Japanese Journal of Portal Hypertension

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Backgraund: Bleeding from gastric varices (GV) is often fatal. Evidence of the efficacy of treatment for bleeding GV has not been yet established in Japan.
Aim: To evaluate effectiveness of various therapies for bleeding GV.
Method: Thirty one hospitals out of 81 hospitals to which 110 active members of the Japanese Society for Portal Hypertension (JSPH) participated in this retrospective multi-center cohort study.
The clinical research committee of the JSPH analyzed effect of treatments to stop bleeding gastric fundal varices. Three hundred thirty eight patients who experienced gastric variceal bleeding and its treatments between 1999 and 2008 were registered to the present study.
Results: As the first therapy to stop bleeding from GV, endoscopic sclerotherapy with N-butyl-2-cyanoacrylate (n = 83) or α-cyanoacrylate monomer (n = 50) and Lipiodol-mixture (CA + Lipiodol) had a lower rebleeding-rate than conservative treatments (n = 65), respectively (P = 0.048). There was no death due to complications of sclerotherapy with CA + Lipiodol such as pulmonary infarction. In 294 cirrhotic patients, both sclerotharapy with CA + Lipiodol (HR 0.214, 95% CI 0.056-0.812, P = 0.024) and balloon-occluded retrograde transvenous obliteration (B-RTO) (HR 0.106, 95% CI 0.017-0.659, P = 0.016) was revealed to have significantly lower rebleeding-rates compared with conservative treatments by the assessment with the Cox proportional monovariate analysis, respectively. Sclerotherapy with CA + Lipiodol was shown to be the only effective treatment for gastric varices by the multivariate analysis (HR 0.26, 95% CI 0.078-0.885, P = 0.031) corrected by age, sex and the Child classification. By the addition of several second-line procedures such as B-RTO, surgical operation and sclerotherapy with ethanolamine oleate to the first therapy, rebleeding was rendered quite rare except in patients with the Child C cirrhosis.
Conclusions: Sclerotherapy with CA + Lipiodol is the best and safety method to treat gastric variceal bleeding.

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We examined a relationship between the size of para-esophageal vein (PEV) visualized by computed tomography (CT) and early variceal recurrence after endoscopic treatment. Forty-two patients who underwent endoscopic injection sclerotherapy (EIS) or endoscopic variceal ligation (EVL) were divided into a PEV development group and a PEV non-development group according to the diameter of PEV on portal phase of dynamic multi-phase CT. Early recurrence was defined as endoscopic recurrence within 6 months after EIS or EVL. PEV was visualized as porto-systemic collaterals in all patients on the CT image. An early recurrence rate was significantly lower in the PEV development group (6%) than the PEV non-development group (38%). This result suggests that PEV is a drainage vein to reduce portal pressure, and that developed PEV plays an important role to prevent variceal recurrence. The result also indicates that dynamic CT is a useful modality for evaluating PEV, and it gives us useful information to estimate early recurrence after EIS or EVL.

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