Among the ectopic varices, cholangojejunal anastomotic varices are rare, and treatment and long-term prognosis are not clear. Therefore, in order to clarify the clinical characteristics of cholangiojejunal anastomotic varices, we retrospectively examined 10 cases experienced so far. Ten cases were retrospectively evaluated from the three factors: patient factors, treatment factors, and prognostic factors, and their clinical characteristics were identified. There were 8 cases of extrahepatic portal vein obstruction after pancreaticoduodenectomy, and 2 cases of extrahepatic hepaticojejunostomy (Roux-en-Y reconstruction) for biliary atresia. The initial treatment was endoscopic cyanoacrylate injection in 4 cases, para-endoscopic injection sclerotherapy using polidocanol in 2 cases, hemostatic forceps in 1 case, and PSE in 1 case. Two cases were followed up without treatment. In the case of endoscopic cyanoacrylate injection, one case had gastrointestinal perforation, but all were hemostasis with the first treatment and there was no recurrence. On the other hand, all 3 cases of local treatment such as para-endoscopic injection sclerotherapy using polidocanol and hemostatic forceps had recurrence of bleeding, and anastomotic stenosis, liver dysfunction, cholangitis, and liver abscess were observed in 2 cases. In conclusion, from the viewpoint of treatment, endoscopic cyanoacrylate injection may be optimal.

In Japan, endoscopic injection sclerotherapy (EIS) is the first-line prophylactic treatment for high-risk esophagogastric varices. However, EIS is technically demanding, largely due to challenges in maintaining a clear visual field during the procedure. We hypothesized that gel immersion endoscopy, a novel technique for improving visualization during therapeutic endoscopy, might enhance the success of EIS. In this retrospective study, 59 patients who underwent EIS were divided into two groups based on gel use, and the intravascular injection success rate and volume of sclerosant injected was compared. The gel group showed significantly higher injection success and greater sclerosant delivery. Furthermore, the injection success rates in the gel group remained high even in follow-up sessions, where varices typically become smaller and harder to puncture. These findings indicate that gel use during EIS enables better visualization and helps stabilize low intraluminal pressure, thereby contributing to improved procedural outcomes.

Covert hepatic encephalopathy (CHE) is a subclinical complication of liver cirrhosis that is associated with poor prognosis. Identification of practical biomarkers for CHE is therefore essential in clinical practice. To clarify factors associated with CHE, we conducted a multicenter retrospective study involving 402 patients with cirrhosis from 17 institutions. CHE was diagnosed using the Stroop test. Laboratory parameters, including serum albumin and 25-hydroxyvitamin D₃ (25[OH]D₃), were analyzed to identify risk factors for CHE.

The cohort consisted of 233 men and 169 women, with a median age of 69 years. Esophageal varices (EV) were present in 45% of patients. Multivariate analysis identified low 25(OH)D₃ levels (<16.5 ng/ml) and the presence of EV as independent predictors of CHE (p<0.05). When the analysis was restricted to laboratory markers, low serum albumin (<3.7 g/dl) and low 25 (OH) D₃ levels remained significant. The prevalence of CHE increased with the accumulation of these risk factors: 59.2% in patients with low 25(OH)D₃ and EV, 53.8% in those with low albumin and low 25(OH)D₃, and 66.7% in those with all three factors.

In conclusion, low serum 25(OH)D₃ and albumin levels, as well as the presence of EV, are significantly associated with CHE in patients with cirrhosis. Early identification and monitoring of these risk factors may facilitate timely diagnosis and management of CHE.

This study aimed to clarify the morphological changes in esophageal varices after achieving sustained virological response (SVR) with direct-acting antivirals (DAAs) in patients with cirrhosis.

A total of 243 patients underwent esophagogastroduodenoscopy before DAA treatment and after achieving SVR. Morphological changes in esophageal varices were investigated using esophagogastroduodenoscopy. The improvement, unchanged, and aggravation rates of esophageal varices after SVR were 11.9%, 73.3%, and 14.8%, respectively.

ALBI score at the time of SVR12 was independently associated with both worsening of existing varices and the development of newly formed varices (p=0.045 and p=0.046, respectively). ROC curve analysis revealed that the optimal ALBI score cutoff values for predicting worsening and newly developed EVs after SVR were -2.33 and -2.65, respectively.

In conclusion, patients with liver cirrhosis may still develop worsening or newly formed EVs even after achieving SVR. In particular, patients with poor ALBI scores at SVR12 are at higher risk, and regular endoscopic evaluation should be considered in this population.

Objective: Acute liver failure (ALF) is a life-threatening condition associated with high mortality. This study aimed to evaluate the clinical characteristics and prognostic factors of ALF cases treated at our institution.

Methods: We retrospectively reviewed 47 patients diagnosed with ALF between 2014 and 2025. Etiology, complications, treatments, and predictors of poor outcomes (death or liver transplantation) were analyzed using multivariate logistic regression and decision tree analysis.

Results: The mean age was 58 years, and 49% of patients were male. Hepatitis B infection and circulatory disorders were the leading etiologies, each accounting for 25.5% of cases. Major complications included disseminated intravascular coagulation (DIC) in 61.7%, infections in 40.4%, and shock in 36.2% of patients. Intensive care unit (ICU) management was required in 85.1% of cases. Overall, 57.4% of patients survived with medical treatment alone, 38.3% died, and 4.3% underwent liver transplantation. Multivariate analysis identified hepatic encephalopathy (p=0.0098), platelet count (p=0.0152), and Model for End-Stage Liver Disease (MELD) score (p=0.0218) as independent predictors of poor prognosis. Decision tree analysis demonstrated that a MELD score ≥25 was the primary determinant of poor outcomes. Among patients with MELD scores ≥25, a transplant score ≥4 was associated with 100% mortality.

Conclusion: Prognosis in ALF is significantly associated with MELD score, platelet count, and the presence of hepatic encephalopathy. The combined use of scoring systems may enhance risk stratification and support clinical decision-making in the management of ALF.

Covert hepatic encephalopathy (CHE) impairs quality of life and prognosis in cirrhotic patients. This study aimed to identify risk factors for CHE and to stratify patients at high risk for overt hepatic encephalopathy (HE) who may benefit from early therapeutic intervention. A total of 145 cirrhotic patients without a history or treatment for overt HE were enrolled and classified into CHE (n=91) and no-CHE (n=54) groups. CHE was diagnosed when performance on at least one neuropsychological test, such as the Stroop or number connection test, exceeded the age-adjusted cutoff value. The prevalence of CHE was 62.8%. Compared with the no-CHE group, patients with CHE had significantly lower serum zinc and albumin levels. Multivariate logistic regression identified serum zinc level as an independent determinant, with a cutoff of 74 μg/dl. Subclinical zinc deficiency (<74 μg/dl) showed 55.6% sensitivity and 81.5% specificity for CHE detection. Blood ammonia level and liver functional reserve were not predictive. Patients with zinc ≥ 74 μg/dl had a significantly lower CHE prevalence and better hepatic functional reserve. Subclinical zinc deficiency is closely associated with CHE occurrence in cirrhosis, and zinc measurement may aid in early CHE detection and patient selection for neuropsychological testing.Usefulness of Serum Zinc Levels in the Diagnosis of Complications of Liver Cirrhosis Associated with Portal Hypertension

Background: Esophageal varices are classified into two types according to their venous anatomy at the gastroesophageal junction: the palisading type (major) and the pipeline stem type (minor). Many cases of the pipeline stem type (pipeline varices) have been reported to be resistant to or associated with a high risk during endoscopic therapy. This study aimed to clarify the prevalence and clinicopathological characteristics of pipeline varices.

Materials and methods: Among 1,141 patients who underwent endoscopic treatment for esophageal varices, 210 patients for whom detailed variceal anatomy was available from endoscopic varicealography during injection sclerotherapy or from percutaneous transhepatic portography were retrospectively analyzed. Endoscopic and hemodynamic findings were assessed. Pipeline varices were further classified into typical and subtype variants, and clinical characteristics were compared between these groups

Results: Of the 1,141 patients, 64 (5.6%) had pipeline varices; 49 (76.6%) were classified as the typical type and 15 (23.4%) as the subtype. No significant clinical differences were observed between the two types. Compared with patients with ordinary esophageal varices, those with pipeline varices showed a significantly higher prevalence of portopulmonary venous anastomosis (14.1% vs. 4.8%, p = 0.0197). In both groups, the primary site of esophageal varices was the right esophageal wall, and the left gastric vein was the main feeder in the majority of cases.

Conclusions: Pipeline varices are frequently associated with portopulmonary venous anastomoses. In the absence of a preprocedural diagnosis of such anastomoses, endoscopic treatment of pipeline varices may carry a substantial risk, including severe post-procedural bleeding or fatal systemic complications caused by the inadvertent migration of injected sclerosant into the arterial circulation.

Vol. 31, No. 4 pp.266-270