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The purpose of this study is to evaluate the usefulness of endoscopic color Doppler ultrasonography (ECDUS) in the assessment of hemodynamics of gastric varices. In 77 patients examined, gastric varices were categorized as follows : as for form, 65 were of F₂ type varices, 12 were of F₃ type, and as for location, six were cardiac varices, 32 were fundic varices, and 39 were cardiofornical varices. ECDUS detected color flow image of intramural gastric varices in all 77 patients. The velocity of blood flow calculated by ECDUS was significantly higher in F₃ varices than in F₂ type. Gastric varices were further arbitrarily classified into three types. Type 1 : intramural gastric varices is greater than perigastric veins. Type 2 : intramural gastric varices is nearly equal to well developed perigastric veins, and the gastrorenal shunt is detected. Type 3 : perigastric veins is greater than intramural varices. Velocity of type 2 varices was significantly higher than other type varices. ECDUS can evaluate the hemodynamics of gastric varices and predict the possibility of bleeding, and determine the most effective treatment with ECDUS. In conclusion, ECDUS is useful to assess the hemodynamics of gastric varices.

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Endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) are known to be equally effective for the treatment of esophageal varices. However, indications for each therapy have not been established. Endoscopic ultrasonography (EUS) is a well-accepted procedure for the diagnosis of gastrointestinal lesions, and 3-dimensional imaging has recently been developed. In this study, 3-dimensional EUS (3D-EUS) was used to observe hemodynamics of esophageal varices. The aim of this study was to determine the value of 3D-EUS for selecting patients for endoscopic treatment of esophageal varices. 3D-EUS was performed with a 3D ultrasound image system (EU-M30, EU-IP-2, Olympus Co., Ltd.) using a small probe (12 MHz, 3.4 mm in diameter) according to the mechanical spiral scan method (length 40 mm and pitch 0.5 mm) Varices detected on 3D images were classified according to their architecture as a cardia-inflow type without collateral vessels (type 1), a cardia-inflow type with collateral vessels (type 2), an azygos-perforating type (type 3) and a complicated type (type 4). 3D-EUS was carried out in 32 patients with esophageal varices before the treatment with EIS in 22 patients and with EVL in 10 patients respectively. Then, short-term results were assessed. Fourteen patients (43.8%) were classified as type 1, 4 patients (12.5%) were as type 2, 4 patients (12.5%) were as type 3 and 10 patients (31.3%) were as type 4 according to 3D images. In type 1 better therapeutic results was obtained with EIS than with EVL. In type 3 the numbers of session required to obtain eradication was significantly smaller with EVL than with EIS. Thus, 3D-EUS is useful for the selection of methods of endoscopic treatment for esophageal varices. The azygos-perforating type (type 3) is suggested to be the best indication for EVL by sending the variceal blood flow to collateral pathways.

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We studied variceal recurrence after EVL treatment for esophageal varices in relation to pretreatment of esophageal variceal pressure (EVP). Thirteen patients whose varices were treated by EVL alone or combined therapy of EVL and EIS were included in this study. Six patients showed variceal recurrence and 7 patients did not show recurrence. From the analysis of factors influencing variceal recurrence, EVP and esophageal mucosal status after treatment were the most significant factors. In high EVP group (EVP≥ 15 mmHg), 6 of 9 patients showed variceal recurrence, and of these only one obtained complete eradication of varices, while in low EVP group (EVP < 15 mmHg) no patient showed variceal recurrence including those whose varices were not eradicated completely. These results suggest that measuring of EVP is useful for predicting posttreatment recurrence of esophageal varices.

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We have evaluated the long-term efficacy of a transvenous obliteration of porto-systemic shunt (TOPS) therapy using a self-retaining catheter for solitary gastric varices (GS), and the results are compared with those obtained by endoscopic injection sclerotherapy (EIS). Twenty patients with liver cirrhosis, not complicated with hepatocellular carcinoma, were treated with TOPS and 15 were treated with EIS as a control. Emergency cases were excluded. Mean observation periods were 36.1 (maximum 76) months and 23.7 (maximum 42) months for the TOPS group and the EIS group, respectively. The recurrence rate of GS was 0% for the TOPS group, and was 22% and 43% at 24 months period and 41 months during the observation, respectively, for the EIS group. The difference was highly significant. The recurrence rate for esophageal varices after TOPS was not significantly different from that after EIS (26% at 36 months vs 38% at 36 months). However, the rate of rebleeding was significantly lower in the TOPS group than in the EIS group (5% at 76 months vs 64% at 44 months). The mortality rate during the observation periods was not different between the two groups. These observations indicate that although TOPS doesn't significantly change a survival rate, it can improve the quality of life of patients with solitary gastric varix.

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We studied hemodynamics of supplying vessels, gastric varices, and outflowing vessels in 37 cases of solitary gastric varices based on the images of arterial portography (AP) or percutaneous transhepatic portography (PTP) and balloon occluded retrograde transvenous varicerography (BRTV). Supplying vessels were unidentified in 17 of 33 cases (51.5%) by BRTV and inconsistent in 17 of 31 (54.8%) on comparison of AP or PTP with BRTV. Examination of outflowing vessels, G-R shunt alone was found in 54.3% of patients by AP or PTP, while it was found in 22.2%, less than half of the result by AP or PTP, by BRTV. Visualization of outflowing vessels was inconsistent between AP or PTP and BRTV in only 8 of 32 cases (25.0%). In BRTV of gastric varices, stagnation of the contrast medium was observed in 13 (39.4%), gastric varices were imaged without stagnation in 11 (33.3%), and there was no image obtained in 9 (27.3%). Blockage of accessory outflowing vessels was attempted in 14 cases, and subsequent BRTV showed stagnation of contrast medium in gastric varices in 11 cases (78.6%) and images of gastric varices without stagnation were obtained in 3 cases (14.3%). It is concluded that BRTV is more important than AP or PTP, when balloon occluded retrograde transvenous obliteration (B-RTO) is considered for treatment of gastric varices.

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Endoscopic injection sclerotherapy (EIS) is widely accepted as the treatment for esophageal varices. However, the results have not been optimal. Incomplete eradication of varicose veins results in the recurrence and rebleeding of varices. To diminish the recurrence of varices, we applied argon plasma coagulation (APC) for the endoscopic treatment of varices. APC is a monopolar high-frequency surgical technique in which high-frequency current is applied to the tissue in a non-contact manner via ionized, electrically conductive argon (argon plasma). One of the main advantages of APC is the reproducible and uniform penetration depth of its thermal effect. Therefore, using APC under flexible endoscopy, one can easily coagulate the mucosa of the digestive tract superficially and laterally. After the eradication of major varices by EIS, we coagulated the whole mucosa of the lower esophagus with APC. The ulcer healed in a few weeks and complete eradication of varicose veins was achieved due to the fibrosis of the esophageal wall. We applied APC to 9 patients with esophageal varices and obtained sufficient results. This experience confirmed to us that a mucosa-fibrosing therapy with APC after EIS was a good choice for the treatment of esophageal varices

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We reported two patients who developed gastric varices immediately after endoscopic variceal ligation for esophageal varices, although pretreatment endoscopical examination had revealed no sign of gastric varices. In both cases angiography and computer tomography failed to demonstrate portocavanal shunts including gastrorenal shunt. Following successful treatment with endoscopic injection sclerotherapy using ethanolamine oleate, ethanol and cyanoacrylate, para-esophageal colateral veins developed and was demonstrated either by angiography or computer tomography. These observations suggest that gastric varices can easily occur after the abrupt occlusion of esophageal varices in cases in which para-esophageal colateral veins have previously not existed. Postoperative development of such shunts, therefore, may reduce the possibility of recurrence through decompression of portal blood pressure

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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[in Japanese]

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