophageal Varices

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The Role of Endoscopic Ultrasound for Esophageal Varices diagnostics Review The Role of Endoscopic Ultrasound for Esophageal Varices Kazunori Nagashima, Atsushi Irisawa * , Keiichi Tominaga , Ken Kashima, Yasuhito Kunogi, Takahito Minaguchi, Naoya Izawa, Akira Yamamiya , Akane Yamabe, Koki Hoshi, Kenichi Goda and Makoto Iijima Department of Gastroenterology, Dokkyo Medical University School of Medicine, 880 Kitakobayashi Mibu, Tochigi 321-0293, Japan; [email protected] (K.N.); [email protected] (K.T.); [email protected] (K.K.); [email protected] (Y.K.); [email protected] (T.M.); [email protected] (N.I.); [email protected] (A.Y.); [email protected] (A.Y.); [email protected] (K.H.); [email protected] (K.G.); [email protected] (M.I.) * Correspondence: [email protected]; Tel.: +81-282-87-2147 Received: 26 October 2020; Accepted: 23 November 2020; Published: 25 November 2020 Abstract: Esophageal varices are caused by the development of collateral circulation in the esophagus as a result of portal hypertension. It is important to administer appropriate preventive treatment because bleeding varices can be fatal. Esophageal varices have complex and diverse hemodynamics, and there are various variations for each case. Endoscopic ultrasound (EUS) can estimate the hemodynamics of each case. Therefore, observation by EUS in esophageal varices provides useful information, such as safe and effective treatment selection, prediction of recurrence, and appropriate follow-up after treatment. Although treatment for the esophagogastric varices can be performed without EUS imaging, understanding the local hemodynamics of the varices using EUS prior to treatment will lead to more safe and effective treatment. EUS observation is an indispensable tool for thorough variceal care. Keywords: esophageal varices; endoscopic ultrasound; hemodynamics; endoscopic injection sclerotherapy; endoscopic variceal ligation 1. Introduction Transabdominal ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) are established diagnostic tools for abdominal diseases. Despite their widespread use, these techniques have limitations. In contrast, endoscopic ultrasound (EUS) complements these modalities, and has been proven useful for evaluating the mediastinum, pancreas, biliary tract, gastrointestinal tract, liver, and adrenal glands [1–4]. Esophageal varices are caused by the development of collateral circulation in the esophagus as a result of portal hypertension. It is important to administer appropriate preventive treatment because bleeding varices can be fatal. Varices found in the esophageal lumen are just the tip of the iceberg. To prevent the occurrence of varices, it is important to evaluate and understand the underlying hemodynamics associated with portal hypertension. In the actual preventive treatment of varices, effective treatment methods and factors associated with recurrence after treatment differ according to hemodynamics [5–8]. As in the case of other organs, contrast-enhanced CT (3D construction) and contrast-enhanced MRI are useful for determining portal vein hemodynamics in cases of portal hypertension. However, while these modalities are useful for understanding the state of the portal vein overall, they are insufficient for determining localized detailed hemodynamics of esophageal varices. EUS, however, enables observation near esophageal varices and helps to understand the localized Diagnostics 2020, 10, 1007; doi:10.3390/diagnostics10121007 www.mdpi.com/journal/diagnostics Diagnostics 2020,, 1010,, 1007x FOR PEER REVIEW 22 of of 12 understand the localized detailed hemodynamics of esophageal varices [9,10]. This suggests that detaileduseful information hemodynamics can be of obtained esophageal for the varices selection [9,10 of]. treatment This suggests suited that to the useful hemodynamics information of can each be obtainedindividual for varix the selectionand for the of treatmentprediction suited of recurre to thence hemodynamics [5–8]. Furtherm ofore, each EUS individual is considered varix andhighly for theuseful prediction for determining of recurrence the treatment [5–8]. Furthermore, response and EUS can is considered easily evaluate highly the useful presence for determining or absence the of treatmentresidual blood response flow and that can is difficult easily evaluate to determine the presence by normal or absence endoscopic of residual observation blood flow [5]. thatIn this is di reviewfficult toarticle, determine we conducted by normal a review endoscopic of the observation literature of [5 ].the In effectiveness this review article, of EUS we diagnosis conducted and a its review role ofin the literaturetreatment ofof theesophageal effectiveness varices. of EUS diagnosis and its role in the treatment of esophageal varices. 2. Hemodynamics of Esophageal Varices Increased intrahepatic vascular resistance and the volume of portal vein blood flowflow causescauses increased portal vein pressure, which results in a countercurrent phenomenon from from the portal vein, thus resulting inin the formationformation ofof esophagealesophageal varices.varices. The blood vessels involved in the formation of esophageal varices include feeding veins, such as the left gastric vein (LGV), posterior gastric vein, and short gastric gastric vein, vein, as as well well as as vessels vessels with with a bamboo a bamboo blind-like blind-like pattern, pattern, paraesophageal paraesophageal veins, veins, and andperforating perforating veins. veins. The Thecollateral collateral pathway pathway of the of the portal portal vein vein that that develops develops in in relation relation to to esophageal varices isis primarilyprimarily thethe pathwaypathway communicating communicating the the portal portal vein vein and and azygos azygos vein. vein. A A Japanese Japanese study study of percutaneousof percutaneous trans trans hepatic hepatic portography portography targeting targeting 65 patients 65 patients with with liver liver cirrhosis cirrhosis accompanied accompanied with esophagealwith esophageal varices varices revealed revealed that, in that, all patients, in all patients, the primary the pathwayprimary thatpathway was feeding that was the feeding esophageal the varicesesophageal was varices the LGV was [11 the]. LGV [11]. In most cases of esophagealesophageal varices,varices, the esophageal varices form via bamboobamboo blind-likeblind-like vesselsvessels from the anterior anterior branch branch of of the the LGV, LGV, and and drain drain blood blood into into the the azygos azygos vein vein (Figure (Figure 1).1). By By contrast, contrast, in insome some cases, cases, the the posterior posterior branch branch of of the the LGV LGV co communicatesmmunicates with with the the paraesophageal paraesophageal veins without passing the bamboo blind-like vessels, and the varicesvarices are fed from the paraesophageal veins via the veins perforating the esophageal wall. The morphologymorphology and hemodynamics of the LGV in patients with portal hypertension were studied to evaluateevaluate factors aaffectingffecting thethe developmentdevelopment ofof esophagealesophageal varices [12]. [12]. It It was was shown shown that that the the diameter diameter of the of theLGV LGV trunk trunk increases increases with with increasing increasing variceal variceal size. size.This study This studyalso demonstrated also demonstrated the branching the branching pattern patternof the LGV of theand LGV its relationship and its relationship with collateral with collateralchannels. channels.This branching This branching pattern patternwas found was foundto be toclosely be closely associated associated with with the thedevelopment development of ofesophageal esophageal varices varices because because dominance dominance of the of anteri the anterioror branch branch may maybe responsible be responsible for directing for directing LGV LGVblood blood flow toward flow toward varices varices at the atlevel the of level the ofprox theimal proximal stomach stomach [12]. However, [12]. However, it has been it has pointed been pointedout that outinflow that inflowof the ofLGV the of LGV the of upper the upper third third of the of thestomach stomach also also contributes contributes to to the the onset onset and development of varices. Kiyono et al. [13] [13] noted th thatat the hemodynamics in th thee left gastric artery may act asas anan initiator initiator of of variceal variceal formation, formation, and and that th theat LGVthe LGV contributes contributes to the to onset the ofonset esophageal of esophageal varices. Onvarices. angiography On angiography of the LGV, of the there LGV, was there a diff waserence a di observedfference observed in the mean in the detection mean detection time for recurrent time for esophagealrecurrent esophageal varices between varices patients between with patients recurrent with varicesrecurrent (7.0 varices s) and (7.0 patients s) and without patients recurrence without (5.6recurrence s). Thus, (5.6 various s). Thus, hemodynamics various hemodynamics are involved ar ine esophagealinvolved in varices,esophageal making varices, it important making toit understandimportant to the understand underlying the pathology underlying for pathology treatment. for treatment. Figure 1. Diagram of the hemodynamics of esophageal varices. Figure 1. Diagram of the hemodynamics of esophageal varices. Diagnostics 2020, 10, x FOR PEER REVIEW 3 of 12 DiagnosticsDiagnostics 20202020,, 1010,, x 1007 FOR PEER REVIEW 3 3of of 12 12 3. EUS Procedure
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