Esophageal varices on computed tomography and subsequent variceal hemorrhage.

PubMed

Somsouk, Ma; To'o, Katherine; Ali, Mujtaba; Vittinghoff, Eric; Yeh, Benjamin M; Yee, Judy; Monto, Alex; Inadomi, John M; Aslam, Rizwan

2014-04-01

Endoscopy is recommended to screen for esophageal varices in patients with cirrhosis. The objective of this study was to identify features on abdominal CT imaging associated variceal hemorrhage (VH). A case-control study was performed among patients with cirrhosis who had a CT scan. Consecutive patients who experienced VH were included as cases, and patients without VH served as controls. Two radiologists recorded the maximal esophageal varix diameter in addition to other measures of portal hypertension at CT. The most powerful CT parameter associated with VH was the esophageal varix diameter (5.8 vs. 2.7 mm, p < 0.001; adjusted OR 1.84 per mm, p = 0.009). 63% of individuals with VH had a maximal varix diameter ≥5 mm compared to 7.5% of cirrhotic patients without VH (p < 0.001). In contrast, the proportion of individuals whose largest varix was <3 mm was 7.4% among VH cases compared to 54.7% among controls (p = 0.001). The varix diameter powerfully discriminated those with and without VH (C-statistic 0.84). A large esophageal varix diameter is strongly associated with subsequent VH. A threshold of <3 and ≥5 mm appears to identify patients with cirrhosis at low and high risk for hemorrhage.

Emergency endoscopic variceal ligation in cirrhotic patients with blood clots in the stomach but no active bleeding or stigmata increases the risk of rebleeding.

PubMed

Kim, Su Jin; Choi, Cheol Woong; Kang, Dae Hwan; Kim, Hyung Wook; Park, Su Bum; Hong, Young Mi; Yoon, Ki Tae; Cho, Mong; Nam, Hyung Seok; Islam, Sm Bakhtiar Ui

2016-12-01

This study aimed to evaluate the efficacy and safety of emergency variceal ligation for the prevention of rebleeding in cirrhotic patients who are found on initial endoscopy to have blood clots in the stomach but no actively bleeding esophageal and gastric varices or stigmata. This study included 28 cirrhotic patients who underwent emergency prophylactic EVL and 41 who underwent an elective intervention between January 2009 and June 2014. Clinical outcomes were analyzed, including the rebleeding, 6-week mortality, and rebleeding-free survival rates. The rebleeding rate was higher in the emergency than in the elective group (28.6% vs. 7.3%, P =0.041). Multivariate analysis showed that emergency prophylactic EVL (odds ratio [OR] = 7.4, 95% confidence interval [CI]=1.634.8, P =0.012) and Child-Pugh score C (OR=10.6, 95% CI=1.4-80.8, P =0.022) were associated with rebleeding. In the emergency group, the gastric varices were associated with rebleeding (OR=12.0, 95% CI=1.7-83.5, P =0.012). Emergency EVL may be associated with variceal rebleeding when blood clots are present in the stomach without active esophageal and gastric variceal bleeding or stigmata. Elective intervention should be considered as a safer strategy for preventing variceal rebleeding in this situation.

Circumferential suture technique for esophageal transection to treat esophageal variceal bleeding.

PubMed

Jeng, L B; Chen, M F

1993-01-01

The EEA stapler has been used routinely for esophageal transection to treat esophageal variceal bleeding for some time. It carries the risk of postoperative leakage and is not suitable in those cases receiving recent sclerotherapy. The circumferential suture technique presented in this paper can be used in any situation requiring esophageal transection. It has been utilized by us in twenty-two emergent cases with good results.

Prediction of esophageal varices and variceal hemorrhage in patients with acute upper gastrointestinal bleeding.

PubMed

Rockey, Don C; Elliott, Alan; Lyles, Thomas

2016-03-01

In patients with upper gastrointestinal bleeding (UGIB), identifying those with esophageal variceal hemorrhage prior to endoscopy would be clinically useful. This retrospective study of a large cohort of patients with UGIB used logistic regression analyses to evaluate the platelet count, aspartate aminotransferase (AST) to platelet ratio index (APRI), AST to alanine aminotransferase (ALT) ratio (AAR) and Lok index (all non-invasive blood markers) as predictors of variceal bleeding in (1) all patients with UGIB and (2) patients with cirrhosis and UGIB. 2233 patients admitted for UGIB were identified; 1034 patients had cirrhosis (46%) and of these, 555 patients (54%) had acute UGIB due to esophageal varices. In all patients with UGIB, the platelet count (cut-off 122,000/mm(3)), APRI (cut-off 5.1), AAR (cut-off 2.8) and Lok index (cut-off 0.9) had area under the curve (AUC)s of 0.80 0.82, 0.64, and 0.80, respectively, for predicting the presence of varices prior to endoscopy. To predict varices as the culprit of bleeding, the platelet count (cut-off 69,000), APRI (cut-off 2.6), AAR (cut-off 2.5) and Lok Index (0.90) had AUCs of 0.76, 0.77, 0.57 and 0.73, respectively. Finally, in patients with cirrhosis and UGIB, logistic regression was unable to identify optimal cut-off values useful for predicting varices as the culprit bleeding lesion for any of the non-invasive markers studied. For all patients with UGIB, non-invasive markers appear to differentiate patients with varices from those without varices and to identify those with a variceal culprit lesion. However, these markers could not distinguish between a variceal culprit and other lesions in patients with cirrhosis. Copyright © 2016 American Federation for Medical Research.

Streptococcus sanguinis meningitis following endoscopic ligation for oesophageal variceal haemorrhage.

PubMed

Liu, Yu-Ting; Lin, Chin-Fu; Lee, Ya-Ling

2013-05-01

We report a case of acute purulent meningitis caused by Streptococcus sanguinis after endoscopic ligation for oesophageal variceal haemorrhage in a cirrhotic patient without preceding symptoms of meningitis. Initial treatment with flomoxef failed. The patient was cured after 20 days of intravenous penicillin G. This uncommon infection due to S. sanguinis adds to the long list of infectious complications among patients with oesophageal variceal haemorrhage.

Therapeutic esophageal interventions for dysphagia and bleeding.

PubMed

Siersema, Peter D

2006-07-01

This article reviews the most notable results of esophageal interventions for dysphagia and bleeding published in 2005. Long-term rubber tube placement was shown to be an interesting treatment option for difficult esophageal strictures. Two studies demonstrated that only 50% of patients who had undergone pneumatic dilation for achalasia were dysphagia-free after long-term follow-up. It was shown that patients with dysphagia from esophageal cancer should be treated by intraluminal radiotherapy (brachytherapy), whereas stent placement was preferable in those with a poor prognosis. Temporary stent placement is an option in patients undergoing radiotherapy for inoperable esophageal cancer to increase the dysphagia-free period. Two studies were published on the successful use of silicone-covered plastic stents for sealing of leaks after surgery of the esophagus. The optimal treatment for bleeding varices was confirmed to be endoscopic band ligation. A meta-analysis demonstrated that adding sclerotherapy to band ligation for secondary prophylaxis of bleeding varices had no effect on clinical outcome. In 2005, new techniques for the treatment of complicated strictures were presented. In addition, expanding indications for stents were reported. Finally, endoscopic band ligation was confirmed to be the most optimal technique for the treatment of varices.

Jejunal variceal bleeding after esophageal transection in a patient with idiopathic portal hypertension.

PubMed

Migou, S; Hashizume, M; Tsugawa, K; Kishihara, F; Kawanaka, H; Ohta, M; Tanoue, K; Kuroiwa, T; Kawamoto, K; Sugimachi, K

1998-01-01

This report describes a 38-year-old man with massive gastrointestinal bleeding from jejunal varices. He had been previously diagnosed to have idiopathic portal hypertension and esophageal varices, and had undergone an esophageal transection 8 years earlier. The pre-operative diagnosis was a suspected hemorrhage from the small intestine as visualized by 99mTc-HSAD scintigraphy (technetium 99m-labeled human serum albumin D-type) and was not considered to be repeated massive lower GI tract bleeding. An exploratory laparotomy was performed, and intra-operative endoscopy revealed active bleeding from the jejunal varices. A partial resection of the small intestine resulted in a complete resolution of the bleeding. A review of the literature thereafter disclosed twelve previously reported cases of jejunal variceal bleeding.

Severe bleeding from esophageal varices resistant to endoscopic treatment in a non cirrhotic patient with portal hypertension

PubMed Central

Caronna, Roberto; Bezzi, Mario; Schiratti, Monica; Cardi, Maurizio; Prezioso, Giampaolo; Benedetti, Michele; Papini, Federica; Mangioni, Simona; Martino, Gabriele; Chirletti, Piero

2008-01-01

A non cirrhotic patient with esophageal varices and portal vein thrombosis had recurrent variceal bleeding unsuccessfully controlled by endoscopy and esophageal transection. Emergency transhepatic portography confirmed the thrombosed right branch of the portal vein, while the left branch appeared angulated, shifted and stenotic. A stent was successfully implanted into the left branch and the collateral vessels along the epatoduodenal ligament disappeared. In patients with esophageal variceal hemorrhage and portal thrombosis if endoscopy fails, emergency esophageal transection or nonselective portocaval shunting are indicated. The rare patients with only partial portal thrombosis can be treated directly with stenting through an angioradiologic approach. PMID:18644135

Prediction of Esophageal Varices in Patients with Cirrhosis: Usefulness of Three-dimensional MR Elastography with Echo-planar Imaging Technique

PubMed Central

Shin, Sung Ui; Yu, Mi Hye; Yoon, Jeong Hee; Han, Joon Koo; Choi, Byung-Ihn; Glaser, Kevin J.; Ehman, Richard L.

2014-01-01

Purpose To determine the diagnostic performance of magnetic resonance (MR) elastography in comparison to spleen length and dynamic contrast material–enhanced (DCE) MR imaging in association with esophageal varices in patients with liver cirrhosis by using endoscopy as the reference standard. Materials and Methods This retrospective study received institutional review board approval, and informed consent was waived. One hundred thirty-nine patients with liver cirrhosis who underwent liver DCE MR imaging, including MR elastography, were included. Hepatic stiffness (HS) and spleen stiffness (SS) values assessed with MR elastography, as well as spleen length, were correlated with the presence of esophageal varices and high-risk varices by using Spearman correlation analysis. The diagnostic performance of MR elastography was compared with that of DCE MR imaging and combined assessment of MR elastography and DCE MR imaging by using receiver operating characteristic analysis. MR elastography reproducibility was assessed prospectively, with informed consent, in another 15 patients by using intraclass correlation coefficients. Results There were significant positive linear correlations between HS, SS, and spleen length and the grade of esophageal varices (r = 0.46, r = 0.48, and r = 0.36, respectively; all P < .0001). HS and SS values (>4.81 kPa and >7.60 kPa, respectively) showed better performance than did spleen length in the association with esophageal varices (P = .0306 and P = .0064, respectively). Diagnostic performance of HS and SS in predicting high-risk varices was comparable to that of DCE MR imaging (P = .1282 and P = .1371, respectively). When MR elastography and DCE MR imaging were combined, sensitivity improved significantly (P = .0004). MR elastography was highly reproducible (intraclass correlation coefficient > 0.9). Conclusion HS and SS are associated with esophageal varices and showed better performance than did spleen length in assessing the presence

Gastric Varices Bleed at Lower Portosystemic Pressure Gradients than Esophageal Varices.

PubMed

Morrison, Joseph D; Mendoza-Elias, Nasya; Lipnik, Andrew J; Lokken, R Peter; Bui, James T; Ray, Charles E; Gaba, Ron C

2018-05-01

To quantify and compare portosystemic pressure gradients (PSGs) between bleeding esophageal varices (EV) and gastric varices (GV). In a single-center, retrospective study, 149 patients with variceal bleeding (90 men, 59 women, mean age 52 y) with EV (n = 69; 46%) or GV (n = 80; 54%) were selected from 320 consecutive patients who underwent successful transjugular intrahepatic portosystemic shunt (TIPS) creation from 1998 to 2016. GV were subcategorized using the Sarin classification as gastroesophageal varices (GEV) (n = 57) or isolated gastric varices (IGV) (n = 23). PSG before TIPS was measured from the main portal vein to the right atrium. PSGs were compared across EV, GEV, and IGV groups using 1-way analysis of variance. Overall mean baseline PSG was 21 mm Hg ± 6. PSG was significantly higher in patients with EV versus GV (23 mm Hg vs 19 mm Hg; P < .001). Mean PSG was highest among EV (23 mm Hg) with lower PSGs identified for GEV (20 mm Hg) and IGV (16 mm Hg); this difference was statistically significant (P < .001). Among 95 acute bleeding cases, a similar pattern was evident (EV 23 mm Hg vs GEV mm Hg 20 vs IGV 17 mm Hg; P < .001). At baseline PSG < 12 mm Hg, 13% (3/23) of IGV bled versus 9% (5/57) of GEV and 3% (2/69) of EVs (P = .169). Mean final PSG after TIPS was 8 mm Hg (IGV 6 mm Hg vs EV and GEV 8 mm Hg; P = .005). GV bleed at lower PSGs than EV. EV, GEV, and IGV bleeding is associated with successively lower PSGs. These findings highlight distinct physiology, anatomy, and behavior of GV compared with EV. Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.

Feasibility of transnasal endoscopy in screening for esophageal and gastric varices in patients with chronic liver disease

PubMed Central

de Faria, Anderson Antônio; Dias, Carlos Alberto Freitas; Dias Moetzsohn, Luciana; de Castro Carvalho, Silas; Ferrari, Tereza Abreu; Nunes Arantes, Vitor

2017-01-01

Background and study aims  Screening for esophageal and gastric varices is indicated for patients with portal hypertension or cirrhosis. Typically, conventional endoscopy is used; however, the need for sedation increases the costs and risks, especially in cirrhotic patients. Use of transnasal endoscopy with an ultrathin endoscope enables study of the upper gastrointestinal tract without the need for sedation. The objective of this study is to evaluate the feasibility of transnasal endoscopy in screening for esophageal and gastric varices in patients with chronic liver disease. Patients and methods  This was a prospective study in which transnasal endoscopy was carried out in patients with cirrhosis or portal hypertension who had indications for screening of esophageal and gastric varices. The following variables were evaluated: demographical data, duration of procedure, patient tolerance and acceptance, adverse events (AEs), endoscopic findings and interobserver agreement related to portal hypertension alterations ( kappa index). Results  A total of 50 patients entered the study. The most common cause of liver disease was chronic viral hepatitis (66 %). Among the cirrhotic patients, most of the patients were Child-Pugh A (74 %). In 5 patients (10 %), nasal intubation was not possible. Two patients (4 %) experienced minor epistaxis. Tolerance was excellent or good in 92 % according with a visual analogic scale. In 16 patients (32 %), esophageal varices were detected and in 2 patients (4 %) gastric varices were detected. The mean duration of the procedure was 7 minutes. Conclusions  Transnasal endoscopy is feasible, effective and well tolerated for screening of esophageal and gastric varices in patients with chronic liver disease. It can be performed in outpatient clinics safely and without the use of sedation. PMID:28691048

Regression of esophageal varices and splenomegaly in two patients with hepatitis-C-related liver cirrhosis after interferon and ribavirin combination therapy.

PubMed

Lee, Soon Jae; Cho, Yoo-Kyung; Na, Soo-Young; Choi, Eun Kwang; Boo, Sun Jin; Jeong, Seung Uk; Song, Hyung Joo; Kim, Heung Up; Kim, Bong Soo; Song, Byung-Cheol

2016-09-01

Some recent studies have found regression of liver cirrhosis after antiviral therapy in patients with hepatitis C virus (HCV)-related liver cirrhosis, but there have been no reports of complete regression of esophageal varices after interferon/peg-interferon and ribavirin combination therapy. We describe two cases of complete regression of esophageal varices and splenomegaly after interferon-alpha and ribavirin combination therapy in patients with HCV-related liver cirrhosis. Esophageal varices and splenomegaly regressed after 3 and 8 years of sustained virologic responses in cases 1 and 2, respectively. To our knowledge, this is the first study demonstrating that complications of liver cirrhosis, such as esophageal varices and splenomegaly, can regress after antiviral therapy in patients with HCV-related liver cirrhosis.

Esophageal Varices

MedlinePlus

... that carries blood to your liver. This pressure (portal hypertension) forces the blood to seek other pathways through ... the amount of pressure in the portal vein (portal hypertension). Large varices. The larger the varices, the more ...

Peroral endoscopic myotomy for the treatment of achalasia in a patient with esophageal varices. A case report.

PubMed

Shen, Naning; Wang, Xin; Zhang, Xiaoyin; Yao, Liping; Xie, Huahong; Zhang, Hongbo

2017-06-01

Achalasia is very uncommon, and rarely does achalasia co-exist with esophageal varices. We present a 62-year-old woman who was diagnosed with both achalasia and esophageal varices in December 2014 and had a past history of hematemesis. The patient's achalasia symptoms' Eckardt score was 9, and her hepatic function was Child-Pugh grade A6. After comprehensive assessment of the patient's health and discussion of the pros and cons of various therapies for achalasia, the patient underwent a peroral endoscopic myotomy. She was symptom-free after the operation and had no recurrence of achalasia symptoms at 20-month follow-up. No adverse events were reported. Peroral endoscopic myotomy for achalasia with esophageal varices has not been previously reported in the English literature.

Factors predicting the presence of esophageal or gastric varices in patients with advanced liver disease.

PubMed

Zaman, A; Hapke, R; Flora, K; Rosen, H R; Benner, K

1999-11-01

Recently it has been recommended that all cirrhotic patients without previous variceal hemorrhage undergo endoscopic screening to detect varices and that those with large varices should be treated with beta-blockers (American College of Gastroenterology guidelines). However, endoscopic screening only of patients at highest risk for varices may be the most cost effective. Ninety-eight patients without a history of variceal hemorrhage underwent esophagogastroduodenoscopy as part of a liver transplant evaluation. Univariate/multivariate analysis was used to evaluate associations between the presence of varices and patient characteristics including etiology of liver disease, Child-Pugh class, physical findings (spider angiomata, splenomegaly, and ascites), encephalopathy, laboratory parameters (prothrombin time, albumin, bilirubin, BUN, creatinine, and platelets), and abdominal ultrasound findings (portal vein diameter/flow, splenomegaly, and ascites). The causes of cirrhosis among the 67 men and 31 women (mean age, 48 yr) included 28% Hepatitis C/alcoholism, 25% Hepatitis C, 13% alcoholism, 9% primary sclerosing cholangitis/primary biliary cirrhosis, 9% cryptogenic, 6% Hepatitis B, 1% Hepatitis B and C, and 9% other. Patients were Child-Pugh class A 34%, B 51%, and C 15%. Endoscopic findings included esophageal varices in 68% of patients (30% were large), gastric varices in 15%, and portal hypertensive gastropathy in 58%. Platelet count <88,000 was the only parameter identified by univariate/multivariate analysis (p < 0.05) as associated with the presence of large esophageal varices (odds ratio 5.5; 95% confidence interval 1.8-20.6) or gastric varices (odds ratio 5; 95% confidence interval 1.4-23). Platelet count <88,000 is associated with the presence of esophagogastric varices. A large prospective study is needed to verify and validate these findings and may allow identification of a group of patients who would most benefit from endoscopic screening for varices.

Measuring the hemodynamic response to primary pharmacoprophylaxis of variceal bleeding: a cost-effectiveness analysis.

PubMed

Imperiale, Thomas F; Chalasani, Naga; Klein, Robert W

2003-12-01

The hemodynamic response to ss-blockers alone or with nitrates is highly predictive of efficacy in prevention of variceal bleeding. Hemodynamic monitoring (HDM) requires catheterization of the hepatic vein and measurement of the hepatic venous pressure gradient, the difference between wedged and free hepatic venous pressure. The aim of this study was to compare HDM with no HDM in patients considered for primary pharmacoprophylaxis of esophageal variceal bleeding. A decision model was constructed to compare HDM with no HDM in cirrhotic patients with moderate to large esophageal varices. Patients intolerant to beta-blocker therapy would undergo endoscopic variceal ligation; those with an inadequate hemodynamic response (HDR) to beta-blocker therapy could have nitrates added before ligation was considered. Variceal bleeding was treated with ligation, with transjugular intrahepatic portosystemic shunt (TIPS) reserved for refractory bleeding. Probabilities of treatment responses as well as risks of bleeding and mortality were based on published literature. Only direct costs were considered during the 5-yr time horizon. Outcomes were cost in United States dollars, survival length in life-years, and proportions of patients who experienced variceal bleeding, TIPS insertion, and mortality from any cause. In the base case analysis, HDM was either cost-saving ($2,523 US dollars /life-year gained) or cost-effective (incremental cost-effectiveness ratio of $5,200 US dollars/life-year saved) compared with no HDM, depending on whether nitrates were added to beta-blocker therapy. HDM reduced variceal bleeding by nearly 60% and had a small effect on all-cause mortality. In the sensitivity analysis, HDM was sensitive to the time horizon, as it was not cost-effective for a time horizon of <22 months and was not cost-saving before 49 months. The cost-effectiveness of HDM was not sensitive to reasonable variation in the probability of HDR to beta-blocker therapy, risk of bleeding, risk

von Willebrand factor as a novel noninvasive predictor of portal hypertension and esophageal varices in hepatitis B patients with cirrhosis.

PubMed

Wu, Hao; Yan, Shiping; Wang, Guangchuan; Cui, Shaobo; Zhang, Chunqing; Zhu, Qiang

2015-01-01

At present, there is no perfect noninvasive method to assess portal hypertension and esophageal varices. Early predicting esophageal varices can provide evidence for managing cirrhotic patients. We aimed to further investigate von Willebrand factor (vWF) as a noninvasive predictor of portal hypertension, especially of esophageal varices. A total of 60 hepatitis B patients with cirrhosis and 45 healthy subjects were enrolled in this study. Levels of six markers were examined. All patients underwent hepatic venous pressure gradient (HVPG) and esophagogastroduodenoscopy. We evaluated the performance of six factors for diagnosis of portal hypertension and esophageal varices. The vWF levels in liver tissues were observed by immunohistochemistry. Correlations between the level of vWF in liver tissues and HVPG and between levels of vWF in tissues and plasma were examined. Cutoff values of plasma vWF (1510.5 mU/mL and 1701 mU/mL) showed high positive predictive value (PPV, 90.2% and 87.5%) in predicting clinically significant portal hypertension and severe portal hypertension. Cutoff values of vWF (1414 mU/ml and 1990 mU/mL, PPV 90.3% and 86.3%, respectively) were provided to detect the presence and degree of esophageal varices. Linear correlations were observed between levels of vWF in liver tissues and HVPG (r(2) = 0.552, p < 0.001) and between the level of vWF in liver tissues and in plasma (r(2) = 0.461, p < 0.001). The vWF is a noninvasive predictor of portal hypertension and esophageal varices in hepatitis B patients with cirrhosis. Increased levels of vWF in liver tissues may induce the elevated plasma vWF levels, but molecular mechanism is needed for further study.

Albumin and magnetic resonance imaging-liver volume to identify hepatitis B-related cirrhosis and esophageal varices

PubMed Central

Li, Hang; Chen, Tian-Wu; Li, Zhen-Lin; Zhang, Xiao-Ming; Li, Cheng-Jun; Chen, Xiao-Li; Chen, Guang-Wen; Hu, Jia-Ni; Ye, Yong-Quan

2015-01-01

AIM: To investigate whether liver lobe volume and albumin (ALB) could predict the presence and severity of liver cirrhosis, and esophageal varices. METHODS: Seventy-one cirrhotic patients with hepatitis B and 21 healthy individuals were enrolled in this study. All the participants underwent abdominal enhanced magnetic resonance imaging to measure each liver lobe volume, and biochemical workup for testing ALB and Child-Pugh class. All cirrhotic patients underwent upper gastrointestinal endoscopy to show the presence of cirrhotic esophageal varices. Right liver lobe volume (RV), left medial liver lobe volume (LMV), left lateral liver lobe volume (LLV), and caudate lobe volume (CV) were measured using enhanced magnetic resonance imaging. The ratios of RV to ALB (RV/ALB), LMV to ALB (LMV/ALB), LLV to ALB (LLV/ALB) and CV to ALB (CV/ALB) were calculated. Statistical analyses were performed to determine whether and how the combination of liver lobe volume measured using magnetic resonance imaging and albumin could predict the presence and severity of liver cirrhosis, and the presence of esophageal varices. RESULTS: RV, LMV, LLV and CV decreased (r = -0.51-0.373; all P < 0.05), while RV/ALB increased (r = 0.424; P < 0.05), with the progress of Child-Pugh class of liver cirrhosis. RV, LMV, CV, LLV/ALB and CV/ALB could identify presence of liver cirrhosis; LLV and LMV could distinguish Child-Pugh class A from B; RV, LMV, LLV, CV, RV/ALB and LLV/ALB could distinguish class A from C; RV and LLV/ALB could differentiate B from C; and RV, RV/ALB and CV/ALB could identify presence of esophageal varices (all P < 0.05). Among these parameters, CV/ALB could best identify the presence of liver cirrhosis, with an area under receiver operating characteristic curve (AUC) of 0.860, a sensitivity of 82.0% and a specificity of 83.0%. LLV could best distinguish class A from B, with an AUC of 0.761, a sensitivity of 74.4% and a specificity of 73.1%. RV could best distinguish class A from C

Creatinine-modified Child-Turcotte-Pugh score is a good predictor of a short-term survival in patients with bleeding from esophageal varices.

PubMed

Radisavljević, Mirjana; Bjelaković, Goran; Jović, Jasna; Radovanović-Dinić, Biljana; Benedoto-Stojanov, Danijela; Brzački, Vesna; Marković-Živković, Bojana

2017-01-01

Bleeding from esophageal varices is a significant factor in mortality of patients with terminal liver cirrhosis. This complication is a major health problem for recipients on the list for liver transplant. In that regard, studying predictors of variceal bleeding episode is very important. Also, it is important to find the best survival predictor among prognostic scores. The aim of the study was to compare validity of prognostic scores in assessment of survival in hospital-treated patients after bleeding from esophageal varices, and to compare validity of baseline Child-Turcotte-Pugh (CTP) and Modul for End-stage Liver Disease (MELD) scores with CTP creatinine modified (CTP-crea) I and II scores in assessment of survival in patients within a long-term follow-up period after the episode of bleeding from esophageal varices. The study included a total of 126 patients suffering from terminal liver cirrhosis submited to testing CTP score score I and II, MELD score, MELD Na score, integrated MELD score, MELD sodium (MESO) index, United Kingdom Model for End-Stage Liver Disease (UKELD) score and updated MELD score. Patients with bleeding from esophageal varices most often had CTP score rank C (46,9%). CTP score rank B had 37.5% patients, while the smallest percentage of patients had CTP rank A, 15.6% of them. Patients who have values of CTP score higher than 10.50 and bleeding from esophagus, have 3.2 times higher chance for death outcome compared to other patients. Patients who have values of CTP-crea I score higher than 10.50 and bleeding from esophagus, have 3.1 times higher chance for death out-come than other patients. Patients who have values of CTP-crea II score higher than 11.50 and bleeding from esophagus, have 3,7 times higher chance for death outcome compared to other patients. Survival of patients with bleeding from esophageal varices in the short-term follow up can be predicted by following CTP score and creatinine modified CTP scores. Patients with bleeding

Endoscopic variceal ligation-induced ulcer bleeding

PubMed Central

Cho, Eunae; Jun, Chung Hwan; Cho, Sung Bum; Park, Chang Hwan; Kim, Hyun Soo; Choi, Sung Kyu; Rew, Jong Sun

2017-01-01

Abstract This study was aimed to determine the risk factors of endoscopic variceal ligation-(EVL) induced ulcer bleeding. The prevalence of EVL-induced ulcer bleeding is reported to be 3.6%. However, there are only limited reports of this serious complication, and the risk factors and the treatment methods are not well established. A total of 430 patients who had undergone EVL in Chonnam National University Hospital from January 2014 to October 2016 were studied. EVL was performed for prophylaxis or acute hemorrhage. The patients were classified into 2 groups: a bleeding group (n = 33) and a non-bleeding group (n = 397). The patients who had endoscopically confirmed EVL-induced ulcer bleeding were included in the bleeding group. EVL-induced ulcer bleeding occurred in 7.7% (n = 33) of the patients. In a multivariate analysis, model for end-stage liver disease (MELD) score >10 (odds ratio [OR]: 3.42, 95% confidence interval [CI]: 1.10–10.64), concomitant GV F3 (OR: 14.1, 95% CI: 2.84–71.43), and detachment of o-ring bands on follow-up endoscopy (OR: 8.06, 95% CI: 2.55–25.64) were independent predictive factors of EVL-induced ulcer bleeding. Various endoscopic modalities were attempted for hemostasis (EVL in 8 cases [24.2%], endoscopic variceal obturation [EVO] with cyanoacrylate in 6 cases [18.2%], argon plasma coagulation [APC] in 1 case (3%), Sengstaken–Blakemore (SB) tube in 3 cases [9.1%]), and proton pump inhibitor therapy only in 15 cases (45.5%). MELD score >10, concomitant GV F3, and detachment of o-ring bands on follow-up endoscopy are risk factors for EVL-induced ulcer bleeding. PMID:28614248

Coil-Assisted Retrograde Transvenous Obliteration (CARTO) for the Treatment of Portal Hypertensive Variceal Bleeding: Preliminary Results

PubMed Central

Lee, Edward W; Saab, Sammy; Gomes, Antoinette S; Busuttil, Ronald; McWilliams, Justin; Durazo, Francisco; Han, Steven-Huy; Goldstein, Leonard; Tafti, Bashir A; Moriarty, John; Loh, Christopher T; Kee, Stephen T

2014-01-01

OBJECTIVES: To describe the technical feasibility, safety, and clinical outcomes of coil-assisted retrograde transvenous obliteration (CARTO) in treating portal hypertensive non-esophageal variceal hemorrhage. METHODS: From October 2012 to December 2013, 20 patients who received CARTO for the treatment of portal hypertensive non-esophageal variceal bleeding were retrospectively evaluated. All 20 patients had at least 6-month follow-up. All patients had detachable coils placed to occlude the efferent shunt and retrograde gelfoam embolization to achieve complete thrombosis/obliteration of varices. Technical success, clinical success, rebleeding, and complications were evaluated at follow-up. RESULTS: A 100% technical success rate (defined as achieving complete occlusion of efferent shunt with complete thrombosis/obliteration of bleeding varices and/or stopping variceal bleeding) was demonstrated in all 20 patients. Clinical success rate (defined as no variceal rebleeding) was 100%. Follow-up computed tomography after CARTO demonstrated decrease in size with complete thrombosis and disappearance of the varices in all 20 patients. Thirteen out of the 20 had endoscopic confirmation of resolution of varices. Minor post-CARTO complications, including worsening of esophageal varices (not bleeding) and worsening of ascites/hydrothorax, were noted in 5 patients (25%). One patient passed away at 24 days after the CARTO due to systemic and portal venous thrombosis and multi-organ failure. Otherwise, no major complication was noted. No variceal rebleeding was noted in all 20 patients during mean follow-up of 384±154 days. CONCLUSIONS: CARTO appears to be a technically feasible and safe alternative to traditional balloon-occluded retrograde transvenous obliteration or transjugular intrahepatic portosystemic shunt, with excellent clinical outcomes in treating portal hypertensive non-esophageal variceal bleeding. PMID:25273155

Spleen and Liver Stiffness Is Positively Correlated with the Risk of Esophageal Variceal Bleeding.

PubMed

Buechter, Matthias; Kahraman, Alisan; Manka, Paul; Gerken, Guido; Jochum, Christoph; Canbay, Ali; Dechêne, Alexander

2016-01-01

Portal hypertension (PH) is a common complication of chronic liver disease and results in esophageal and gastric variceal bleeding, which is associated with a high mortality rate. Measurement of the hepatic venous pressure gradient (HVPG) is considered the gold standard for diagnosing PH and estimating the risk of varices and bleeding. In contrast, upper gastrointestinal (GI) endoscopy (UGE) can reliably demonstrate the presence of varices and bleeding. Both measures are invasive, and HVPG is mainly restricted to tertiary centers. Therefore, the development of noninvasive methods of assessing the severity of PH and the risk of variceal bleeding is warranted. We retrospectively examined the correlation of spleen stiffness (SSM) and liver stiffness measurements (LSM) with the incidence of variceal bleeding among 143 patients who underwent combined liver and spleen elastography between 2013 and 2015. For 19 of 103 patients (16.8%), upper GI variceal bleeding was diagnosed and treated endoscopically. The median SSM of all patients was 35.3 kilopascals (kPa); the median LSM, 11.7 kPa. Patients with previous bleeding episodes had significantly higher SSM (75.0 kPa) and LSM (37.3 kPa) than those without a history of bleeding (SSM, 30.6 kPa; LSM, 8.2 kPa; p < 0.0001). Seventy-five patients (66.4%) underwent UGE in addition to SSM and LSM: 25 with no esophageal varices (EVs; SSM, 29.5 kPa; LSM, 11.4 kPa), 16 with EV grade 1 (SSM, 35.9 kPa; LSM, 33.4 kPa), 21 with EV grade 2 (SSM, 67.8 kPa; LSM, 27.0 kPa) and 13 with EV grade 3 (SSM, 75.0 kPa; LSM, 26.3 kPa). No statistically significant differences were found between respective grades of EV but were found between the presence and absence of varices. At a calculated cutoff level of 42.6 kPa (with application of 95% CI), SSM had sensitivity of 89% and specificity of 64% in determining the risk of bleeding, with a negative predictive value (NPV) of 0.97 (LSM sensitivity, 84%; LSM specificity, 80%; LSM NPV, 0.96 at LSM cutoff

Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension

PubMed Central

Biecker, Erwin

2013-01-01

Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. The management of acute bleeding has changed over the last years. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. Pharmacologic therapy is recommended for most patients; band ligation is an alternative in patients with contraindications for or intolerability of beta blockers. Treatment options for secondary prophylaxis include variceal band ligation, beta blockers, a combination of nitrates and beta blockers, and combination of band ligation and pharmacologic treatment. A clear superiority of one treatment over the other has not been shown. Bleeding from portal hypertensive gastropathy or ectopic varices is less common. Treatment options include beta blocker therapy, injection therapy, and interventional radiology. PMID:27335828

Non-variceal upper gastrointestinal bleeding in cirrhotic patients in Nile Delta.

PubMed

Gabr, Mamdouh Ahmed; Tawfik, Mohamed Abd El-Raouf; El-Sawy, Abd Allah Ahmed

2016-01-01

Acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients occurs mainly from esophageal and gastric varices; however, quite a large number of cirrhotic patients bleed from other sources as well. The aim of the present work is to determine the prevalence of non-variceal UGIB as well as its different causes among the cirrhotic portal hypertensive patients in Nile Delta. Emergency upper gastrointestinal (UGI) endoscopy for AUGIB was done in 650 patients. Out of these patients, 550 (84.6%) patients who were proved to have cirrhosis were the subject of the present study. From all cirrhotic portal hypertensive patients, 415 (75.5%) bled from variceal sources (esophageal and gastric) while 135 (24.5%) of them bled from non-variceal sources. Among variceal sources of bleeding, esophageal varices were much more common than gastric varices. Peptic ulcer was the most common non-variceal source of bleeding. Non-variceal bleeding in cirrhosis was not frequent, and sources included peptic ulcer, portal hypertensive gastropathy, and erosive disease of the stomach and duodenum.

Bleeding esophageal varices

MedlinePlus

... treated with medicines and medical procedures to prevent future bleeding. These include: Drugs called beta blockers, such ... Future problems caused by varices may include: Narrowing or stricture of the esophagus due to scarring after ...

Balloon-occluded retrograde transvenous obliteration versus endoscopic injection sclerotherapy for isolated gastric varices: a comparative study.

PubMed

Emori, Keigo; Toyonaga, Atsushi; Oho, Kazuhiko; Kumamoto, Masafumi; Haruta, Tsuyoshi; Inoue, Hiroto; Morita, Yukihiko; Mitsuyama, Keiichi; Tsuruta, Osamu; Sata, Michio

2014-01-01

Isolated gastric varices (IGV) have a lower risk of bleeding than esophageal varices, however IGV bleeding is associated with a higher mortality than bleeding of esophageal varices. In recent years, two widely used treatments for IGV have been balloon-occluded retrograde transvenous obliteration (B-RTO) and endoscopic injection sclerotherapy (EIS) using cyanoacrylate or ethanolamine oleate (EO). This study compared these two treatment methods for IGV. The subjects were 112 patients who were treated at our hospital for IGV bleeding between October 1990 and December 2003. Forty-nine (49) patients were treated with B-RTO and 63 patients with EIS. These two patient groups were compared as regards content of treatment, post-treatment incidence of variceal bleeding, incidence of IGV rebleeding, survival rate, cause of death, and complications. Multivariate analysis was performed on post-treatment variceal bleeding and survival. Although EO was used in higher amounts in the B-RTO group than in the EIS group, the B-RTO group had a significantly lower number of treatment sessions and a significantly shorter treatment period (p<0.05). The EIS group had significantly more patients with IGV rebleeding after treatment than the B-RTO group. Treatment method was the only independent prognostic factor of IGV bleeding after treatment (p=0.024). The two groups did not differ significantly in the percentage of patients with aggravated esophageal varices after treatment. Bleeding from ectopic varices was not observed in any patient. There was no significant difference in survival by treatment method. The presence of hepatocellular carcinoma was the only independent prognostic factor for survival (p=0.003). It is concluded that B-RTO was more effective than EIS in the eradication of IGV and prevention of IGV recurrence and rebleeding.

Endoscopic Cyanoacrylate Injection with Post-injection Audible Doppler Assessment of Gastric Varices: A Single-Institution Experience.

PubMed

Catron, Tom D; Smallfield, George B; Kang, Le; Sterling, Richard K; Siddiqui, Mohammad S

2017-11-01

Gastric varices (GV) have higher rates of morbidity and mortality from hemorrhage than esophageal varices. Several studies have shown the safety and efficacy of cyanoacrylate (CA) injection for acute gastric variceal hemorrhage. We report data from our experience with CA injection for GV before and after routine use of post-injection audible Doppler assessment (ADA) for GV obturation and describe long-term outcomes after this therapy. We retrospectively identified patients who had documented GV, underwent CA injection, and had at least 2 weeks of follow-up. We recorded and analyzed the survival and rebleeding rates with patient demographics, clinical data, and endoscopy findings between two groups of patients who were categorized by CA injection prior to and after inception of the ADA technique. Seventy-one patients were identified with 16 patients analyzed in a group where ADA was not used (Pre-ADA) and 55 analyzed where ADA was used (Post-ADA). No rebleeding events were observed within 1 week of initial CA injection. No embolic events were reported after any initial CA injection within 4 weeks. The rate of bleed-free survival at 1 year was 69.6% in the Pre-ADA group and 85.8% in the Post-ADA without statistical significance. The all-cause 1-year mortality was 13.8% in the Pre-ADA group and 10.7% in the Post-ADA group without statistical significance. ADA of CA-injected GV does not appear to significantly affect adverse events or clinical outcomes; however, our findings are limited by small sample size and cohort proportions allowing for significant type II statistical error. Further prospective investigation is required to determine the impact of ADA on clinical outcomes after GV obturation.

Jejunal varices diagnosed by capsule endoscopy in patients with post-liver transplant portal hypertension.

PubMed

Bass, Lee M; Kim, Stanley; Superina, Riccardo; Mohammad, Saeed

2017-02-01

Portal hypertension secondary to portal vein obstruction following liver transplant occurs in 5%-10% of children. Jejunal varices are uncommon in this group. We present a case series of children with significant GI blood loss, negative upper endoscopy, and jejunal varices detected by CE. Case series of patients who had CE for chronic GI blood loss following liver transplantation. Three patients who had their initial transplants at a median age of 7 months were identified at our institution presenting at a median age of 8 years (range 7-16 years) with a median Hgb of 2.8 g/dL (range 1.8-6.8 g/dL). Upper endoscopy was negative for significant esophageal varices, gastric varices, and bleeding portal gastropathy in all three children. All three patients had significant jejunal varices noted on CE in mid-jejunum. Jejunal varices were described as large prominent bluish vessels underneath visualized mucosa, one with evidence of recent bleeding. The results led to venoplasty of the portal vein in two patients and a decompressive shunt in one patient with resolution of GI bleed and anemia. CE is useful to diagnose intestinal varices in children with portal hypertension and GI bleeding following liver transplant. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Endoscopic treatments for portal hypertension.

PubMed

Lo, Gin-Ho

2018-02-01

Acute esophageal variceal hemorrhage is a dreaded complication of portal hypertension. Its management has evolved rapidly in recent years. Endoscopic therapy is often employed to arrest bleeding varices as well as to prevent early rebleeding. The combination of vasoconstrictor and endoscopic therapy is superior to vasoconstrictor or endoscopic therapy alone for control of acute esophageal variceal hemorrhage. After control of acute variceal bleeding, combination of banding ligation and beta-blockers is generally recommended to prevent variceal rebleeding. To prevent the catastrophic event of acute variceal bleeding, endoscopic banding ligation is an important tool in the prophylaxis of first bleeding. Endoscopic obturation with cyanoacrylate is usually utilized to arrest acute gastric variceal hemorrhage as well as to prevent rebleeding. It can be concluded that endoscopic therapies play a pivotal role in management of portal hypertensive bleeding.

Pulmonary vein stenosis with collateralization via esophageal varices: Long-term follow-up after successful treatment with drug-eluting stent.

PubMed

Goldberg, Jason F; Jensen, Craig L; Krishnamurthy, Rajesh; Varghese, Nidhy P; Justino, Henri

2018-01-01

We describe the long-term follow-up of a child with recurrent hemoptysis due to severe pulmonary vein stenosis decompressing via collaterals to esophageal varices. Case report SETTING: Tertiary children's hospital PATIENT: Single child through ages 2- to 11-year old INTERVENTIONS: The child underwent cutting balloon angioplasty, bare metal stenting, and implantation of a PTFE-covered stent, all of which failed rapidly. Only after placement of a paclitaxel drug eluting stent did he have prolonged relief from hemoptysis and long-term patency of the treated vein. The stents were serially dilated to keep up with somatic growth of the child, eventually culminating in the need to induce intentional stent fracture. We highlight novel transcatheter techniques to treat this vexing condition, discuss mechanisms of disease treatment and progression, and present the only patient with this rare combination of lesions to have achieved both longstanding pulmonary vein patency and resolution of esophageal varices. © 2017 Wiley Periodicals, Inc.

Can transient elastography, Fib-4, Forns Index, and Lok Score predict esophageal varices in HCV-related cirrhotic patients?

PubMed

Hassan, Eman M; Omran, Dalia A; El Beshlawey, Mohamad L; Abdo, Mahmoud; El Askary, Ahmad

2014-02-01

Gastroesophageal varices are present in approximately 50% of patients with liver cirrhosis. The aim of this study was to evaluate liver stiffness measurement (LSM), Fib-4, Forns Index and Lok Score as noninvasive predictors of esophageal varices (EV). This prospective study included 65 patients with HCV-related liver cirrhosis. All patients underwent routine laboratory tests, transient elastograhy (TE) and esophagogastroduodenoscopy. FIB-4, Forns Index and Lok Score were calculated. The diagnostic performances of these methods were assessed using sensitivity, specificity, positive predictive value, negative predictive value, accuracy and receiver operating characteristic curves. All predictors (LSM, FIB-4, Forns Index and Lok Score) demonstrated statistically significant correlation with the presence and the grade of EV. TE could diagnose EV at a cutoff value of 18.2kPa. Fib-4, Forns Index, and Lok Score could diagnose EV at cutoff values of 2.8, 6.61 and 0.63, respectively. For prediction of large varices (grade 2, 3), LSM showed the highest accuracy (80%) with a cutoff of 22.4kPa and AUROC of 0.801. Its sensitivity was 84%, specificity 72%, PPV 84% and NPV 72%. The diagnostic accuracies of FIB-4, Forns Index and Lok Score were 70%, 70% and76%, respectively, at cutoffs of 3.3, 6.9 and 0.7, respectively. For diagnosis of large esophageal varices, adding TE to each of the other diagnostic indices (serum fibrosis scores) increased their sensitivities with little decrease in their specificities. Moreover, this combination decreased the LR- in all tests. Noninvasive predictors can restrict endoscopic screening. This is very important as non invasiveness is now a major goal in hepatology. Copyright © 2013 Elsevier España, S.L. and AEEH y AEG. All rights reserved.

Gastric Varices: An Overview for the Gastroenterology Nurse.

PubMed

Dale, Cheryl

2016-01-01

Gastric varices can occur in as many as one-third of patients with portal hypertension. Within the nursing literature, however, articles focus on the management of esophageal varices and portal hypertensive gastrointestinal bleeding with few publications about management of gastric varices. Given the advancement in therapies, it is prudent for gastroenterology nurses to have an understanding of its management and treatment options. This article reviews the pathophysiology, classification, and management of patients with gastric varices and outlines the importance of the nurse's role in the education and ongoing care for this patient group.

[Hospital mortality associated with upper gastrointestinal hemorrhage due to ruptured esophageal varices at the Lomé Campus Hospital in Togo].

PubMed

Bouglouga, O; Bagny, A; Lawson-Ananissoh, L; Djibril, M

2014-01-01

To study hospital mortality associated with upper gastrointestinal hemorrhages due to variceal bleeding in the department of hepatology and gastroenterology at the Lome Campus University Hospital. This retrospective cross-sectional and analytic study examined the 55 patients admitted for variceal bleeding on upper endoscopies during the 3-year period from January 1, 2008, through December 31, 2010. These patients accounted for 4.1% of all hospitalizations during the study period in the department. Their average age was 35 years, and their sex-ratio 4. A history of chronic liver disease was found in 65.5%. Liver cirrhosis was the principal cause of the esophageal varices, complicated by hepatocellular carcinoma in 30.9% of them. The mortality rate was 25.5% and was not related to the cause of portal hypertension. All the patients with a recurrence of bleeding died. Mortality was associated with jaundice. Blood transfusion did not significantly improve the prognosis. the mortality rate among patients with upper gastrointestinal hemorrhage linked to variceal bleeding is high in our unit. The prevention of hepatitis virus B is important because it is the main cause of chronic liver disease causing portal hypertension in our department.

Medical and Endoscopic Management of Gastric Varices

PubMed Central

Al-Osaimi, Abdullah M. S.; Caldwell, Stephen H.

2011-01-01

In the past 20 years, our understanding of the pathophysiology and management options among patients with gastric varices (GV) has changed significantly. GV are the most common cause of upper gastrointestinal bleeding in patients with portal hypertension after esophageal varices (EV) and generally have more severe bleeding than EV. In the United States, the majority of GV patients have underlying portal hypertension rather than splenic vein thrombosis. The widely used classifications are the Sarin Endoscopic Classification and the Japanese Vascular Classifications. The former is based on the endoscopic appearance and location of the varices, while the Japanese classification is based on the underlying vascular anatomy. In this article, the authors address the current concepts of classification, epidemiology, pathophysiology, and emerging management options of gastric varices. They describe the stepwise approach to patients with gastric varices, including the different available modalities, and the pearls, pitfalls, and stop-gap measures useful in managing patients with gastric variceal bleed. PMID:22942544

The model for the end-stage liver disease and Child-Pugh score in predicting prognosis in patients with liver cirrhosis and esophageal variceal bleeding.

PubMed

Benedeto-Stojanov, Daniela; Nagorni, Aleksandar; Bjelaković, Goran; Stojanov, Dragan; Mladenović, Bojan; Djenić, Nebojsa

2009-09-01

Esophageal variceal bleeding is one of the most frequent and gravest complications of liver cirrhosis, directly life-threatening. By monitoring certain clinical and laboratory hepatocellular insufficiency parameters (Child-Pugh score), it is possible to determine prognosis in patients who are bleeding and evaluate further therapy. Recently, the Model for the End-Stage Liver Disease (MELD) has been proposed as a tool to predict mortality risk in cirrhotic patients. The aim of the study was to evaluate survival prognosis of cirrhotic patients by the MELD and Child-Pugh scores and to analyze the MELD score prognostic value in patients with both liver cirrhosis and variceal bleeding. We retrospectively evaluated the survival rate of a group of 100 cirrhotic patients of a median age of 57 years. The Child-Pugh score was calculated and the MELD score was computed according to the original formula for each patient. We also analysed clinical and laboratory hepatocellular insufficiency parameters in order to examine their connection with a 15-month survival. The MELD values were correlated with the Child-Pugh scores. The Student's t-test was used for statistical analysis. Twenty-two patients died within 15-months followup. Age and gender did not affect survival rate. The Child-Pugh and MELD scores, as well as ascites and encephalopathy significantly differed between the patients who survived and those who died (p < 0.0001). The International Normalized Ratio (INR) values, serum creatinine and bilirubin were significantly higher, and albumin significantly lower in the patients who died (p < 0.0001). The MELD score was significantly higher in the group of patients who died due to esophageal variceal bleeding (p < 0.0001). In cirrhotic patients the MELD score is an excellent survival predictor at least as well as the Child-Pugh score. Increase in the MELD score is associated with decrease in residual liver function. In the group of patients with liver cirrhosis and esophageal

Massive Hemorrhage from Ectopic Duodenal Varices: Importance of a Multidisciplinary Approach

PubMed Central

House, Tyler; Webb, Patrick; Baarson, Chad

2017-01-01

Duodenal variceal bleeding is an uncommon complication of portal hypertension that can easily go unrecognized and reach mortality rates as high as 40%. Cirrhosis is the most common cause of duodenal varices. In most cases, duodenal varices occur concomitantly with esophageal varices, further complicating identification with initial endoscopy. Although many modalities have been explored with respect to management and treatment approaches, guidelines have yet to be established owing to the infrequency in which bleeding occurs from ectopic duodenal varices. We present a case of massive duodenal variceal hemorrhage that highlights the complexity of initial diagnosis and ultimately required a transesophageal intrahepatic portosystemic shunt with coil embolization for control of bleeding. PMID:28203136

Embolization of Bleeding Stomal Varices by Direct Percutaneous Approach

DOE Office of Scientific and Technical Information (OSTI.GOV)

Arulraj, Ramakrishnan, E-mail: arulraas@yahoo.com; Mangat, Kamarjit S., E-mail: Kamarjit.mangat@uhb.nhs.uk; Tripathi, Dhiraj, E-mail: d.tripathi@bham.ac.uk

2011-02-15

Stomal varices can occur in patients with stoma in the presence of portal hypertension. Suture ligation, sclerotherapy, angiographic embolization, stoma revision, beta blockade, portosystemic shunt, and liver transplantation have been described as therapeutic options for bleeding stomal varices. We report the case of a 21-year-old patient with primary sclerosing cholangitis and colectomy with ileostomy for ulcerative colitis, where stomal variceal bleeding was successfully treated by direct percutaneous embolization. We consider percutaneous embolization to be an effective way of treating acute stomal bleeding in decompensated patients while awaiting decisions regarding shunt procedures or liver transplantation.

A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices.

PubMed

Ryan, Barbara M; Stockbrugger, Reinhold W; Ryan, J Mark

2004-04-01

Gastric varices (GV) occur in 20% of patients with portal hypertension either in isolation or in combination with esophageal varices (EV). There is no consensus for optimum treatment of GV and because they comprise an inhomogeneous entity, accurate classification is vital to determine the appropriate management. Gastroesophageal varices (GOV) are classified as GOV1 (EV extending down to cardia or lesser curve) or GOV2 (esophageal and fundal varices). Isolated gastric varices (IGV) may be located in the fundus (IGV1) or elsewhere in the stomach (IGV2). GV possibly bleed less frequently than EV, but GV bleeding is typically difficult to control, associated with a high risk for rebleeding, and high mortality. Fundal varices, large GV (>5 mm), presence of a red spot, and Child's C liver status are associated with a high risk for bleeding. GOV1 have a much lower risk for bleeding. A portosystemic pressure gradient of > or =12 mm Hg is not necessary for GV bleeding, probably related to the high frequency of spontaneous gastrorenal shunts in these patients. GOV1 should be treated as for EV. First-line treatment of bleeding fundal varices is endoscopic variceal obturation. TIPS is currently second-line acute treatment and is used for prevention of rebleeding. The role of some newer interventional radiologic techniques requires further appraisal. This review describes the pathophysiology, diagnosis, natural history, endoscopic, and interventional radiologic treatment options for GV.

Balloon-Occluded Retrograde Transvenous Obliteration of Gastric Varices: Concept, Basic Techniques, and Outcomes

PubMed Central

Saad, Wael E. A.

2012-01-01

Patients with gastric variceal bleeding require a multidisciplinary team approach including hepatologists, endoscopists, diagnostic radiologists, and interventional radiologists. Upper gastrointestinal endoscopy is the first-line diagnostic and management tool for bleeding gastric varices, as it is in all upper gastrointestinal bleeding scenarios. In the United States when endoscopy fails to control gastric variceal bleeding, a transjugular intrahepatic portosystemic shunt (TIPS) traditionally is performed along the classic teachings of decompressing the portal circulation. However, TIPS has not shown the same effectiveness in controlling gastric variceal bleeding that it has with esophageal variceal bleeding. For the past 2 decades, the balloon-occluded retrograde transvenous obliteration (BRTO) procedure has become common practice in Asia for the management of gastric varices. BRTO is gaining popularity in the United States. It has been shown to be effective in controlling gastric variceal bleeding with low rebleed rates. BRTO has many advantages over TIPS in that it is less invasive and can be performed on patients with poor hepatic reserve and those with encephalopathy (and may even improve both). However, its by-product is occlusion of a spontaneous hepatofugal (TIPS equivalent) shunt, and thus it is contradictory to the traditional American doctrine of portal decompression. Indeed, BRTO causes an increase in portal hypertension, with potential aggravation of esophageal varices and ascites. This article discusses the concept, technique, and outcomes of BRTO within the broader management of gastric varices. PMID:23729982

Long-term outcome of 154 patients receiving balloon-occluded retrograde transvenous obliteration for gastric fundal varices.

PubMed

Imai, Yukinori; Nakazawa, Manabu; Ando, Satsuki; Sugawara, Kayoko; Mochida, Satoshi

2016-11-01

This study aims to clarify the long-term outcome of therapeutic strategies including balloon-occluded retrograde transvenous obliteration (B-RTO) for patients with gastric fundal varices. The subjects were 154 patients with gastric fundal varices fulfilling the criteria for receiving B-RTO. In patients showing variceal bleeding, endoscopic therapies and/or balloon tamponade was performed to achieve hemostasis. B-RTO was accomplished with injection of 5% ethanolamine oleate through a standard balloon catheter except for patients with atypical varices, in whom a microballoon catheter was used to occlude drainage vessels other than a gastrorenal shunt. In patients complicated with esophageal varices at baseline, endoscopic therapies were performed following B-RTO. Balloon-occluded retrograde transvenous obliteration was performed successfully in 147 patients (95%), including 15 patients using a microballoon catheter. Complete variceal obliteration was achieved in all patients. Additional endoscopic therapies for esophageal varices were performed in 31 patients. Gastric varices did not recur in any of these patients. The cumulative survival rates at 1, 3, and 5 years after B-RTO were 91%, 76%, and 72%, respectively. Child-Pugh scores and hepatocellular carcinoma complication were identified as prognostic factors associated with survival rates. The cumulative exacerbation rates of esophageal varices at 1, 3, and 5 years were 13%, 20%, and 27%, respectively, and rupture developed in six patients, which were successfully treated with endoscopic therapies. Therapeutic strategies including B-RTO with a microballoon catheter were useful to achieve a favorable outcome in patients with gastric fundal varices especially in those manifesting Child-Pugh class-A liver damage and/or those without hepatocellular carcinoma complication. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

The Role of Therapeutic Endoscopy in Patients With Cirrhosis-Related Causes of Gastrointestinal Bleeding.

PubMed

Kezer, Camille A; Gupta, Neil

2018-06-09

This article aims to review current therapeutic endoscopic treatments available for the management of gastrointestinal bleeding related to cirrhosis. Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices as well as for acute bleeding and secondary prophylaxis of select gastric varices. Sclerotherapy is a treatment option for acute bleeding and secondary prophylaxis of esophageal varices when band ligation is technically difficult. Cyanoacrylate glue injection is an effective treatment for acute bleeding of gastric and ectopic varices. Argon plasma coagulation is first-line and radiofrequency ablation is second-line treatment for chronic bleeding secondary to gastric antral vascular ectasia. There are a variety of endoscopic treatment modalities for cirrhosis-related gastrointestinal bleeding, and the appropriate therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events.

Prediction of the First Variceal Haemorrhage

PubMed Central

1997-01-01

We followed 87 cirrhotic patients with esophageal varices and without previous hemorrhage for a mean period of 24 mo to prospectively evaluate the occurance of variceal bleeding within (early) or after (late) 6 mo from entry and the contribution of portal Doppler ultrasound parameters to the prediction of early and late hemorrhage. Clinical, biochemical, endoscopic and portal Doppler ultrasound parameters were recorded at entry. Variceal bleeding occurred in 22 patients (25.3%). Nine (40.9%) bled within the first 6 mo. Cox regression analysis identified variceal size, cherry-red spots, serum bilirubin and congestion index of the portal vein (the ratio of portal vein [cross-sectional area] and portal blood flow velocity) as the only independent predictors of first variceal hemorrhage. Discriminant analysis was used to find the prognostic index cut off points to identify patients who bled within 6 mo (prognostic group 1) or after 6 mo (prognostic group 2) or remained free of bleeding (prognostic group 3). The cumulative proportion of patients correctly classified was 73% in prognostic group 1, 47% in prognostic group 2 and more than 80% in prognostic group 3. The addition of Doppler ultrasound flowmetry to clinical, biochemical and endoscopic parameter only improved the classification of patients with early bleeding. PMID:9184882

Endoscopic Ultrasound (EUS) for Esophageal and Gastric Varices: How Can it Improve the Outcomes and Reduce Complications of Glue Injection

PubMed Central

Bhatia, Vikram

2012-01-01

A large part of portal venous system and the paragastric and para-esophageal collateral circulation is within the reach of endoscopic ultrasound (EUS). The EUS is more sensitive than gastroscopy for the detection of gastric varices (GV), and can accurately distinguish GV from thickened gastric folds. Gastric varices are depicted by serpiginous, anechoic, Doppler-positive mural channels, with larger collateral channels visible outside the gastric wall. The EUS has also been used to monitor the completeness of GV obturation after glue injection. There are limited data that this strategy may be clinically beneficial to prevent GV re-bleed. The EUS has been used to deliver glue injections under real-time monitoring into the vascular channels, with or without steel coils as scaffolding for the glue. The potential advantages of this technique include a straight scope position, lack of hindrance from pooled blood in gastric fundus, smaller glue volume requirements, and precise intra-vascular placement of glue with avoidance of intramural injections, and reduced embolic complications. PMID:25755407

Portal hypertension associated with sickle cell disease.

PubMed

Kumar, Sunil; Joshi, R; Jain, A P

2007-01-01

We report a 12-year-old girl with sickle cell disease who presented with pain in abdomen, fever, joint pain and hematemesis. On examination she had mild jaundice and splenomegaly. Upper GI endoscopy showed esophageal varices. She was treated with variceal band ligation and is well on folic acid supplements and propranolol.

Percutaneous transhepatic embolization of gastroesophageal varices combined with partial splenic embolization for the treatment of variceal bleeding and hypersplenism

PubMed Central

Gong, Wei-Dong; Xue, Ke; Chu, Yuan-Kui; Wang, Qing; Yang, Wei; Quan, Hui; Yang, Peng; Wang, Zhi-Min; Wu, Zhi-Qun

2015-01-01

This study aims to evaluate the therapeutic results of percutaneous transhepatic embolization of gastroesophageal varices combined with partial splenic embolization in patients with liver cirrhosis, and to explore the role of this minimally invasive treatment as an alternative to surgery. 25 patients with liver cirrhosis were received percutaneous transhepatic embolization of gastroesophageal varices combined with partial splenic embolization. Another 25 patients with liver cirrhosis underwent Hassab’s operation. They were followed up, and received endoscopy, B ultrasound, liver function and hematologic examination at 24 months after the therapy. In minimal invasive group, before treatment and after 24 month following up after treatment, improved varices, improved portal hypertension and improved hypersplenism were showed comparing with the surgery group, and that they were measured by endoscopic visualization, ultrasound and blood counts. the white blood cell and platelet count were 2.33±0.65 (109/L) and 3.63±1.05 (1010/L), 7.98±3.0 (109/L) and 16.3±9.10 (1010/L) (P<0.05); the diameter of the portal vein were 1.47±0.25 cm, 1.31±0.23 cm (P<0.05). Esophageal varices passed from grade III to lower grade II in 11 patients, and from grade II to lower grade I in 6 patients at 24 month following up. In surgical group, the white blood cell and platelet count were 2.2±0.60 (109/L), 4.1±1.25 (1010/L) before treatment; 9.3±2.56 (109/L), 32.1±12.47 (1010/L) after the treatment at 24 month following up (P<0.05). The diameter of the portal vein were 1.43±0.22 cm before the treatment and 1.28±0.18 cm after the treatment (P<0.05). Esophageal varices passed from grade III to lower grade II in 13 patients, and from grade II to lower grade I in 7 patients. The combination of PGEV and PSE can be considered as an option for the treatment of variceal bleeding with hypersplenism. PMID:26770628

Jejunal varices after choledochojejunostomy treated with laparotomic transcatheter variceal embolization.

PubMed

Waguri, Nobuo; Azumi, Rie; Sugimura, Kazuhito; Arao, Yoshihisa; Ikarashi, Shunzo; Sakai, Norihiro; Ogawa, Masahiro; Osaki, Akihiko; Sato, Munehiro; Aiba, Tsuneo; Yoneyama, Osamu; Furukawa, Koichi; Igarashi, Kentarou

2016-01-01

Portal hypertension induces collateral shunt formation between the portal and systemic circulation, decompressing the elevated portal pressure. Ectopic varices outside of the gastroesophageal region, such as jejunal varices, are rare conditions. This report describes the successful embolization of ruptured jejunal varices resulting from an extrahepatic portal obstruction. A 62-year-old man was admitted to our hospital with recurrent massive gastrointestinal bleeding. Fourteen months earlier, he had undergone a choledochojejunostomy and pancreatic cystojejunostomy for bile duct stenosis with an enlarged pancreatic pseudocyst due to severe chronic pancreatitis. Contrast-enhanced computed tomography showed jejunal intramural dilated vessels close to the choledochojejunal anastomosis, but extravasation was not observed. Due to the lack of a rapid definitive diagnosis, the patient required massive blood transfusions. Hemorrhagic scintigraphy using 99m Tc-HSAD finally identified the site of the hemorrhage. Angiography and double-balloon endoscopy revealed the anastomotic jejunal varices to be the result of an extrahepatic portal obstruction. Laparotomic transcatheter variceal embolization with microcoils was successful in halting the refractory gastrointestinal bleeding. This surgery preserved hepatopetal portal venous flow by another route, and no complications were observed. At present, 4 years post-surgery, there has been no recurrence of gastrointestinal hemorrhage. The development of jejunal varices is often associated with postoperative adhesions. Some patients with a history of hepatico- or choledochojejunostomy may experience portal hypertension resulting from extrahepatic portal obstruction, leading to the formation of jejunal varices as hepatopetal portal collaterals. The choice of therapy in each patient should be based on the individual hemodynamics of the ectopic varices.

Narrow-band imaging can increase the visibility of fibrin caps after bleeding of esophageal varices: a case with extensive esophageal candidiasis.

PubMed

Furuichi, Yoshihiro; Kasai, Yoshitaka; Takeuchi, Hirohito; Yoshimasu, Yuu; Kawai, Takashi; Sugimoto, Katsutoshi; Kobayashi, Yoshiyuki; Nakamura, Ikuo; Itoi, Takao

2017-08-01

A 58-year-old man with hepatitis B cirrhosis noticed black stools and underwent an endoscopy at a community hospital. The presence of esophageal varices (EVs) was confirmed, but the bleeding point was not found. He was referred to our institution and underwent a second endoscopy. Extensive white patches of esophageal candidiasis were visible on endoscopy by white-light imaging (WLI), but it was difficult to find the fibrin cap of the EVs. This was easier under narrow-band imaging (NBI), however, as the color turned red from absorption by hemoglobin adhered to it. We retrospectively measured the color differences (CD) between the fibrin cap and the surrounding mucosa 10 times using the CIE (L*a*b*) color space method. The median value of CD increased after NBI (13.9 → 43.0, p < 0.001), with increased visibility. However, the median CD between the white patch and surrounding mucosa decreased after NBI (44.8 → 30.3, p < 0.001). The fibrin cap was paler than the white patch of candidiasis, but the increased visibility of the fibrin cap by NBI enabled it to be found more easily. This is the first report of a case in which NBI was helpful in locating a fibrin cap of EVs.

Bleeding due to ectopic varices in a urinary diversion: A multidisciplinary diagnostic and therapeutic challenge

PubMed Central

Acosta, Eduardo Mariano Albers; Reyes, Alfonsi Friera; Menéndez, Ricardo Brime

2015-01-01

The ectopic varices in patients with portal hypertension are those that occur at any level of the gastrointestinal (GI) tract, regardless of the varices that occur at the esophageal level. These ectopic varices account for 2–5% of the causes of GI bleeding varices. The risk of bleeding is quadrupled compared to the esophagogastric area, with a mortality of up to 40%. The transjugular intrahepatic portosystemic shunt, should be considered in cases secondary to recurrent bleeding varices. We present a case report of an urological emergency of bleeding in a urinary diversion secondary to ectopic varices successfully treated through the placement of transjugular intrahepatic portosystemic shunt. The condition described here is rare, but important, as it can be a life-threatening complication of portal hypertension. This kind of complication should be known by urologic surgeons managing patients with urinary diversions. PMID:26834901

Vocal cord paralysis post patent ductus arteriosus ligation surgery: risks and co-morbidities.

PubMed

Rukholm, Gavin; Farrokhyar, Forough; Reid, Diane

2012-11-01

1. To determine the prevalence of left vocal cord paralysis (LVCP) post patent ductus arteriosus (PDA) ligation at a Tertiary Care Centre. 2. To identify risk factors associated with LVCP. 3. To identify co-morbidities associated with LVCP. 4. To determine the frequency of pre- and post-operative nasopharyngolaryngoscopic (NPL) examination in this patient population. Retrospective chart review of all infants who underwent PDA ligation surgery at a tertiary care academic hospital between July 2003 and July 2010. Data on patient age, gender, weight, method of PDA ligation, and results of NPL scoping were collected, as well as patient co-morbidities post PDA ligation. One hundred and fifteen patients underwent PDA ligation surgery. Four patients were excluded due to bilateral vocal cord paralysis. Of the remaining 111 patients, nineteen patients (17.1%) were found to have LVCP. Low birth weight was identified as a significant risk factor for LVCP (p=0.002). Gastroesophageal reflux was identified as a significant co-morbidity associated with LVCP post PDA ligation (p=0.002). Only 0.9% of patients were scoped pre-operatively, and 27.9% were scoped postoperatively. LVCP is associated with multiple morbidities. The authors strongly recommend routine post-operative scoping of all patients post PDA ligation surgery, and preoperative scoping when possible. A prospective study is warranted, in order to confirm the prevalence of LVCP as well as risk factors and associated co-morbidities. Crown Copyright © 2012. Published by Elsevier Ireland Ltd. All rights reserved.

Variceal bleeding and portal hypertension: new lights on old horizon.

PubMed

Bhasin, D K; Siyad, I

2004-02-01

New clinical, endoscopic, and imaging modalities for diagnosing varices and predicting bleeding are being investigated. Transnasal endoscopy and ultrathin battery-powered esophagoscopes are being used to improve patient comfort and compliance. Patients who respond to portal pressure-reducing drugs not only have a reduced risk of bleeding, but also a reduced risk of developing other complications, with improved survival. Nitrates have been shown to have no definite role in primary prophylaxis against variceal bleeding. The hemodynamic response to treatment has an independent prognostic value for the risk of variceal bleeding. Newer drugs have been investigated for reducing the hepatic venous pressure gradient, but with little success. Survival after bleeding has increased due to improved patient care and technological advances. Combined radiographic and endoscopic management of gastric varices is evolving and appears to be promising. Nonvariceal bleeding from portal hypertensive gastropathy is increasingly being recognized as a potential cause of bleeding in patients with portal hypertension, and pharmacotherapy with octreotide appears to be promising for the treatment of this condition. Variceal band ligation in children has been found to be as safe and effective as in adults.

BPC 157 therapy to detriment sphincters failure-esophagitis-pancreatitis in rat and acute pancreatitis patients low sphincters pressure.

PubMed

Petrovic, I; Dobric, I; Drmic, D; Sever, M; Klicek, R; Radic, B; Brcic, L; Kolenc, D; Zlatar, M; Kunjko, K; Jurcic, D; Martinac, M; Rasic, Z; Boban Blagaic, A; Romic, Z; Seiwerth, S; Sikiric, P

2011-10-01

Possibly, acute esophagitis and pancreatitis cause each other, and we focused on sphincteric failure as the common causative key able to induce either esophagitis and acute pancreatitis or both of them, and thereby investigate the presence of a common therapy nominator. This may be an anti-ulcer pentadecapeptide BPC 157 (tested for inflammatory bowel disease, wound treatment) affecting esophagitis, lower esophageal and pyloric sphincters failure and acute pancreatitis (10 μg/kg, 10 ng/kg intraperitoneally or in drinking water). The esophagitis-sphincter failure procedure (i.e., insertion of the tubes into the sphincters, lower esophageal and pyloric) and acute pancreatitis procedure (i.e., bile duct ligation) were combined in rats. Esophageal manometry was done in acute pancreatitis patients. In rats acute pancreatitis procedure produced also esophagitis and both sphincter failure, decreased pressure 24 h post-surgery. Furthermore, bile duct ligation alone immediately declines the pressure in both sphincters. Vice versa, the esophagitis-sphincter failure procedure alone produced acute pancreatitis. What's more, these lesions (esophagitis, sphincter failure, acute pancreatitis when combined) aggravate each other (tubes into sphincters and ligated bile duct). Counteraction occurred by BPC 157 therapies. In acute pancreatitis patients lower pressure at rest was in both esophageal sphincters in acute pancreatitis patients. We conclude that BPC 157 could cure esophagitis/sphincter/acute pancreatitis healing failure.

Upper gastrointestinal ectopic variceal bleeding treated with various endoscopic modalities: Case reports and literature review.

PubMed

Park, Sang Woo; Cho, Eunae; Jun, Chung Hwan; Choi, Sung Kyu; Kim, Hyun Soo; Park, Chang Hwan; Rew, Jong Sun; Cho, Sung Bum; Kim, Hee Joon; Han, Mingui; Cho, Kyu Man

2017-01-01

Ectopic variceal bleeding is a rare (2-5%) but fatal gastrointestinal bleed in patients with portal hypertension. Patients with ectopic variceal bleeding manifest melena, hematochezia, or hematemesis, which require urgent managements. Definitive therapeutic modalities of ectopic varices are not yet standardized because of low incidence. Various therapeutic modalities have been applied on the basis of the experiences of experts or availability of facilities, with varying results. We have encountered eight cases of gastrointestinal ectopic variceal bleeding in five patients in the last five years. All patients were diagnosed with liver cirrhosis presenting melena or hematemesis. All patients were treated with various endoscopic modalities (endoscopic variceal obturation [EVO] with cyanoacrylate in five cases, endoscopic variceal band ligation (EVL) in two cases, hemoclipping in one case). Satisfactory hemostasis was achieved without radiologic interventions in all cases. EVO and EVL each caused one case of portal biliopathy, and EVL induced ulcer bleeding in one case. EVO generally accomplished better results of variceal obturations than EVL or hemoclipping, without serious adverse events. EVO may be an effective modality for control of ectopic variceal bleeding without radiologic intervention or surgery.

[Recurrent variceal bleeding in a patient with portal and splenic vein thrombosis secondary to complex thrombophilia].

PubMed

Ławniczak, Małgorzata; Raszeja-Wyszomirska, Joanna; Marlicz, Wojciech; Białek, Andrzej; Wiechowska-Kozłowska, Anna; Lubikowski, Jerzy; Wójcicki, Maciej; Starzyńska, Teresa

2008-08-01

Thrombophilia in adults is one of main causes of portal vein thrombosis. Esophageal and gastric varices, ascites and hypersplenism are well known complications of portal hypertension. There are controversial issues on the management, especially anticoagulant therapy and surgical treatment of these patients. We present a 42-years old woman with a history of three acute coronary episodes suffering from recurrent variceal bleeding due to portal and splenic vein thrombosis in the course of myeloproliferative disorder and protein C deficiency. It was 10 months delay of diagnosis. She was successfully treated with medical and surgical treatment (esophageal stapler transection, cardial devascularization, and splenectomy). In the paper we discuss complexity of diagnosis and surgical treatment.

Advances in the management of childhood portal hypertension.

PubMed

McKiernan, Patrick; Abdel-Hady, Mona

2015-05-01

Portal hypertension is one of the most serious complications of childhood liver disease, and variceal bleeding is the most feared complication. Most portal hypertension results from cirrhosis but extra hepatic portal vein obstruction is the single commonest cause. Upper gastrointestinal endoscopy endoscopy remains necessary to diagnose gastro-esophageal varices. Families of children with portal hypertension should be provided with written instructions in case of gastrointestinal bleeding. Children with large varices should be considered for primary prophylaxis on a case-by-case basis. The preferred method is variceal band ligation. Children with acute bleeding should be admitted to hospital and treated with antibiotics and pharmacotherapy before urgent therapeutic endoscopy. All children who have bled should then receive secondary prophylaxis. The preferred method is variceal band ligation and as yet there is little evidence to support the use of β-blockers. Children with extrahepatic portal vein obstruction should be assessed for suitability of mesoportal bypass.

Prevention of Portal Hypertension: from Variceal Development to Clinical Decompensation

PubMed Central

Vorobioff, Julio D.; Groszmann, Roberto J

2015-01-01

Pharmacological treatment of portal hypertension (PH) has been exclusively devoted to gastro-esophageal varices related events at different frameworks including prophylactic, emergency or preventive therapy. The goals of treatment are to avoid the first bleeding episode, stop active bleeding and prevent bleeding recurrence, respectively. The objective of pre-primary prophylaxis (PPP) is to avoid variceal development and therefore, it necessarily deals with cirrhotic patients at earlier stages of the disease. At these earlier stages, nonselective beta blocker (NSBB) have been ineffective in preventing the development of varices and other complications of PH. Therefore, treatment should not rely on NSBB. It is possible, that at these earlier stages, etiological treatment of liver disease itself could prevent the progression of PH. This review will focus mainly on early treatment of PH, because if successful, it may translate into histological-hemodynamic improvements, avoiding not only variceal development but also other PH related complications, such as ascites and porto-systemic encephalopathy (PSE). Moreover, the advent of new therapies may allow not only the prevention of the complications of PH, but also the chance of a substantial degree of regression in the cirrhotic process with the possible prevention of hepatocellular carcinoma (HCC). PMID:24913395

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, and King Scores for Diagnosis of Esophageal Varices in Liver Cirrhosis: A Retrospective Study.

PubMed

Deng, Han; Qi, Xingshun; Peng, Ying; Li, Jing; Li, Hongyu; Zhang, Yongguo; Liu, Xu; Sun, Xiaolin; Guo, Xiaozhong

2015-12-20

BACKGROUND Aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, fibrosis index (FI), and King scores might be alternatives to the use of upper gastrointestinal endoscopy for the diagnosis of esophageal varices (EVs) in liver cirrhosis. This study aimed to evaluate their diagnostic accuracy in predicting the presence and severity of EVs in liver cirrhosis. MATERIAL AND METHODS All patients who were consecutively admitted to our hospital and underwent upper gastrointestinal endoscopy between January 2012 and June 2014 were eligible for this retrospective study. Areas under curve (AUCs) were calculated. Subgroup analyses were performed according to the history of upper gastrointestinal bleeding (UGIB) and splenectomy. RESULTS A total of 650 patients with liver cirrhosis were included, and 81.4% of them had moderate-severe EVs. In the overall analysis, the AUCs of these non-invasive scores for predicting moderate-severe EVs and presence of any EVs were 0.506-0.6 and 0.539-0.612, respectively. In the subgroup analysis of patients without UGIB, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.601-0.664 and 0.596-0.662, respectively. In the subgroup analysis of patients without UGIB or splenectomy, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.627-0.69 and 0.607-0.692, respectively. CONCLUSIONS APRI, AAR, FIB-4, FI, and King scores had modest diagnostic accuracy of EVs in liver cirrhosis. They might not be able to replace the utility of upper gastrointestinal endoscopy for the diagnosis of EVs in liver cirrhosis.

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, and King Scores for Diagnosis of Esophageal Varices in Liver Cirrhosis: A Retrospective Study

PubMed Central

Deng, Han; Qi, Xingshun; Peng, Ying; Li, Jing; Li, Hongyu; Zhang, Yongguo; Liu, Xu; Sun, Xiaolin; Guo, Xiaozhong

2015-01-01

Background Aspartate aminotransferase-to-platelet ratio index (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, fibrosis index (FI), and King scores might be alternatives to the use of upper gastrointestinal endoscopy for the diagnosis of esophageal varices (EVs) in liver cirrhosis. This study aimed to evaluate their diagnostic accuracy in predicting the presence and severity of EVs in liver cirrhosis. Material/Methods All patients who were consecutively admitted to our hospital and underwent upper gastrointestinal endoscopy between January 2012 and June 2014 were eligible for this retrospective study. Areas under curve (AUCs) were calculated. Subgroup analyses were performed according to the history of upper gastrointestinal bleeding (UGIB) and splenectomy. Results A total of 650 patients with liver cirrhosis were included, and 81.4% of them had moderate-severe EVs. In the overall analysis, the AUCs of these non-invasive scores for predicting moderate-severe EVs and presence of any EVs were 0.506–0.6 and 0.539–0.612, respectively. In the subgroup analysis of patients without UGIB, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.601–0.664 and 0.596–0.662, respectively. In the subgroup analysis of patients without UGIB or splenectomy, their AUCs for predicting moderate-severe varices and presence of any EVs were 0.627–0.69 and 0.607–0.692, respectively. Conclusions APRI, AAR, FIB-4, FI, and King scores had modest diagnostic accuracy of EVs in liver cirrhosis. They might not be able to replace the utility of upper gastrointestinal endoscopy for the diagnosis of EVs in liver cirrhosis. PMID:26687574

[Acute liver ischaemia after gastro-oesophageal variceal bleeding].

PubMed

Senosiain Lalastra, Carla; Arribas Anta, Julia; Moreira Vicente, Víctor; Martínez González, Javier; Maroto Castellanos, Maite; García Sánchez, María Concepción; Zaera de la Fuente, Celia; López Durán, Sergio; Cañete Ruiz, Ángel; Albillos Martínez, Agustín

2016-11-01

Variceal upper gastrointestinal bleeding (UGIB) can trigger acute hypoxic hepatitis (AHH). The aim of this study was to analyse the incidence, associated risk factors and mortality of AHH after variceal UGIB. Retrospective study of cirrhotic patients with variceal UGIB, classified into 2 groups according to the development of AHH. AHH was diagnosed when AST and ALT reached levels 10 times above the upper limit of normal, after ruling out other causes of hepatitis. The standard initial treatment consisted of haemodynamic support, emergency endoscopy with rubber band ligation, somatostatin and antibiotics. In the case of failure of primary haemostasis, a transjugular intrahepatic portosystemic shunt (TIPS) was implanted. Both groups (AHH and non-AHH) were compared. Sixty-eight cirrhotic patients with variceal UGIB admitted to the gastroenterology department of Hospital Ramón y Cajal between January 2007 and March 2012 were analysed. Eleven of these patients (16.2%) developed AHH. Univariate analysis showed the following items as risk factors: diabetes (OR: 7.5; CI: 1.9-29), shock (OR: 8.5; CI: 2.06-34) and persistent bleeding (OR: 9.0, CI: 1.6-49, P=.03). However, multivariate analysis confirmed only diabetes (OR: 8.61; CI: 1.4-52.5) and shock (OR: 7.58; CI: 1.26-45.51) as risk factors. Mortality rate in the AHH group was 45%, compared to 10.5% in the non-HAA group (P=.012). AHH after variceal UGIB occurred in 16.2% of cirrhotic patients and was associated with a poorer prognosis, with a mortality rate of 45%. Our findings suggest that diabetes and shock are risk factors for the development of AHH. Early identification of at-risk patients could therefore help prevent AHH. Copyright © 2016 Elsevier España, S.L.U. y AEEH y AEG. All rights reserved.

Esophageal capsule endoscopy is not the optimal technique to determine the need for primary prophylaxis in patients with cirrhosis

PubMed Central

Krok, Karen L.; Wagennar, Rebecca Rankin; Kantsevoy, Sergey V.

2016-01-01

Introduction Capsule endoscopy has been suggested as a potential alternative to endoscopy for detection of esophagogastric varices and severe portal hypertensive gastropathy (PHG). The aim of the study was to determine whether PillCam esophageal capsule endoscopy could replace endoscopy for screening purposes. Material and methods Sixty-two patients with cirrhosis with no previous variceal bleeding had PillCam capsule endoscopy and video endoscopy performed on the same day. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of capsule endoscopy were compared to endoscopy for the presence and severity of esophageal and gastric varices, PHG and the need for primary prophylaxis. Patients’ preference was assessed by a questionnaire. Results Four (6%) patients were unable to swallow the capsule. Sensitivity, specificity, PPV and NPV of capsule endoscopy for detecting any esophageal varices (92%, 50%, 92%, 50%), large varices (55%, 91%, 75%, 80%), variceal red signs (58%, 87%, 69%, 80%), PHG (95%, 50%, 95%, 50%), and the need for primary prophylaxis (91%, 57%, 78%, 80%) were not optimal, with only moderate agreement (κ) between capsule and upper GI endoscopy. Had only a capsule endoscopy been performed, 12 (21.4%) patients would have received inappropriate treatment. Capsule endoscopy also failed to detect (0/13) gastric varices. The majority of patients ranked capsule endoscopy as more convenient (69%) and their preferred (61%) method. Conclusions Despite the preference expressed by patients for capsule endoscopy, we believe that upper GI endoscopy should remain the preferred screening method for primary prophylaxis. PMID:27186182

Patient Response to Endoscopic Therapy for Gastroesophageal Varices Based on Endoscopic Ultrasound Findings.

PubMed

Tseng, Yujen; Ma, Lili; Luo, Tiancheng; Zeng, Xiaoqing; Li, Feng; Li, Na; Wei, Yichao; Chen, Shiyao

2018-04-27

Gastroesophageal variceal hemorrhage is a common complication of portal hypertension. Endoscopic therapy is currently recommended for preventing gastroesophageal variceal rebleed. However, the rate of variceal rebleed and its associated mortality remain concerning. This study is aimed at differentiating patient response to endoscopic therapy based on endoscopic ultrasound (EUS) findings. One-hundred seventy patients previously treated with repeat endoscopic therapy for secondary prophylaxis were enrolled and classified into two groups based on treatment response. Prior to consolidation therapy, all patients received an EUS examination to observe for extraluminal phenomena. All available follow-up endoscopic examination records were retrieved to validate study results. Of the 170 subjects, 106 were poor responders, while 64 were good responders. The presence of para-gastric, gastric perforating, and esophageal perforating veins was associated with poor patient response (p＜0.001). The odds ratio for para-gastric veins was 5.374. Follow-up endoscopic findings for poor responders with incomplete variceal obliteration was closely correlated with the presence of para-gastric veins (p=0.002). The presence of para-gastric veins is a characteristic of poor response to endoscopic therapy for treating gastroesophageal varices. Early identification of this subgroup necessitates a change in course of treatment to improve overall patient outcome.

Gastric Polyp Growth during Endoscopic Surveillance for Esophageal Varices or Barrett's Esophagus.

PubMed

Livovsky, Dan M; Pappo, Orit; Skarzhinsky, Galina; Peretz, Asaf; Turvall, Elliot; Ackerman, Zvi

2016-05-01

We recently observed patients with chronic liver disease (CLD) or chronic reflux symptoms (CRS) who developed gastric polyps (GPs) while undergoing surveillance gastroscopies for the detection of esophageal varices or Barrett's esophagus, respectively. To identify risk factors for GP growth and estimate its growth rate. GP growth rate was defined as the number of days since the first gastroscopy (without polyps) in the surveillance program, until the gastroscopy when a GP was discovered. Gastric polyp growth rates in CLD and CRS patients were similar. However, hyperplastic gastric polyps (HGPs) were detected more often (87.5% vs. 60.5%, P = 0.051) and at a higher number (2.57 ± 1.33 vs. 1.65 ± 0.93, P = 0.021) in the CLD patients. Subgroup analysis revealed the following findings only in CLD patients with HGPs: (i) a positive correlation between the GP growth rate and the patient's age; the older the patient, the higher the GP growth rate (r = 0.7, P = 0.004). (ii) A negative correlation between the patient's age and the Ki-67 proliferation index value; the older the patient, the lower the Ki-67 value (r = -0.64, P = 0.02). No correlation was detected between Ki-67 values of HGPs in CLD patients and the presence of portal hypertension, infection with Helicobacter pylori, or proton pump inhibitor use. In comparison with CRS patients, CLD patients developed HGPs more often and at a greater number. Young CLD patients may have a tendency to develop HGPs at a faster rate than elderly CLD patients.

DNA methylation profiling of esophageal adenocarcinoma using Methylation Ligation-dependent Macroarray (MLM).

PubMed

Guilleret, Isabelle; Losi, Lorena; Chelbi, Sonia T; Fonda, Sergio; Bougel, Stéphanie; Saponaro, Sara; Gozzi, Gaia; Alberti, Loredana; Braunschweig, Richard; Benhattar, Jean

2016-10-14

Most types of cancer cells are characterized by aberrant methylation of promoter genes. In this study, we described a rapid, reproducible, and relatively inexpensive approach allowing the detection of multiple human methylated promoter genes from many tissue samples, without the need of bisulfite conversion. The Methylation Ligation-dependent Macroarray (MLM), an array-based analysis, was designed in order to measure methylation levels of 58 genes previously described as putative biomarkers of cancer. The performance of the design was proven by screening the methylation profile of DNA from esophageal cell lines, as well as microdissected formalin-fixed and paraffin-embedded (FFPE) tissues from esophageal adenocarcinoma (EAC). Using the MLM approach, we identified 32 (55%) hypermethylated promoters in EAC, and not or rarely methylated in normal tissues. Among them, 21promoters were found aberrantly methylated in more than half of tumors. Moreover, seven of them (ADAMTS18, APC, DKK2, FOXL2, GPX3, TIMP3 and WIF1) were found aberrantly methylated in all or almost all the tumor samples, suggesting an important role for these genes in EAC. In addition, dysregulation of the Wnt pathway with hypermethylation of several Wnt antagonist genes was frequently observed. MLM revealed a homogeneous pattern of methylation for a majority of tumors which were associated with an advanced stage at presentation and a poor prognosis. Interestingly, the few tumors presenting less methylation changes had a lower pathological stage. In conclusion, this study demonstrated the feasibility and accuracy of MLM for DNA methylation profiling of FFPE tissue samples. Copyright © 2016 Elsevier Inc. All rights reserved.

Use of portal pressure studies in the management of variceal haemorrhage

PubMed Central

Addley, Jennifer; Tham, Tony CK; Cash, William Jonathan

2012-01-01

Portal hypertension occurs as a complication of liver cirrhosis and complications such as variceal bleeding lead to significant demands on resources. Endoscopy is the gold standard method for screening cirrhotic patients however universal endoscopic screening may mean a lot of unnecessary procedures as the presence of oesophageal varices is variable hence a large time and cost burden on endoscopy units to carry out both screening and subsequent follow up of variceal bleeds. A less invasive method to identify those at high risk of bleeding would allow earlier prophylactic measures to be applied. Hepatic venous pressure gradient (HVPG) is an acceptable indirect measurement of portal hypertension and predictor of the complications of portal hypertension in adult cirrhotics. Varices develop at a HVPG of 10-12 mmHg with the appearance of other complications with HPVG > 12 mmHg. Variceal bleeding does not occur in pressures under 12 mmHg. HPVG > 20 mmHg measured early after admission is a significant prognostic indicator of failure to control bleeding varices, indeed early transjugular intrahepatic portosystemic shunt (TIPS) in such circumstances reduces mortality significantly. HVPG can be used to identify responders to medical therapy. Patients who do not achieve the suggested reduction targets in HVPG have a high risk of rebleeding despite endoscopic ligation and may not derive significant overall mortality benefit from endoscopic intervention alone, ultimately requiring TIPS or liver transplantation. Early HVPG measurements following a variceal bleed can help to identify those at risk of treatment failure who may benefit from early intervention with TIPS. Therefore, we suggest using HVPG measurement as the investigation of choice in those with confirmed cirrhosis in place of endoscopy for intitial variceal screening and, where indicated, a trial of B-blockade, either intravenously during the initial pressure study with assessment of response or oral therapy with

Use of portal pressure studies in the management of variceal haemorrhage.

PubMed

Addley, Jennifer; Tham, Tony Ck; Cash, William Jonathan

2012-07-16

Portal hypertension occurs as a complication of liver cirrhosis and complications such as variceal bleeding lead to significant demands on resources. Endoscopy is the gold standard method for screening cirrhotic patients however universal endoscopic screening may mean a lot of unnecessary procedures as the presence of oesophageal varices is variable hence a large time and cost burden on endoscopy units to carry out both screening and subsequent follow up of variceal bleeds. A less invasive method to identify those at high risk of bleeding would allow earlier prophylactic measures to be applied. Hepatic venous pressure gradient (HVPG) is an acceptable indirect measurement of portal hypertension and predictor of the complications of portal hypertension in adult cirrhotics. Varices develop at a HVPG of 10-12 mmHg with the appearance of other complications with HPVG > 12 mmHg. Variceal bleeding does not occur in pressures under 12 mmHg. HPVG > 20 mmHg measured early after admission is a significant prognostic indicator of failure to control bleeding varices, indeed early transjugular intrahepatic portosystemic shunt (TIPS) in such circumstances reduces mortality significantly. HVPG can be used to identify responders to medical therapy. Patients who do not achieve the suggested reduction targets in HVPG have a high risk of rebleeding despite endoscopic ligation and may not derive significant overall mortality benefit from endoscopic intervention alone, ultimately requiring TIPS or liver transplantation. Early HVPG measurements following a variceal bleed can help to identify those at risk of treatment failure who may benefit from early intervention with TIPS. Therefore, we suggest using HVPG measurement as the investigation of choice in those with confirmed cirrhosis in place of endoscopy for intitial variceal screening and, where indicated, a trial of B-blockade, either intravenously during the initial pressure study with assessment of response or oral therapy with

Surgical disconnection of patent paraumbilical vein in refractory hepatic encephalopathy.

PubMed

Ishikawa, Yoshinori; Yoshida, Hiroshi; Mamada, Yasuhiro; Taniai, Nobuhiko; Bando, Koichi; Mizuguchi, Yoshiaki; Kakinuma, Daisuke; Kanda, Tomohiro; Akimaru, Koho; Tajiri, Takashi

2008-06-01

Refractory hepatic encephalopathy (HE) frequently develops in patients with cirrhosis and portal-systemic shunt. Recently, patients with refractory HE associated with portal-systemic shunt have been treated with interventional radiology. We describe a promising new treatment for portal-systemic shunt, ligation of the patent paraumbilical vein (PUV) after partial splenic embolization, in patients with refractory HE. Four patients with cirrhosis (3 women and 1 man; mean age, 56 years) and refractory HE due to a patent PUV were studied. Patency of the PUV had recurred in 1 patient after primary occlusion by interventional radiological procedures. The Child-Pugh class was B in 2 patients and C in 2. Before the present treatment, all patients had been hospitalized at least 3 times because of recurrent HE. Partial splenic embolization was performed in all patients to decrease portal venous pressure before surgery. Surgical ligation of the patent PUV was performed under epidural anesthesia. The patent PUV was carefully skeletonized and doubly ligated. Esophageal varices were evaluated with upper gastrointestinal endoscopy before and after surgery. The mean follow-up duration was 15.8 months. After ligation, there were no clinically significant complications. Esophageal varices were unchanged. The serum ammonia level was higher before surgery (162.3 +/- 56.4 mug/dL, mean +/- SD) than after surgery (41.8 +/- 20.2 mug/dL; p=0.0299). No patient had symptoms of HE. Ligation of the patent PUV is an effective treatment for patients with refractory HE.

Interventional Radiologic Treatment for Idiopathic Portal Hypertension

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hirota, Shozo; Ichikawa, Satoshi; Matsumoto, Shinichi

1999-07-15

Purpose: To evaluate the usefulness of interventional radiological treatment for idiopathic portal hypertension. Methods: Between 1995 and 1998, we performed an interventional radiological treatment in five patients with idiopathic portal hypertension, four of whom had refused surgery and one of whom had undergone surgery. Three patients with gastroesophageal varices (GEV) were treated by partial splenic embolization (PSE), one patient with esophageal varices (EV) and massive ascites by transjugular intrahepatic portosytemic shunt (TIPS) and PSE, and one patient with GEV by percutaneous transhepatic obliteration (PTO). Midterm results were analyzed in terms of the effect on esophageal and/or gastric varices. Results: Inmore » one woman with severe GEV who underwent three sessions of PSE, there was endoscopic confirmation that the GEV had disappeared. In one man his EV shrunk markedly after two sessions of PSE. In two patients slight reduction of the EV was obtained with one application of PSE combined with endoscopic variceal ligation therapy. PTO for GV in one patient resulted in good control of the varices. All patients have survived for 16-42 months since the first interventional treatment, and varices are well controlled. Conclusion: Interventional radiological treatment is effective for patients with idiopathic portal hypertension, whether or not they have undergone surgery.« less

Two randomized controlled studies comparing the nutritional benefits of branched-chain amino acid (BCAA) granules and a BCAA-enriched nutrient mixture for patients with esophageal varices after endoscopic treatment.

PubMed

Sakai, Yoshiyuki; Iwata, Yoshinori; Enomoto, Hirayuki; Saito, Masaki; Yoh, Kazunori; Ishii, Akio; Takashima, Tomoyuki; Aizawa, Nobuhiro; Ikeda, Naoto; Tanaka, Hironori; Iijima, Hiroko; Nishiguchi, Shuhei

2015-01-01

The usefulness of branched-chain amino acid (BCAA) granules and BCAA-enriched nutrient mixtures for patients with liver cirrhosis is often reported. However, no randomized controlled studies have investigated the usefulness of these supplements in the nutritional intervention of cirrhotic patients receiving endoscopic treatment for esophageal varices. Patients without BCAA before endoscopic treatment were divided into study 1, and those who received BCAA were divided into study 2. In study 1, 44 eligible patients were divided into a control group (n = 13), a general liquid nutrient (snack) group (n = 15), and a BCAA-enriched nutrient mixture (BCAA-EN) group (n = 16). In study 2, 48 eligible patients were divided into a BCAA group (n = 24) and a BCAA-EN group (n = 24). The nutritional status including non-protein respiratory quotient (NPRQ) levels, weight gain, and albumin were evaluated on days 0, 7, and 50. In study 1, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 as compared with the snack group. In study 2, the BCAA-EN group showed significant improvement in NPRQ levels on day 7 and in weight levels on day 50 relative to the BCAA group, while the BCAA group showed improved serum albumin levels on day 7 compared to the BCAA-EN group. The BCAA-enriched nutrient mixture maintained NPRQ and weight in cirrhotic patients. Our findings suggest that supplements including both BCAA and a nutritional energy supplement would be beneficial for cirrhotic patients undergoing endoscopic treatment for esophageal varices.

Comparison of different ligature materials used for T-tube esophageal exclusion.

PubMed

Lee, Y C; Luh, S P; Tsai, C C; Hsu, H C; Chu, S H

1992-03-01

Four different ligature materials--plain catgut, chromic catgut, dexon and silk--were used for ligature of the distal arm during T-tube exclusion of the cervical esophagus in 12 dogs. Ligature by plain catgut was maintained for only a short period, but the duration of esophageal occlusion with the other three ligature materials was around 10 days. Ligated esophageal segments were examined grossly and histologically two months after the procedure. The diameter of the esophageal lumen in the ligated segments had become smaller compared with the neighboring normal esophageal lumen. The most prominent histologic changes were atrophy and fibrosis of the muscle coat, vessel congestion and inflammatory cell infiltration in the ligated segments. These tissue reactions were more severe in the chromic catgut and silk ligatures. Among the 11 evaluable dogs, four had symptoms of dysphagia after removal of the T-tube. All four dogs had a sinus discharge and granuloma formation at the T-tube esophagostoma. The diameter of the esophageal lumen was more constricted in dogs with dysphagia. Among the four ligature materials, dexon had the advantages of a long duration of occlusion, less tissue fibrosis and little sequel of esophageal stenosis, making it the most suitable for ligature during esophageal exclusion.

Outcomes in variceal hemorrhage following the use of a balloon tamponade device.

PubMed

Nadler, Jonathan; Stankovic, Nikola; Uber, Amy; Holmberg, Mathias J; Sanchez, Leon D; Wolfe, Richard E; Chase, Maureen; Donnino, Michael W; Cocchi, Michael N

2017-10-01

Variceal hemorrhage is associated with high morbidity and mortality. A balloon tamponade device (BTD), such as the Sengstaken-Blakemore or Minnesota tube, may be used in cases of variceal hemorrhage. While these devices may be effective at controlling acute bleeding, the effect on patient outcomes remains less clear. We sought to describe the number of patients with variceal hemorrhage and a BTD who survive to discharge, survive to one-year, and develop complications related to a BTD. In this retrospective study, we identified patients at a single, tertiary care center who underwent placement of a BTD for upper gastrointestinal hemorrhage between 2003 and 2014. Patient characteristics and outcomes were summarized using descriptive statistics. 34 patients with a BTD were identified. Median age was 57.5 (IQR 47-63) and 76% (26/34) were male. Approximately 59% (20/34) of patients survived to discharge, and 41% (13/32) were alive after one year. Two patients were lost to follow-up. Of those surviving to discharge, 95% (19/20) had undergone transjugular intrahepatic portosystemic shunt (TIPS), while 36% (5/14) of patients who did not survive to discharge had TIPS (p<0.01). One complication, an esophageal perforation, was identified and managed conservatively. In this cohort of patients undergoing BTD placement for variceal hemorrhage, approximately 59% of patients were alive at discharge and 41% were alive after one year. Placement of a BTD as a temporizing measure in the management of acute variceal hemorrhage may be helpful, particularly when utilized as a bridge to more definitive therapy. Copyright © 2017 Elsevier Inc. All rights reserved.

Outcomes in variceal hemorrhage following the use of a balloon tamponade device

PubMed Central

Nadler, Jonathan; Stankovic, Nikola; Uber, Amy; Holmberg, Mathias J.; Sanchez, Leon D.; Wolfe, Richard E.; Chase, Maureen; Donnino, Michael W.; Cocchi, Michael N.

2017-01-01

Background Variceal hemorrhage is associated with high morbidity and mortality. A balloon tamponade device (BTD), such as the Sengstaken-Blakemore or Minnesota tube, may be used in cases of variceal hemorrhage. While these devices may be effective at controlling acute bleeding, the effect on patient outcomes remains less clear. We sought to describe the number of patients with variceal hemorrhage and a BTD who survive to discharge, survive to one-year, and develop complications related to a BTD. Methods In this retrospective study, we identified patients at a single, tertiary care center who underwent placement of a BTD for upper gastrointestinal hemorrhage between 2003 and 2014. Patient characteristics and outcomes were summarized using descriptive statistics. Results 34 patients with a BTD were identified. Median age was 57.5 (IQR 47–63) and 76% (26/34) were male. Approximately 59% (20/34) of patients survived to discharge, and 41% (13/32) were alive after one year. Two patients were lost to follow-up. Of those surviving to discharge, 95% (19/20) had undergone transjugular intrahepatic portosystemic shunt (TIPS), while 36% (5/14) of patients who did not survive to discharge had TIPS (p < 0.01). One complication, an esophageal perforation, was identified and managed conservatively. Conclusion In this cohort of patients undergoing BTD placement for variceal hemorrhage, approximately 59% of patients were alive at discharge and 41% were alive after one year. Placement of a BTD as a temporizing measure in the management of acute variceal hemorrhage may be helpful, particularly when utilized as a bridge to more definitive therapy. PMID:28460805

Quantitative fibrosis parameters highly predict esophageal-gastro varices in primary biliary cirrhosis.

PubMed

Wu, Q-M; Zhao, X-Y; You, H

2016-01-01

Esophageal-gastro Varices (EGV) may develop in any histological stages of primary biliary cirrhosis (PBC). We aim to establish and validate quantitative fibrosis (qFibrosis) parameters in portal, septal and fibrillar areas as ideal predictors of EGV in PBC patients. PBC patients with liver biopsy, esophagogastroscopy and Second Harmonic Generation (SHG)/Two-photon Excited Fluorescence (TPEF) microscopy images were retrospectively enrolled in this study. qFibrosis parameters in portal, septal and fibrillar areas were acquired by computer-assisted SHG/TPEF imaging system. Independent predictor was identified using multivariate logistic regression analysis. PBC patients with liver biopsy, esophagogastroscopy and Second Harmonic Generation (SHG)/Two-photon Excited Fluorescence (TPEF) microscopy images were retrospectively enrolled in this study. qFibrosis parameters in portal, septal and fibrillar areas were acquired by computer-assisted SHG/TPEF imaging system. Independent predictor was identified using multivariate logistic regression analysis. Among the forty-nine PBC patients with qFibrosis images, twenty-nine PBC patients with both esophagogastroscopy data and qFibrosis data were selected out for EGV prognosis analysis and 44.8% (13/29) of them had EGV. The qFibrosis parameters of collagen percentage and number of crosslink in fibrillar area, short/long/thin strings number and length/width of the strings in septa area were associated with EGV (p < 0.05). Multivariate logistic analysis showed that the collagen percentage in fibrillar area ≥ 3.6% was an independent factor to predict EGV (odds ratio 6.9; 95% confidence interval 1.6-27.4). The area under receiver operating characteristic (ROC), diagnostic sensitivity and specificity was 0.9, 100% and 75% respectively. Collagen percentage in Collagen percentage in the fibrillar area as an independent predictor can highly predict EGV in PBC patients.

Portal hypertension in children: High-risk varices, primary prophylaxis and consequences of bleeding.

PubMed

Duché, Mathieu; Ducot, Béatrice; Ackermann, Oanez; Guérin, Florent; Jacquemin, Emmanuel; Bernard, Olivier

2017-02-01

Primary prophylaxis of bleeding is debated for children with portal hypertension because of the limited number of studies on its safety and efficacy, the lack of a known endoscopic pattern carrying a high-risk of bleeding for all causes, and the assumption that the mortality of a first bleed is low. We report our experience with these issues. From 1989 to 2014, we managed 1300 children with portal hypertension. Endoscopic features were recorded; high-risk varices were defined as: grade 3 esophageal varices, grade 2 varices with red wale markings, or gastric varices. Two hundred forty-six children bled spontaneously and 182 underwent primary prophylaxis. The results of primary prophylaxis were reviewed as well as bleed-free survival, overall survival and life-threatening complications of bleeding. High-risk varices were found in 96% of children who bled spontaneously and in 11% of children who did not bleed without primary prophylaxis (p<0.001), regardless of the cause of portal hypertension. Life-threatening complications of bleeding were recorded in 19% of children with cirrhosis and high-risk varices who bled spontaneously. Ten-year probabilities of bleed-free survival after primary prophylaxis in children with high-risk varices were 96% and 72% for non-cirrhotic causes and cirrhosis respectively. Ten-year probabilities of overall survival after primary prophylaxis were 100% and 93% in children with non-cirrhotic causes and cirrhosis respectively. In children with portal hypertension, bleeding is linked to the high-risk endoscopic pattern reported here. Primary prophylaxis of bleeding based on this pattern is fairly effective and safe. In children with liver disease, the risk of bleeding from varices in the esophagus is linked to their large size, the presence of congestion on their surface and their expansion into the stomach but not to the child's age nor to the cause of portal hypertension. Prevention of the first bleed in children with high-risk varices can

Can proton pump inhibitors reduce rebleeding following Histoacryl sclerotherapy for gastric variceal hemorrhage?

PubMed

Kim, Ka Rham; Jun, Chung Hwan; Cho, Kyu Man; Wi, Jin Woo; Park, Seon Young; Cho, Sung Bum; Lee, Wan Sik; Park, Chang Hwan; Joo, Young Eun; Kim, Hyun Soo; Choi, Sung Kyu; Rew, Jong Sun

2015-09-01

To evaluate the efficacy of proton pump inhibitors (PPIs) in reducing rebleeding and bleeding-related death rates after endoscopic gastric variceal obliteration (GVO) using N-butyl-2-cyanoacrylate (NBC). This study enrolled 341 patients who were consecutively diagnosed with and treated for bleeding gastric varices. The patients were divided into PPI and non-PPI groups, and their endoscopic findings, initial hemostasis outcomes, rebleeding and bleeding-related death rates, and treatment-related complications were analyzed. The rate of initial hemostasis was 97.1%. rebleeding occurred in 2.2% of patients within 2 weeks, 3.9% of patients within 4 weeks, 18.9% of patients within 6 months, and 27.6% of patients within 12 months of the GVO procedure. A previous history of variceal bleeding (relative risk [RR], 1.955; 95% confidence interval [CI], 1.263 to 3.028; p = 0.003) and use of PPIs (RR, 0.554; 95% CI, 0.352 to 0.873; p = 0.011) were associated with rebleeding. Child-Pugh class C (RR, 10.914; 95% CI, 4.032 to 29.541; p < 0.001), failure of initial hemostasis (RR, 13.329; 95% CI, 2.795 to 63.556; p = 0.001), and the presence of red-colored concomitant esophageal varices (RR, 4.096; 95% CI, 1.320 to 12.713; p = 0.015) were associated with bleeding-related death. The prophylactic use of PPIs reduces rebleeding after GVO using NBC in patients with gastric variceal hemorrhage. However, prophylactic use of PPIs does not reduce bleeding-related death.

Influence of high-risk esophageal varices on outcomes in hepatocellular carcinoma patients: benefits of prophylactic endoscopic therapies.

PubMed

Tamaoki, Masashi; Toshikuni, Nobuyuki; Matsueda, Kazuhiro; Yamamoto, Hiroshi

2012-01-01

To clarify whether high-risk esophageal varices (EVs) influence outcomes in hepatocellular carcinoma (HCC) patients and to determine whether prophylactic endoscopic therapies(PETs) provide benefits for such patients. Ninety-six consecutive patients with naive HCC complicated by EVs were analyzed. Patients with low-risk EVs (group A, n=53), those with high-risk EVs not treated with PETs (group B, n=31), and those with high-risk EVs treated with PETs (group C, n=12) were compared with respect to first bleeding and mortality. Furthermore, factors associated with outcomes were examined. The first bleeding rates were higher in group B than in group A; the survival rates were lower in group B than in group A. High-risk EVs and advanced stage HCC were risk factors for both outcomes in groups A and B. By contrast, the first bleeding rates tended to be lower in group C than in group B, while the survival rates did not significantly differ. In groups B and C, advanced stage HCC was a risk factor for both outcomes, whereas PETs significantly decreased first bleeding. High-risk EVs negatively influence both first bleeding and mortality in HCC patients and PETs may have a preventive effect on bleeding.

Prevention and management of gastroesophageal varices

PubMed Central

2018-01-01

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices. PMID:29249128

Is it safe to perform endoscopic band ligation for the duodenum? A pilot study in ex vivo porcine models.

PubMed

Kakutani, Hiroshi; Sasaki, Shigemasa; Ueda, Kaoru; Takakura, Kazuki; Sumiyama, Kazuki; Imazu, Hiroo; Hino, Syoryoku; Kawamura, Muneo; Tajiri, Hisao

2013-04-01

In the digestive tract, endoscopic band ligation (EBL) has been routinely used for the treatment of variceal bleeding and superficial malignancies. In recent years, endoscopic treatments for duodenal varices, adenoma, and cancer have also actively incorporated EBL. Although there have been a number of reports on the risks associated with the use of EBL in the esophagus, stomach, and colon, few studies have focused on EBL in the duodenum. We performed EBL procedures to evaluate the risks associated with the use of EBL in the duodenum. Overall, EBLs were performed at nine sites in duodenum sampled from a pig immediately after sacrifice. Submucosal saline injections were placed in three of the nine studied sites. Regardless of saline injection, the full thickness of the duodenal wall was ligated in all attempts. Routine EBL is not recommended in the duodenum because the risk of perforation is unacceptably high.

Prospective comparison of three risk scoring systems in non-variceal and variceal upper gastrointestinal bleeding.

PubMed

Thanapirom, Kessarin; Ridtitid, Wiriyaporn; Rerknimitr, Rungsun; Thungsuk, Rattikorn; Noophun, Phadet; Wongjitrat, Chatchawan; Luangjaru, Somchai; Vedkijkul, Padet; Lertkupinit, Comson; Poonsab, Swangphong; Ratanachu-ek, Thawee; Hansomburana, Piyathida; Pornthisarn, Bubpha; Thongbai, Thirada; Mahachai, Varocha; Treeprasertsuk, Sombat

2016-04-01

Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre-endoscopic Rockall scores (PRS) in comparing non-variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re-bleeding among patients with non-variceal and variceal UGIB. During January, 2010 and September, 2011, patients with UGIB from 11 hospitals were prospectively enrolled. The GBS, FRS, and PRS were calculated. Discriminative ability for each score was assessed using the receiver operated characteristics curve (ROC) analysis. A total of 981 patients presented with acute UGIB, 225 patients (22.9%) had variceal UGIB. The areas under the ROC (AUC) of the GBS, FRS, and PRS for predicting the need for treatment were 0.77, 0.69, and 0.61 in non-variceal versus 0.66, 0.66, and 0.59 in variceal UGIB. The AUC for predicting mortality and re-bleeding during admission were 0.66, 0.80, and 0.76 in non-variceal versus 0.63, 0.57, and 0.63 in variceal UGIB. AUC score was not statistically significant for predicting need for therapy and clinical outcome in variceal UGIB. The GBS ≤ 2 and FRS ≤ 1 identified low-risk non-variceal UGIB patients for death and re-bleeding during hospitalization. In contrast to non-variceal UGIB, the GBS, FRS, and PRS were not precise scores for assessing the need for therapy, mortality, and re-bleeding during admission in variceal UGIB. © 2015 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage.

PubMed

Chang, Min-Yung; Kim, Man-Deuk; Kim, Taehwan; Shin, Wonseon; Shin, Minwoo; Kim, Gyoung Min; Won, Jong Yun; Park, Sung Il; Lee, Do Yun

2016-01-01

To evaluate the feasibility, safety, and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) to treat gastric variceal hemorrhage in patients with portal hypertension. From May 2012 to June 2014, 19 patients (11 men and 8 women, median age; 61, with history of gastric variceal hemorrhage; 17, active bleeding; 2) who underwent PARTO using a vascular plug and a gelfoam pledget were retrospectively analyzed. Clinical and laboratory data were examined to evaluate primary (technical and clinical success, complications) and secondary (worsening of esophageal varix [EV], change in liver function) end points. Median follow-up duration was 11 months, from 6.5 to 18 months. The Wilcoxon signed-rank test was used to compare laboratory data before and after the procedure. Technical success (complete occlusion of the efferent shunt and complete filling of gastric varix [GV] with a gelfoam slurry) was achieved in 18 of 19 (94.7%) patients. The embolic materials could not reach the GV in 1 patient who had endoscopic glue injection before our procedure. The clinical success rate (no recurrence of gastric variceal bleeding) was the same because the technically failed patient showed recurrent bleeding later. Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3). Ten patients underwent follow-up endoscopy; all exhibited GV improvement, except 2 without endoscopic change. Five patients exhibited aggravated EV, and 2 of them had a bleeding event. Laboratory findings were significantly improved after PARTO. PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension.

Predictors of post-treatment stenosis in cervical esophageal cancer undergoing high-dose radiotherapy.

PubMed

Kim, Jun Won; Kim, Tae Hyung; Kim, Jie-Hyun; Lee, Ik Jae

2018-02-21

To evaluate toxicity and treatment outcome of high-dose radiotherapy (RT) for cervical esophageal cancer (CEC). We reviewed a total of 62 consecutive patients who received definitive RT for stage I to III cervical esophageal cancer between 2001 and 2015. Patients who received < 45 Gy, treated for lesions below sternal notch, treated with palliative aim, treated with subsequent surgical resection, or diagnosed with synchronous hypopharyngeal cancer were excluded. Treatment failures were divided into local (occurring within the RT field), outfield-esophageal, and regional [occurring in regional lymph node(s)] failures. Factors predictive of esophageal stenosis requiring endoscopic dilation were analyzed. Grade 1, 2, and 3 esophagitis occurred in 19 (30.6%), 39 (62.9%), and 4 patients (6.5%), respectively, without grade ≥ 4 toxicities. Sixteen patients (25.8%) developed post-RT stenosis, of which 7 cases (43.8%) were malignant. Four patients (6.5%) developed tracheoesophageal fistula (TEF), of which 3 (75%) cases were malignant. Factors significantly correlated with post-RT stenosis were stage T3/4 ( P = 0.001), complete circumference involvement ( P < 0.0001), stenosis at diagnosis ( P = 0.024), and endoscopic complete response ( P = 0.017) in univariate analysis, while complete circumference involvement was significant in multivariate analysis ( P = 0.003). A higher dose (≥ 60 Gy) was not associated with occurrence of post-RT stenosis or TEF. With a median follow-up of 24.3 (range, 3.4-152) mo, the 2 y local control, outfield esophageal control, progression-free survival, and overall survival (OS) rates were 78.9%, 90.2%, 49.6%, and 57.3%, respectively. Factors significantly correlated with OS were complete circumference involvement ( P = 0.023), stenosis at diagnosis ( P < 0.0001), and occurrence of post-RT stenosis or TEF ( P < 0.001) in univariate analysis, while stenosis at diagnosis ( P = 0.004) and occurrence of post-RT stenosis or TEF ( P = 0.023) were

Esophageal motor disorders are frequent during pre and post lung transplantation. Can they influence lung rejection?

PubMed

Ciriza de Los Ríos, Constanza; Canga Rodríguez-Valcárcel, Fernando; de Pablo Gafas, Alicia; Castel de Lucas, Isabel; Lora Pablos, David; Castellano Tortajada, Gregorio

2018-06-01

lung transplantation (LTx) is a viable option for most patients with end-stage lung diseases. Esophageal motor disorders (EMD) are frequent in candidates for LTx, but there is very little data about changes in esophageal motility post-LTx. the aim of our study was to assess esophageal motor disorders by high resolution manometry (HRM) both pre-LTx and six months post-LTx in patients with and without organ rejection. HRM (Manoscan®) was performed in 57 patients both pre-LTx and six months post-LTx. HRM plots were analyzed according to the Chicago classification 3.0. EMD were found in 33.3% and in 49.1% of patients pre-LTx and post-LTx, respectively, and abnormal peristalsis was more frequently found post-LTx (p = 0.018). Hypercontractile esophagus was frequently found post-LTx (1.8% and 19.3% pre-LTx and post-LTx, respectively). Esophagogastric junction (EGJ) morphology changed significantly pre-LTx and post-LTx; type I (normal) was more frequent post-LTx (63-2% and 82.5% respectively, p = 0.007). EMD were more frequent post-LTx in both the non-rejection and rejection group, although particularly in the rejection group (43.2% and 69.2% respectively, p = 0.09). EMD such as distal spasm, hypercontractile esophagus and EGJ outflow obstruction were also observed more frequently post-LTx in the rejection group. significant changes in esophageal motility were observed pre-LTx and particularly post-LTx; hypercontractile esophagus was a frequent EMD found post-LTx. EMD were more frequent in the group of patients that experienced organ rejection compared to the non-rejection group. EMD leading to an impaired esophageal clearance should be considered as an additional factor that contributes to LTx failure.

Predictive factors for rebleeding and death in alcoholic cirrhotic patients with acute variceal bleeding: a multivariate analysis.

PubMed

Krige, Jake E J; Kotze, Urda K; Distiller, Greg; Shaw, John M; Bornman, Philippus C

2009-10-01

Bleeding from esophageal varices is a leading cause of death in alcoholic cirrhotic patients. The aim of the present single-center study was to identify risk factors predictive of variceal rebleeding and death within 6 weeks of initial treatment. Univariate and multivariate analyses were performed on 310 prospectively documented alcoholic cirrhotic patients with acute variceal hemorrhage (AVH) who underwent 786 endoscopic variceal injection treatments between January 1984 and December 2006. All injections were administered during the first 6 weeks after the patients were treated for their first variceal bleed. Seventy-five (24.2%) patients experienced a rebleed, 38 within 5 days of the initial treatment and 37 within 6 weeks of their initial treatment. Of the 15 variables studied and included in a multivariate analysis using a logistic regression model, a bilirubin level >51 mmol/l and transfusion of >6 units of blood during the initial hospital admission were predictors of variceal rebleeding within the first 6 weeks. Seventy-seven (24.8%) patients died, 29 (9.3%) within 5 days and 48 (15.4%) between 6 and 42 days after the initial treatment. Stepwise multivariate logistic regression analysis showed that six variables were predictors of death within the first 6 weeks: encephalopathy, ascites, bilirubin level >51 mmol/l, international normalized ratio (INR) >2.3, albumin <25 g/l, and the need for balloon tube tamponade. Survival was influenced by the severity of liver failure, with most deaths occurring in Child-Pugh grade C patients. Patients with AVH and encephalopathy, ascites, bilirubin levels >51 mmol/l, INR >2.3, albumin <25 g/l and who require balloon tube tamponade are at increased risk of dying within the first 6 weeks. Bilirubin levels >51 mmol/l and transfusion of >6 units of blood were predictors of variceal rebleeding.

Costs and clinical outcomes of primary prophylaxis of variceal bleeding in patients with hepatic cirrhosis: a decision analytic model.

PubMed

Saab, Sammy; DeRosa, Vincent; Nieto, Jose; Durazo, Francisco; Han, Steven; Roth, Bennett

2003-04-01

Current guidelines recommend upper endoscopic screening for patients with hepatic cirrhosis and primary prophylaxis with a nonselective beta-blocker for those with large varices. However, only 25% of cirrhotics develop large varices. Thus, the aim of this study is to evaluate the most cost-effective approach for primary prophylaxis of variceal hemorrhage. Using a Markov model, we compared the costs and clinical outcomes of three strategies for primary prophylaxis of variceal bleeding. In the first strategy, patients were given a beta-blocker without undergoing upper endoscopy. In the second strategy, patients underwent upper endoscopic screening; those found to have large varices were treated with a beta-blocker. In the third strategy, no prophylaxis was used. Selected sensitivity analyses were performed to validate outcomes. Our results show screening prophylaxis was associated with a cost of $37,300 and 5.72 quality-adjusted life yr (QALYs). Universal prophylaxis was associated with a cost of $34,100 and 6.65 QALYs. The no prophylaxis strategy was associated with a cost of $36,600 and 4.84 QALYs. The incremental cost-effectiveness ratio was $800/QALY for the endoscopic strategy relative to the no prophylaxis strategy. Screening endoscopy was cost saving when the compliance, bleed risk without beta-blocker, and variceal bleed costs were increased, and when the discount rate, bleed risk on beta-blockers, and cost of upper endoscopy were decreased. In contrast, the universal prophylaxis strategy was persistently cost saving relative to the no prophylaxis strategy. In comparing the strategies, sensitivity analysis on the death rates from variceal hemorrhage did not alter outcomes. Our results provide economic and clinical support for primary prophylaxis of esophageal variceal bleeding in patients with hepatic cirrhosis. Universal prophylaxis with beta-blocker is preferred because it is consistently associated with the lowest costs and highest QALYs.

[Predicting very early rebleeding after acute variceal bleeding based in classification and regression tree analysis (CRTA).].

PubMed

Altamirano, J; Augustin, S; Muntaner, L; Zapata, L; González-Angulo, A; Martínez, B; Flores-Arroyo, A; Camargo, L; Genescá, J

2010-01-01

Variceal bleeding (VB) is the main cause of death among cirrhotic patients. About 30-50% of early rebleeding is encountered few days after the acute episode of VB. It is necessary to stratify patients with high risk of very early rebleeding (VER) for more aggressive therapies. However, there are few and incompletely understood prognostic models for this purpose. To determine the risk factors associated with VER after an acute VB. Assessment and comparison of a novel prognostic model generated by Classification and Regression Tree Analysis (CART) with classic-used models (MELD and Child-Pugh [CP]). Sixty consecutive cirrhotic patients with acute variceal bleeding. CART analysis, MELD and Child-Pugh scores were performed at admission. Receiver operating characteristic (ROC) curves were constructed to evaluate the predictive performance of the models. Very early rebleeding rate was 13%. Variables associated with VER were: serum albumin (p = 0.027), creatinine (p = 0.021) and transfused blood units in the first 24 hrs (p = 0.05). The area under the ROC for MELD, CHILD-Pugh and CART were 0.46, 0.50 and 0.82, respectively. The value of cut analyzed by CART for the significant variables were: 1) Albumin 2.85 mg/dL, 2) Packed red cells 2 units and 3) Creatinine 1.65 mg/dL the ABC-ROC. Serum albumin, creatinine and number of transfused blood units were associated with VER. A simple CART algorithm combining these variables allows an accurate predictive assessment of VER after acute variceal bleeding. Key words: cirrhosis, variceal bleeding, esophageal varices, prognosis, portal hypertension.

The long-term benefits of nucleos(t)ide analogs in compensated HBV cirrhotic patients with no or small esophageal varices: A 12-year prospective cohort study.

PubMed

Lampertico, Pietro; Invernizzi, Federica; Viganò, Mauro; Loglio, Alessandro; Mangia, Giampaolo; Facchetti, Floriana; Primignani, Massimo; Jovani, Manol; Iavarone, Massimo; Fraquelli, Mirella; Casazza, Giovanni; de Franchis, Roberto; Colombo, Massimo

2015-11-01

Esophageal varices (EV) are a marker of disease severity in compensated cirrhosis due to hepatitis B virus (HBV) which predicts also the risk of hepatocellular carcinoma (HCC), clinical decompensation and anticipated liver related death. The dynamics and prognostic significance of EV in patients under long-term HBV suppression by nucleos(t)ide analogs (NUC), are poorly known. A standardized protocol (Baveno) including 414 upper gastrointestinal (GI) endoscopies was applied to 107 HBeAg-negative compensated cirrhotic patients (93% Child-Pugh A) during a median of 12 (range 2 to 17) years of NUC therapy. Patients who initially started on lamivudine (LMV) and then developed resistance (LMV-R), were rescued by early administration of adefovir, or were switched to tenofovir. Surveillance included serum HBV DNA every three months and abdominal ultrasound every six months. Twenty-seven patients had baseline F1 EV which regressed in 18, remained unchanged in eight and progressed in one patient; the 12-year cumulative incidence of EV regression was 83% (95% CI: 52-92%). De novo F1/F2 EV developed in 6/80 patients with a 12-year cumulative incidence of 10% (95% CI: 5-20%). Six of seven patients with de novo varices or progression of pre-existing varices had either a clinical breakthrough due to LMV-R and/or developed a HCC. No bleedings from ruptured EV occurred, 12 patients died (9 HCC) and 15 were transplanted (13 HCC): the 12-year cumulative incidence of HCC and overall survival was 33% (95% CI: 24-42%) and 76% (95% CI: 67-83%), respectively. Long-term pharmacological suppression of HBV in HBeAg-seronegative patients with compensated cirrhosis leads to a significant regression of pre-existing EV accompanied by a negligible risk of developing de novo EV. Copyright © 2015 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

Measuring spleen stiffness to predict varices in chronic hepatitis B cirrhotic patients with or without receiving non-selective beta-blockers.

PubMed

Wong, Grace Lai-Hung; Kwok, Raymond; Chan, Henry Lik-Yuen; Tang, Stephen Pui-Kit; Lee, Eugenia; Lam, Thomas Chi-Ho; Lau, Tiffany Wing-Yan; Ma, Teresa Man-Kee; Wong, Betsy Chi-Kuen; Wong, Vincent Wai-Sun

2016-08-01

we aimed to investigate the accuracy of liver (LSM) spleen stiffness measurement (SSM) with transient elastography (TE) to predict varices in the presence of non-selective beta-blockers (NSBB). In this cross-sectional study of consecutive patients with chronic hepatitis B (CHB) and cirrhosis, all patients underwent TE and upper endoscopic examinations. LSM and SSM in predicting varices in patients receiving and not receiving NSBB were evaluated. Altogether 144 CHB patients (29 receiving NSBB; 35 with any varices, 31 and 11 with esophageal and gastric varices, respectively) were recruited. Their mean LSM and SSM were 13.3 ± 9.0 kPa and 32.8 ± 19.2 kPa, respectively. The correlation between LSM and SSM was better in the NSBB subgroup (r = 0.525, P = 0.003) than its counterpart (r = 0.329, P  < 0.001). The area under receiver operating characteristic curve (AUROC) of LSM and SSM for any varices was 0.675 and 0.685 (P = 0.002 and 0.001), respectively. SSM of 18.9 kPa had a negative predictive value of 92.1% and negative likelihood ratio of 0.27 for ruling out any varices; and SSM of 54.9 kPa had a positive predictive value of 56.5% and a positive likelihood ratio of 4.05 to rule in varices. The AUROC of LSM for varices was 0.742 and 0.549 in patients with or without NSBB, respectively; the corresponding AUROC of SSM was 0.572 and 0.603, respectively. SSM only has modest accuracy to predict varices independent of NSBB use. An SSM cutoff value of 18.9 kPa may be adopted to achieve a high negative predictive value to rule out varices. © 2016 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.

Inflammation: a way to understanding the evolution of portal hypertension

PubMed Central

Aller, María-Angeles; Arias, Jorge-Luis; Cruz, Arturo; Arias, Jaime

2007-01-01

Background Portal hypertension is a clinical syndrome that manifests as ascites, portosystemic encephalopathy and variceal hemorrhage, and these alterations often lead to death. Hypothesis Splanchnic and/or systemic responses to portal hypertension could have pathophysiological mechanisms similar to those involved in the post-traumatic inflammatory response. The splanchnic and systemic impairments produced throughout the evolution of experimental prehepatic portal hypertension could be considered to have an inflammatory origin. In portal vein ligated rats, portal hypertensive enteropathy, hepatic steatosis and portal hypertensive encephalopathy show phenotypes during their development that can be considered inflammatory, such as: ischemia-reperfusion (vasodilatory response), infiltration by inflammatory cells (mast cells) and bacteria (intestinal translocation of endotoxins and bacteria) and lastly, angiogenesis. Similar inflammatory phenotypes, worsened by chronic liver disease (with anti-oxidant and anti-enzymatic ability reduction) characterize the evolution of portal hypertension and its complications (hepatorenal syndrome, ascites and esophageal variceal hemorrhage) in humans. Conclusion Low-grade inflammation, related to prehepatic portal hypertension, switches to high-grade inflammation with the development of severe and life-threatening complications when associated with chronic liver disease. PMID:17999758

Predictors of post-treatment stenosis in cervical esophageal cancer undergoing high-dose radiotherapy

PubMed Central

Kim, Jun Won; Kim, Tae Hyung; Kim, Jie-Hyun; Lee, Ik Jae

2018-01-01

AIM To evaluate toxicity and treatment outcome of high-dose radiotherapy (RT) for cervical esophageal cancer (CEC). METHODS We reviewed a total of 62 consecutive patients who received definitive RT for stage I to III cervical esophageal cancer between 2001 and 2015. Patients who received < 45 Gy, treated for lesions below sternal notch, treated with palliative aim, treated with subsequent surgical resection, or diagnosed with synchronous hypopharyngeal cancer were excluded. Treatment failures were divided into local (occurring within the RT field), outfield-esophageal, and regional [occurring in regional lymph node(s)] failures. Factors predictive of esophageal stenosis requiring endoscopic dilation were analyzed. RESULTS Grade 1, 2, and 3 esophagitis occurred in 19 (30.6%), 39 (62.9%), and 4 patients (6.5%), respectively, without grade ≥ 4 toxicities. Sixteen patients (25.8%) developed post-RT stenosis, of which 7 cases (43.8%) were malignant. Four patients (6.5%) developed tracheoesophageal fistula (TEF), of which 3 (75%) cases were malignant. Factors significantly correlated with post-RT stenosis were stage T3/4 (P = 0.001), complete circumference involvement (P < 0.0001), stenosis at diagnosis (P = 0.024), and endoscopic complete response (P = 0.017) in univariate analysis, while complete circumference involvement was significant in multivariate analysis (P = 0.003). A higher dose (≥ 60 Gy) was not associated with occurrence of post-RT stenosis or TEF. With a median follow-up of 24.3 (range, 3.4-152) mo, the 2 y local control, outfield esophageal control, progression-free survival, and overall survival (OS) rates were 78.9%, 90.2%, 49.6%, and 57.3%, respectively. Factors significantly correlated with OS were complete circumference involvement (P = 0.023), stenosis at diagnosis (P < 0.0001), and occurrence of post-RT stenosis or TEF (P < 0.001) in univariate analysis, while stenosis at diagnosis (P = 0.004) and occurrence of post-RT stenosis or TEF (P = 0

Plug-Assisted Retrograde Transvenous Obliteration for the Treatment of Gastric Variceal Hemorrhage

PubMed Central

Chang, Min-Yung; Kim, Taehwan; Shin, Wonseon; Shin, Minwoo; Kim, Gyoung Min; Won, Jong Yun; Park, Sung Il; Lee, Do Yun

2016-01-01

Objective To evaluate the feasibility, safety, and clinical outcomes of plug-assisted retrograde transvenous obliteration (PARTO) to treat gastric variceal hemorrhage in patients with portal hypertension. Materials and Methods From May 2012 to June 2014, 19 patients (11 men and 8 women, median age; 61, with history of gastric variceal hemorrhage; 17, active bleeding; 2) who underwent PARTO using a vascular plug and a gelfoam pledget were retrospectively analyzed. Clinical and laboratory data were examined to evaluate primary (technical and clinical success, complications) and secondary (worsening of esophageal varix [EV], change in liver function) end points. Median follow-up duration was 11 months, from 6.5 to 18 months. The Wilcoxon signed-rank test was used to compare laboratory data before and after the procedure. Results Technical success (complete occlusion of the efferent shunt and complete filling of gastric varix [GV] with a gelfoam slurry) was achieved in 18 of 19 (94.7%) patients. The embolic materials could not reach the GV in 1 patient who had endoscopic glue injection before our procedure. The clinical success rate (no recurrence of gastric variceal bleeding) was the same because the technically failed patient showed recurrent bleeding later. Acute complications included fever (n = 2), fever and hypotension (n = 2; one diagnosed adrenal insufficiency), and transient microscopic hematuria (n = 3). Ten patients underwent follow-up endoscopy; all exhibited GV improvement, except 2 without endoscopic change. Five patients exhibited aggravated EV, and 2 of them had a bleeding event. Laboratory findings were significantly improved after PARTO. Conclusion PARTO is technically feasible, safe, and effective for gastric variceal hemorrhage in patients with portal hypertension. PMID:26957908

Portal hypertension and gastrointestinal bleeding: Diagnosis, prevention and management

PubMed Central

Biecker, Erwin

2013-01-01

Bleeding from esophageal varices is a life threatening complication of portal hypertension. Primary prevention of bleeding in patients at risk for a first bleeding episode is therefore a major goal. Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol. Variceal endoscopic band ligation is equally effective but procedure related morbidity is a drawback of the method. Therapy of acute bleeding is based on three strategies: vasopressor drugs like terlipressin, antibiotics and endoscopic therapy. In refractory bleeding, self-expandable stents offer an option for bridging to definite treatments like transjugular intrahepatic portosystemic shunt (TIPS). Treatment of bleeding from gastric varices depends on vasopressor drugs and on injection of varices with cyanoacrylate. Strategies for primary or secondary prevention are based on non-selective beta-blockers but data from large clinical trials is lacking. Therapy of refractory bleeding relies on shunt-procedures like TIPS. Bleeding from ectopic varices, portal hypertensive gastropathy and gastric antral vascular ectasia-syndrome is less common. Possible medical and endoscopic treatment options are discussed. PMID:23964137

Safety of direct endoscopic necrosectomy in patients with gastric varices

PubMed Central

Storm, Andrew C; Thompson, Christopher C

2016-01-01

AIM: To determine the feasibility and safety of transgastric direct endoscopic necrosectomy (DEN) in patients with walled-off necrosis (WON) and gastric varices. METHODS: A single center retrospective study of consecutive DEN for WON was performed from 2012 to 2015. All DEN cases with gastric fundal varices noted on endoscopy, computed tomography (CT) or magnetic resonance imaging (MRI) during the admission for DEN were collected for analysis. In all cases, external urethral sphincter (EUS) with doppler was used to exclude the presence of intervening gastric varices or other vascular structures prior to 19 gauge fine-needle aspiration (FNA) needle access into the cavity. The tract was serially dilated to 20 mm and was entered with an endoscope for DEN. Pigtail stents were placed to facilitate drainage of the cavity. Procedure details were recorded. Comprehensive chart review was performed to evaluate for complications and WON recurrence. RESULTS: Fifteen patients who underwent DEN for WON had gastric varices at the time of their procedure. All patients had an INR < 1.5 and platelets > 50. Of these patients, 11 had splenic vein thrombosis and 2 had portal vein thrombosis. Two patients had isolated gastric varices, type 1 and the remaining 13 had > 5 mm gastric submucosal varices on imaging by CT, MRI or EUS. No procedures were terminated without completing the DEN for any reason. One patient had self-limited intraprocedural bleeding related to balloon dilation of the tract. Two patients experienced delayed bleeding at 2 and 5 d post-op respectively. One required no therapy or intervention and the other received 1 unit transfusion and had an EGD which revealed no active bleeding. Resolution rate of WON was 100% (after up to 2 additional DEN in one patient) and no patients required interventional radiology or surgical interventions. CONCLUSION: In patients with WON and gastric varices, DEN using EUS and doppler guidance may be performed safely. Successful resolution

Stratifying risk in the prevention of recurrent variceal hemorrhage: Results of an individual patient meta-analysis.

PubMed

Albillos, Agustín; Zamora, Javier; Martínez, Javier; Arroyo, David; Ahmad, Irfan; De-la-Peña, Joaquin; Garcia-Pagán, Juan-Carlos; Lo, Gin-Ho; Sarin, Shiv; Sharma, Barjesh; Abraldes, Juan G; Bosch, Jaime; Garcia-Tsao, Guadalupe

2017-10-01

Endoscopic variceal ligation plus beta-blockers (EVL+BB) is currently recommended for variceal rebleeding prophylaxis, a recommendation that extends to all patients with cirrhosis with previous variceal bleeding irrespective of prognostic stage. Individualizing patient care is relevant, and in published studies on variceal rebleeding prophylaxis, there is a lack of information regarding response to therapy by prognostic stage. This study aimed at comparing EVL plus BB with monotherapy (EVL or BB) on all-source rebleeding and mortality in patients with cirrhosis and previous variceal bleeding stratified by cirrhosis severity (Child A versus B/C) by means of individual time-to-event patient data meta-analysis from randomized controlled trials. The study used individual data on 389 patients from three trials comparing EVL plus BB versus BB and 416 patients from four trials comparing EVL plus BB versus EVL. Compared with BB alone, EVL plus BB reduced overall rebleeding in Child A (incidence rate ratio 0.40; 95% confidence interval, 0.18-0.89; P = 0.025) but not in Child B/C, without differences in mortality. The effect of EVL on rebleeding was different according to Child (P for interaction <0.001). Conversely, compared with EVL, EVL plus BB reduced rebleeding in both Child A and B/C, with a significant reduction in mortality in Child B/C (incidence rate ratio 0.46; 95% confidence interval, 0.25-0.85; P = 0.013). Outcomes of therapies to prevent variceal rebleeding differ depending on cirrhosis severity: in patients with preserved liver function (Child A), combination therapy is recommended because it is more effective in preventing rebleeding, without modifying survival, while in patients with advanced liver failure (Child B/C), EVL alone carries an increased risk of rebleeding and death compared with combination therapy, underlining that BB is the key element of combination therapy. (Hepatology 2017;66:1219-1231). © 2017 by the American Association for the Study of

Orally administered L-arginine and glycine are highly effective against acid reflux esophagitis in rats

PubMed Central

Nagahama, Kenji; Nishio, Hikaru; Yamato, Masanori; Takeuchi, Koji

2012-01-01

Summary Background Reflux esophagitis is caused mainly by excessive exposure of the mucosa to gastric contents. In the present study, we examined the effect of several amino acids on acid reflux esophagitis in rats. Material/Methods After 18 h of fasting, acid reflux esophagitis was induced by ligating both the pylorus and the transitional region between the forestomach and the corpus under ether anesthesia, and the animals were killed 4 h later. The severity of esophagitis was reduced by the oral administration of omeprazole, a proton pump inhibitor, or pepstatin, a specific pepsin inhibitor. Results The development of esophageal lesions was dose-dependently prevented by L-arginine and glycine, given intragastrically (i.g.) after the ligation, with complete inhibition obtained at 250 mg/kg and 750 mg/kg, respectively, and these effects were not influenced by the prior s.c. administration of indomethacin or L-NAME. By contrast, both L-alanine and L-glutamine given i.g. after the ligation aggravated these lesions in a dose-dependent manner. These amino acids had no effect on acid secretion but increased the pH of the gastric contents to 1.8~2.3 due to their buffering action. Conclusions The results confirmed an essential role for acid and pepsin in the pathogenesis of acid reflux esophagitis in the rat model and further suggested that various amino acids affect the severity of esophagitis in different ways, due to yet unidentified mechanisms; L-alanine and L-glutamine exert a deleterious effect on the esophagitis, while L-arginine and glycine are highly protective, independent of endogenous prostaglandins and nitric oxide. PMID:22207112

[Application of degree of portal systemic shunting in assessing upper gastrointestinal bleeding in patients with schistosomiasis cirrhosis].

PubMed

Shuai, Ju; Ying, Li; Chang-Xue, Ji; Biao, Zhang

2017-03-27

To discuss the application of the degree of portal systemic shunting in assessing the upper gastrointestinal bleeding in patients with hepatic schistosomiasis. Thirty-three patients with upper gastrointestinal bleeding caused by hepatic schistosomiasis (a bleeding group) and 29 schistosomiasis cirrhosis patients without bleeding (a non-bleeding group) were enrolled as investigation subjects in Jinshan Hospital. The subjects were scanned by the 128 abdominal slice spiral CT. The portal systemic shunting vessels were reconstructed by using thin slab maximum intensity projection (TSMIP) and multiplanar reconstruction (MPR). The degrees of the shunting vessels of the subjects were evaluated and compared, and the relationship between upper gastrointestinal bleeding and the degree of the shunting was analyzed. In the bleeding group, the occurrence rates of the shunting vessels were found as follows: 86.4% in left gastric varices, 68.2% in short gastric varices, 50.0% in esophageal varices, 50.0% in para-esophageal varices, 37.9% in gastric varices, 69.7% in gastric-renal varices, 51.5% in spleen-renal varices, 25.8% in abdominal wall varices, 15.2% in omentum varices, 63.6% in para-splenic varices, 34.8% in umbilical varices, 40.9% in retroperitoneal-paravertebral varices, and 36.4% in mesenteric varices. In the bleeding group, the occurrence rates and the degree of shunt were significantly higher than those in the non-bleeding group in esophageal varices, esophageal vein, left gastric vein and gastric varices (all P < 0.05). CT portal vein reconstruction can accurately display the location, degree and walking of all kinds of shunting vessels. Esophageal varices, esophageal vein, left gastric vein and gastric varices can accurately predict the risk of upper gastrointestinal bleeding in patients with hepatic schistosomiasis. The patents with higher degree of the shunting vessels have a higher risk of gastrointestinal bleeding.

Gastric varices and hepatic encephalopathy: treatment with vascular plug and gelatin sponge-assisted retrograde transvenous obliteration--a primary report.

PubMed

Gwon, Dong Il; Ko, Gi-Young; Yoon, Hyun-Ki; Sung, Kyu-Bo; Kim, Jin Hyoung; Shin, Ji Hoon; Ko, Heung Kyu; Song, Ho-Young

2013-07-01

To evaluate technical safety, clinical safety, and effectiveness of vascular plug-assisted retrograde transvenous obliteration (RTO) for treatment of gastric varices (GV) and hepatic encephalopathy (HE). This retrospective study was approved by the institutional review board; written informed consent was waived. From April 2009 to December 2011, 20 patients (13, GV; seven, HE) who had undergone vascular plug-assisted RTO were retrospectively evaluated. After retrograde transvenous placement of a vascular plug in the left adrenal vein or gastrorenal shunt, subsequent gelatin-sponge embolization of both gastrorenal shunt and GV was performed. Follow-up computed tomography (CT) and upper gastrointestinal tract endoscopy were performed; clinical and laboratory data were collected to evaluate primary (technical success, complications, clinical success) and secondary (change of liver function by using the Child-Pugh score, worsening of esophageal varices) end points. Laboratory data before and after vascular plug-assisted RTO were compared (paired-sample t test). Placement of the vascular plug and subsequent gelatin-sponge embolization were technically successful in all 20 patients, with no procedure-related complications. Follow-up CT within 1 week after vascular plug-assisted RTO showed complete thrombosis of GV and gastrorenal shunts in all patients. Clinical symptoms of HE completely resolved in all seven patients with HE; mean serum NH3 level of 127.4 μmol/L ± 58 (standard deviation) before vascular plug-assisted RTO decreased significantly to 28.1 μmol/L ± 9.8 within 1 week after vascular plug-assisted RTO (P = .002). Eighteen patients who underwent follow-up longer than 2 months showed complete obliteration of GV and gastrorenal shunts at CT and endoscopy. There were no cases of variceal bleeding or HE during mean follow-up of 422 days. Improvement in Child-Pugh score was observed in 12 of 18 (67%) patients 1 month after vascular plug-assisted RTO. Worsening

Value of two-phase dynamic multidetector computed tomography in differential diagnosis of post-inflammatory strictures from esophageal cancer

PubMed Central

Karmazanovsky, Grigory G; Buryakina, Svetlana A; Kondratiev, Evgeny V; Yang, Qin; Ruchkin, Dmitry V; Kalinin, Dmitry V

2015-01-01

AIM: To characterize the computed tomography (CT) findings in patients with post-inflammatory esophageal strictures (corrosive and peptic) and reveal the optimal scanning phase protocols for distinguishing post-inflammatory esophageal stricture and esophageal cancer. METHODS: Sixty-five patients with esophageal strictures of different etiology were included in this study: 24 patients with 27 histopathologically confirmed corrosive strictures, 10 patients with 12 peptic strictures and 31 patients with esophageal cancer were evaluated with a two-phase dynamic contrast-enhanced MDCT. Arterial and venous phases at 10 and 35 s after the attenuation of 200 HU were obtained at the descending aorta, with a delayed phase at 6-8 min after the start of injection of contrast media. For qualitative analysis, CT scans of benign strictures were reviewed for the presence/absence of the following features: “target sign”, luminal mass, homogeneity of contrast medium uptake, concentric wall thickening, conically shaped suprastenotic dilatation, smooth boundaries of stenosis and smooth mucous membrane at the transition to stenosis, which were compared with a control group of 31 patients who had esophageal cancer. The quantitative analysis included densitometric parameter acquisition using regions-of-interest measurement of the zone of stenosis and normal esophageal wall and the difference between those measurements (ΔCT) at all phases of bolus contrast enhancement. Esophageal wall thickening, length of esophageal wall thickening and size of the regional lymph nodes were also evaluated. RESULTS: The presence of a concentric esophageal wall, conically shaped suprastenotic dilatation, smooth upper and lower boundaries, “target sign” and smooth mucous membrane at the transition to stenosis were suggestive of a benign cause, with sensitivities of 92.31%, 87.17%, 94.87%, 76.92% and 82.05%, respectively, and specificities of 70.96%, 89.66%, 80.65%, 96.77% and 93.55%, respectively

Fighting Hepatitis B in North Korea: Feasibility of a Bi-modal Prevention Strategy.

PubMed

Unnewehr, Markus; Stich, August

2015-11-01

In North Korea, the prevalence of hepatitis B is high due to natural factors, gaps in vaccination, and the lack of antiviral treatment. Aid projects are urgently needed, however impeded by North Korea's political and economical situation and isolation. The feasibility of a joint North Korean and German humanitarian hepatitis B prevention program was assessed. Part 1: Hepatitis B vaccination catch-up campaign. Part 2: Implementation of endoscopic ligation of esophageal varices (EVL) by trainings in Germany and North Korea. By vaccinating 7 million children between 2010 and 2012, the hepatitis B vaccination gap was closed. Coverage of 99.23% was reached. A total of 11 hepatitis B-induced liver cirrhosis patients (mean age 41.1 yr) with severe esophageal varices and previous bleedings were successfully treated by EVL without major complications. A clinical standard operating procedure, a feedback system and a follow-up plan were developed. The bi-modal preventive strategy was implemented successfully. Parts of the project can serve as an example for other low-income countries, however its general transferability is limited due to the special circumstances in North Korea.

Esophageal motor activity in children with gastro-esophageal reflux disease and esophagitis.

PubMed

Chitkara, Denesh K; Fortunato, Christine; Nurko, Samuel

2005-01-01

To evaluate esophageal body motor contractions occurring during esophageal reflux in pediatric patients with gastro-esophageal reflux disease (GERD). Patients referred for the evaluation of GERD who were evaluated with combined 24-hour pH probe and esophageal manometry test (MP24) were included. Patients were separated into the following groups: Group C -- normal pH probe and normal EGD; Group 1 -- abnormal pH probe and normal EGD; and Group 2 -- abnormal pH probe and EGD with histologic esophagitis. Esophageal motor function during reflux episodes was analyzed. Twenty-five patients were included. All had a normal stationary esophageal manometry. Patients in Groups 1 and 2 had significantly more gastroesophageal reflux by pH probe than Group C (P < 0.01). During the MP24, patients in Group 1 and 2 had significantly fewer contractions per minute pre-, during, and post-GER (P < 0.05). There were significant differences in the number of isolated and prolonged contractions (>7 sec) during prolonged GERD episodes >5 minutes (P < 0.05). Children with GERD have a decreased number and abnormal esophageal body contractions with esophageal reflux. This suggests that children with GERD with and without esophagitis have impaired esophageal body acid clearance.

Spleen Stiffness Is Superior to Liver Stiffness for Predicting Esophageal Varices in Chronic Liver Disease: A Meta-Analysis.

PubMed

Ma, Xiaowen; Wang, Le; Wu, Hao; Feng, Yuemin; Han, Xibiao; Bu, Haoran; Zhu, Qiang

2016-01-01

Liver stiffness (LS) and spleen stiffness (SS) are two most widely accessible non-invasive parameters for predicting esophageal varices (EV), but the reported accuracy of the two predictors have been inconsistent across studies. This meta-analysis aims to evaluate the diagnostic performance of LS and SS measurement for detecting EV in patients with chronic liver disease (CLD), and compare their accuracy. Pubmed/Medline, Embase, Cochrane Library and Ovid were searched for all studies assessing SS and LS simultaneously in EV diagnosis. A total of 16 studies including 1892 patients were included in this meta-analysis, and the pooled statistical parameters were calculated using the bivariate mixed effects models. In detection of any EV, for LS measurement, the summary sensitivity was 0.83 (95% confidence interval [CI]: 0.78-0.87), and the specificity was 0.66 (95% CI: 0.60-0.72). While for SS measurement, the pooled sensitivity and specificity was 0.88 (95% CI: 0.83-0.92) and 0.78 (95% CI: 0.73-0.83). The summary receiver operating characteristic (SROC) curve values of LS and SS were 0.81 (95% CI: 0.77-0.84) and 0.88 (95% CI: 0.85-0.91) respectively, and the results had statistical significance (P<0.01). The diagnostic odds ratio (DOR) of SS (25.73) was significantly higher than that of LS (9.54), with the relative DOR value was 2.48 (95%CI: 1.10-5.60), P<0.05. Under current techniques, SS is significantly superior to LS for identifying the presence of EV in patients with CLD. SS measurement may help to select patients for endoscopic screening.

Does the number of veins ligated during varicococele surgery influence post-operative semen and hormone results?

PubMed

Majzoub, A; Elbardisi, H; Arafa, M; Agarwal, A; Al Said, S; Al Rumaihi, K

2016-09-01

Varicocele is a well-established cause of male subfertility, which is directly proportional to its clinical grade. Although newer ultrasonic grading systems have taken into account the existence of pampiniform venous plexi, little is known about the clinical significance of the number of veins ligated during surgery. Very few undersized studies reported an influence which triggered the need to evaluate such association. This is a retrospective study of 378 patients who underwent left microsurgical subinguinal varicocoelectomy. Semen analyses and blood hormone studies performed pre-operatively were compared to those executed 6 months after surgery. Patients were divided into abnormal semen and normal semen groups based on their initial semen results. They were also subdivided according to the number of veins ligated intraoperatively into three groups: <5, 5-10, and >10 veins. Sperm count, total motility, and progressive motility were significantly increased in 62, 60.3, and 53.3% of patients post-operatively (p = 0.001), respectively. No significant differences in hormone levels were detected overall. Of the 378 patients, 332 had an abnormal semen analysis, while the remaining 46 patients had a normal result. Sperm count, total motility, and progressive motility significantly increased after varicocoelectomy in patients with an abnormal initial semen analysis (p = 0.001). In 48.7% of patients, 5-10 veins were ligated during surgery, whereas 28.3% had >10 and 23% had <5 ligated veins. No statistically significant differences were noted in the initial or the follow-up results among the number of vein subgroups. Varicocele ligation improves patients' fertility potential. This improvement, however, is not influenced by the number of veins ligated intraoperatively. Clinical grading maintains its superiority in the evaluation of varicocele patients. © 2016 American Society of Andrology and European Academy of Andrology.

Successful Management of Neobladder Variceal Bleeding

DOE Office of Scientific and Technical Information (OSTI.GOV)

Atwal, Dinesh; Chatterjee, Kshitij, E-mail: kchatterjee@uams.edu; Osborne, Scott

Hematuria from a neobladder can occur due to a variety of pathologies including tumors, stones, and fistulas. Variceal bleeding in a neobladder is a very rare condition with only one case reported in literature. We present a case of a patient with cirrhosis and portal hypertension and an ileocolic orthotopic neobladder presenting with hematuria. Computed tomographic angiography showed dilated varices around the neobladder which were successfully embolized. To the best of our knowledge, this is the first report case of variceal bleeding in a neobladder successfully managed with the combination of TIPS (transjugular intrahepatic portosystemic shunt) procedure and embolization.

Clinicopathological Features and Treatment of Ectopic Varices with Portal Hypertension

PubMed Central

Sato, Takahiro; Akaike, Jun; Toyota, Jouji; Karino, Yoshiyasu; Ohmura, Takumi

2011-01-01

Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding. PMID:21994879

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, King, Lok, Forns, and FibroIndex Scores in Predicting the Presence of Esophageal Varices in Liver Cirrhosis

PubMed Central

Deng, Han; Qi, Xingshun; Guo, Xiaozhong

2015-01-01

Abstract Aspartate aminotransferase-to-platelet ratio (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, FI, King, Lok, Forns, and FibroIndex scores may be simple and convenient noninvasive diagnostic tests, because they are based on the regular laboratory tests and demographic data. This study aimed to systematically evaluate their diagnostic accuracy for the prediction of varices in liver cirrhosis. All relevant papers were searched via PubMed, EMBASE, CNKI, and Wanfang databases. The area under the summary receiver operating characteristic curve (AUSROC), sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), and diagnostic odds ratio (DOR) were calculated. Overall, 12, 4, 5, 0, 0, 4, 3, and 1 paper was identified to explore the diagnostic accuracy of APRI, AAR, FIB-4, FI, King, Lok, Forns, and FibroIndex scores, respectively. The AUSROCs of APRI, AAR, FIB-4, Lok, and Forns scores for the prediction of varices were 0.6774, 0.7275, 0.7755, 0.7885, and 0.7517, respectively; and those for the prediction of large varices were 0.7278, 0.7448, 0.7095, 0.7264, and 0.6530, respectively. The diagnostic threshold effects of FIB-4 and Forns scores for the prediction of varices were statistically significant. The sensitivities/specificities/PLRs/NLRs/DORs of APRI, AAR, and Lok scores for the prediction of varices were 0.60/0.67/1.77/0.58/3.13, 0.64/0.63/1.97/0.54/4.18, and 0.74/0.68/2.34/0.40/5.76, respectively. The sensitivities/specificities/PLRs/NLRs/DORs of APRI, AAR, FIB-4, Lok, and Forns scores for the prediction of large varices were 0.65/0.66/2.15/0.47/4.97, 0.68/0.58/2.07/0.54/3.93, 0.62/0.64/2.02/0.56/3.57, 0.78/0.63/2.09/0.37/5.55, and 0.65/0.61/1.62/0.59/2.75, respectively. APRI, AAR, FIB-4, Lok, and Forns scores had low to moderate diagnostic accuracy in predicting the presence of varices in liver cirrhosis. PMID:26496312

Ratio of platelet count/spleen diameter predicted the presence of esophageal varices in patients with schistosomiasis liver cirrhosis.

PubMed

Xu, Xiao-Dan; Xu, Chun-Fang; Dai, Jian-Jun; Qian, Jian-Qing; Pin, Xun

2016-05-01

To examine the platelet count (PC)/spleen diameter (SD) ratio in predicting the presence of esophageal varices (EV) in patients with schistosomiasis liver cirrhosis. A total of 95 consecutive patients with EV induced by schistosomiasis liver cirrhosis were enrolled in this trial. A total of 141 schistosomiasis liver cirrhosis patients without EV were enrolled as controls. All patients were diagnosed by endoscopy. Demographic, laboratory, and Doppler ultrasound parameters were collected and analyzed. Binary logistic regression analysis was carried out to identify independent risk factors associated with EV occurrence. Receiver operating curves were generated to obtain the PC/SD ratio cutoff values for the optimal sensitivity and specificity with respect to EV. The accuracy was increased in diagnosing for EV using the ratio of PC/SD compared with the SD alone [area under the curve: 0.891 95% confidence interval (CI): 0.844-0.928 vs. 0.764 95% CI: 0.705-0.817; P<0.01]. The optimal cutoff value was 1004, with a 77.1% (95% CI: 67.9-84.8%) positive-predictive value and an 89.3% (95% CI: 82.7-94.0%) negative-predictive value. Using a cutoff of 1004, it was determined that 117/141 (83.0%) patients without EV could avoid undergoing unnecessary endoscopy, whereas 14/95 (14.7%) patients with EV would be misdiagnosed. In contrast, when the ratio was set at 909, the positive-predictive and negative-predictive values were 79.5% (95% CI: 69.5-87.4%) and 83.1% (95% CI: 76.1-88.8%), respectively. A ratio of 909 would accurately predict the absence of EV in 123/141 (87.2%) patients; however, 24/95 (25.3%) patients with EV would miss the necessary screening endoscopy. The ratio of PC/SD was a useful marker in predicting the presence of EV in patients with schistosomiasis liver cirrhosis.

The cost-effectiveness of hepatic venous pressure gradient monitoring in the prevention of recurrent variceal hemorrhage.

PubMed

Targownik, Laura E; Spiegel, Brennan M R; Dulai, Gareth S; Karsan, Hetal A; Gralnek, Ian M

2004-07-01

Recurrent variceal hemorrhage is common following an initial bleed in patients with cirrhosis. The current standard of care for secondary prophylaxis is endoscopic band ligation (EBL). Combination of beta-blocker and nitrate therapy, guided by hepatic venous pressure gradient (HVPG) monitoring, is a novel alternative strategy. We sought to determine the cost-effectiveness of these competing strategies. Decision analysis with Markov modeling was used to calculate the cost-effectiveness of three competing strategies: (1) EBL; (2) beta-blocker and nitrate therapy without HVPG monitoring (HVPG-); and (3) beta-blocker and nitrate therapy with HVPG monitoring (HVPG+). Patients in the HVPG+ strategy who failed to achieve an HVPG decline from medical therapy were offered EBL. Cost estimates were from a third-party payer perspective. The main outcome measure was the cost per recurrent variceal hemorrhage prevented. Under base-case conditions, the HVPG+ strategy was the most effective yet most expensive approach, followed by EBL and HVPG-. Compared to the EBL strategy, the HVPG+ strategy cost an incremental 5,974 dollars per recurrent bleed prevented. In a population with 100% compliance with all therapies, the incremental cost of HVPG-versus EBL fell to 5,270 dollars per recurrent bleed prevented. The model results were sensitive to the cost of EBL, the cost of HVPG monitoring, and the probability of medical therapy producing an adequate HVPG decline. Compared to EBL for the secondary prophylaxis of variceal rebleeding, combination medical therapy guided by HVPG monitoring is more effective and only marginally more expensive.

Transient lower esophageal sphincter relaxation and esophageal motor response.

PubMed

Schneider, Joachim H; Küper, Markus A; Königsrainer, Alfred; Brücher, Björn L D M

2010-04-01

Gastroesophageal reflux is caused by transient lower esophageal sphincter relaxations (TLESRs) in healthy individuals and in most patients with gastroesophageal reflux disease (GERD). Refluxate is normally propelled by pharyngeally induced swallowing events, but TLESRs may also be accompanied by retrograde esophageal motor responses (EMRs). These contractions have not previously been investigated and their effect on esophageal clearance is not known. The aim of this study was to assess the frequency of EMRs after TLESR in healthy individuals and GERD patients and to develop an animal model for further investigation of EMRs. The frequency of TLESRs and esophageal body contractions after TLESRs was assessed using ambulatory manometry in five healthy individuals and five GERD patients. An animal model was developed for reproducible provocation of TLESRs and subsequent EMRs. Patients with GERD have significantly more TLESRs than healthy individuals. However, post-TLESR EMRs were not more frequent in the GERD group. All post-TLESR EMRs presented as simultaneous contractions of the esophagus. The feline model allowed reproducible initiation of the esophageal motor response after TLESR, showing that EMRs can be induced by external mechanoreceptor stimulation simultaneously with LES relaxation. This experimental design imitates the conditions after fundoplication in humans. The study demonstrated that GERD patients have significantly more TLESRs in comparison with healthy individuals, but these were only incidental to EMRs. Further research is needed to improve our understanding of esophageal motility disorders. The animal model presented offers a feasible tool for investigating TLESR-induced esophageal motility.

Vocal fold varices and risk of hemorrhage.

PubMed

Tang, Christopher Guan-Zhong; Askin, Gülce; Christos, Paul J; Sulica, Lucian

2016-05-01

To establish risk of hemorrhage in patients with varices compared to those without, determine additional risk factors, and make evidence-based treatment recommendations. Retrospective cohort study. Patients who were vocal performers presenting for care during a 24-month period were analyzed to determine incidence of hemorrhage. Patients with varices were compared to those without. Demographic information and examination findings (presence, location, character, and size of varices; presence of mucosal lesions or paresis) were analyzed to determine predictors of hemorrhage. A total of 513 patients (60.4% female, mean age 36.6 years ± 13.95 years) were evaluated; 14 patients presenting with hemorrhage were excluded. One hundred and twelve (22.4%) patients had varices; 387 (77.6%) did not. The rate of hemorrhage in patients with varices was 2.68% at 12 months compared to 0.8% in patients without. Cox proportional hazard regression analysis revealed a hazard ratio of 10.1 for patients with varix developing hemorrhage compared to nonvarix patients (P < 0.0001). The incidence rate of hemorrhage was 3.3 cases per 1,000 person-months for varix patients compared to 0.5 cases per 1,000 person-months in the nonvarix group. There was no significant difference in the incidence of paresis, mucosal lesions, location of varix (left or right side; medial or lateral), or varix morphology (pinpoint, linear, lake) between patients who hemorrhaged and those that did not. The presence of varices increases the risk of hemorrhage. Varix patients had 10 times the rate of hemorrhage compared to nonvarix patients, although the overall incidence is low. This data may be used to inform treatment of patients with varices. 4. Laryngoscope, 126:1163-1168, 2016. © 2015 The American Laryngological, Rhinological and Otological Society, Inc.

Inadvertent intrathecal injection of labetalol in a patient undergoing post-partum tubal ligation.

PubMed

Balestrieri, P J; Hamza, M S; Ting, P H; Blank, R S; Grubb, C T

2005-10-01

After receiving a continuous spinal anesthetic for labor following an inadvertent dural puncture with a 17-gauge epidural needle, a morbidly obese parturient underwent post-partum tubal ligation 12 h after vaginal delivery. The patient received a total of 2 mL of 0.75% hyperbaric bupivacaine for the surgery. In response to moderate hypertension the patient received intravenous labetalol hydrochloride 20 mg. She subsequently was inadvertently administered approximately 15 mg of labetalol through the spinal catheter. The spinal catheter was removed immediately after the procedure. She suffered no apparent adverse neurologic effects.

Endoscopic therapeutic esophageal interventions.

PubMed

Schembre, D B; Kozarek, R A

2000-07-01

At the close of the 20th century, therapeutic endoscopy in the esophagus has expanded to encompass a broad array of interventions. As the number of procedures grows, emphasis in the medical literature has begun to shift to analyses of which procedures should be performed. Many studies published in 1999 on topics ranging from endoscopic treatment of benign and malignant strictures, to variceal bleeding, to Barrett esophagus have focused on which of several methods provides the best long-term response with the fewest interventions. This is a review of the major published studies of endoscopic interventions in the esophagus as well as selected abstracts. The conclusions of these studies and reports of new endoscopic therapies draw a clear map of where nonoperative esophageal therapeutics are headed in the next several years.

Fighting Hepatitis B in North Korea: Feasibility of a Bi-modal Prevention Strategy

PubMed Central

Stich, August

2015-01-01

In North Korea, the prevalence of hepatitis B is high due to natural factors, gaps in vaccination, and the lack of antiviral treatment. Aid projects are urgently needed, however impeded by North Korea's political and economical situation and isolation. The feasibility of a joint North Korean and German humanitarian hepatitis B prevention program was assessed. Part 1: Hepatitis B vaccination catch-up campaign. Part 2: Implementation of endoscopic ligation of esophageal varices (EVL) by trainings in Germany and North Korea. By vaccinating 7 million children between 2010 and 2012, the hepatitis B vaccination gap was closed. Coverage of 99.23% was reached. A total of 11 hepatitis B-induced liver cirrhosis patients (mean age 41.1 yr) with severe esophageal varices and previous bleedings were successfully treated by EVL without major complications. A clinical standard operating procedure, a feedback system and a follow-up plan were developed. The bi-modal preventive strategy was implemented successfully. Parts of the project can serve as an example for other low-income countries, however its general transferability is limited due to the special circumstances in North Korea. PMID:26539001

Use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative in transjugular intrahepatic portosystemic shunting: A retrospective study of 182 cirrhotic portal hypertension patients.

PubMed

Tang, Yingmei; Zheng, Sheng; Yang, Jinhui; Bao, Weimin; Yang, Lihong; Li, Yingchun; Xu, Ying; Yang, Jing; Tong, Yuyun; Gao, Jinhang; Tang, Chengwei

2017-12-01

Transjugular intrahepatic portosystemic shunting (TIPS) is an effective treatment modality for refractory variceal bleeding and ascites in patients with cirrhotic portal hypertension (CPH). Variceal rebleeding and shunt dysfunction are major post-TIPS morbidities. This study aimed to retrospectively evaluate the effectiveness and safety of use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative in patients with CPH undergoing TIPS. Between October 2006 and October 2011, 182 patients with CPH were retrospectively and consecutively hospitalized for elective TIPS with Fluency stenting. Concomitant variceal embolization was given after establishing the shunt. Subcutaneous heparin was given after TIPS and replaced by oral clopidogrel, aspirin, or warfarin for at least 6 months. Main outcome measures included shunt patency rate, recurrence of CPH (rebleeding and/or refractory ascites), hepatic encephalopathy (HE) frequency, and post-TIPS survival. The cumulative primary patency rate was 96%, 94%, 90%, 88%, and 88% at 6, 12, 24, 36, and 48 months, respectively. Shunt stenosis occurred in 16 (9%) patients, gastrointestinal (GI) rebleeding in 32 (17.5%) patients, recurrence of refractory ascites 44 (48%) patients, HE in 42 (23%) patients, and death in 36 (20%) patients during the follow-up period. Use of concomitant variceal embolization and prophylactic antiplatelet/anticoagulative was associated with a favorable shunt patency and a low risk of GI rebleeding.

Laparoscopic splenectomy and azygoportal disconnection for bleeding varices with hypersplenism.

PubMed

Wang, Yue D; Ye, Huan; Ye, Zai Y; Zhu, Yang W; Xie, Zhi J; Zhu, Jin H; Liu, Jin M; Zhao, Ting

2008-02-01

Bleeding from esophageal varices is an important cause of morbidity and mortality in patients with portal hypertension. The ideal surgical procedure should control bleeding with as little impairment of liver function as possible and with low rates of encephalopathy. Recently, significant progress in laparoscopic technology has enabled laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach in a less invasive way. In this paper, we present preliminary results for 25 patients in whom laparoscopic splenectomy and azygoportal disconnection were performed. Laparoscopic splenectomy and devascularization of the lower esophagus and upper stomach were performed in 25 patients with cirrhosis, bleeding portal hypertension, and secondary hypersplenism between January 2000 and October 2006. Among them, 5 patients underwent a laparoscopic modified Sugiura procedure, the lower esophagus was transected, and then reanastomosed with a circular stapler. Laparoscopic splenectomy and azygoportal disconnection were completed in all patients, except in 1 conversion, without significant morbidity. The operation time ranged from 4.0 to 5.5 hours and the blood loss was 100-400 mL. The postoperative hospital stay was 6-15 days. During a postoperative follow-up period of 3 months to 5 years in 22 patients, neither esophagus variceal bleeding nor encephalopathy has recurred. Laparoscopic splenectomy and azygoportal disconnection are feasible, effective, and safe surgical procedures, and have all the benefits of minimally invasive surgery for patients with bleeding portal hypertension and hypersplenism. Laparoscopic splenectomy and azygoportal disconnection offer a new operative method for treatment of bleeding portal hypertension with hypersplenism.

A MELD-based model to determine risk of mortality among patients with acute variceal bleeding.

PubMed

Reverter, Enric; Tandon, Puneeta; Augustin, Salvador; Turon, Fanny; Casu, Stefania; Bastiampillai, Ravin; Keough, Adam; Llop, Elba; González, Antonio; Seijo, Susana; Berzigotti, Annalisa; Ma, Mang; Genescà, Joan; Bosch, Jaume; García-Pagán, Joan Carles; Abraldes, Juan G

2014-02-01

Patients with cirrhosis with acute variceal bleeding (AVB) have high mortality rates (15%-20%). Previously described models are seldom used to determine prognoses of these patients, partially because they have not been validated externally and because they include subjective variables, such as bleeding during endoscopy and Child-Pugh score, which are evaluated inconsistently. We aimed to improve determination of risk for patients with AVB. We analyzed data collected from 178 patients with cirrhosis (Child-Pugh scores of A, B, and C: 15%, 57%, and 28%, respectively) and esophageal AVB who received standard therapy from 2007 through 2010. We tested the performance (discrimination and calibration) of previously described models, including the model for end-stage liver disease (MELD), and developed a new MELD calibration to predict the mortality of patients within 6 weeks of presentation with AVB. MELD-based predictions were validated in cohorts of patients from Canada (n = 240) and Spain (n = 221). Among study subjects, the 6-week mortality rate was 16%. MELD was the best model in terms of discrimination; it was recalibrated to predict the 6-week mortality rate with logistic regression (logit, -5.312 + 0.207 • MELD; bootstrapped R(2), 0.3295). MELD values of 19 or greater predicted 20% or greater mortality, whereas MELD scores less than 11 predicted less than 5% mortality. The model performed well for patients from Canada at all risk levels. In the Spanish validation set, in which all patients were treated with banding ligation, MELD predictions were accurate up to the 20% risk threshold. We developed a MELD-based model that accurately predicts mortality among patients with AVB, based on objective variables available at admission. This model could be useful to evaluate the efficacy of new therapies and stratify patients in randomized trials. Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

PubMed

Spaander, Manon C W; Baron, Todd H; Siersema, Peter D; Fuccio, Lorenzo; Schumacher, Brigitte; Escorsell, Àngels; Garcia-Pagán, Juan-Carlos; Dumonceau, Jean-Marc; Conio, Massimo; de Ceglie, Antonella; Skowronek, Janusz; Nordsmark, Marianne; Seufferlein, Thomas; Van Gossum, André; Hassan, Cesare; Repici, Alessandro; Bruno, Marco J

2016-10-01

recommendation, low quality evidence). 2 ESGE suggests consideration of temporary placement of SEMSs as therapy for refractory benign esophageal strictures (weak recommendation, moderate evidence). Stents should usually be removed at a maximum of 3 months (strong recommendation, weak quality evidence). 3 ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures, because of their lack of embedment and ease of removability (weak recommendation, low quality evidence). 4 For the removal of partially covered esophageal SEMSs that are embedded, ESGE recommends the stent-in-stent technique (strong recommendation, low quality evidence). 5 ESGE recommends that temporary stent placement can be considered for treating esophageal leaks, fistulas, and perforations. The optimal stenting duration remains unclear and should be individualized. (Strong recommendation, low quality evidence.) 6 ESGE recommends placement of a SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive esophageal variceal bleeding (strong recommendation, moderate quality evidence). © Georg Thieme Verlag KG Stuttgart · New York.

UK guidelines on the management of variceal haemorrhage in cirrhotic patients

PubMed Central

Tripathi, Dhiraj; Stanley, Adrian J; Hayes, Peter C; Patch, David; Millson, Charles; Mehrzad, Homoyon; Austin, Andrew; Ferguson, James W; Olliff, Simon P; Hudson, Mark; Christie, John M

2015-01-01

These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool. The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions. PMID:25887380

Clinical, radiologic, and endoscopic characteristics upon diagnosis of patients with prehepatic portal hypertension at the Instituto Nacional de Pediatría from 2001 to 2011.

PubMed

Zárate Mondragón, F; Romero Trujillo, J O; Cervantes Bustamante, R; Mora Tiscareño, M A; Montijo Barrios, E; Cadena León, J F; Cázares Méndez, M; Toro Monjaraz, E M; Ramírez Mayans, J

2014-01-01

Prehepatic portal hypertension in children can be asymptomatic for many years. Once diagnosed, the therapeutic measures (pharmacologic, endoscopic, and surgical) are conditioned by the specific characteristics of each patient. In Mexico, there are no recorded data on the incidence of the disease and patient characteristics. To determine the main clinical, radiologic, and endoscopic characteristics upon diagnosis of these patients at the Instituto Nacional de Pediatría within the time frame of January 2001 and December 2011. A cross-sectional, retrolective, descriptive, and observational study was conducted in which all the medical records of the patients with portal hypertension diagnosis were reviewed. There was a greater prevalence of prehepatic etiology (32/52) (61.5%) in the portal hypertension cases reviewed. Males (62.5%) predominated and 11 of the 32 patients were under 4 years of age. The primary reason for medical consultation was upper digestive tract bleeding with anemia (71.9%) and the main pathology was cavernomatous degeneration of the portal vein (65.6%). Splenoportography was carried out on 17 of the 32 patients. A total of 65.5% of the patients received the combination therapy of propranolol and a proton pump inhibitor. Initial endoscopy revealed esophageal varices in 96.9% of the patients, 12 of whom presented with gastroesophageal varices. Congestive gastropathy was found in 75% of the patients. The varices were ligated in 8 cases, sclerotherapy for esophageal varices was carried out in 5 cases (15.6%), and sclerotherapy for gastric varices was performed in 2 patients. Seventeen patients (53.1%) underwent portosystemic diversion: 10 of the procedures employed a mesocaval shunt and 7 a splenorenal shunt. Nine patients (28.1%) underwent total splenectomy. The primary cause of the disease was cavernomatous degeneration of the portal vein; it was predominant in males and the first symptom was variceal bleeding. Copyright © 2014 Asociación Mexicana

Precise Sequential DNA Ligation on A Solid Substrate: Solid-Based Rapid Sequential Ligation of Multiple DNA Molecules

PubMed Central

Takita, Eiji; Kohda, Katsunori; Tomatsu, Hajime; Hanano, Shigeru; Moriya, Kanami; Hosouchi, Tsutomu; Sakurai, Nozomu; Suzuki, Hideyuki; Shinmyo, Atsuhiko; Shibata, Daisuke

2013-01-01

Ligation, the joining of DNA fragments, is a fundamental procedure in molecular cloning and is indispensable to the production of genetically modified organisms that can be used for basic research, the applied biosciences, or both. Given that many genes cooperate in various pathways, incorporating multiple gene cassettes in tandem in a transgenic DNA construct for the purpose of genetic modification is often necessary when generating organisms that produce multiple foreign gene products. Here, we describe a novel method, designated PRESSO (precise sequential DNA ligation on a solid substrate), for the tandem ligation of multiple DNA fragments. We amplified donor DNA fragments with non-palindromic ends, and ligated the fragment to acceptor DNA fragments on solid beads. After the final donor DNA fragments, which included vector sequences, were joined to the construct that contained the array of fragments, the ligation product (the construct) was thereby released from the beads via digestion with a rare-cut meganuclease; the freed linear construct was circularized via an intra-molecular ligation. PRESSO allowed us to rapidly and efficiently join multiple genes in an optimized order and orientation. This method can overcome many technical challenges in functional genomics during the post-sequencing generation. PMID:23897972

[Varices of the vocal cord: report of 21 cases].

PubMed

Li, Jin-rang; Sun, Jian-jun

2006-04-01

To study the diagnosis and treatment of varices of the vocal cord. The clinical data of 21 cases with varix of vocal cord were analyzed. All the patients presented hoarseness. There were 15 female and 6 male cases with their ages ranged from 23 to 68 years (median 44 years old). The varix was found on the right vocal cord in 12 cases, on the left vocal cord in 9 cases. Isolated varix existed on the vocal cord in 10 cases, varix with vocal cord polyps or nodules in 10 cases, varix with vocal cord paralysis in 1 case. All the patients were diagnosed under the laryngovideoscopy. The lesions appeared on the superior surface of the vocal cord. Varices manifested as abnormally dilated capillary running in the anterior to posterior direction in 6 cases, as clusters of capillary in 3 cases, as a dot or small sheet or short line of capillary in 12 cases. The varices were disappeared in 2 of 8 cases with vocal cord varices and polyps after removed the polyps. The varices of others patients had no change after following up for more than 6 months, but one patient happened hemorrhage of the contralateral vocal cord. Varices are most commonly seen in female. Laryngovideoscopy is the key in determining the vocal fold varices. Management of patients with a varix includes medical therapy, speech therapy, and occasionally surgical vaporization.

Atropine use may lead to post-operative respiratory acidosis in neonates receiving ductal ligation: A retrospective cohort study.

PubMed

Chang, Szu-Ling; Lin, Wen-Li; Weng, Chien-Hsiang; Wu, Shye-Jao; Tsai, Hsin-Jung; Wang, Shwu-Meei; Peng, Chun-Chih; Chang, Jui-Hsing

2018-04-01

Patent ductus arteriosus (PDA) is one of the most common cardiac conditions in preterm infants. Closure of the PDA in symptomatic patients can be achieved medically or surgically. Atropine is commonly administered in general anesthesia as a premedication in this age group but with limited evidence addressing the effect of its use. Our study examined the association of the use of atropine as a premedication in PDA ligation and the risk of post-operative respiratory complications. This retrospective cohort study included 150 newborns who have failed medical treatment for PDA and received PDA ligation during 2008-2012 in a single tertiary medical center. Ninety-two of them (61.3%) received atropine as premedication for general anesthesia while 58 (38.7%) did not. Post-operative respiratory condition, the need of cardiopulmonary resuscitation and the presence of bradycardia were measured. Patients with atropine use were associated with increased odds of respiratory acidosis in both univariate analysis (22.9% vs 7.3%; OR = 3.785, 95% CI = 1.211-11.826, p = 0.022) and multivariate analysis (OR = 4.030, 95% CI = 1.230-13.202, p = 0.021), with an even higher odds of respiratory acidosis in patients receiving both atropine and ketamine. The use of atropine as premedication in general anesthesia for neonatal PDA ligation is associated with higher risk of respiratory acidosis, which worsens with the combined use of ketamine. Copyright © 2017. Published by Elsevier B.V.

Fifty-three years' experience with randomized clinical trials of emergency portacaval shunt for bleeding esophageal varices in Cirrhosis: 1958-2011.

PubMed

Orloff, Marshall J

2014-02-01

Emergency treatment of bleeding esophageal varices (BEV) consists mainly of endoscopic and pharmacologic measures, with transjugular intrahepatic portal-systemic shunt (TIPS) performed when bleeding is not controlled. Surgical shunt has been relegated to salvage. At the University of California, San Diego, Medical Center, our group has conducted 10 studies of emergency portacaval shunt (EPCS) during 46 years. To describe 2 randomized clinical trials (RCTs) conducted from 1988 to 2011 in unselected consecutive patients who received emergency treatment for BEV. In RCT No. 1, a total of 211 unselected consecutive patients with cirrhosis and acute BEV were randomized to emergency endoscopic sclerotherapy (EEST) (n=106) or EPCS (n=105). In RCT No. 2, a total of 154 unselected consecutive patients with cirrhosis and acute BEV were randomized to TIPS (n=78) or EPCS (n=76). Diagnostic workup was completed within 6 hours of initial contact, and primary treatment was initiated within 8 to 12 hours. Regular follow-up for up to 10 years was accomplished in 100% of the patients. In RCT No. 1, EEST or EPCS; in RCT No. 2, TIPS or EPCS. The 2 groups were compared with regard to survival, control of bleeding, portal-systemic encephalopathy, and direct cost of care. RESULTS Distribution in Child risk classes was almost identical. One-third of patients were in Child class C. Permanent control of bleeding was achieved by EEST in only 20% of the patients and by TIPS in only 22%. In contrast, EPCS permanently controlled bleeding in 97% and 100% of the patients in RCT No. 2 and RCT No. 1, respectively (P<.001). Survival was significantly greater following EPCS than after EEST and TIPS (P<.001). Median survival was more than 10 years following EPCS compared with 1.99 years after TIPS. Occlusion of TIPS was demonstrated in 84% of the patients, 63% of whom underwent TIPS revision, which failed in 80% of the cases. Recurrent portal-systemic encephalopathy developed in 35% of the patients who

Conservative management of post-partum hemorrhage secondary to placenta previa-accreta with hypogastric artery ligation and endo-uterine hemostatic suture.

PubMed

Rauf, Melekoglu; Ebru, Celik; Sevil, Eraslan; Selim, Buyukkurt

2017-02-01

The aim of this study was to investigate maternal and neonatal outcomes of conservative management of post-partum hemorrhage due to placenta previa-accreta using hypogastric artery ligation and endo-uterine hemostatic suture to lower uterine segment. The records of 38 patients who were managed conservatively with hypogastric artery ligation and endo-uterine hemostatic suture to control post-partum hemorrhage secondary to placenta previa-accreta between April 2014 and January 2016, were reviewed retrospectively. Placenta previa-accreta was diagnosed according to gray-scale, color and 3-D power Doppler ultrasonography in addition to the intraoperative findings based on fragmentary or difficult separation of the placenta. In the case of conservative treatment protocol failure, cesarean hysterectomy was performed. Of these patients, 55.2% were between 25 and 35 years old; 97.5% were multiparous; 71.2% had two or more previous cesarean section and 68.5% had preterm delivery. Women with placenta accreta had a median estimated blood loss of 450 mL; 57.8% of patients had blood transfusion (mean intraoperative transfusion, 2 units packed red blood cells; range, 0-9 units). Median duration of operation was 112.5 min (range, 45-305 min) and 32 patients (84.3%) with placenta accreta did not undergo cesarean hysterectomy. Conservative treatment of post-partum hemorrhage secondary to placenta previa-accreta with hypogastric artery ligation and endo-uterine hemostatic sutures to the lower segment of the uterus is associated with lower hysterectomy rate compared with the other conservative methods reported in the literature. © 2016 Japan Society of Obstetrics and Gynecology.

Left gastric vein-based noninvasive test for esophageal varices: a same-day comparison of portal hemodynamic assessment with endoscopic appearance.

PubMed

Maruyama, Hitoshi; Kobayashi, Kazufumi; Kiyono, Soichiro; Ogasawara, Sadahisa; Ooka, Yoshihiko; Suzuki, Eiichiro; Chiba, Tetsuhiro; Kato, Naoya

2018-05-25

To examine the effect of hemodynamic assessment of the left gastric vein (LGV) as a noninvasive test to diagnose esophageal varices (EV) in cirrhosis patients. This cross-sectional study consisted of 229 cirrhosis patients (62.7 ± 11.8 years; Child-Pugh score 5-14). One hundred fifty-four patients had EV (67.2%; small, 53; medium, 71; large, 30). All patients underwent a blood test and Doppler ultrasound followed by upper gastrointestinal endoscopy on the same day. The diagnostic ability for EV was compared between LGV-related findings and the platelet count/spleen diameter ratio (Plt/Spl). The detectability of the LGV was higher in patients with EV (129/144, 89.6%) than in those without (35/75, 46.7%; p < 0.0001), and was higher in those with large EV (30/30, 100%) than in those without (134/199, 67.3%; p = 0.0002). The positive detection of the LGV showed 100% sensitivity and negative predictive value (NPV) to identify large EV in the whole cohort and compensated group (n = 127). The best cutoff value in the LGV diameter was 5.35 mm to identify large EV, showing 0.753 area under the receiver operating characteristic curve (AUROC) with 90% sensitivity and 96.5% NPV. The Plt/Spl showed 62.1% sensitivity and 87.1% NPV, and the best cutoff value was 442.9 to identify large EV with 0.658 AUROC, which was comparable to LGV-based assessment (p = 0.162). This same-day comparison study demonstrated the value of LGV-based noninvasive test to identify large EV with high sensitivity and NPV in cirrhosis patients at a lower cost.

Nutrition in peri-operative esophageal cancer management.

PubMed

Steenhagen, Elles; van Vulpen, Jonna K; van Hillegersberg, Richard; May, Anne M; Siersema, Peter D

2017-07-01

Nutritional status and dietary intake are increasingly recognized as essential areas in esophageal cancer management. Nutritional management of esophageal cancer is a continuously evolving field and comprises an interesting area for scientific research. Areas covered: This review encompasses the current literature on nutrition in the pre-operative, peri-operative, and post-operative phases of esophageal cancer. Both established interventions and potential novel targets for nutritional management are discussed. Expert commentary: To ensure an optimal pre-operative status and to reduce peri-operative complications, it is key to assess nutritional status in all pre-operative esophageal cancer patients and to apply nutritional interventions accordingly. Since esophagectomy results in a permanent anatomical change, a special focus on nutritional strategies is needed in the post-operative phase, including early initiation of enteral feeding, nutritional interventions for post-operative complications, and attention to long-term nutritional intake and status. Nutritional aspects of pre-optimization and peri-operative management should be incorporated in novel Enhanced Recovery After Surgery programs for esophageal cancer.

The effects of sleeve gastectomy on gastro-esophageal reflux and gastro-esophageal motility.

PubMed

Hayat, Jamal O; Wan, Andrew

2014-05-01

Sleeve gastrectomy is an increasingly performed bariatric procedure associated with low morbidity and good short to medium term effects on weight loss and comorbid conditions. Studies assessing the prevalence of post-operative gastro-esophageal reflux disease (GERD), show sleeve gastrectomy may provoke de novo GERD symptoms or worsening of pre-existing GERD. Pathophysiological mechanisms of GERD after sleeve gastrectomy include a hypotensive lower esophageal sphincter, increased gastro-esophageal pressure gradient and intra-thoracic migration of the remnant stomach. A reduction in the compliance of the gastric remnant may provoke an increase in transient lower esophageal sphincter relaxations. Time-resolved MRI suggests relative gastric stasis in the proximal remnant and increased emptying from the antrum. A lack of standardisation of technique, along with heterogeneity of studies assessing GERD may explain the wide variability in reported results. Simultaneous and careful repair of an associated hiatus hernia may result in a reduction in the prevalence of post-operative GERD.

Management of acute variceal bleeding.

PubMed

Herrera, Jorge L

2014-05-01

Acute variceal bleeding (AVB) is the most common cause of upper gastrointestinal hemorrhage in patients with cirrhosis. Advances in the management of AVB have resulted in decreased mortality. To minimize mortality, a multidisciplinary approach addressing airway safety, prompt judicious volume resuscitation, vasoactive and antimicrobial pharmacotherapy, and early endoscopy to obliterate varices is necessary. Placement of a transjugular intrahepatic portosystemic shunt (TIPS) has been used as rescue therapy for patients failing initial attempts at hemostasis. Patients who have a high likelihood of failing initial attempts at hemostasis may benefit from a more aggressive approach using TIPS earlier in their management. Copyright © 2014 Elsevier Inc. All rights reserved.

Endoscopic Color Doppler Ultrasonographic Evaluation of GastricVarices Secondary to Left-Sided Portal Hypertension

PubMed Central

Sato, Takahiro; Yamazaki, Katsu; Kimura, Mutsuumi; Toyota, Jouji; Karino, Yoshiyasu

2014-01-01

Gastric varices that arise secondary to the splenic vein occlusion can result in gastrointestinal hemorrhaging. Endoscopic color Doppler ultrasonography (ECDUS) was performed in 16 patients with gastric varices secondary to splenic vein occlusion. This study retrospectively evaluated the role of ECDUS in the diagnosis of gastric varices secondary to splenic vein occlusion. Thirteen patients had co-existing pancreatic diseases: 8 with chronic pancreatitis, 4 with cancer of the pancreatic body or tail and 1 with severe acute pancreatitis. Of the remaining 3 patients, 1 had myeloproliferative disease, 1 had advanced gastric cancer, and the third had splenic vein occlusion due to an obscure cause. The endoscopic findings of gastric varices were: variceal form (F) classified as enlarged tortuous (F2) in 12 cases and large, coil-shaped (F3) in 4 cases, and positive for erosion or red color sign of the variceal surface in 4 cases and negative in 12 cases. ECDUS color flow images of gastric variceal flow clearly depicted a round fundal region at the center, with varices expanding to the curvatura ventriculi major of the gastric body in all 16 cases. The velocities of F3 type gastric varices were significantly higher than those of the F2 type. The wall thickness of varices positive for erosion or red color sign was significantly less than the negative cases. I conclude that ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion at the round fundal region at the center, with varices expanding to the curvatura ventriculi major of the gastric body. PMID:26852679

Intraductal ultrasonographic anatomy of biliary varices in patients with portal hypertension.

PubMed

Takagi, Tadayuki; Irisawa, Atsushi; Shibukawa, Goro; Hikichi, Takuto; Obara, Katsutoshi; Ohira, Hiromasa

2015-01-01

The term, portal biliopathy, denotes various biliary abnormalities, such as stenosis and/or dilatation of the bile duct, in patients with portal hypertension. These vascular abnormalities sometimes bring on an obstructive jaundice, but they are not clear which vessels participated in obstructive jaundice. The aim of present study was clear the bile ductal changes in patients with portal hypertension in hopes of establishing a therapeutic strategy for obstructive jaundice caused by biliary varices. Three hundred and thirty-seven patients who underwent intraductal ultrasound (IDUS) during endoscopic retrograde cholangiography for biliary abnormalities were enrolled. Portal biliopathy was analyzed using IDUS. Biliary varices were identified in 11 (2.7%) patients. IDUS revealed biliary varices as multiple, hypoechoic features surrounding the bile duct wall. These varices could be categorized into one of two groups according to their location in the sectional image of bile duct: epicholedochal and paracholedochal. Epicholedochal varices were identified in all patients, but paracholedochal varices were observed only in patients with extrahepatic portal obstruction. IDUS was useful to characterize the anatomy of portal biliopathy in detail.

Transjugular Intrahepatic Portosystemic Shunt Creation and Variceal Coil or Plug Embolization Ineffectively Attain Gastric Variceal Decompression or Occlusion: Results of a 26-Patient Retrospective Study.

PubMed

Lakhoo, Janesh; Bui, James T; Lokken, R Peter; Ray, Charles E; Gaba, Ron C

2016-07-01

To assess the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) creation with or without variceal coil and/or plug embolization in decompressing or occluding gastric varices (GVs). In this retrospective study, 78 patients with GV bleeding who underwent TIPS creation with or without embolotherapy with metallic coils and/or plugs from 1999 to 2014 were identified. Individuals who had a bare-metal TIPS and/or lacked post-TIPS imaging or endoscopic follow-up were excluded. The final cohort included 26 patients (16 men; median age, 54 y; median Model for End-stage Liver Disease score, 16). Variceal types, supplying vessels, and postprocedure GV patency on cross-sectional imaging or endoscopy were assessed. The primary study outcome measure was GV patency rate as a surrogate for efficacy of TIPS creation with or without embolization. GVs included gastroesophageal varix types 1 (n = 10) and 2 (n = 2), isolated GV types 1 (n = 4) and 2 (n = 2), and unspecified (n = 8). TIPS creation resulted in a median final portosystemic pressure gradient of 7 mm Hg. Multiple GV-supplying vessels (left/posterior/short gastric veins) were present in 65% of patients (n = 17). Embolization was performed in 69% (n = 18). Thirteen, four, and nine patients had imaging, endoscopic, or both imaging/endoscopic follow-up. GV patency rate was 65% (n = 17; 61%/75% with/without embolization) at a median of 128.5 days (range, 1-1,295 d) after TIPS creation. Incidence of recurrent bleeding was 27% (n = 7), and the 90-day mortality rate was 15% (n = 4). In this study, most GVs showed persistent patency despite TIPS decompression and variceal embolization, and the incidence of recurrent bleeding was high. The findings suggest suboptimal efficacy for GVs, and indicate a need for study of alternative or adjunctive approaches to GV treatment, such as chemical obliteration. Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.

 Schistosomal portal hypertension: Randomized trial comparing endoscopic therapy alone or preceded by esophagogastric devascularization and splenectomy.

PubMed

Costa Lacet, Celina Maria; Neto, João Batista; Ribeiro, Laercio Tenório; Oliveira, Francisco Silva; Wyszomirska, Rozangela Fernandes; Strauss, Edna

2016-01-01

 Background. Upper gastrointestinal bleeding is a major cause of morbidity and mortality in patients with portal hypertension secondary to schistosomiasis mansoni. To evaluate the efficacy of combined surgery and sclerotherapy versus endoscopic treatment alone in the prophylaxis of esophageal variceal rebleeding due to portal hypertension in schistosomiasis. During a two-years period consecutive patients with schistosomiasis and a recent bleeding history were evaluated for prospective randomization. Absolute exclusion criteria were alcoholism or other liver diseases, whereas platelet count < 50,000/mm3, INR > 1.5 or presence of gastric varices were relative exclusion criteria. By random allocation 25 (group A) have received endoscopic sclerotherapy for esophageal varices alone and 22 (group B) combined treatment: esophagogastric devascularization with splenectomy followed by sclerotherapy. Interim analysis at 24 months has shown significant statistical differences between the groups and the randomization was halted. Mean age was 38.9 ± 15.4 years and 58.46% were male. Mean follow-up was 38.6 ± 20.1 months. Endoscopic comparison of the size of esophageal varices before and after treatment did not show significant differences among the two groups. Treatment efficacy was assessed by the rate of recurrent esophageal variceal bleeding, that was more common in group A- 9/25 patients (36.0%) vs. 2/22 (9.0%) in group B (p = 0.029). Other complications were odynophagia, dysphagia and esophageal ulcer in group A and ascites and portal vein thrombosis in the surgical group. In portal hypertension due to schistosomiasis, combined surgical and endoscopic treatment was more effective for the prevention of recurrent esophageal variceal bleeding.

Ileal Varices Treated with Balloon-Occluded Retrograde Transvenous Obliteration.

PubMed

Sato, Takahiro; Yamazaki, Katsu; Toyota, Jouji; Karino, Yoshiyasu; Ohmura, Takumi; Akaike, Jun

2009-04-01

A 55-year-old man with hepatitis B virus antigen-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed blood retention in the entire colon, but no bleeding lesion was found. Computed tomography images showed that vessels in the ileum were connected to the right testicular vein, and we suspected ileal varices to be the most probable cause of bleeding. We immediately performed double balloon enteroscopy, but failed to find any site of bleeding owing to the difficulty of fiberscope insertion with sever adhesion. Using a balloon catheter during retrograde transvenous venography, we found ileal varices communicating with the right testicular vein (efferent vein) with the superior mesenteric vein branch as the afferent vein of these varices. We performed balloon occluded retrograde transvenous obliteration by way of the efferent vein of the varices and have detected no further bleeding in this patient one year after treatment.

One step minilaparotomy-assisted transmesenteric portal vein recanalization combined with transjugular intrahepatic portosystemic shunt placement: A novel surgical proposal in pediatrics

PubMed Central

Pelizzo, Gloria; Quaretti, Pietro; Moramarco, Lorenzo Paolo; Corti, Riccardo; Maestri, Marcello; Iacob, Giulio; Calcaterra, Valeria

2017-01-01

Transjugular intrahepatic portosystemic shunt (TIPS) placement is a standard procedure for the treatment of portal hypertension complications. When this conventional approach is not feasible, alternative procedures for systemic diversion of portal blood have been proposed. A one-step interventional approach, combining minilaparotomy-assisted transmesenteric (MAT) antegrade portal recanalization and TIPS, is described in an adolescent with recurrent esophageal varice bleeding and portal cavernoma (PC). A 16-year-old girl was admitted to our Unit because of repeated bleeding episodes over a short period of time due to esophageal varices in the context of a PC. A portal vein recanalization through an ileocolic vein isolation with the MAT approach followed by TIPS during the same session was performed. In the case of failed portal recanalization, this approach, would also be useful for varice endovascular embolization. Postoperative recovery was uneventful. Treatment consisting of propanolol, enoxaparin and a proton pump inhibitor was prescribed after the procedure. One month post-op, contrast enhanced computed tomography confirmed the patency of the portal and intrahepatic stent grafts. No residual peritoneal fluid was detected nor opacification of the large varices. Endoscopy showed good improvement of the varices. Doppler ultrasound confirmed the accelerated flow in the portal stent and hepatopetal flow inside the intrahepatic portal branches. Three months post-op, TIPS maintained its hourglass shape despite a slight expansion. Portal hypertension and life threatening conditions related to PC would benefit from one-step portal recanalization. MAT-TIPS is feasible and safe for the treatment of PC even in children. This minimally invasive procedure avoids or delays surgical treatment or re-transplantation when necessary in pediatric patients. PMID:28487619

Ultrathin disposable gastroscope for screening and surveillance of gastroesophageal varices in patients with liver cirrhosis: a prospective comparative study.

PubMed

Huynh, Dep K; Toscano, Leanne; Phan, Vinh-An; Ow, Tsai-Wing; Schoeman, Mark; Nguyen, Nam Q

2017-06-01

This study aims to evaluate the role of unsedated, ultrathin disposable gastroscopy (TDG) against conventional gastroscopy (CG) in the screening and surveillance of gastroesophageal varices (GEVs) in patients with liver cirrhosis. Forty-eight patients (56.4 ± 1.3 years; 38 male, 10 female) with liver cirrhosis referred for screening (n = 12) or surveillance (n = 36) of GEVs were prospectively enrolled. Unsedated gastroscopy was initially performed with TDG, followed by CG with conscious sedation. The 2 gastroscopies were performed by different endoscopists blinded to the results of the previous examination. Video recordings of both gastroscopies were validated by an independent investigator in a random, blinded fashion. Endpoints were accuracy and interobserver agreement of detecting GEVs, safety, and potential cost saving. CG identified GEVs in 26 (54%) patients, 10 of whom (21%) had high-risk esophageal varices (HREV). Compared with CG, TDG had an accuracy of 92% for the detection of all GEVs, which increased to 100% for high-risk GEVs. The interobserver agreement for detecting all GEVs on TDG was 88% (κ = 0.74). This increased to 94% (κ = 0.82) for high-risk GEVs. There were no serious adverse events. Unsedated TDG is safe and has high diagnostic accuracy and interobserver reliability for the detection of GEVs. The use of clinic-based TDG would allow immediate determination of a follow-up plan, making it attractive for variceal screening and surveillance programs. (Clinical trial (ANZCTR) registration number: ACTRN12616001103459.). Crown Copyright © 2017. Published by Elsevier Inc. All rights reserved.

Effects of cholestasis on learning and locomotor activity in bile duct ligated rats.

PubMed

Hosseini, Nasrin; Alaei, Hojjatallah; Nasehi, Mohammad; Radahmadi, Maryam; Mohammad Reza, Zarrindast

2014-01-01

Cognitive functions are impaired in patients with liver disease. Bile duct ligation causes cholestasis that impairs liver function. This study investigated the impact of cholestasis progression on the acquisition and retention times in the passive avoidance test and on the locomotor activity of rats. Cholestasis was induced in male Wistar rats by ligating the main bile duct. Locomotor activity, learning and memory were assessed by the passive avoidance learning test at day 7, day 14, and day 21 post-bile duct ligation. The serum levels of bilirubin, alanine aminotransferase, and alkaline phosphatase were measured. The results showed that acquisition time and locomotor activity were not affected at day 7 and day 14, but they were significantly (P < 0.05) impaired at day 21 post-bile duct ligation compared with the results for the control group. Additionally, memory was significantly impaired on day 7 (P < 0.01), day 14, and day 21 (P < 0.001) compared with the control groups. The levels of total bilirubin, direct bilirubin, indirect bilirubin, alanine aminotransferase, and alkaline phosphatase were significantly higher at day 7, day 14, and day 21 post-bile duct ligation compared with the levels in the sham group. Based on these findings, both liver and memory function were affected in the early stage of cholestasis (7 days after bile duct ligation), while learning and locomotor activity were impaired at 21 days after bile duct ligation following the progression of cholestasis.

Biodegradable esophageal stent placement does not prevent high-grade stricture formation after circumferential mucosal resection in a porcine model.

PubMed

Pauli, Eric M; Schomisch, Steve J; Furlan, Joseph P; Marks, Andrea S; Chak, Amitabh; Lash, Richard H; Ponsky, Jeffrey L; Marks, Jeffrey M

2012-12-01

Advanced esophageal dysplasia and early cancers have been treated traditionally with esophagectomy. Endoscopic esophageal mucosectomy (EEM) offers less-invasive therapy, but high-degree stricture formation limits its applicability. We hypothesized that placement of a biodegradable stent (BD-stent) immediately after circumferential EEM would prevent stricturing. Ten pigs (five unstented controls, five BD-stent) were utilized. Under anesthesia, a flexible endoscope with a band ligator and snare was used to incise the mucosa approximately 20 cm proximal to the lower esophageal sphincter. A 10-cm, circumferential, mucosal segment was dissected and excised by using snare electrocautery. In the stented group, an 18-×120-mm, self-expanding, woven polydioxanone stent (ELLA-CS, Hradec-Kralove) was deployed. Weekly esophagograms evaluated for percent reduction in esophageal diameter, stricture length, and proximal esophageal dilation. Animals were euthanized when the stricture exceeded 80% and were unable to gain weight (despite high-calorie liquid diet) or at 14 weeks. The control group rapidly developed esophageal strictures; no animal survived beyond the third week of evaluation. At 2 weeks post-EEM, the BD-stent group had a significant reduction in esophageal diameter (77.7 vs. 26.6%, p < 0.001) and degree of proximal dilation (175 vs. 131%, p = 0.04) compared with controls. Survival in the BD-stent group was significantly longer than in the control group (9.2 vs. 2.4 weeks, p = 0.01). However, all BD-stent animals ultimately developed clinically significant strictures (range, 4-14 weeks). Comparison between the maximum reduction in esophageal diameter and stricture length (immediately before euthanasia) demonstrated no differences between the groups. Circumferential EEM results in severe stricture formation and clinical deterioration within 3 weeks. BD-stent placement significantly delays the time of clinical deterioration from 2.4 to 9.2 weeks, but does not affect the

Randomized controlled trial comparing esophageal dilation to no dilation among adults with esophageal eosinophilia and dysphagia.

PubMed

Kavitt, R T; Ates, F; Slaughter, J C; Higginbotham, T; Shepherd, B D; Sumner, E L; Vaezi, M F

2016-11-01

The role of esophageal dilation in patients with esophageal eosinophilia with dysphagia remains unknown. The practice of dilation is currently based on center preferences and expert opinion. The aim of this study is to determine if, and to what extent, dysphagia improves in response to initial esophageal dilation followed by standard medical therapies. We conducted a randomized, blinded, controlled trial evaluating adult patients with dysphagia and newly diagnosed esophageal eosinophilia from 2008 to 2013. Patients were randomized to dilation or no dilation at time of endoscopy and blinded to dilation status. Endoscopic features were graded as major and minor. Subsequent to randomization and endoscopy, all patients received fluticasone and dexlansoprazole for 2 months. The primary study outcome was reduction in overall dysphagia score, assessed at 30 and 60 days post-intervention. Patients with severe strictures (less than 7-mm esophageal diameter) were excluded from the study. Thirty-one patients were randomized and completed the protocol: 17 randomized to dilation and 14 to no dilation. Both groups were similar with regard to gender, age, eosinophil density, endoscopic score, and baseline dysphagia score. The population exhibited moderate to severe dysphagia and moderate esophageal stricturing at baseline. Overall, there was a significant (P < 0.001) but similar reduction in mean dysphagia score at 30 and 60 days post-randomization compared with baseline in both groups. No significant difference in dysphagia scores between treatment groups after 30 (P = 0.93) or 60 (P = 0.21) days post-intervention was observed. Esophageal dilation did not result in additional improvement in dysphagia score compared with treatment with proton pump inhibitor and fluticasone alone. In patients with symptomatic esophageal eosinophilia without severe stricture, dilation does not appear to be a necessary initial treatment strategy. © 2015 International Society for

Ileal Varices Treated with Balloon-Occluded Retrograde Transvenous Obliteration

PubMed Central

Sato, Takahiro; Yamazaki, Katsu; Toyota, Jouji; Karino, Yoshiyasu; Ohmura, Takumi; Akaike, Jun

2009-01-01

A 55-year-old man with hepatitis B virus antigen-positive liver cirrhosis was admitted to our hospital with anal bleeding. Colonoscopy revealed blood retention in the entire colon, but no bleeding lesion was found. Computed tomography images showed that vessels in the ileum were connected to the right testicular vein, and we suspected ileal varices to be the most probable cause of bleeding. We immediately performed double balloon enteroscopy, but failed to find any site of bleeding owing to the difficulty of fiberscope insertion with sever adhesion. Using a balloon catheter during retrograde transvenous venography, we found ileal varices communicating with the right testicular vein (efferent vein) with the superior mesenteric vein branch as the afferent vein of these varices. We performed balloon occluded retrograde transvenous obliteration by way of the efferent vein of the varices and have detected no further bleeding in this patient one year after treatment. PMID:27956966

Self-Expanding Metal Stents for the Treatment of Post-Surgical Esophageal Leaks: A Tertiary Referral Center Experience.

PubMed

Anderloni, Andrea; Genco, Chiara; Massidda, Marco; Di Leo, Milena; Fumagalli, Uberto Romario; Rosati, Riccardo; Correale, Loredana; Maselli, Roberta; Ferrara, Elisa Chiara; Jovani, Manol; Repici, Alessandro

2018-06-05

The study aimed to evaluate the effectiveness and safety of self-expanding metal stents (SEMS) in the management of post-surgical esophageal leaks. Retrospective data of consecutive patients with a post-surgical esophageal leak treated by means of a metal stent between January 2008 and December 2014 at the Humanitas Research Hospital (Milan, Italy) were extracted from a prospectively maintained register of SEMS used for benign indications, such as post-surgical benign esophageal strictures and/or leaks. The primary outcome of the study was to assess the rate of successful leak closure and to identify the variables associated with its achievement. As a secondary outcome, we evaluated the overall safety of SEMS placement and the efficacy and safety for different types of SEMS in this specific setting of patients. Leak resolution was documented with endoscopic and/or imaging studies. In the case of leak persistence, further attempts of esophageal stenting were carried out at the discretion of both endoscopists and surgeons. A total of 49 patients were included in the study (men 41 of 49, 83.7%, mean age 62.4 ± 11.9). One patient was excluded from analysis, because of death 1 day after stent insertion due to worsening of pre-existing mediastinitis. A total number of 82 stents were placed (mean number of stents per patient: 1.7) in 49 patients: 35 patients (71.4%) received a partially covered SEMS (PCSEMS) as the first stent positioned, while the remaining 14 (28.6%) received a fully covered SEMS (FCSEMS); but 1 patient (2%) died following stent insertion; therefore, data regarding therapeutic success were available for 48 patients. Stents were left in place for a mean period of 21.9 ± 15.2 days. Leak closure after the first stent placement was achieved in 22 of 48 (45.8%) patients. Of the 26 patients with failure of index stent placement, 18 patients underwent further stenting attempts (69.2%), and secondary closure of leak was achieved in 7 (38.9%) of these 18

Tubal ligation

MedlinePlus

... tying; Tying the tubes; Hysteroscopic tubal occlusion procedure; Contraception - tubal ligation; Family planning - tubal ligation ... Tubal ligation is considered a permanent form of birth control. It is NOT recommended as a short-term ...

Prior to the Oral Therapy, What Do We Know About HCV-4 in Egypt: A Randomized Survey of Prevalence and Risks Using Data Mining Computed Analysis

PubMed Central

Abd Elrazek, Abd Elrazek; Bilasy, Shymaa E.; Elbanna, Abduh E. M.; Elsherif, Abd Elhalim A.

2014-01-01

Abstract Hepatitis C virus (HCV) affects over 180 million people worldwide and it's the leading cause of chronic liver diseases and hepatocellular carcinoma. HCV is classified into seven major genotypes and a series of subtypes. In general, HCV genotype 4 (HCV-4) is common in the Middle East and Africa, where it is responsible for more than 80% of HCV infections. Although HCV-4 is the cause of approximately 20% of the 180 million cases of chronic hepatitis C worldwide, it has not been a major subject of research yet. The aim of the current study is to survey the morbidities and disease complications among Egyptian population infected with HCV-4 using data mining advanced computing methods mainly and other complementary statistical analysis. Six thousand six hundred sixty subjects, aged between 17 and 58 years old, from different Egyptian Governorates were screened for HCV infection by ELISA and qualitative PCR. HCV-positive patients were further investigated for the incidence of liver cirrhosis and esophageal varices. Obtained data were analyzed by data mining approach. Among 6660 subjects enrolled in this survey, 1018 patients (15.28%) were HCV-positive. Proportion of infected-males was significantly higher than females; 61.6% versus 38.4% (P = 0.0052). Around two-third of infected-patients (635/1018; 62.4%) were presented with liver cirrhosis. Additionally, approximately half of the cirrhotic patients (301/635; 47.4%) showed degrees of large esophageal varices (LEVs), with higher variceal grade observed in males. Age for esophageal variceal development was 47 ± 1. Data mining analysis yielded esophageal wall thickness (>6.5 mm), determined by conventional U/S, as the only independent predictor for esophageal varices. This study emphasizes the high prevalence of HCV infection among Egyptian population, in particular among males. Egyptians with HCV-4 infection are at a higher risk to develop cirrhotic liver and esophageal varices. Data mining, a new

Direct Percutaneous Embolization of Bleeding Stomal Varices

DOE Office of Scientific and Technical Information (OSTI.GOV)

Naidu, Sailen G., E-mail: naidu.sailen@mayo.ed; Castle, Erik P.; Kriegshauser, J. Scott

2010-02-15

Stomal variceal bleeding can develop in patients with underlying cirrhosis and portal hypertension. Most patients are best treated with transjugular intrahepatic portosystemic shunt (TIPS) creation because this addresses the underlying problem of portal hypertension. However, some patients are not good candidates for TIPS creation because they have end-stage liver disease or encephalopathy. We describe such a patient who presented with recurrent bleeding stomal varices, which was successfully treated with percutaneous coil embolization. The patient had bleeding-free survival for 1 month before death from unrelated causes.

A comparative analysis of whole genome sequencing of esophageal adenocarcinoma pre- and post-chemotherapy

PubMed Central

Noorani, Ayesha; Lynch, Andy G.; Achilleos, Achilleas; Eldridge, Matthew; Bower, Lawrence; Weaver, Jamie M.J.; Crawte, Jason; Ong, Chin-Ann; Shannon, Nicholas; MacRae, Shona; Grehan, Nicola; Nutzinger, Barbara; O'Donovan, Maria; Hardwick, Richard; Tavaré, Simon; Fitzgerald, Rebecca C.

2017-01-01

The scientific community has avoided using tissue samples from patients that have been exposed to systemic chemotherapy to infer the genomic landscape of a given cancer. Esophageal adenocarcinoma is a heterogeneous, chemoresistant tumor for which the availability and size of pretreatment endoscopic samples are limiting. This study compares whole-genome sequencing data obtained from chemo-naive and chemo-treated samples. The quality of whole-genomic sequencing data is comparable across all samples regardless of chemotherapy status. Inclusion of samples collected post-chemotherapy increased the proportion of late-stage tumors. When comparing matched pre- and post-chemotherapy samples from 10 cases, the mutational signatures, copy number, and SNV mutational profiles reflect the expected heterogeneity in this disease. Analysis of SNVs in relation to allele-specific copy-number changes pinpoints the common ancestor to a point prior to chemotherapy. For cases in which pre- and post-chemotherapy samples do show substantial differences, the timing of the divergence is near-synchronous with endoreduplication. Comparison across a large prospective cohort (62 treatment-naive, 58 chemotherapy-treated samples) reveals no significant differences in the overall mutation rate, mutation signatures, specific recurrent point mutations, or copy-number events in respect to chemotherapy status. In conclusion, whole-genome sequencing of samples obtained following neoadjuvant chemotherapy is representative of the genomic landscape of esophageal adenocarcinoma. Excluding these samples reduces the material available for cataloging and introduces a bias toward the earlier stages of cancer. PMID:28465312

Septic Complication After Balloon-Occluded Retrograde Transvenous Obliteration of Duodenal Variceal Bleeding

DOE Office of Scientific and Technical Information (OSTI.GOV)

Akasaka, Thai; Shibata, Toshiya, E-mail: ksj@kuhp.kyoto-u.ac.jp; Isoda, Hiroyoshi

2010-12-15

We report a 64-year-old woman with duodenal varices who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) complicated by intraprocedural variceal rupture. The patient developed shivering and a fever higher than 40{sup o}C 3 days after the B-RTO procedure. A blood culture grew Entereobacter cloacoe. This case represents a rare septic complication of B-RTO for duodenal varices.

Prediction of esophageal variceal bleeding in B-viral liver cirrhosis using the P2/MS noninvasive index based on complete blood counts.

PubMed

Kim, Beom Kyung; Ahn, Sang Hoon; Han, Kwang-Hyub; Park, Jun Yong; Han, Min Seok; Jo, Jung Hyun; Kim, Ja Kyung; Lee, Kwan Sik; Chon, Chae Yoon; Kim, Do Young

2012-01-01

Periodic endoscopy for esophageal varices (EVs) and prophylactic treatment of high-risk EVs, i.e., medium/large EVs, small EVs with the red-color sign or decompensation, are recommended in cirrhotic patients. We assessed the cumulative risks for future EV bleeding using the following simple P2/MS index: (platelet count)2/[monocyte fraction (%) × segmented neutrophil fraction (%)]. We enrolled 475 consecutive B-viral cirrhosis patients for 4 years, none of whom experienced EV bleeding. All underwent laboratory work-ups, endoscopy and ultrasonography. Those with EV bleeding took a nonselective β-blocker as prophylaxis. The major endpoint was the first occurrence of EV bleeding, analyzed using the Kaplan-Meier and Cox regression methods. Among patients with EV bleeding (n = 131), 25 experienced their first EV bleeding during follow-up. To differentiate the risk for EV bleeding, we divided them into two subgroups according to their P2/MS value (subgroup 1: P2/MS ≥9 and subgroup 2: P2/MS <9). The risk was significantly higher in subgroup 2 (p = 0.029). From multivariate analysis, a lower P2/MS (p = 0.040) remained a significant predictor for EV bleeding along with large varix size (p = 0.015), red-color sign (p = 0.041) and Child-Pugh classification B/C (p = 0.001). In subgroup 1, the risk for EV bleeding was similar to that of patients with low-risk EVs (p = 0.164). The P2/MS is a reliable predictor for the risk of EV bleeding among patients with EV bleeding. According to risk stratification, different prophylactic treatments should be considered for the subgroup with a P2/MS <9. Copyright © 2012 S. Karger AG, Basel.

Diagnostic Accuracy of APRI, AAR, FIB-4, FI, King, Lok, Forns, and FibroIndex Scores in Predicting the Presence of Esophageal Varices in Liver Cirrhosis: A Systematic Review and Meta-Analysis.

PubMed

Deng, Han; Qi, Xingshun; Guo, Xiaozhong

2015-10-01

Aspartate aminotransferase-to-platelet ratio (APRI), aspartate aminotransferase-to-alanine aminotransferase ratio (AAR), FIB-4, FI, King, Lok, Forns, and FibroIndex scores may be simple and convenient noninvasive diagnostic tests, because they are based on the regular laboratory tests and demographic data. This study aimed to systematically evaluate their diagnostic accuracy for the prediction of varices in liver cirrhosis.All relevant papers were searched via PubMed, EMBASE, CNKI, and Wanfang databases. The area under the summary receiver operating characteristic curve (AUSROC), sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), and diagnostic odds ratio (DOR) were calculated.Overall, 12, 4, 5, 0, 0, 4, 3, and 1 paper was identified to explore the diagnostic accuracy of APRI, AAR, FIB-4, FI, King, Lok, Forns, and FibroIndex scores, respectively. The AUSROCs of APRI, AAR, FIB-4, Lok, and Forns scores for the prediction of varices were 0.6774, 0.7275, 0.7755, 0.7885, and 0.7517, respectively; and those for the prediction of large varices were 0.7278, 0.7448, 0.7095, 0.7264, and 0.6530, respectively. The diagnostic threshold effects of FIB-4 and Forns scores for the prediction of varices were statistically significant. The sensitivities/specificities/PLRs/NLRs/DORs of APRI, AAR, and Lok scores for the prediction of varices were 0.60/0.67/1.77/0.58/3.13, 0.64/0.63/1.97/0.54/4.18, and 0.74/0.68/2.34/0.40/5.76, respectively. The sensitivities/specificities/PLRs/NLRs/DORs of APRI, AAR, FIB-4, Lok, and Forns scores for the prediction of large varices were 0.65/0.66/2.15/0.47/4.97, 0.68/0.58/2.07/0.54/3.93, 0.62/0.64/2.02/0.56/3.57, 0.78/0.63/2.09/0.37/5.55, and 0.65/0.61/1.62/0.59/2.75, respectively.APRI, AAR, FIB-4, Lok, and Forns scores had low to moderate diagnostic accuracy in predicting the presence of varices in liver cirrhosis.

Histomorphologic changes of esophageal mucosa in experimental third degree stricture.

PubMed

Shaprynskyi, Volodymyr O; Shaprinskiy, Yevgeniy V; Karyi, Yaroslav V; Lysenko, Serhii A

Nowadays the level of early and late complications after the operations for esophageal corrosive strictures such as esophago-organ anastomotic leak, development of infections, pneumonia, pleural empyema, mediastinitis, peritonitis, postoperative corrosive stricture development etc. remains rather high. Besides, postoperative mortality rate is high as well - 3.5-30 %. For that reason, an experimental model of esophageal stricture was suggested and ultrastructural mucosal changes in the stricture itself were studied to elaborate the unified pathogenic approach in treatment of esophageal stricture and improvement of its results. The aim of our work was to study the dynamics of ultrastructural changes both in normal esophageal walls and in third degree esophageal stricture Materials and Methods: The experiment was carried out on white male rats weighting 250-300 grams, to whom the third degree esophageal stricture model was created. After layer-by-layer incision of anterior abdominal wall abdominal portion of the esophagus was completely ligated (10 rats). In the control group (6 rats) anterior abdominal wall was opened with its subsequent layered closure. The animals were withdrawn from the experiment on the third day by ketamine overdose, and the samples were taken for ultrastructural study. Electron microscopic study of submicroscopic organization of basal, prickle, superficial epithelial cells in stratified non-squamous epithelium, smooth myocytes of muscle plate and contractile elements in esophageal muscular layer was carried out. Nuclear membrane, membranes of mitochondria, endoplasmic reticulum and cytoplasmic Golgi complex were found to be subjected to focal lysis. The third degree esophageal stricture caused destructive lesions in ultrastructural architectonics of stratified non-squamous epithelium cells, smooth myocytes of muscle plate and contractile elements in esophageal muscular layer of rats. Thus, catabolic processes leading to organelle disintegration

Interobserver Agreement on Endoscopic Classification of Oesophageal Varices in Children.

PubMed

D'Antiga, Lorenzo; Betalli, Pietro; De Angelis, Paola; Davenport, Mark; Di Giorgio, Angelo; McKiernan, Patrick J; McLin, Valerie; Ravelli, Paolo; Durmaz, Ozlem; Talbotec, Cecile; Sturm, Ekkehard; Woynarowski, Marek; Burroughs, Andrew K

2015-08-01

Data regarding agreement on endoscopic features of oesophageal varices in children with portal hypertension (PH) are scant. The aim of this study was to evaluate endoscopic visualisation and classification of oesophageal varices in children by several European clinicians, to build a rational basis for future multicentre trials. Endoscopic pictures of the distal oesophagus of 100 children with a clinical diagnosis of PH were distributed to 10 endoscopists. Observers were requested to classify variceal size according to a 3-degree scale (small, medium, and large, class A), a 2-degree scale (small and large, class B), and to recognise red wales (presence or absence, class Red). Overall agreement was considered fair if Fleiss and Cohen κ test was ≥0.30, good if ≥0.40, excellent if ≥0.60, and perfect if ≥0.80. Agreement between observers was fair with class A (κ = 0.34) and class B (κ = 0.38), and good with class Red (κ = 0.49). The agreement was good on presence versus absence of varices (class A = 0.53, class B = 0.48). The agreement among the observers was good in class A when endoscopic features of severe PH (medium and large sizes, red marks) were grouped and compared with mild features (absent and small varices) (κ = 0.58). Experts working in different centres show a fairly good agreement on endoscopic features of PH in children, although a better training of paediatric endoscopists may improve the agreement in grading severity of varices in this setting.

Hand-assisted laparoscopic Hassab's procedure for esophagogastric varices with portal hypertension.

PubMed

Kobayashi, Takashi; Miura, Kohei; Ishikawa, Hirosuke; Soma, Daiki; Zhang, Zhengkun; Ando, Takuya; Yuza, Kizuki; Hirose, Yuki; Katada, Tomohiro; Takizawa, Kazuyasu; Nagahashi, Masayuki; Sakata, Jun; Kameyama, Hitoshi; Wakai, Toshifumi

2017-10-23

Laparoscopic surgery for patients with portal hypertension is considered to be contraindicated because of the high risk of massive intraoperative hemorrhaging. However, recent reports have shown hand-assisted laparoscopic surgery for devascularization and splenectomy to be a safe and effective method of treating esophagogastric varices with portal hypertension. The aim of this study is to evaluate the efficacy of hand-assisted laparoscopic devascularization and splenectomy (HALS Hassab's procedure) for the treatment of esophagogastric varices with portal hypertension. From 2009 to 2016, seven patients with esophagogastric varices with portal hypertension were treated with hand-assisted laparoscopic devascularization and splenectomy in our institute. Four men and three women with a median age of 61 years (range 35-71) were enrolled in this series. We retrospectively reviewed the medical records for the perioperative variables, postoperative mortality and morbidity, and postoperative outcomes of esophagogastric varices. The median operative time was 455 (range 310-671) min. The median intraoperative blood loss was 695 (range 15-2395) ml. The median weight of removed spleen was 507 (range 242-1835) g. The conversion rate to open surgery was 0%. The median postoperative hospital stay was 21 (range 13-81) days. During a median 21 (range 3-43) months of follow-up, the mortality rate was 0%. Four postoperative complications (massive ascites, enteritis, intra-abdominal abscess, and intestinal ulcer) were observed in two patients. Those complications were treated successfully without re-operation. Esophagogastric varices in all patients disappeared or improved. Bleeding from esophagogastric varices was not observed during the follow-up period. Although our data are preliminary, hand-assisted laparoscopic devascularization and splenectomy proved an effective procedure for treating esophagogastric varices in patients with portal hypertension.

Scintigraphic scoring system for grading severity of gastro-esophageal reflux on 99mTc sulfur colloid gastro-esophageal reflux scintigraphy: A prospective study of 39 cases with pre and post treatment assessment.

PubMed

Puranik, Ameya D; Nair, Gopinathan; Aggarwal, Rajiv; Bandyopadhyay, Abhijit; Shinto, Ajit; Zade, Anand

2013-04-01

The study aimed at developing a scoring system for scintigraphic grading of gastro-esophageal reflux (GER), on gastro-esophageal reflux scintigraphy (GERS) and comparison of clinical and scintigraphic scores, pre- and post-treatment. A total of 39 cases with clinically symptomatic GER underwent 99mTc sulfur colloid GERS; scores were assigned based on the clinical and scintigraphic parameters. Post domperidone GERS was performed after completion of treatment. Follow up GERS was performed and clinical and scintigraphic parameters were compared with baseline parameters. Paired t-test on pre and post domperidone treatment clinical scores showed that the decline in post-treatment scores was highly significant, with P value < 0.001. The scintigraphic scoring system had a sensitivity of 93.9% in assessing treatment response to domperidone, specificity of 83.3% i.e., 83.3% of children with no decline in scintigraphic scores show no clinical response to Domperidone. The scintigraphic scoring system had a positive predictive value of 96.9% and a negative predictive value of 71.4%. GERS with its quantitative parameters is a good investigation for assessing the severity of reflux and also for following children post-treatment.

Distal Esophageal Duplication Cyst with Gastro-Esophageal Reflux Disease: A Rare Association and a Management Challenge.

PubMed

Jan, Iftikhar Ahmad; Al Nuaimi, Asma; Al Hamoudi, Basma; Al Naqbi, Khalid; Bilal, Mohammad

2016-02-01

Esophageal duplication cysts are rare congenital abnormalities of the foregut and may be associated with other conditions. Association of esophageal duplication with Gastro-Esophageal Reflux Disease (GERD) has not been reported in children. We are reporting a case of a 16 months baby who had antenatal diagnosis of diaphragmatic hernia. Postnatal CTchest, however, suggested a distal esophageal duplication cyst and a contrast esophagogram showed grade-IV GER. A thoracoscopy in another hospital excluded esophageal duplication at that time. Later, he presented with hematemesis in our department and was re-evaluated. Repeat CTconfirmed a persistent 2.5 x 1.3 cm cyst in distal esophagus. Upper GI endoscopy suggested grade-II esophagitis with a wide patent gastro-esophageal junction. The child was treated with left thoracotomy, excision of the duplication cyst and thoracic fundoplication. He had an uneventful post-operative recovery and is doing well at 6 months follow-up.

Analysis of risk factors for post-operative complications and prognostic predictors of disease recurrence following definitive treatment of patients with esophageal cancer from two medical centers in Northwest China

PubMed Central

Wang, Jichang; Zhang, Boxiang; Meng, Jinying; Xiao, Guodong; Li, Xiang; Li, Gang; Qin, Sida; Du, Ning; Zhang, Jia; Zhang, Jing; Xu, Chongwen; Tang, Shou-Ching; Liang, Rui; Ren, Hong; Sun, Xin

2017-01-01

Evaluating the clinicopathological features of patients receiving definitive treatment for esophageal cancer may facilitate the identification of patterns and factors associated with post-operative complications, and enable the development of a surveillance strategy for surviving patients at a higher risk of disease recurrence. In the present study, clinical data from 579 patients with esophageal cancer that underwent radical resection of esophagus were collected. These patients were admitted to two medical centers in Northwest China, and information regarding the presence or absence of basic chronic diseases and post-operative results were retrospectively analyzed. The level of selected stem cell markers, including aldehyde dehydrogenase 1, CD133, integrin subunit α 6, integrin subunit β 4 and T-cell factor-4, were determined in esophageal cancer tissue samples in order to determine whether these markers may be useful predictors of disease prognosis and recurrence. Post-operative complications in patients receiving radical resection of the esophagus included respiratory system complications, cardiovascular abnormalities and esophageal anastomotic fistulae. Diabetes, basic respiratory disease and lower pre-surgical serum albumin levels were observed to be individual risk factors associated with post-operative complications, including respiratory system complications of acute respiratory failure and pulmonary infection, cardiovascular abnormalities of atrial fibrillation and arrhythmia, as well as the development of esophageal anastomotic fistulae. Diagnosis of esophageal cancer at later stage was significantly correlated with anastomotic fistula. Molecular detection of stem cell markers for prognosis prediction was achieved by immunohistochemical and immunofluorescence staining assays. The results demonstrated that the presence of stem-like cells in cancer tissues was associated with poor disease prognosis and a high recurrence ratio. In conclusion, the results

Protective Effects of Chlorogenic Acid against Experimental Reflux Esophagitis in Rats

PubMed Central

Kang, Jung-Woo; Lee, Sun-Mee

2014-01-01

Esophageal reflux of gastric contents causes esophageal mucosal damage and inflammation. Recent studies show that oxygen-derived free radicals mediate mucosal damage in reflux esophagitis (RE). Chlorogenic acid (CGA), an ester of caffeic acid and quinic acid, is one of the most abundant polyphenols in the human diet and possesses anti-inflammatory, antibacterial and anti-oxidant activities. In this context, we investigated the effects of CGA against experimental RE in rats. RE was produced by ligating the transitional region between the forestomach and the glandular portion and covering the duodenum near the pylorus ring with a small piece of catheter. CGA (10, 30 and 100 mg/kg) and omeprazole (positive control, 10 mg/kg) were administered orally 48 h after the RE operation for 12 days. CGA reduced the severity of esophageal lesions, and this beneficial effect was confirmed by histopathological observations. CGA reduced esophageal lipid peroxidation and increased the reduced glutathione/oxidized glutathione ratio. CGA attenuated increases in the serum level of tumor necrosis factor-α, and expressions of inducible nitric oxide synthase and cyclooxygenase-2 protein. CGA alleviates RE-induced mucosal injury, and this protection is associated with reduced oxidative stress and the anti-inflammatory properties of CGA. PMID:25414772

Modified devascularization surgery for isolated gastric varices assessed by endoscopic ultrasonography.

PubMed

Hsieh, J-S; Wang, W-M; Perng, D-S; Huang, C-J; Wang, J-Y; Huang, T-J

2004-04-01

This study aimed to assess the role of endoscopic ultrasonography (EUS) in the surgical management of isolated gastric varices (IGV), and to report the authors' experience in the treatment of IGV with modified devascularization surgery. In this study, 26 cirrhotic patients with IGV were treated with devascularization surgery for variceal hemorrhage. Preoperatively, percutaneous transhepatic portography (PTP) and EUS were used to determine the mode of therapy for IGV. Fundectomy was performed for 14 patients with fundic IGV, whereas 12 patients with cardiac IGV underwent proximal gastrectomy. A significantly higher proportion of patients with cardiac varices showed grade 3 IGV on preoperative EUS than those who had fundic varices (p < 0.05). No major complications were observed during or after the operation, and only one patient died of prolonged shock and massive transfusion. Postoperatively, gastric varices had been eradicated completely in 25 of 26 patients, as determined by EUS study. During a mean follow-up period of 50 months, two patients had recurrent varices without bleeding, as demonstrated by EUS. The overall 5-year survival rate for the fundic IGV group was 67.9%, whereas that for the cardiac IGV group was 64.3% (p > 0.05). This study showed that devascularization surgery is highly effective for the prevention of recurrent bleeding from IGV and provides an alternative treatment method. Preoperatively, EUS is very helpful in detailed devascularization of patients with specific IGV, and may be used also for postoperative follow-up evaluation.

[Esophageal perforation and mediastinitis caused by fishbone ingestion: report of 3 cases].

PubMed

Vásquez, Julio C; Montesinos, Efraín; Castillo, Luis; Rojas, Luis; Peralta, Julio

2006-01-01

We present 3 consecutive cases of fishbone perforation of the esophagus that resulted in acute mediastinitis. All patients were successfully managed with drainage and debridement of the mediastinum and pleural cavity. However, temporary exclusion with external ligation of the esophagus was also performed in one patient, with spontaneous recanalization two weeks later. We discuss the possible role of this surgical maneuver in the management of esophageal perforation.

INVASIVE AND NON-INVASIVE TECHNIQUES FOR DETECTING PORTAL HYPERTENSION AND PREDICTING VARICEAL BLEEDING IN CIRRHOSIS: A REVIEW

PubMed Central

Zardi, Enrico Maria; Di Matteo, Francesco Maria; Pacella, Claudio Maurizio; Sanyal, Arun J

2016-01-01

Portal hypertension is a severe syndrome that may derive from pre-sinusoidal, sinusoidal and post-sinusoidal causes. As a consequence, several complications (i.e., ascites, oesophageal varices) may develop. In sinusoidal portal hypertension, hepatic venous pressure gradient (HVPG) is a reliable method for defining the grade of portal pressure, establishing the effectiveness of the treatment and predicting the occurrence of complications; however, some questions exist regarding its ability to discriminate bleeding from nonbleeding varices in cirrhotic patients. Other imaging techniques (transient elastography, endoscopy, endosonography and duplex Doppler sonography) for assessing causes and complications of portal hypertensive syndrome are available and may be valuable for the management of these patients. In this review, we evaluate invasive and non-invasive techniques currently employed to obtain a clinical prediction of deadly complications, such as variceal bleeding in patients affected by sinusoidal portal hypertension, in order to create a diagnostic algorithm to manage them. Again, HVPG appears to be the reference standard to evaluate portal hypertension and monitor the response to treatment, but its ability to predict several complications and support management decisions might be further improved through the diagnostic combination with other imaging techniques. PMID:24328372

Invasive and non-invasive techniques for detecting portal hypertension and predicting variceal bleeding in cirrhosis: a review.

PubMed

Zardi, Enrico Maria; Di Matteo, Francesco Maria; Pacella, Claudio Maurizio; Sanyal, Arun J

2014-02-01

Portal hypertension is a severe syndrome that may derive from pre-sinusoidal, sinusoidal, and post-sinusoidal causes. As a consequence, several complications (i.e. ascites, oesophageal varices) may develop. In sinusoidal portal hypertension, hepatic venous pressure gradient (HVPG) is a reliable method for defining the grade of portal pressure, establishing the effectiveness of the treatment, and predicting the occurrence of complications; however, some questions exist regarding its ability to discriminate bleeding from non-bleeding varices in cirrhotic patients. Other imaging techniques (transient elastography, endoscopy, endosonography, and duplex Doppler sonography) for assessing causes and complications of portal hypertensive syndrome are available and may be valuable for the management of these patients. In this review, we evaluate invasive and non-invasive techniques currently employed to obtain a clinical prediction of deadly complications, such as variceal bleeding in patients affected by sinusoidal portal hypertension, in order to create a diagnostic algorithm to manage them. Again, HVPG appears to be the reference standard to evaluate portal hypertension and monitor the response to treatment, but its ability to predict several complications and support management decisions might be further improved through the diagnostic combination with other imaging techniques.

ENDOSCOPIC DIAGNOSIS AND THERAPY IN GASTRO-ESOPAGEAL VARICEAL BLEEDING

PubMed Central

Sanyal, Arun J.

2016-01-01

Gastroesophageal variceal hemorrhage is a medical emergency with high morbidity and mortality. Endoscopic therapy is the mainstay of management of bleeding varices. It requires attention to technique and the appropriate choice of therapy for a given patient at a given point in time. Subjects must be monitored continuously after initiation of therapy for control of bleeding and second line definitive therapies introduced quickly if endoscopic and pharmacologic treatment fails. PMID:26142034

Animal model of acid-reflux esophagitis: pathogenic roles of acid/pepsin, prostaglandins, and amino acids.

PubMed

Takeuchi, Koji; Nagahama, Kenji

2014-01-01

Esophagitis was induced in rats within 3 h by ligating both the pylorus and transitional region between the forestomach and glandular portion under ether anesthesia. This esophageal injury was prevented by the administration of acid suppressants and antipepsin drug and aggravated by exogenous pepsin. Damage was also aggravated by pretreatment with indomethacin and the selective COX-1 but not COX-2 inhibitor, whereas PGE2 showed a biphasic effect depending on the dose; a protection at low doses, and an aggravation at high doses, with both being mediated by EP1 receptors. Various amino acids also affected this esophagitis in different ways; L-alanine and L-glutamine had a deleterious effect, while L-arginine and glycine were highly protective, both due to yet unidentified mechanisms. It is assumed that acid/pepsin plays a major pathogenic role in this model of esophagitis; PGs derived from COX-1 are involved in mucosal defense of the esophagus; and some amino acids are protective against esophagitis. These findings also suggest a novel therapeutic approach in the treatment of esophagitis, in addition to acid suppressant therapy. The model introduced may be useful to test the protective effects of drugs on esophagitis and investigate the mucosal defense mechanism in the esophagus.

[Conservative treatment of benign esophageal strictures using dilation. Analysis of 500 cases].

PubMed

Andreollo, N A; Lopes, L R; Inogutti, R; Brandalise, N A; Leonardi, L S

2001-01-01

The benign esophageal stenoses (BES) are common complications owing to many etiologies: gastroesophageal reflux, ingestion of corrosive agents, esophageal surgery, radiotherapy, postendoscopic variceal sclerotherapy, drug ingestion, prolonged nasogastric intubation, extrinsic compression and esophageal webs. Esophageal dilatations are worldwide recommended to treat this complication, employing dilators of many types and diameters and facilitating the food ingestion. Evaluation of the results and advantages of the conservative treatment of the BES using esophageal dilatations, in outpatient service of upper digestive endoscopy. During the period from 1981 to 1999, 500 patients with BES were treated and followed up at the Gastrocenter - UNICAMP, in an individually Program of Esophageal Dilatation for each case. The highest number of cases was under ages from 31 to 60 years old (52,8%), and males (59,2%). The most predominant etiologies were: peptic stenosis (30,4%), caustic ingestion (23,6%), anastomosis (23,2%), megaesophagus (8,0%) and prolonged nasogastric ingestion entubation (6,4%), totalizing 91,6% of the BES. Most of patients (94,2%) were submitted to the maximum of 25 dilations. Dilators from 10,5 to 16 mm were employed in 95,6% of the cases. The duration of the treatment was 24 months in 76,2% of the BES. Esophageal perforations occurred in 6 patients (1,2%), without mortality. Were considered excellent, good and bad results, respectively in 76,2%, 18,2% and 5,6% of the cases. On the other hand, excellent results were recorded in 81,0% of the peptic stenosis, 66,1% of the caustic stenosis and 82,7% of the anastomotic stenosis. The conservative treatment failed in 9,3% of the caustic stenosis, 4,3% of the anastomotic stenosis and 3,9% of the peptic stenosis. Thus, the caustic stenosis were unsuccessfull in the highest percentage of unsuccessful. The conservative treatment using guidewire dilators (Savary-Gilliard and Eder-Puestow) is the first choice in the

Acid reflux directly causes sleep disturbances in rat with chronic esophagitis.

PubMed

Nakahara, Kenichi; Fujiwara, Yasuhiro; Tsukahara, Takuya; Yamagami, Hirokazu; Tanigawa, Tetsuya; Shiba, Masatsugu; Tominaga, Kazunari; Watanabe, Toshio; Urade, Yoshihiro; Arakawa, Tetsuo

2014-01-01

Gastroesophageal reflux disease (GERD) is strongly associated with sleep disturbances. Proton pump inhibitor (PPI) therapy improves subjective but not objective sleep parameters in patients with GERD. This study aimed to investigate the association between GERD and sleep, and the effect of PPI on sleep by using a rat model of chronic acid reflux esophagitis. Acid reflux esophagitis was induced by ligating the transitional region between the forestomach and the glandular portion and then wrapping the duodenum near the pylorus. Rats underwent surgery for implantation of electrodes for electroencephalogram and electromyogram recordings, and they were transferred to a soundproof recording chamber. Polygraphic recordings were scored by using 10-s epochs for wake, rapid eye movement sleep, and non-rapid eye movement (NREM) sleep. To examine the role of acid reflux, rats were subcutaneously administered a PPI, omeprazole, at a dose of 20 mg/kg once daily. Rats with reflux esophagitis presented with several erosions, ulcers, and mucosal thickening with basal hyperplasia and marked inflammatory infiltration. The reflux esophagitis group showed a 34.0% increase in wake (232.2±11.4 min and 173.3±7.4 min in the reflux esophagitis and control groups, respectively; p<0.01) accompanied by a reduction in NREM sleep during light period, an increase in sleep fragmentation, and more frequent stage transitions. The use of omeprazole significantly improved sleep disturbances caused by reflux esophagitis, and this effect was not observed when the PPI was withdrawn. Acid reflux directly causes sleep disturbances in rats with chronic esophagitis.

Acid Reflux Directly Causes Sleep Disturbances in Rat with Chronic Esophagitis

PubMed Central

Nakahara, Kenichi; Fujiwara, Yasuhiro; Tsukahara, Takuya; Yamagami, Hirokazu; Tanigawa, Tetsuya; Shiba, Masatsugu; Tominaga, Kazunari; Watanabe, Toshio; Urade, Yoshihiro; Arakawa, Tetsuo

2014-01-01

Background & Aims Gastroesophageal reflux disease (GERD) is strongly associated with sleep disturbances. Proton pump inhibitor (PPI) therapy improves subjective but not objective sleep parameters in patients with GERD. This study aimed to investigate the association between GERD and sleep, and the effect of PPI on sleep by using a rat model of chronic acid reflux esophagitis. Methods Acid reflux esophagitis was induced by ligating the transitional region between the forestomach and the glandular portion and then wrapping the duodenum near the pylorus. Rats underwent surgery for implantation of electrodes for electroencephalogram and electromyogram recordings, and they were transferred to a soundproof recording chamber. Polygraphic recordings were scored by using 10-s epochs for wake, rapid eye movement sleep, and non-rapid eye movement (NREM) sleep. To examine the role of acid reflux, rats were subcutaneously administered a PPI, omeprazole, at a dose of 20 mg/kg once daily. Results Rats with reflux esophagitis presented with several erosions, ulcers, and mucosal thickening with basal hyperplasia and marked inflammatory infiltration. The reflux esophagitis group showed a 34.0% increase in wake (232.2±11.4 min and 173.3±7.4 min in the reflux esophagitis and control groups, respectively; p<0.01) accompanied by a reduction in NREM sleep during light period, an increase in sleep fragmentation, and more frequent stage transitions. The use of omeprazole significantly improved sleep disturbances caused by reflux esophagitis, and this effect was not observed when the PPI was withdrawn. Conclusions Acid reflux directly causes sleep disturbances in rats with chronic esophagitis. PMID:25215524

Management of Portal Hypertension After Liver Transplantation.

PubMed

Korda, D; Deák, P Á; Kiss, G; Gerlei, Z; Kóbori, L; Görög, D; Fehérvári, I; Piros, L; Máthé, Z; Doros, A

2017-09-01

Post-transplantation portal hypertension has severe complications, such as esophageal varix bleeding, therapy refractory ascites, extreme splenomegaly, and graft dysfunction. The aim of our study was to analyze the effectiveness of the therapeutic strategies and how to visualize the procedure. A retrospective study involving liver transplantation patients from the Semmelweis University Department of Transplantation and Surgery was performed between 2005 and 2015. The prevalence, etiology, and leading complications of the condition were determined. The applied interventions' effects on the patients' ascites volume, splenic volume, and the occurrence of variceal bleeding were determined. Mean portal blood flow velocity and congestion index values were calculated using Doppler ultrasonography. The prevalence of post-transplantation portal hypertension requiring intervention was 2.8%. The most common etiology of the disease was portal anastomotic stenosis. The most common complications were esophageal varix bleeding and therapy refractory ascites. The patients' ascites volume decreased significantly (2923.3 ± 1893.2 mL vs. 423.3 ± 634.3 mL; P < .05), their splenic volume decreased markedly. After the interventions, only one case of recurrent variceal bleeding was reported. The calculated Doppler parameters were altered in the opposite direction in cases of pre-hepatic versus intra- or post-hepatic portal hypertension. After the interventions, these parameters shifted towards the physiologic ranges. The interventions performed in our clinic were effective in most cases. The patients' ascites volume, splenic volume, and the prevalence of variceal bleeding decreased after the treatment. Doppler ultrasonography has proved to be a valuable imaging modality in the diagnosis and the follow-up of post-transplantation portal hypertension. Copyright © 2017 Elsevier Inc. All rights reserved.

The low incidence of bacteremia after esophageal endoscopic submucosal dissection (ESD) obviates the need for prophylactic antibiotics in esophageal ESD.

PubMed

Kawata, Noboru; Tanaka, Masaki; Kakushima, Naomi; Takizawa, Kohei; Imai, Kenichiro; Hotta, Kinichi; Matsubayashi, Hiroyuki; Tsukahara, Mika; Kawamura, Ichiro; Kurai, Hanako; Ono, Hiroyuki

2016-11-01

Although a high incidence of bacteremia after esophageal endoscopic procedures has been reported, the incidence of bacteremia associated with esophageal endoscopic submucosal dissection (ESD) remains unknown. Therefore, we investigated the incidence of bacteremia associated with esophageal ESD. From April 2013 to March 2014, patients who underwent esophageal ESD were enrolled prospectively. Two sets of blood cultures were collected from patients at the following time points: (1) immediately after ESD; (2) the next morning; and (3) when fever ≥38 °C was present after ESD. A total of 424 blood culture sets were collected from 101 patients. Six patients had positive blood cultures immediately after ESD (4 %, 7/202 sets). Another patient had a positive blood culture the next morning (0.5 %, 1/202 sets). Ten patients (10 %) developed a post-ESD fever ≥38 °C, and blood cultures from these patients were all negative (0/20 sets). The seven patients with positive blood cultures had no post-ESD fever or infectious symptoms. Growth of Bacteroides thetaiotaomicron was only observed in one patient (1 %) with positive blood cultures immediately after ESD, and this patient was diagnosed with transient bacteremia. The other six patients were considered to have contaminants in their blood cultures. Thus, the incidence of bacteremia after esophageal ESD was 1 % [95 % confidence interval (CI) 0-5 %]. No patient had infectious symptoms, and none required antibiotics after ESD. The incidence of bacteremia after esophageal ESD was low and post-ESD fever was not associated with bacteremia. We conclude that use of routine prophylactic antibiotics to patients undergoing esophageal ESD is unnecessary. UMIN000012908.

ALCOHOLIC VERSUS NONALCOHOLIC CIRRHOSIS IN A RANDOMIZED CONTROLLED TRIAL OF EMERGENCY THERAPY OF BLEEDING VARICES

PubMed Central

Orloff, Marshall J.; Isenberg, Jon I.; Wheeler, Henry O.; Haynes, Kevin S.; Jinich-Brook, Horacio; Rapier, Roderick; Vaida, Florin; Hye, Robert J.; Orloff, Susan L.

2010-01-01

Background It has been proposed that portal-systemic shunts be avoided in alcoholic cirrhotics because survival rate is allegedly lower in alcoholics than in nonalcoholics. We examined this issue in a randomized controlled trial. Methods 211 unselected, consecutive patients with cirrhosis and bleeding esophageal varices were randomized to endoscopic sclerotherapy (EST) (n=106) or emergency portacaval shunt (EPCS) (105). Treatment was initiated within 8 hours. EST failure was treated by rescue PCS. 10-yr follow-up was 96%. Results Results strongly favored EPCS over EST (p<0.001). Among EPCS patients, 83% were alcoholic and 17% nonalcoholic. Outcomes were (1) permanent control of bleeding 100% vs. 100%; (2) 5-yr survival 71% vs.78%; (3) encephalopathy 14% vs. 19%; (4) yearly charges $38,300 vs. $43,000. Conclusions EPCS results were similar in alcoholic and nonalcoholic cirrhotics. EPCS is an effective first line emergency treatment in all forms of cirrhosis, including alcoholic. PMID:21195430

Rubber band ligation of hemorrhoids: A guide for complications

PubMed Central

Albuquerque, Andreia

2016-01-01

Rubber band ligation is one of the most important, cost-effective and commonly used treatments for internal hemorrhoids. Different technical approaches were developed mainly to improve efficacy and safety. The technique can be employed using an endoscope with forward-view or retroflexion or without an endoscope, using a suction elastic band ligator or a forceps ligator. Single or multiple ligations can be performed in a single session. Local anaesthetic after ligation can also be used to reduce the post-procedure pain. Mild bleeding, pain, vaso-vagal symptoms, slippage of bands, priapism, difficulty in urination, anal fissure, and chronic longitudinal ulcers are normally considered minor complications, more frequently encountered. Massive bleeding, thrombosed hemorrhoids, severe pain, urinary retention needing catheterization, pelvic sepsis and death are uncommon major complications. Mild pain after rubber band ligation is the most common complication with a high frequency in some studies. Secondary bleeding normally occurs 10 to 14 d after banding and patients taking anti-platelet and/or anti-coagulant medication have a higher risk, with some reports of massive life-threatening haemorrhage. Several infectious complications have also been reported including pelvic sepsis, Fournier’s gangrene, liver abscesses, tetanus and bacterial endocarditis. To date, seven deaths due to these infectious complications were described. Early recognition and immediate treatment of complications are fundamental for a favourable prognosis. PMID:27721924

Rubber band ligation of hemorrhoids: A guide for complications.

PubMed

Albuquerque, Andreia

2016-09-27

Rubber band ligation is one of the most important, cost-effective and commonly used treatments for internal hemorrhoids. Different technical approaches were developed mainly to improve efficacy and safety. The technique can be employed using an endoscope with forward-view or retroflexion or without an endoscope, using a suction elastic band ligator or a forceps ligator. Single or multiple ligations can be performed in a single session. Local anaesthetic after ligation can also be used to reduce the post-procedure pain. Mild bleeding, pain, vaso-vagal symptoms, slippage of bands, priapism, difficulty in urination, anal fissure, and chronic longitudinal ulcers are normally considered minor complications, more frequently encountered. Massive bleeding, thrombosed hemorrhoids, severe pain, urinary retention needing catheterization, pelvic sepsis and death are uncommon major complications. Mild pain after rubber band ligation is the most common complication with a high frequency in some studies. Secondary bleeding normally occurs 10 to 14 d after banding and patients taking anti-platelet and/or anti-coagulant medication have a higher risk, with some reports of massive life-threatening haemorrhage. Several infectious complications have also been reported including pelvic sepsis, Fournier's gangrene, liver abscesses, tetanus and bacterial endocarditis. To date, seven deaths due to these infectious complications were described. Early recognition and immediate treatment of complications are fundamental for a favourable prognosis.

The Relationship of the Post-reflux Swallow-induced Peristaltic Wave Index and Esophageal Baseline Impedance with Gastroesophageal Reflux Disease Symptoms

PubMed Central

Cho, Young Kyu; Lee, Joon Seong; Lee, Tae Hee; Hong, Su Jin; Park, Sang Joon; Jeon, Seong Ran; Kim, Hyun Gun; Kim, Jin-Oh

2017-01-01

Background/Aims The post-reflux swallow-induced peristaltic wave (PSPW) index and esophageal baseline impedance (BI) are novel impedance parameters used to evaluate esophageal chemical clearance and mucosal integrity. However, their relationship with reflux symptoms is not known. We aim to evaluate the correlations of PSPW index and esophageal BI with gastroesophageal reflux disease (GERD) symptoms. Methods We performed a retrospective review of multichannel intraluminal impedance and pH (MII-pH) tracings in patients with suspected GERD. Reflux symptoms were also analyzed from checklists using ordinal scales. The PSPW index and esophageal BIs in 6 spots (z1–z6) were measured. Bivariate (Spearman) correlation was used to analyze the relationship between the PSPW index or esophageal BI, and the degree of GERD symptoms measured. Results The MII-pH records of 143 patients were analyzed. The PSPW index was significantly lower in patients who had heartburn and negatively correlated with the degree of heartburn (r = −0.186, P < 0.05). On the contrary, the PSPW index was not significantly correlated with the degree of dysphagia (r = −0.013, P = 0.874). Distal esophageal BI was not significantly correlated with heartburn, but negatively correlated with the degree of dysphagia (z3: r = −0.328, z4: r = −0.361, z5: r = −0.316, z6: r = −0.273; P < 0.05). Conclusions These findings suggest that delayed chemical clearance of the esophagus may induce heartburn, but that it is not related to dysphagia. However, a lack of esophageal mucosal integrity may be related to dysphagia. PMID:28044052

Correlation Between Severity Of Portal Hypertensive Gastropathy And Size Of Oesophageal Varices In Cirrhotic Hepatitis-C Patients.

PubMed

Saleem, Khurram; Baig, Faisal Amin; Nida, Mahwish; Javed, Munaza

2018-01-01

Portal hypertension can lead to oesophageal varices (EV) and portal hypertensive gastropathy (PHG). The aim of this study is to determine the relationship between severity of Portal hypertensive gastropathy and size of oesophageal varices. One hundred and ninety-five patients of hepatitis C positive chronic liver disease having oesophageal varices were assessed for severity of portal hypertensive gastropathy. Mild Portal Hypertensive Gastropathy was observed in 16 (8.2 %), moderate in 54 (27.7 %) and severe in 120 (61.6 %) patients. Grade 1 Oesophageal Varices were present in 79 (40.5%) patients, grade 2 in 44 (21.9%) patients, grade 3 in 62 (31.8%) and grade 4 in 10 (5.2%) patients. No significant correlation was observed between grades of gastropathy and size of varices. The frequency of portal hypertensive gastropathy was 97.5% in Hepatitis C positive cirrhotic patients having oesophageal varices. Severity of gastropathy is not related to the grade or size of oesophageal varices.

Two cases of esophageal cancer with portal hypertension: esophagectomy with venous shunt procedure.

PubMed

Kato, T; Motohara, T; Kaneko, Y; Shikishima, H; Okushiba, S; Kondo, S; Kato, H

2001-01-01

We performed venous shunt procedure in the reconstruction of the esophagus after esophagectomy using the gastric tube in two cases of esophageal cancer with portal hypertension due to liver cirrhosis. In both cases, the short-term postoperative course was uneventful, without congestion in the gastric tube. In Case 1 where the short gastric vein had been used as the shunt vein, the long-term postoperative course was also uneventful, without hepatic encephalopathy or hemorrhage from deterioration of the varices of the gastric tube. However, in Case 2 where the left gastroepiploic vein had been used, hepatic encephalopathy developed due to excessive shunt flow. These results suggested that appropriate shunt flow could be expected by using short gastric vein.

Esophageal rupture caused by explosion of an automobile tire tube: a case report.

PubMed

Yu, Yongkang; Ding, Sheng; Zheng, Yifeng; Li, Wei; Yang, Lie; Zheng, Xiushan; Liu, Xiaoyan; Jiang, Jianqing

2013-08-23

There have been no reports in the literature of esophageal rupture in adults resulting from an explosion of an automobile tire. We report the first case of just such an occurrence after an individual bit into a tire, causing it to explode in his mouth. A 47-year-old Han Chinese man presented with massive hemorrhage in his left eye after he accidentally bit an automobile tire tube which burst into his mouth. He was diagnosed with esophageal rupture based on a chest computed tomography scan and barium swallow examination. Drainage of empyema (right chest), removal of thoracic esophagus, exposure of cervical esophagus, cardiac ligation and gastrostomy were performed respectively. After that, esophagogastrostomy was performed. Successful anastomosis was obtained at the neck with no postoperative complications 3 months after the surgery. The patient was discharged with satisfactory outcomes. We present this case report to bring attention to esophageal rupture in adults during the explosion of an automobile tire tube in the mouth.

Splenic artery ligature associated with endoscopic banding for schistosomal portal hypertension.

PubMed

Colaneri, Renata Potonyacz; Coelho, Fabrício Ferreira; de Cleva, Roberto; Perini, Marcos Vinícius; Herman, Paulo

2014-11-28

To propose a less invasive surgical treatment for schistosomal portal hypertension. Ten consecutive patients with hepatosplenic schistosomiasis and portal hypertension with a history of upper gastrointestinal hemorrhage from esophageal varices rupture were evaluated in this study. Patients were subjected to a small supraumbilical laparotomy with the ligature of the splenic artery and left gastric vein. During the procedure, direct portal vein pressure before and after the ligatures was measured. Upper gastrointestinal endoscopy was performed at the 30(th) postoperative day, when esophageal varices diameter were measured and band ligature performed. During follow-up, other endoscopic procedures were performed according to endoscopy findings. There was no intra-operative mortality and all patients had confirmed histologic diagnoses of schistosomal portal hypertension. During the immediate postoperative period, two of the ten patients had complications, one characterized by a splenic infarction, and the other by an incision hematoma. Mean hospitalization time was 4.1 d (range: 2-7 d). Pre- and post-operative liver function tests did not show any significant changes. During endoscopy thirty days after surgery, a decrease in variceal diameters was observed in seven patients. During the follow-up period (57-72 mo), endoscopic therapy was performed and seven patients had their varices eradicated. Considering the late postoperative evaluation, nine patients had a decrease in variceal diameters. A mean of 3.9 endoscopic banding sessions were performed per patient. Two patients presented bleeding recurrence at the late postoperative period, which was controlled with endoscopic banding in one patient due to variceal rupture and presented as secondary to congestive gastropathy in the other patient. Both bleeding episodes were of minor degree with no hemodynamic consequences or need for blood transfusion. Ligature of the splenic artery and left gastric vein with supraumbilical

Balloon-Occluded Percutaneous Transhepatic Obliteration of Isolated Vesical Varices Causing Gross Hematuria

PubMed Central

Lim, Dong Hoon; Kim, Min Seok; Kim, Chul Sung

2013-01-01

Gross hematuria secondary to vesical varices is an unusual presentation. We report such a case recurrent gross hematuria in a male patient who had a history of bladder substitution with ileal segments that had been treated by balloon-occluded percutaneous transhepatic obliteration of vesical varices. PMID:23323037

Effect of Valsalva's manoeuvre and hyoscinbutylbromide on the pressure gradient across the wall of oesophageal varices.

PubMed Central

Hosking, S W; Robinson, P; Johnson, A G

1987-01-01

To assess whether Valsalva's manoeuvre might cause variceal bleeding, 22 patients with oesophageal varices were studied. In 12 patients who received no previous treatment to their varices the median pressure gradient across the varix wall at rest was 19 (6-36) mmHg, and in 10 patients whose varices were thrombosed at their distal end the median pressure gradient in the proximal patent varix was 8 (1-6) mmHg. In untreated patients groups, the pressure gradient rose by 6-12 mmHg during Valsalva's manoeuvre in four patients, fell by 4-11 mmHg in five patients and was virtually unchanged in the remainder. These changes seem unlikely to cause variceal bleeding. Patients who repeated Valsalva's manoeuvre showed similar changes on each occasion. Six patients in the untreated group also received hyoscinbutylbromide 20 mg iv. No change was seen in the pressure gradient in five patients, suggesting that it is of little value in preventing variceal bleeding. PMID:3500098

Circadian occurrence of variceal bleeding in patients with liver cirrhosis.

PubMed

Siringo, S; Bolondi, L; Sofia, S; Hermida, R C; Gramantieri, L; Gaiani, S; Piscaglia, F; Carbone, C; Misitano, B; Corinaldesi, R

1996-12-01

Several clinical events have a rhythmicity over the 24 h period. We assessed the presence of periodic rhythm in the occurrence of haematemesis in patients with liver cirrhosis under different daylight regimens, namely during standard time and during daylight savings. Over a 48 month period there were 212 consecutive admissions of 118 cirrhotics with variceal bleeding. Complete data were available for 181 episodes of bleeding: 121 (66.9%) started with haematemesis and 60 (33.1%) started with melaena. One hundred and two (56%) episodes occurred during daylight savings and 79 (44%) occurred during standard time. The cosinor test showed a 24 h biphasic peak for the occurrence of haematemesis (09.45 and 21.45 h). Moreover, a biphasic diurnal asymmetric frequency was also found by multiple component rhythmometry. The time peaks of onset of variceal haemorrhage did not change significantly during standard time and daylight savings. Patients with more than one haematemesis episode significantly bled over the same time interval. The present study confirms that over the 24 h period variceal bleeding in cirrhotic patients occurs with a predictable rhythmicity that does not seem to be under the control of the light-dark cycle. The finding of a chronorisk for variceal haemorrhage addresses specific questions for pathophysiological studies as well as for new treatment strategies.

Percutaneous Retrograde Sclerotherapy for Refractory Bleeding of Jejunal Varices: Direct Injection via Superficial Epigastric Vein

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nakata, Manabu, E-mail: nktmnbohsu@jichi.ac.jp; Nakata, Waka, E-mail: waka-s@jichi.ac.jp; Isoda, Norio, E-mail: isodano1@jichi.ac.jp

2012-02-15

Small-bowel varices are rare and almost always occur in cases with portal hypertension. We encountered a patient with bleeding jejunal varices due to liver cirrhosis. Percutaneous retrograde sclerotherapy was performed via the superficial epigastric vein. Melena disappeared immediately after treatment. Disappearance of jejunal varices was confirmed by contrast-enhanced computed tomography. After 24 months of follow-up, no recurrent melena was observed.

The effects of restraint on uptake of radioactive sulfate in the salivary and gastric secretions of rats with pyloric ligation

NASA Technical Reports Server (NTRS)

Chayvialle, J. A.; Lambert, R.; Ruet, D.

1980-01-01

The effects of restraint on the amount of nondialysable radioactive sulfate in the gastric wall and the gastric juice and saliva were investigated. It was found that restraint provokes a significant decrease in salivary radioactive sulfate. This, in turn, is responsible for the decrease of sulfate in the gastric contents observed under these conditions in rats with pyloric ligation. Esophageal ligation associated with this prevents passage of saliva and lowers the amount of radioactive sulfate in the gastric juice. Restraint causes then an increase in the amount of sulfate in the gastric juice, the value observed being very much lower than that of rats with a free esophagus. At the level of the gastric wall, the change observed during restraint does not reach a significant threshold.

Water-Soluble Phosphinothiols for Traceless Staudinger Ligation and Integration with Expressed Protein Ligation

PubMed Central

Tam, Annie; Soellner, Matthew B.; Raines, Ronald T.

2010-01-01

The traceless Staudinger ligation is an effective means to synthesize an amide bond between two groups of otherwise orthogonal reactivity: a phosphinothioester and an azide. An important application of the Staudinger ligation is in the ligation of peptides at a variety of residues. Here, we demonstrate that the traceless Staudinger ligation can be achieved in water with a water-soluble reagent. Those reagents that provide a high yield of amide product discourage protonation of the nitrogen in the key iminophosphorane intermediate. The most efficacious reagent, bis(p-dimethylaminoethylphenyl)phosphinomethanethiol, mediates the rapid ligation of equimolar substrates in water. This reagent is also able to perform a transthioesterification reaction with the thioester intermediate formed during intein-mediated protein splicing. Hence, the traceless Staudinger ligation can be integrated with expressed protein ligation, extending the reach of modern protein chemistry. PMID:17713909

Effects of double ligation of Stensen's duct on the rabbit parotid gland.

PubMed

Maria, O M; Maria, S M; Redman, R S; Maria, A M; Saad El-Din, T A; Soussa, E F; Tran, S D

2014-04-01

Salivary gland duct ligation is an alternative to gland excision for treating sialorrhea or reducing salivary gland size prior to tumor excision. Duct ligation also is used as an approach to study salivary gland aging, regeneration, radiotherapy, sialolithiasis and sialadenitis. Reports conflict about the contribution of each salivary cell population to gland size reduction after ductal ligation. Certain cell populations, especially acini, reportedly undergo atrophy, apoptosis and proliferation during reduction of gland size. Acini also have been reported to de-differentiate into ducts. These contradictory results have been attributed to different animal or salivary gland models, or to methods of ligation. We report here a bilateral double ligature technique for rabbit parotid glands with histologic observations at 1, 7, 14, 30, 60 days after ligation. A large battery of special stains and immunohistochemical procedures was employed to define the cell populations. Four stages with overlapping features were observed that led to progressive shutdown of gland activities: 1) marked atrophy of the acinar cells occurred by 14 days, 2) response to and removal of the secretory material trapped in the acinar and ductal lumens mainly between 30 and 60 days, 3) reduction in the number of parenchymal (mostly acinar) cells by apoptosis that occurred mainly between 14-30 days, and 4) maintenance of steady-state at 60 days with a low rate of fluid, protein, and glycoprotein secretion, which greatly decreased the number of leukocytes engaged in the removal of the luminal contents. The main post- ligation characteristics were dilation of ductal and acinar lumens, massive transient infiltration of mostly heterophils (rabbit polymorphonuclear leukocytes), acinar atrophy, and apoptosis of both acinar and ductal cells. Proliferation was uncommon except in the larger ducts. By 30 days, the distribution of myoepithelial cells had spread from exclusively investing the intercalated ducts

Pharmacological constriction of the lower oesophageal sphincter: a simple method of arresting variceal haemorrhage.

PubMed Central

Hosking, S W; Doss, W; el-Zeiny, H; Robinson, P; Barsoum, M S; Johnson, A G

1988-01-01

The effect of pharmacological constriction of the lower oesophageal sphincter (LOS) on oesophageal varices was investigated in an experimental study followed by a controlled clinical trial. In the experimental study intravariceal pressure was measured just above the LOS in 11 patients before and after constricting the LOS by intravenous pentagastrin. Intravariceal pressure fell from a mean of 23 (range 12-36) mmHg to 4 (range 0-7) mmHg (p less than 0.001). This marked pressure drop indicated the considerable compression of varices that occurred within the LOS. A prospective controlled clinical trial examined whether LOS constriction (effected by the longer acting metoclopramide) would compress varices sufficiently to arrest active variceal bleeding originating from the lowest 2 cm oesophagus--the area encircled by the LOS. Of 11 patients who received metoclopramide, 10 stopped bleeding compared with four of the 11 who received placebo (p less than 0.01). Pharmacological constriction of the LOS appears to offer a new and effective approach for arresting active bleeding from oesophageal varices. PMID:3044932

Esophageal motility in eosinophilic esophagitis.

PubMed

Weiss, A H; Iorio, N; Schey, R

2015-01-01

Eosinophilic esophagitis (EoE) is characterized by eosinophilic infiltration of the esophagus and is a potential cause of dysphagia and food impaction, most commonly affecting young men. Esophageal manometry findings vary from normal motility to aperistalsis, simultaneous contractions, diffuse esophageal spasm, nutcracker esophagus or hypotonic lower esophageal sphincter (LES). It remains unclear whether esophageal dysmotility plays a significant role in the clinical symptoms of EoE. Our aim is to review the pathogenesis, diagnosis, and effect of treatment on esophageal dysmotility in EoE. A literature search utilizing the PubMed database was performed using keywords: eosinophilic esophagitis, esophageal dysmotility, motility, manometry, impedance planimetry, barium esophagogram, endoscopic ultrasound, and dysphagia. Fifteen studies, totaling 387 patients with eosinophilic esophagitis were identified as keeping in accordance with the aim of this study and included in this review. The occurrence of abnormal esophageal manometry was reported to be between 4 and 87% among patients with EoE. Esophageal motility studies have shown reduced distensibility, abnormal peristalsis, and hypotonicity of the LES in patients with EoE, which may also mimic other esophageal motility disorders such as achalasia or nutcracker esophagus. Studies have shown conflicting results regarding the presence of esophageal dysmotility and symptoms with some reports suggesting a higher rate of food impaction, while others report no correlation between motor function and dysphagia. Motility dysfunction of the esophagus in EoE has not been well reported in the literature and studies have reported conflicting evidence regarding the clinical significance of dysmotility seen in EoE. The correlation between esophageal dysmotility and symptoms of EoE remains unclear. Larger studies are needed to investigate the incidence of esophageal dysmotility, clinical implications, and effect of treatment on

Predictors of a variceal source among patients presenting with upper gastrointestinal bleeding.

PubMed

Alharbi, Ahmad; Almadi, Majid; Barkun, Alan; Martel, Myriam

2012-04-01

Patients with upper gastrointestinal bleeding (UGIB) require an early, tailored approach best guided by knowledge of the bleeding lesion, especially a variceal versus a nonvariceal source. To identify, by investigating a large national registry, variables that would be predictive of a variceal origin of UGIB using clinical parameters before endoscopic evaluation. A retrospective study was conducted in 21 Canadian hospitals during the period from January 2004 until the end of May 2005. Consecutive charts for hospitalized patients with a primary or secondary discharge diagnosis of UGIB were reviewed. Data regarding demographics, including historical, physical examination, initial laboratory investigations, endoscopic and pharmacological therapies administered, as well as clinical outcomes, were collected. Multivariable logistic regression modelling was performed to identify clinical predictors of a variceal source of bleeding. The patient population included 2020 patients (mean [± SD] age 66.3±16.4 years; 38.4% female). Overall, 215 (10.6%) were found to be bleeding from upper gastrointestinal varices. Among 26 patient characteristics, variables predicting a variceal source of bleeding included history of liver disease (OR 6.36 [95% CI 3.59 to 11.3]), excessive alcohol use (OR 2.28 [95% CI 1.37 to 3.77]), hematemesis (OR 2.65 [95% CI 1.61 to 4.36]), hematochezia (OR 3.02 [95% CI 1.46 to 6.22]) and stigmata of chronic liver disease (OR 2.49 [95% CI 1.46 to 4.25]). Patients treated with antithrombotic therapy were more likely to experience other causes of hemorrhage (OR 0.44 [95% CI 0.35 to 0.78]). Presenting historical and physical examination data, and initial laboratory tests carry significant predictive ability in discriminating variceal versus nonvariceal sources of bleeding.

Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018.

PubMed

Sung, Joseph Jy; Chiu, Philip Cy; Chan, Francis K L; Lau, James Yw; Goh, Khean-Lee; Ho, Lawrence Hy; Jung, Hwoon-Young; Sollano, Jose D; Gotoda, Takuji; Reddy, Nageshwar; Singh, Rajvinder; Sugano, Kentaro; Wu, Kai-Chun; Wu, Chun-Yin; Bjorkman, David J; Jensen, Dennis M; Kuipers, Ernst J; Lanas, Angel

2018-04-24

Non-variceal upper gastrointestinal bleeding remains an important emergency condition, leading to significant morbidity and mortality. As endoscopic therapy is the 'gold standard' of management, treatment of these patients can be considered in three stages: pre-endoscopic treatment, endoscopic haemostasis and post-endoscopic management. Since publication of the Asia-Pacific consensus on non-variceal upper gastrointestinal bleeding (NVUGIB) 7 years ago, there have been significant advancements in the clinical management of patients in all three stages. These include pre-endoscopy risk stratification scores, blood and platelet transfusion, use of proton pump inhibitors; during endoscopy new haemostasis techniques (haemostatic powder spray and over-the-scope clips); and post-endoscopy management by second-look endoscopy and medication strategies. Emerging techniques, including capsule endoscopy and Doppler endoscopic probe in assessing adequacy of endoscopic therapy, and the pre-emptive use of angiographic embolisation, are attracting new attention. An emerging problem is the increasing use of dual antiplatelet agents and direct oral anticoagulants in patients with cardiac and cerebrovascular diseases. Guidelines on the discontinuation and then resumption of these agents in patients presenting with NVUGIB are very much needed. The Asia-Pacific Working Group examined recent evidence and recommends practical management guidelines in this updated consensus statement. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Evaluation of common vaginal tunic ligation during field castration in draught colts.

PubMed

Carmalt, J L; Shoemaker, R W; Wilson, D G

2008-09-01

The objective of this study was to determine if ligation of the common vaginal tunic could prevent or reduce the incidence of omental herniation and eventration in draught colts undergoing routine field castration. It was found that common vaginal tunic ligation, while not completely preventing omental herniation and evisceration, significantly reduced the incidence of these complications and should be considered in those males deemed at increased risk of significant post castration complications.

MULTIMODAL IMAGING IN VORTEX VEIN VARICES.

PubMed

Veronese, Chiara; Staurenghi, Giovanni; Pellegrini, Marco; Maiolo, Chiara; Primavera, Laura; Morara, Mariachiara; Armstrong, Grayson W; Ciardella, Antonio P

2017-03-22

The aim of this study is to describe the clinical presentation of vortex vein varices with multimodal imaging. The authors carried out a retrospective case series of eight patients (7 female, 1 male) with an average age of 60.2 years (min 8, max 84, median 68.5) presenting with vortex vein varices. All patients were evaluated at the Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy and at Luigi Sacco Hospital, University of Milan, Milan, Italy. Patients underwent complete ophthalmologic examinations, including best corrected visual acuity, intraocular pressure, anterior segment, and fundus examination. Imaging studies, including fundus color photography, near-infrared reflectance imaging, fundus autofluorescence, fluorescein angiography, indocyanine green angiography, and spectral-domain enhanced depth imaging optical coherence tomography were also performed. Ultra-widefield fluorescein angiography and ultra-widefield indocyanine angiography using the Heidelberg Retina Angiograph and the Staurenghi 230 SLO Retina Lens were used to demonstrate the disappearance of all retinal lesions when pressure was applied to the globe. All eight cases initially presented to the emergency room. One patient presented secondary to trauma, two patients presented for suspected hemangioma, whereas the other five were referred to the authors' hospitals for suspected retinal lesions. On examination, retinal abnormalities were identified in all 8 patients, with 7 (87.5%) oculus dexter and 1 (12.5%) oculus sinister, and with 1 (12.5%) inferotemporally, 3 (37.5%) superonasally, 3 (37.5%) inferonasally, and 1 (12.5%) inferiorly. Fundus color photography showed an elevated lesion in seven patients and a nonelevated red lesion in one patient. In all patients, near-infrared reflectance imaging showed a hyporeflective lesion in the periphery of the retina. Fundus autofluorescence identified round hypofluorescent rings surrounding weakly hyperfluorescent lesions in all

Retroperitoneal Varix ligation with sclerotherapy: a prospective randomized comparative study

PubMed Central

Abdelsalam, Yaser M.; Saeed, Waleed M.; Elganainy, Ehab O.; Ahmed, Abdelfatah I.

2017-01-01

Introduction The aim of this article is to compare the results of high varix ligation with and without sclerotherapy. Material and methods Between November 2014 and December 2015, sixty patients with varicocele were included in this study. Patients were divided into two equal groups; group I (underwent high varix ligation), and group II (underwent high varix ligation with a retrograde injection of 2 mL of 5% ethanolamine oleate in the lower end of the bisected gonadal vein). The operative time, intra- and postoperative complications, postoperative pain, improvement of semen parameters, incidence of recurrence and achieving of unassisted pregnancy were recorded for both groups. Results The age range was 19–34 years in group I and 21–37 years in group II. The operative time was shorter in group I (34.6 ±7.81 min) than group II (43.3 ±8.5 min) (P <0.001), which was statistically significant. Improvement of semen parameters and the occurrence of spontaneous pregnancy were insignificant between both groups. No intraoperative complications occurred. The postoperative complications were statistically insignificant in both groups. Conclusions Combined varix ligation with retrograde sclerotherapy does not offer significant advantages over high varix ligation alone with a longer operative time and prolonged post-operative pain. PMID:29104794

Management of portal hypertension in children

PubMed Central

Gugig, Roberto; Rosenthal, Philip

2012-01-01

Portal hypertension can be caused by a wide variety of conditions. It frequently presents with bleeding from esophageal varices. The approach to acute variceal hemorrhage in children is a stepwise progression from least invasive to most invasive. Management of acute variceal bleeding is straightforward. But data on primary prophylaxis and long term management prevention of recurrent variceal bleeding in children is scarce, therefore prospective multicenter trials are needed to establish best practices. PMID:22468080

Successful Treatment of Mesenteric Varices After Living Donor Liver Transplantation with Retrograde Transvenous Obliteration Via an Abdominal Wall Vein

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ikeda, Osamu, E-mail: osamu-3643ik@do9.enjoy.ne.jp; Tamura, Yoshitaka; Nakasone, Yutaka

2010-06-15

Balloon-occluded retrograde transvenous obliteration is an established treatment for gastric varices; it has been used more rarely to treat mesenteric varices. We report a 12-year-old girl who had received a living donor liver transplant and suffered melena due to ruptured mesenteric varices. We addressed treatment of the mesenteric varices by retrograde transvenous obliteration of an abdominal wall collateral vein detected by superior mesenteric arteriography.

Incidence of white spot lesions among patients treated with self- and conventional ligation systems.

PubMed

Akin, Mehmet; Tezcan, Mucella; Ileri, Zehra; Ayhan, Faruk

2015-07-01

The aim of this study was to investigate the incidence of white spot lesions (WSLs) and its relationship with various patient and treatment variables, in patients treated with self-ligation and conventional ligation orthodontic bracket systems. Two-hundred randomly selected patient records (136 female, 64 male) for self-ligation and (108 female, 92 male) for conventional ligation groups were examined to determine WSL development. In the self-ligation group, Damon 3MX (Ormco, Glendora, Calif) brackets had been used, and in the conventional ligation group, Equilibrium 2 (Dentaurum, Phorzeim, Germany) had been used. Labial surfaces of 24 teeth in the pre- and post-treatment photographic records were scored using the WSL index. The prevalence of patients who developed at least 1 WSL before treatment was 19%, whereas after treatment, it was 49% in the self-ligation and 54% in the conventional ligation groups. Before treatment, the patients had only mild WSL, but after treatment, severe WSL and cavitation were observed in both groups. Bracket type, age, and hygiene care were significantly associated with new WSL development (P = 0.008, P = 0.004, P = 0.013, respectively). Bracket type and more importantly, the hygiene care therapy provided appeared to influence the development of new WSLs. Ligation can promote plaque accumulation and thereby new WSL development in conventional bracket systems. This article investigates the incidence of WSLs in patients treated with self-ligation and conventional ligation. The present study showed that incidence of WSL less in the self-ligation than in the conventional ligation but hygiene care was mostly important factor in developed WSL.

Transcatheter Embolotherapy with N-Butyl Cyanoacrylate for Ectopic Varices

DOE Office of Scientific and Technical Information (OSTI.GOV)

Choi, Jin Woo; Kim, Hyo-Cheol, E-mail: angiointervention@gmail.com; Jae, Hwan Jun, E-mail: jaemdphd@gmail.com

PurposeTo address technical feasibility and clinical outcome of transcatheter embolotherapy with N-butyl cyanoacrylate (NBCA) for bleeding ectopic varices.MethodsThe institutional review board approved this retrospective study and waived informed consent. From January 2004 to June 2013, a total of 12 consecutive patients received transcatheter embolotherapy using NBCA for bleeding ectopic varices in our institute. Clinical and radiologic features of the endovascular procedures were comprehensively reviewed.ResultsPreprocedural computed tomography images revealed ectopic varices in the jejunum (n = 7), stoma (n = 2), rectum (n = 2), and duodenum (n = 1). The 12 procedures consisted of solitary embolotherapy (n = 8) and embolotherapy with portal decompression (main portal vein stenting in 3,more » transjugular intrahepatic portosystemic shunt in 1). With regard to vascular access, percutaneous transhepatic access (n = 7), transsplenic access (n = 4), and transjugular intrahepatic portosystemic shunt tract (n = 1) were used. There was no failure in either the embolotherapy or the vascular accesses (technical success rate, 100 %). Two patients died within 1 month from the procedure from preexisting fatal medical conditions. Only one patient, with a large varix that had been partially embolized by using coils and NBCA, underwent rebleeding 5.5 months after the procedure. The patient was retreated with NBCA and did not undergo any bleeding afterward for a follow-up period of 2.5 months. The remaining nine patients did not experience rebleeding during the follow-up periods (range 1.5–33.2 months).ConclusionTranscatheter embolotherapy using NBCA can be a useful option for bleeding ectopic varices.« less

An Unusual Reason for Gastric Variceal Hemorrhage: Wandering Spleen.

PubMed

Köseoğlu, Hüseyin; Atalay, Roni; Büyükaşık, Naciye Şemnur; Canyiğit, Murat; Özer, Mehmet; Solakoğlu, Tevfik; Akın, Fatma Ebru; Bolat, Aylin Demirezer; Yürekli, Öykü Tayfur; Ersoy, Osman

2015-12-01

Wandering spleen is the displacement of the spleen due to the loss or weakening of the ligaments of the spleen and is seen very rarely with an incidence of less than 0.5 %. It can cause portal hypertension, but gastric variceal hemorrhage is a quite rare condition within the spectrum of this uncommon disease. We report a 22-year-old woman with wandering spleen presenting with life-threatening gastric variceal hemorrhage. Her diagnosis was made by computerized tomography. Endoscopic therapy was not adequate to stop the bleeding, and urgent splenectomy was performed. After surgery she has been well with no symptoms until now.

Ectopic Varices in the Gastrointestinal Tract: Short- and Long-Term Outcomes of Percutaneous Therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Macedo, Thanila A., E-mail: macedo.thanila@mayo.edu; Andrews, James C.; Kamath, Patrick S.

2005-04-15

To evaluate the results of percutaneous management of ectopic varices, a retrospective review was carried out of 14 patients (9 men, 5 women; mean age 58 years) who between 1992 and 2001 underwent interventional radiological techniques for management of bleeding ectopic varices. A history of prior abdominal surgery was present in 12 of 14 patients. The interval between the surgery and percutaneous intervention ranged from 2 to 38 years. Transhepatic portal venography confirmed ectopic varices to be the source of portal hypertension-related gastrointestinal bleeding. Embolization of the ectopic varices was performed by a transhepatic approach with coil embolization of themore » veins draining into the ectopic varices. Transjugular intrahepatic portosystemic shunt (TIPS) was performed in the standard fashion. Eighteen procedures (12 primary coil embolizations, 1 primary TIPS, 2 re-embolizations, 3 secondary TIPS) were performed in 13 patients. One patient was not a candidate for percutaneous treatment. All interventions but one (re-embolization) were technically successful. In 2 of 18 interventions, re-bleeding occurred within 72 hr (both embolization patients). Recurrent bleeding (23 days to 27 months after initial intervention) was identified in 9 procedures (8 coil embolizations, 1 TIPS due to biliary fistula). One patient had TIPS revision because of ultrasound surveillance findings. New encephalopathy developed in 2 of 4 TIPS patients. Percutaneous coil embolization is a simple and safe treatment for bleeding ectopic varices; however, recurrent bleeding is frequent and reintervention often required. TIPS can offer good control of bleeding at the expense of a more complex procedure and associated risk of encephalopathy.« less

SU-C-BRA-04: Use of Esophageal Wall Thickness in Evaluation of the Response to Chemoradiation Therapy for Esophageal Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Wang, J; Kligerman, S; Lu, W

2015-06-15

Purpose: To quantitatively evaluate the esophageal cancer response to chemoradiation therapy (CRT) by measuring the esophageal wall thickness in CT. Method: Two datasets were used in this study. The first dataset is composed of CT scans of 15 esophageal cancer patients and 15 normal controls. The second dataset is composed of 20 esophageal cancer patients who underwent PET/CT scans before (Pre-CRT) and after CRT (Post-CRT). We first segmented the esophagus using a multi-atlas-based algorithm. The esophageal wall thickness was then computed, on each slice, as the equivalent circle radius of the segmented esophagus excluding the lumen. To evaluate the changesmore » of wall thickness, we computed the standard deviation (SD), coefficient of variation (COV, SD/Mean), and flatness [(Max–Min)/Mean] of wall thickness along the entire esophagus. Results: For the first dataset, the mean wall thickness of cancer patients and normal controls were 6.35 mm and 6.03 mm, respectively. The mean SD, COV, and flatness of the wall thickness were 2.59, 0.21, and 1.27 for the cancer patients and 1.99, 0.16, and 1.13 for normal controls. Statistically significant differences (p < 0.05) were identified in SD and flatness. For the second dataset, the mean wall thickness of pre-CRT and post-CRT patients was 7.13 mm and 6.84 mm, respectively. The mean SD, COV, and flatness were 1.81, 0.26, and 1.06 for pre-CRT and 1.69, 0.26, and 1.06 for post-CRT. Statistically significant difference was not identified for these measurements. Current results are based on the entire esophagus. We believe significant differences between pre- and post-CRT scans could be obtained, if we conduct the measurements at tumor sites. Conclusion: Results show thicker wall thickness in pre-CRT scans and differences in wall thickness changes between normal and abnormal esophagus. This demonstrated the potential of esophageal wall thickness as a marker in the tumor CRT response evaluation. This work was supported in

Bleeding Duodenal Varices Successfully Treated with Balloon-Occluded Retrograde Transvenous Obliteration (B-RTO) Assisted by CT During Arterial Portography

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tsurusaki, Masakatsu, E-mail: he3m-trsk@asahi-net.or.jp; Sugimoto, Koji; Matsumoto, Shinichi

2006-12-15

A 60-year-old woman with massive hemorrhage from duodenal varices was transferred to our hospital for the purpose of transcatheter intervention. Although digital subtraction arterial portography could not depict the entire pathway of collateral circulation, the efferent route of the duodenal varices was clearly demonstrated on subsequent CT during arterial portography. Balloon-occluded retrograde transvenous obliteration (B-RTO) of the varices was performed via the efferent vein and achieved complete thrombosis of the varices.

Leptin Aggravates Reflux Esophagitis by Increasing Tissue Levels of Macrophage Migration Inhibitory Factor in Rats.

PubMed

Murata, Tsugihiro; Asanuma, Kiyotaka; Ara, Nobuyuki; Iijima, Katsunori; Hatta, Waku; Hamada, Shin; Asano, Naoki; Koike, Tomoyuki; Imatani, Akira; Masamune, Atsushi; Shimosegawa, Tooru

2018-05-01

Leptin, produced primarily by the adipose tissue, acts as a pro-inflammatory modulator, thereby contributing to the development of obesity-related disease. Although high levels of leptin in the obese are closely related to gastroesophageal reflux disease, the mechanism by which leptin influences esophageal inflammation remains unknown. Macrophage migration inhibitory factor (MIF) is produced by immune cells, such as T lymphocytes and macrophages, and MIF is known to induce the production of tumor necrosis factor α (TNF-α), interleukin 1β (IL-1β) and interleukin 6 (IL-6). We therefore investigated the mechanism whereby leptin aggravates reflux esophagitis, by focusing on esophageal tissue levels of MIF and CD3+ T lymphocytes, both of which are crucial for the reflux-induced epithelial damage. Esophageal inflammation was surgically induced in male Wistar rats by ligating the forestomach and narrowing the duodenum to facilitate gastroesophageal reflux, followed by administration of leptin or vehicle with an osmotic pump system for 1 week. We demonstrated that the administration of leptin exacerbated the reflux esophagitis with the apparent infiltration of CD3+ T lymphocytes and caused the significant increase in the esophageal tissue levels of MIF. Moreover, the leptin caused increases in the esophageal tissue levels of TNF-α, IL-1β and IL-6, downstream targets of MIF. Importantly, the increases in these pro-inflammatory cytokines were accompanied by increased protein levels of phospho-STAT3 and phospho-AKT, pivotal molecules of leptin signaling pathways. In conclusion, through enhancing the MIF-induced inflammatory signaling, leptin could contribute to the development of gastroesophageal reflux disease.

Patients with established gastro-esophageal reflux disease might benefit from Helicobacter pylori eradication

PubMed Central

Moschos, John M.; Kouklakis, George; Vradelis, Stergios; Zezos, Petros; Pitiakoudis, Michael; Chatzopoulos, Dimitrios; Zavos, Christos; Kountouras, Jannis

2014-01-01

Background The aim of this study was to investigate the effect of Helicobacter pylori (H. pylori) eradication in selected H. pylori-positive patients with a primary diagnosis of gastro-esophageal reflux disease (GERD) by using the 3-h postprandial esophageal pH monitoring. Methods We recruited patients with erosive esophagitis at endoscopy and H. pylori infection at histology, successfully cured following eradication therapy; the selected H. pylori-positive patients had weekly reflux symptoms for at least six months and endoscopically established Grade A or B esophagitis. Twenty-nine eligible patients were initially subjected to esophageal manometry and ambulatory 3-h postprandial esophageal pH monitoring. All patients received H. pylori triple eradication therapy accompanied by successful H. pylori eradication. After successful eradication of H. pylori (confirmed by 13C urea breath test), a second manometry and 3-h postprandial esophageal pH monitoring were introduced to assess the results of eradication therapy, after a 3-month post-treatment period. Results All 29 selected H. pylori-positive patients became negative due to successful H. pylori eradication, evaluated by 13C urea breath test after a 4-week post-treatment period. Post-eradication, 62.1% patients showed similar manometric pattern at baseline; 17.2% showed improvement; 17.2% normalization; and 3.4% deterioration of the manometric patterns. The DeMeester symptom scoring in the 3-h postprandial ambulatory esophageal pH monitoring was improved after eradication of H. pylori (median 47.47 vs. 22.00, Wilcoxon’s singed rank; P=0.016). On comparing the pH monitoring studies for each patient at baseline and post-eradication period, 82.8% patients showed improvement and 17.2% deterioration of the DeMeester score. Conclusion By using 3-h postprandial esophageal pH monitoring, this study showed, for the first time, that H. pylori eradication may positively influence GERD symptoms. Large-scale controlled

Patients with established gastro-esophageal reflux disease might benefit from Helicobacter pylori eradication.

PubMed

Moschos, John M; Kouklakis, George; Vradelis, Stergios; Zezos, Petros; Pitiakoudis, Michael; Chatzopoulos, Dimitrios; Zavos, Christos; Kountouras, Jannis

2014-01-01

The aim of this study was to investigate the effect of Helicobacter pylori ( H. pylori ) eradication in selected H. pylori -positive patients with a primary diagnosis of gastro-esophageal reflux disease (GERD) by using the 3-h postprandial esophageal pH monitoring. We recruited patients with erosive esophagitis at endoscopy and H. pylori infection at histology, successfully cured following eradication therapy; the selected H. pylori -positive patients had weekly reflux symptoms for at least six months and endoscopically established Grade A or B esophagitis. Twenty-nine eligible patients were initially subjected to esophageal manometry and ambulatory 3-h postprandial esophageal pH monitoring. All patients received H. pylori triple eradication therapy accompanied by successful H. pylori eradication. After successful eradication of H. pylori (confirmed by 13 C urea breath test), a second manometry and 3-h postprandial esophageal pH monitoring were introduced to assess the results of eradication therapy, after a 3-month post-treatment period. All 29 selected H. pylori -positive patients became negative due to successful H. pylori eradication, evaluated by 13 C urea breath test after a 4-week post-treatment period. Post-eradication, 62.1% patients showed similar manometric pattern at baseline; 17.2% showed improvement; 17.2% normalization; and 3.4% deterioration of the manometric patterns. The DeMeester symptom scoring in the 3-h postprandial ambulatory esophageal pH monitoring was improved after eradication of H. pylori (median 47.47 vs. 22.00, Wilcoxon's singed rank; P=0.016). On comparing the pH monitoring studies for each patient at baseline and post-eradication period, 82.8% patients showed improvement and 17.2% deterioration of the DeMeester score. By using 3-h postprandial esophageal pH monitoring, this study showed, for the first time, that H. pylori eradication may positively influence GERD symptoms. Large-scale controlled relative studies are warranted to

Severe gastric variceal bleeding successfully treated by emergency splenic artery embolization.

PubMed

Sankararaman, Senthilkumar; Velayuthan, Sujithra; Vea, Romulo; Herbst, John

2013-06-01

Bleeding from gastric varices due to splenic vein obstruction is extremely rare in children, but it can be catastrophic. Reported herein is the case of a teenager with splenic vein thrombosis and chronic decompensated liver disease from autoimmune hepatitis who presented with massive gastric variceal bleeding. Standard medical management did not control the bleeding. Due to decompensated liver disease and continuous active bleeding, emergency partial splenic artery embolization was preferred over splenectomy or a shunt procedure. Bleeding was successfully controlled by partial splenic artery embolization by decreasing the inflow of blood into the portal system. It is concluded that emergency partial splenic artery embolization is a safer alternative life-saving procedure to manage severe gastric variceal bleeding due to splenic vein obstruction in a patient with high surgical risk. To our knowledge, only one other patient with similar management has been reported in the pediatric age group. © 2013 The Authors. Pediatrics International © 2013 Japan Pediatric Society.

Ligation Bias in Illumina Next-Generation DNA Libraries: Implications for Sequencing Ancient Genomes

PubMed Central

Seguin-Orlando, Andaine; Schubert, Mikkel; Clary, Joel; Stagegaard, Julia; Alberdi, Maria T.; Prado, José Luis; Prieto, Alfredo; Willerslev, Eske; Orlando, Ludovic

2013-01-01

Ancient DNA extracts consist of a mixture of endogenous molecules and contaminant DNA templates, often originating from environmental microbes. These two populations of templates exhibit different chemical characteristics, with the former showing depurination and cytosine deamination by-products, resulting from post-mortem DNA damage. Such chemical modifications can interfere with the molecular tools used for building second-generation DNA libraries, and limit our ability to fully characterize the true complexity of ancient DNA extracts. In this study, we first use fresh DNA extracts to demonstrate that library preparation based on adapter ligation at AT-overhangs are biased against DNA templates starting with thymine residues, contrarily to blunt-end adapter ligation. We observe the same bias on fresh DNA extracts sheared on Bioruptor, Covaris and nebulizers. This contradicts previous reports suggesting that this bias could originate from the methods used for shearing DNA. This also suggests that AT-overhang adapter ligation efficiency is affected in a sequence-dependent manner and results in an uneven representation of different genomic contexts. We then show how this bias could affect the base composition of ancient DNA libraries prepared following AT-overhang ligation, mainly by limiting the ability to ligate DNA templates starting with thymines and therefore deaminated cytosines. This results in particular nucleotide misincorporation damage patterns, deviating from the signature generally expected for authenticating ancient sequence data. Consequently, we show that models adequate for estimating post-mortem DNA damage levels must be robust to the molecular tools used for building ancient DNA libraries. PMID:24205269

Local anaesthetic infiltration for the rubber band ligation of early symptomatic haemorrhoids: a systematic review and meta-analysis.

PubMed

Sajid, M S; Bhatti, M I; Caswell, J; Sains, P; Baig, M K

2015-03-01

The objective of this article is to systematically analyse the randomized, controlled trials evaluating the effectiveness of local anaesthetic infiltration prior to the rubber band ligation of early symptomatic haemorrhoids. Published randomized, controlled trials comparing the use of local anaesthetic (LA) versus no-local anaesthetic (NLA) for the rubber band ligation of early symptomatic haemorrhoids were analysed using RevMan®, and the combined outcomes were expressed as odds ratios (OR) and standardized mean difference (SMD). Four randomized, controlled trials evaluating 387 patients were retrieved from the standard electronic databases. The risk of treatment failure (OR 0.44; 95% CI 0.07, 2.79; z = 0.87; p = 0.39) and post-procedure complications (OR 0.48; 95% CI 0.08, 2.76; z = 0.83; p = 0.41) was similar between two techniques. However, the post-procedure pain score (SMD -5.19; 95% CI -9.08, -1.30; z = 2.62; p < 0.009) was significantly lower in the group of patients undergoing rubber band ligation of haemorrhoids under local anaesthetic injection. The use of LA appears to have clinically measurable advantages over NLA in the rubber band ligation of early symptomatic haemorrhoids to lessen post-procedure pain.

FOLFOX-6 Induction Chemotherapy Followed by Esophagectomy and Post-operative Chemoradiotherapy in Patients With Esophageal Adenocarcinoma

ClinicalTrials.gov

2017-08-03

Adenocarcinoma of the Esophagus; Adenocarcinoma of the Gastroesophageal Junction; Adenocarcinoma of the Gastric Cardia; Stage IIIA Esophageal Cancer; Stage IIIB Esophageal Cancer; Stage IIIC Esophageal Cancer

[Hodgkin's disease with esophageal involvement].

PubMed

Njeh, M; Yengui, N; Tahri, N; Kchaou, M; Sellami, A; Jlidi, R; Krichen, M S

2000-10-01

Esophageal involvement in Hodgkin's disease, commonly known as a belated localization of the advanced forms, has been seldom reported (3 to 5% in post-mortem series and 0.7% in clinical series). We report the case of a 61-year-old man who had an esophagus localization revealing Hodgkin's disease stage IV EBb of Ann Arbor classification. The originality of this case was represented by: the revelation mode of the esophageal involvement such as dysphagia and upper gastrointestinal bleeding; the localization at the distal third of the esophagus with contiguous involvement of the gastric fundus; the absence of mediastinal nodes showing the primitive character of the esophageal injury. This observation incites us to consider Hodgkin's disease in the list of differential diagnoses of tumoral dysphagia, even if there was no ganglionic and/or visceral localization of the disease.

Endotherapy for severe and complete pharyngo-esophageal post-radiation stenosis using wires, balloons and pharyngo-esophageal puncture (PEP) (with videos).

PubMed

Tang, Shou-jiang; Singh, Shailender; Truelson, John M

2010-01-01

Pharyngo-esophageal stenosis (PES) and upper esophageal stricture are common in patients who receive radiation therapy for laryngeal and hypopharyngeal cancers. In severe or complete stenosis, the patients generally have complete dysphagia with inability to swallow their saliva. Diagnostic and therapeutic esophagogastroduodenoscopy (EGD) plays an important role in investigating the dysphagia and in managing the underlying stenosis. We translate endoscopic retrograde cholangiopancreatography (ERCP) techniques and skills in approaching pancreaticobiliary obstruction in the management of severe and complete PES. We select and report three cases of severe or complete PES in which flexible endoscopic therapy was successfully provided by using fluoroscopy, ERCP wire guides, endoscopic balloons, and by performing pharyngo-esophageal puncture (PEP). We propose the term PEP in managing complete PES. We believe this approach can offer safety and efficiency with very high success rate.

Torque expression in self-ligating orthodontic brackets and conventionally ligated brackets: A systematic review

PubMed Central

Al-Thomali, Yousef; Mohamed, Roshan-Noor; Basha, Sakeenabi

2017-01-01

Background To evaluate the torque expression of self ligating (SL) orthodontic brackets and conventionally ligated brackets and the torque expression in active and passive SL brackets. Material and Methods Our systematic search included MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus, and key journals and review articles; the date of the last search was April 4th 2016. We graded the methodological quality of the studies by means of the Quality Assessment Tool for Quantitative Studies, developed for the Effective Public Health Practice Project (EPHPP). Results In total, 87 studies were identified for screening, and 9 studies were eligible. The quality assessment rated one of the study as being of strong quality, 7 (77.78%) of these studies as being of moderate quality. Three out of 7 studies which compared SL and conventionally ligated brackets showed, conventionally ligated brackets with highest torque expression compared to SL brackets. Badawi showed active SL brackets with highest torque expression compared to passive SL brackets. Major and Brauchli showed no significant differences in torque expression of active and passive SL brackets. Conclusions Conventionally ligated brackets presented with highest torque expression compared to SL brackets. Minor difference was recorded in a torque expression of active and passive SL brackets. Key words:Systematic review, self ligation, torque expression, conventional ligation. PMID:28149476

Torque expression in self-ligating orthodontic brackets and conventionally ligated brackets: A systematic review.

PubMed

Al-Thomali, Yousef; Mohamed, Roshan-Noor; Basha, Sakeenabi

2017-01-01

To evaluate the torque expression of self ligating (SL) orthodontic brackets and conventionally ligated brackets and the torque expression in active and passive SL brackets. Our systematic search included MEDLINE, EMBASE, CINAHL, PsychINFO, Scopus, and key journals and review articles; the date of the last search was April 4th 2016. We graded the methodological quality of the studies by means of the Quality Assessment Tool for Quantitative Studies, developed for the Effective Public Health Practice Project (EPHPP). In total, 87 studies were identified for screening, and 9 studies were eligible. The quality assessment rated one of the study as being of strong quality, 7 (77.78%) of these studies as being of moderate quality. Three out of 7 studies which compared SL and conventionally ligated brackets showed, conventionally ligated brackets with highest torque expression compared to SL brackets. Badawi showed active SL brackets with highest torque expression compared to passive SL brackets. Major and Brauchli showed no significant differences in torque expression of active and passive SL brackets. Conventionally ligated brackets presented with highest torque expression compared to SL brackets. Minor difference was recorded in a torque expression of active and passive SL brackets. Key words: Systematic review, self ligation, torque expression, conventional ligation.

Congenital esophageal stenosis associated with esophageal atresia/tracheoesophageal fistula: clinical and radiologic features.

PubMed

Yoo, Hye Jin; Kim, Woo Sun; Cheon, Jung-Eun; Yoo, So-Young; Park, Kwi-Won; Jung, Sung-Eun; Shin, Su-Mi; Kim, In-One; Yeon, Kyung Mo

2010-08-01

Congenital esophageal stenosis (CES) can be associated with esophageal atresia/tracheoesophageal fistula (EA/TEF). Because there are a variety of degrees of obstruction and symptoms of CES, it is frequently difficult to make a pre- and post-operative diagnosis of the distal CES associated with EA/TEF. To evaluate the clinical and radiologic features of congenital esophageal stenosis associated with esophageal atresia/tracheoesophageal fistula. We retrospectively reviewed postoperative esophagograms and medical records of 187 children (107 boys, 80 girls) who had primary repair of EA/TEF from 1992 to 2009 at our institution. We evaluated the incidence of CES, clinical findings, radiologic features and management of CES in these children. CES was diagnosed in 22 of 187 EA/TEF children (12%); one child had double CES lesions, for a total of 23 lesions. Ten of those 22 children (45%) had presented with significant symptoms of esophageal obstruction. The diagnosis of CES was delayed in 10 children (45%) until 1-10 years of age. On esophagogram, CES (n = 23) was located in the distal esophagus (n = 20, 87%) or mid-esophagus (n = 3, 13%). The degree of stenosis was severe (n = 6, 26%), moderate (n = 10, 43%), or mild (n = 7, 30%). Eight children, including two with unsuccessful esophageal balloon dilatation of CES, were treated surgically. Histologic examination revealed tracheobronchial remnant (n = 7) or fibromuscular hyperplasia (n = 1). One child with surgically treated CES developed achalasia at the age of 3 years 9 months. Esophagography after EA/TEF repair should be performed with a high index of suspicion for the presence of distal CES, because the diagnosis and adequate management of CES can often be delayed.

Endoscopic management of esophageal stenosis in children: New and traditional treatments.

PubMed

Dall'Oglio, Luigi; Caldaro, Tamara; Foschia, Francesca; Faraci, Simona; Federici di Abriola, Giovanni; Rea, Francesca; Romeo, Erminia; Torroni, Filippo; Angelino, Giulia; De Angelis, Paola

2016-02-25

Post-esophageal atresia anastomotic strictures and post-corrosive esophagitis are the most frequent types of cicatricial esophageal stricture. Congenital esophageal stenosis has been reported to be a rare but typical disease in children; other pediatric conditions are peptic, eosinophilic esophagitis and dystrophic recessive epidermolysis bullosa strictures. The conservative treatment of esophageal stenosis and strictures (ES) rather than surgery is a well-known strategy for children. Before planning esophageal dilation, the esophageal morphology should be assessed in detail for its length, aspect, number and level, and different conservative strategies should be chosen accordingly. Endoscopic dilators and techniques that involve different adjuvant treatment strategies have been reported and depend on the stricture's etiology, the availability of different tools and the operator's experience and preferences. Balloon and semirigid dilators are the most frequently used tools. No high-quality studies have reported on the differences in the efficacies and rates of complications associated with these two types of dilators. There is no consensus in the literature regarding the frequency of dilations or the diameter that should be achieved. The use of adjuvant treatments has been reported in cases of recalcitrant stenosis or strictures with evidence of dysphagic symptoms. Corticosteroids (either systemically or locally injected), the local application of mitomycin C, diathermy and laser ES sectioning have been reported. Some authors have suggested that stenting can reduce both the number of dilations and the treatment length. In many cases, this strategy is effective when either metallic or plastic stents are utilized. Treatment complications, such esophageal perforations, can be conservatively managed, considering surgery only in cases with severe pleural cavity involvement. In cases of stricture relapse, even if such relapses occur following the execution of well

Identifying Emergency Department Patients at Low Risk for a Variceal Source of Upper Gastrointestinal Hemorrhage.

PubMed

Klein, Lauren R; Money, Joel; Maharaj, Kaveesh; Robinson, Aaron; Lai, Tarissa; Driver, Brian E

2017-11-01

Assessing the likelihood of a variceal versus nonvariceal source of upper gastrointestinal bleeding (UGIB) guides therapy, but can be difficult to determine on clinical grounds. The objective of this study was to determine if there are easily ascertainable clinical and laboratory findings that can identify a patient as low risk for a variceal source of hemorrhage. This was a retrospective cohort study of adult ED patients with UGIB between January 2008 and December 2014 who had upper endoscopy performed during hospitalization. Clinical and laboratory data were abstracted from the medical record. The source of the UGIB was defined as variceal or nonvariceal based on endoscopic reports. Binary recursive partitioning was utilized to create a clinical decision rule. The rule was internally validated and test characteristics were calculated with 1,000 bootstrap replications. A total of 719 patients were identified; mean age was 55 years and 61% were male. There were 71 (10%) patients with a variceal UGIB identified on endoscopy. Binary recursive partitioning yielded a two-step decision rule (platelet count > 200 × 10 9 /L and an international normalized ratio [INR] < 1.3), which identified patients who were low risk for a variceal source of hemorrhage. For the bootstrapped samples, the rule performed with 97% sensitivity (95% confidence interval [CI] = 91%-100%) and 49% specificity (95% CI = 44%-53%). Although this derivation study must be externally validated before widespread use, patients presenting to the ED with an acute UGIB with platelet count of >200 × 10 9 /L and an INR of <1.3 may be at very low risk for a variceal source of their upper gastrointestinal hemorrhage. © 2017 by the Society for Academic Emergency Medicine.

Liver stiffness and platelet count for identifying patients with compensated liver disease at low risk of variceal bleeding.

PubMed

Marot, Astrid; Trépo, Eric; Doerig, Christopher; Schoepfer, Alain; Moreno, Christophe; Deltenre, Pierre

2017-05-01

The 2015 Baveno VI guidelines recommend against performing upper gastrointestinal endoscopy in patients with compensated cirrhosis who have a liver stiffness <20 kPa and a platelet count >150 000/mm³ because of a low prevalence of varices at risk of bleeding in this population. The aim was to synthesize the available evidence on the usefulness of the combined use of liver stiffness and platelet count to identify patients without oesophageal varices. Meta-analysis of trials evaluating the usefulness of a given cut-off for liver stiffness and platelet count to rule out the presence of oesophageal varices. Fifteen studies were included. All studies excepting five used the Baveno VI criteria. Compared to patients with either high liver stiffness or low platelet count, those with low liver stiffness and normal platelet count had a lower risk of varices at risk of bleeding (OR=0.22, 95% CI=0.13-0.39, P<.001) with low heterogeneity between studies (I 2 =21%). They also had a lower risk of varices (OR=0.23, 95% CI=0.17-0.32, P<.001) with moderate heterogeneity between studies (I 2 =28%). In patients with low liver stiffness and normal platelet count, the pooled estimate rates for varices at risk of bleeding was 0.040 (95% CI=0.027-0.059) with low heterogeneity between studies (I 2 =3%). Patients with low liver stiffness and normal platelet count have a lower risk of varices than those with either high liver stiffness or low platelet count. Varices at risk of bleeding are found in no more than 4% of patients when liver stiffness is <20 kPa and platelet count is normal. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

A Combined Training Program for Veterans with Amnestic Mild Cognitive Impairment

DTIC Science & Technology

2015-10-01

Acute illness or unstable chronic illness, e.g., history of severe liver disease (cirrhosis,  esophageal varices, ascites,  portal   hypertension ...unstable chronic illness, e.g., history of severe liver disease (cirrhosis,  esophageal varices, ascites,  portal   hypertension , hepatic encephalopathy...impairment such as hypertension , obesity, and type II diabetes mellitus [1; 2; 3; 4]. Hence, it may be that by improving cardiovascular health and reducing

Management of stomal varices with transvenous obliteration utilizing sodium tetradecyl sulfate foam sclerosis.

PubMed

Saad, Wael E A; Schwaner, Sandra; Lippert, Allison; Sabri, Saher S; Al-Osaimi, Abdullah; Matsumoto, Alan H; Angle, John F; Caldwell, Stephen

2014-12-01

The management of parastomal varices is not established. Transjugular intrahepatic portosystemic shunt (TIPS) creation is the most commonly described treatment; however, the rebleed rate after TIPS is 21-37%. The purpose of the study is to determine the effectiveness of transvenous obliteration using sodium tetradecyl sulfate (STS) and to describe a new simplified technique in obliterating these varices. Four patients are presented who underwent transvenous obliteration using STS. One was obliterated using balloon occlusion from the systemic veins, the second was obliterated without balloon from a transhepatic antegrade approach, and the last two patients were obliterated using the direct antegrade technique. This simplified technique requires only a micropuncture kit (not requiring balloons or coils) and ultrasound transducer compression of the systemic draining veins, relying on high portal pressure to keep the sclerosant confined to the varices. The sclerosant is essentially trapped between the portal pressure and the ultrasound-transducer compression (10-15 min). Technical success was achieved in all four patients without procedural or postprocedural complications and no rebleeding for a mean follow-up of 17 (range 2-33) months. Transvenous obliteration of parastomal varices utilizing STS as a sclerosant is safe and effective. The newly described technique is simple, feasible, and requires minimal equipment (no balloons or coils or catheters).

Intra and post-operative complications of esophageal achalasia.

PubMed

Pugliese, Luigi; Peri, Andrea; Tinozzi, Francesco Paolo; Zonta, Sandro; di Stefano, Michele; Meloni, Federica; Pietrabissa, Andrea

2013-01-01

To evaluate and discuss all the potential complications affecting morbidity of patients treated with surgery for primary achalasia. A review of the available English literature published to date has been conducted. All articles reporting surgical experience in achalasia were examined and then were selected only those specifically inherent to the topic at issue. Mucosal perforation is the main intra-operative complication while persistence or recurrence of the disease and gastro-esophageal reflux are those mostly affecting patients afterwards, even at long-term follow-up. A few other less common morbidities, as well as the technical considerations useful to minimize and manage each complication mentioned, are reported. Minimally invasive surgery for achalasia consent to treat patients with a low rate of perioperative complications that can be managed with conservative approach in the majority of cases. Risk of esophageal cancer exists in these patients and remains although surgical therapy. Laparoscopic Heller myotomy along with partial fundoplication is a safe and effective procedure that should be considered as the treatment of choice at first evaluation of achalasic patients rather than endoscopic techniques. Robotic technology may add further contribution in diminishing perioperative complications.

Echocardiographic demonstration of intracardiac glue after endoscopic obturation of gastroesophageal varices.

PubMed

Gallet, B; Zemour, G; Saudemont, J P; Renard, P; Hillion, M L; Hiltgen, M

1995-01-01

Systemic embolism is an unusual complication of endoscopic obturation of gastroesophageal varices with glue. This report describes a case of cerebral embolism after this procedure. Intracardiac glue within the left atrium was demonstrated by echocardiography. Cardiac fluoroscopy demonstrated an abnormal vessel connecting periesophageal veins with the right upper pulmonary vein. Cardiac surgery was performed. Intracardiac glue was removed and the entering orifice of the abnormal vessel in the right upper pulmonary vein was sutured. To our knowledge, this is the first reported case of intracardiac glue after variceal obturation. Echocardiography is useful in the diagnosis of this rare complication.

Selective inhibition of esophageal cancer cells by combination of HDAC inhibitors and Azacytidine

PubMed Central

Ahrens, Theresa D; Timme, Sylvia; Hoeppner, Jens; Ostendorp, Jenny; Hembach, Sina; Follo, Marie; Hopt, Ulrich T; Werner, Martin; Busch, Hauke; Boerries, Melanie; Lassmann, Silke

2015-01-01

Esophageal cancers are highly aggressive tumors with poor prognosis despite some recent advances in surgical and radiochemotherapy treatment options. This study addressed the feasibility of drugs targeting epigenetic modifiers in esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC) cells. We tested inhibition of histone deacetylases (HDACs) by SAHA, MS-275, and FK228, inhibition of DNA methyltransferases by Azacytidine (AZA) and Decitabine (DAC), and the effect of combination treatment using both types of drugs. The drug targets, HDAC1/2/3 and DNMT1, were expressed in normal esophageal epithelium and tumor cells of ESCC or EAC tissue specimens, as well as in non-neoplastic esophageal epithelial (Het-1A), ESCC (OE21, Kyse-270, Kyse-410), and EAC (OE33, SK-GT-4) cell lines. In vitro, HDAC activity, histone acetylation, and p21 expression were similarly affected in non-neoplastic, ESCC, and EAC cell lines post inhibitor treatment. Combined MS-275/AZA treatment, however, selectively targeted esophageal cancer cell lines by inducing DNA damage, cell viability loss, and apoptosis, and by decreasing cell migration. Non-neoplastic Het-1A cells were protected against HDACi (MS-275)/AZA treatment. RNA transcriptome analyses post MS-275 and/or AZA treatment identified novel regulated candidate genes (up: BCL6, Hes2; down: FAIM, MLKL), which were specifically associated with the treatment responses of esophageal cancer cells. In summary, combined HDACi/AZA treatment is efficient and selective for the targeting of esophageal cancer cells, despite similar target expression of normal and esophageal cancer epithelium, in vitro and in human esophageal carcinomas. The precise mechanisms of action of treatment responses involve novel candidate genes regulated by HDACi/AZA in esophageal cancer cells. Together, targeting of epigenetic modifiers in esophageal cancers may represent a potential future therapeutic approach. PMID:25923331

Comparison between Ultroid and rubber band ligation in treatment of internal hemorrhoids.

PubMed

Azizi, Rasoul; Rabani-Karizi, Behzad; Taghipour, Mohammad Ali

2010-01-01

Hemorrhoid is one of the most common surgical diseases and different methods are available for its treatment. This study is a comparison between two methods of treatment of internal hemorrhoid, Monopolar low voltage instrument (Ultroid) and Rubber Band Ligation. This method has been carried out prospectively in which 50 patients who were treated with rubber band ligation and 50 patients with Ultroid were compared according to the incidence of complications, post-operative pain and treatment response. According to this study complete success rate with Ultroid was 82% and partial success rate was 10% and no response to treatment was seen in 8%. In Rubber Band method the complete response rate was 94% (P=0.2). With Ultroid, 74% of patient reported no postoperative pain, 24% reported mild and moderate pain and 2% of patients complained of severe pain. With Rubber band ligation, 72% of patients reported no post-operative pain, 26% reported mild and moderate pain and 1% complained of severe pain (P=0.00). Rubber Band ligation and Ultroid are both considered as outpatient procedures for treatment of hemorrhoids. Both methods are mostly used for grade 1, 2 and sometime grade 3 hemorrhoids. In Ultroid method the operator is required to hold the probe for a period of time, and in most cases, the surgeon should spend between 20-25 minutes for the coagulation of three piles. Some surgeons do not have patience for this modality of internal hemorrhoid treatment. In this study we achieved acceptable results comparable with those of other techniques.

The role of protein disulfide isomerase in the post-ligation phase of β3 integrin-dependent cell adhesion.

PubMed

Leader, Avi; Mor-Cohen, Ronit; Ram, Ron; Sheptovitsky, Vera; Seligsohn, Uri; Rosenberg, Nurit; Lahav, Judith

2015-12-01

Protein disulfide isomerase (PDI) catalyzes disulfide bond exchange. It is crucial for integrin-mediated platelet adhesion and aggregation and disulfide bond exchange is necessary for αIIbβ3 and αvβ3 activation. However, the role of disulfide bond exchange and PDI in the post-ligation phase of αIIbβ3 and αvβ3 mediated cell adhesion has yet to be determined. To investigate a possible such role, we expressed wild type (WT) human αIIb and either WT human β3, or β3 harboring single or double cysteine to serine substitutions disrupting Cys473-Cys503 or Cys523-Cys544 bonds, in baby hamster kidney (BHK) cells, leading to expression of both human αIIbβ3 and a chimeric hamster/human αvβ3. Adhesion to fibrinogen-coated wells was studied in the presence or absence of bacitracin, a PDI inhibitor, with and without an αvβ3 blocker. Flow cytometry showed WT and mutant αIIbβ3 expression in BHK cells and indicated that mutated αIIbβ3 receptors were constitutively active while WT αIIbβ3 was inactive. Both αIIbβ3 and αvβ3 integrins, WT and mutants, mediated adhesion to fibrinogen as shown by reduced but still substantial adhesion following treatment with the αvβ3 blocker. Mutated αIIbβ3 integrins disrupted in the Cys523-Cys544 bond still depended on PDI for adhesion as shown by the inhibitory effect of bacitracin in the presence of the αvβ3 blocker. Mutated integrins disrupted in the Cys473-Cys503 bond showed a similar trend. PDI-mediated disulfide bond exchange plays a pivotal role in the post-ligation phase of αIIbβ3-mediated adhesion to fibrinogen, while this step in αvβ3-mediated adhesion is independent of disulfide exchange. Copyright © 2015 Elsevier Ltd. All rights reserved.

From Reflux Esophagitis to Esophageal Adenocarcinoma

PubMed Central

Souza, Rhonda F.

2016-01-01

Reflux esophagitis causes Barrett's metaplasia, an abnormal esophageal mucosa predisposed to adenocarcinoma. Medical therapy for reflux esophagitis focuses on decreasing gastric acid production with proton pump inhibitors. We have reported that reflux esophagitis in a rat model develops from a cytokine-mediated inflammatory injury, not from a caustic chemical (acid) injury. In this model, refluxed acid and bile stimulate the release of inflammatory cytokines from esophageal squamous cells, recruiting lymphocytes first to the submucosa and later to the luminal surface. Emerging studies on acute reflux esophagitis in humans support this new concept, suggesting that reflux-induced cytokine release may be a future target for medical therapies. Sometimes, reflux esophagitis heals with Barrett's metaplasia, a process facilitated by reflux-related nitric oxide (NO) production and Sonic Hedgehog secretion by squamous cells. We have shown that NO reduces expression of genes that promote a squamous cell phenotype, while Hedgehog signaling induces genes that mediate the development of the columnar cell phenotypes of Barrett's metaplasia. Agents targeting esophageal NO production or Hedgehog signaling conceivably could prevent the development of Barrett's esophagus. Persistent reflux promotes cancer in Barrett's metaplasia. We have reported that acid and bile salts induce DNA damage in Barrett's cells. Bile salts also cause NF-κB activation in Barrett's cells, enabling them to resist apoptosis in the setting of DNA damage, and likely contributing to carcinogenesis. Oral treatment with ursodeoxycholic acid prevents the esophageal DNA damage and NF-κB activation induced by toxic bile acids. Altering bile acid composition might be another approach to cancer prevention. PMID:27331918

Infrared coagulation versus rubber band ligation in early stage hemorrhoids.

PubMed

Gupta, P J

2003-10-01

The ideal therapy for early stages of hemorrhoids is always debated. Some are more effective but are more painful, others are less painful but their efficacy is also lower. Thus, comfort or efficacy is a major concern. In the present randomized study, a comparison is made between infrared coagulation and rubber band ligation in terms of effectiveness and discomfort. One hundred patients with second degree bleeding piles were randomized prospectively to either rubber band ligation (N = 54) or infrared coagulation (N = 46). Parameters measured included postoperative discomfort and pain, time to return to work, relief in incidence of bleeding, and recurrence rate. The mean age was 38 years (range 19-68 years). The mean duration of disease was 17.5 months (range 12 to 34 months). The number of male patients was double that of females. Postoperative pain during the first week was more intense in the band ligation group (2-5 vs 0-3 on a visual analogue scale). Post-defecation pain was more intense with band ligation and so was rectal tenesmus (P = 0.0059). The patients in the infrared coagulation group resumed their duties earlier (2 vs 4 days, P = 0.03), but also had a higher recurrence or failure rate (P = 0.03). Thus, we conclude that band ligation, although more effective in controlling symptoms and obliterating hemorrhoids, is associated with more pain and discomfort to the patient. As infrared coagulation can be conveniently repeated in case of recurrence, it could be considered to be a suitable alternative office procedure for the treatment of early stage hemorrhoids.

Esophageal epiphrenic diverticulum associated with diffuse esophageal spasm.

PubMed

Matsumoto, Hideo; Kubota, Hisako; Higashida, Masaharu; Manabe, Noriaki; Haruma, Ken; Hirai, Toshihiro

2015-01-01

Esophageal diverticulum, a relatively rare condition, has been considered to be associated with motor abnormalities such as conditions that cause a lack of coordination between the distal esophagus and lower esophageal sphincter. We herein report a case of esophageal epiphrenic diverticulum associated with diffuse esophageal spasm. A 73-year-old woman presented with dysphagia and regurgitation. Imaging examinations revealed a right-sided esophageal diverticulum located about 10cm above the esophagogastric junction. High-resolution manometry revealed normal esophageal motility. However, 24-h pH monitoring revealed continuous acidity due to pooling of residue in the diverticulum. An esophageal epiphrenic diverticulum was diagnosed and resected thoracoscopically. Her dysphagia recurred 2 years later. High-resolution manometry revealed diffuse esophageal spasm. The diverticulum in the present case was considered to have been associated with diffuse esophageal spasm. The motility disorder was likely not identified at the first evaluation. In this case, the patient's symptoms spontaneously resolved without any treatment; however, longer-term follow-up is needed. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Mesocaval Shunt Creation for Jejunal Variceal Bleeding with Chronic Portal Vein Thrombosis.

PubMed

Yoon, Ja Kyung; Kim, Man Deuk; Lee, Do Yun; Han, Seok Joo

2018-01-01

The creation of transjugular intrahepatic portosystemic shunt (TIPS) is a widely performed technique to relieve portal hypertension, and to manage recurrent variceal bleeding and refractory ascites in patients where medical and/or endoscopic treatments have failed. However, portosystemic shunt creation can be challenging in the presence of chronic portal vein occlusion. In this case report, we describe a minimally invasive endovascular mesocaval shunt creation with transsplenic approach for the management of recurrent variceal bleeding in a portal hypertension patient with intra- and extrahepatic portal vein occlusion. © Copyright: Yonsei University College of Medicine 2018.

From Reflux Esophagitis to Esophageal Adenocarcinoma.

PubMed

Souza, Rhonda F

Reflux esophagitis causes Barrett's metaplasia, an abnormal esophageal mucosa predisposed to adenocarcinoma. Medical therapy for reflux esophagitis focuses on decreasing gastric acid production with proton pump inhibitors. We have reported that reflux esophagitis in a rat model develops from a cytokine-mediated inflammatory injury, not from a caustic chemical (acid) injury. In this model, refluxed acid and bile stimulate the release of inflammatory cytokines from esophageal squamous cells, recruiting lymphocytes first to the submucosa and later to the luminal surface. Emerging studies on acute reflux esophagitis in humans support this new concept, suggesting that reflux-induced cytokine release may be a future target for medical therapies. Sometimes, reflux esophagitis heals with Barrett's metaplasia, a process facilitated by reflux-related nitric oxide (NO) production and Sonic Hedgehog (Hh) secretion by squamous cells. We have shown that NO reduces expression of genes that promote a squamous cell phenotype, while Hh signaling induces genes that mediate the development of the columnar cell phenotypes of Barrett's metaplasia. Agents targeting esophageal NO production or Hh signaling conceivably could prevent the development of Barrett's esophagus. Persistent reflux promotes cancer in Barrett's metaplasia. We have reported that acid and bile salts induce DNA damage in Barrett's cells. Bile salts also cause NF-x03BA;B activation in Barrett's cells, enabling them to resist apoptosis in the setting of DNA damage and likely contributing to carcinogenesis. Oral treatment with ursodeoxycholic acid prevents the esophageal DNA damage and NF-x03BA;B activation induced by toxic bile acids. Altering bile acid composition might be another approach to cancer prevention. © 2016 S. Karger AG, Basel.

Baveno VI Recommendation on Avoidance of Screening Endoscopy in Cirrhotic Patients: Are We There Yet?

PubMed Central

Silva, Mário Jorge; Bernardes, Carlos; Pinto, João; Loureiro, Rafaela; Duarte, Pedro; Mendes, Milena; Calinas, Filipe

2017-01-01

Introduction Recent studies assessed the predictive value of liver transient elastography, combined or not with platelet count, for the presence of esophageal varices in patients with liver cirrhosis, and multiple cutoffs have been proposed. The Baveno VI consensus states that patients with compensated advanced chronic liver disease, liver stiffness <20 kPa, and a platelet count >150,000 have a very low risk of having varices requiring treatment and can avoid screening endoscopy. We aimed to validate this recommendation in a cohort of cirrhotic patients. Methods Retrospective analysis of all patients evaluated at the Gastroenterology Department (Centro Hospitalar de Lisboa Central) between September 2009 and October 2015 with a liver stiffness (FibroScan®) compatible with liver cirrhosis as well as upper endoscopy and blood tests within 12 months from elastography. Patients on propranolol ≥80 mg/day or carvedilol ≥12.5 mg/day, as well as those with previous variceal bleeding, variceal endoscopic treatments, or cirrhosis decompensations were excluded. We validated the new Baveno VI recommendation and explored alternative cutoffs. Results Ninety-seven patients were analyzed, 76.3% (74/97) male, mean age 54.3 ± 11.2 years. Most patients (55.7%) had no varices and 14.4% had varices requiring treatment. Most patients (78.4%) had cirrhosis related to chronic hepatitis C. If the new Baveno VI recommendation had been applied to this cohort, upper endoscopy would have been avoided in 11.3% (11/97) of patients, none of them with esophageal varices requiring treatment: specificity 100%, sensitivity 13.3%, positive predictive value 100%, and negative predictive value 16.3% for absence of varices requiring treatment. If screening endoscopy had been avoided in those patients with liver stiffness <30 kPa and platelet count ≥120,000, endoscopy would have been avoided in 27.8% (27/97) of patients, none of whom with esophageal varices requiring treatment: specificity 100

Statin use after esophageal cancer diagnosis and survival: A population based cohort study.

PubMed

Cardwell, Chris R; Spence, Andrew D; Hughes, Carmel M; Murray, Liam J

2017-06-01

A recent epidemiological study of esophageal cancer patients concluded statin use post-diagnosis was associated with large (38%) and significant reductions in cancer-specific mortality. We investigated statin use and cancer-specific mortality in a large population-based cohort of esophageal cancer patients. Newly diagnosed [2009-2012] esophageal cancer patients were identified from the Scottish Cancer Registry and linked with the Prescribing Information System and Scotland Death Records (to January 2015). Time-dependent Cox regression models were used to calculate hazard ratios (HR) for cancer-specific mortality and 95% confidence intervals (CIs) by post-diagnostic statin use (using a 6 month lag to reduce reverse causation) and to adjust these HRs for potential confounders. 1921 esophageal cancer patients were included in the main analysis, of whom 651 (34%) used statins after diagnosis. There was little evidence of a reduction in esophageal cancer-specific mortality in statin users compared with non-users after diagnosis (adjusted HR=0.93, 95% CI, 0.81, 1.07) and no dose response associations were seen. However, statin users compared with non-users in the year before diagnosis had a weak reduction in esophageal cancer-specific mortality (adjusted HR=0.88, 95% CI, 0.79, 0.99). In this large population-based esophageal cancer cohort, there was little evidence of a reduction in esophageal cancer-specific mortality with statin use after diagnosis. Copyright © 2017 Elsevier Ltd. All rights reserved.

Chronic thalidomide administration enhances vascular responsiveness to vasopressin in portal-systemic collaterals of bile duct-ligated rats.

PubMed

Chang, Ching-Chih; Wang, Sun-Sang; Huang, Hui-Chun; Lee, Fa-Yauh; Lin, Han-Chieh; Lee, Jing-Yi; Chen, Yi-Chou; Lee, Shou-Dong

2009-05-01

Arginine vasopressin (AVP) controls gastroesophageal variceal bleeding, partly due to its vasoconstrictive effect on portal-systemic collaterals. It has been shown that chronic thalidomide treatment decreases portal pressure, attenuates hyperdynamic circulation and inhibits vascular endothelial growth factor (VEGF) and tumor necrosis factor (TNF)-alpha in partially portal vein-ligated rats. This study investigated the effects of chronic thalidomide treatment on portal-systemic collateral vascular responsiveness to AVP in common bile duct-ligated (CBDL) cirrhotic rats. In the first series, CBDL-induced cirrhotic rats received thalidomide (50 mg/kg/day orally) or distilled water (control) from the 35th to 42nd day after ligation. On the 43rd day after ligation, the body weight, mean arterial pressure, portal pressure, and heart rate were measured. An in situ collateral vascular perfusion model was used to obtain the cumulative concentration-response curves of collateral vessels to AVP (10(-10) to 3 x 10(-7) M). Plasma levels of VEGF and TNF-alpha were measured, and expressions of VEGF and TNF-alpha mRNA in the left adrenal veins were also determined. In the second series, the cumulative concentration-response curves of collateral vessels to AVP in CBDL rats with or without thalidomide (10(-5) M) preincubation in the perfusate were obtained. The thalidomide and control groups were not significantly different in terms of heart rate, mean arterial pressure and portal pressure (p > 0.05). The collateral vascular perfusion pressure change to AVP was significantly enhanced at 10(-8) M after thalidomide treatment (p = 0.041). Compared with the control group, thalidomide-treated rats had significantly lower plasma VEGF levels (p < 0.001), accompanied by an insignificant reduction in plasma TNF-alpha levels (p > 0.05). The expressions of VEGF and TNF-alpha mRNA in the left adrenal veins of thalidomide-treated CBDL rats were not significantly changed compared with those of the

Surgical treatment analysis of idiopathic esophageal achalasia.

PubMed

Aquino, José Luis Braga de; Said, Marcelo Manzano; Pereira, Douglas Rizzanti; Amaral, Paula Casals do; Lima, Juliana Carolina Alves; Leandro-Merhi, Vânia Aparecida

2015-01-01

Idiopathic esophageal achalasia is an inflammatory disease of unknown origin, characterized by aperistalsis of the esophageal body and failure of the lower esophageal sphincter in response to swallowing, with consequent dysphagia. To demonstrate the results of surgical therapy in these patients, evaluating the occurred local and systemic complications. Were studied retrospectively 32 patients, 22 of whom presented non-advanced stage of the disease (Stage I/II) and 10 with advanced disease (Stage III/IV). All of them had the clinical conditions to be submitted to surgery. The diagnoses were done by clinical, endoscopic, cardiological, radiological and esophageal manometry analysis. Pre-surgical evaluation was done with a questionnaire based on the most predisposing factors in the development of the disease and the surgical indication was based on the stage of the disease. The patients with non-advanced stages were submitted to cardiomyotomy with fundoplication, wherein in the post-surgical early assessment, only one (4,4%) presented pulmonary infection, but had a good outcome. In patients with advanced disease, seven were submitted to esophageal mucosectomy preserving the muscular layer, wherein one patient (14,2%) presented dehiscence of gastric cervical esophagus anastomosis as well as pulmonary infection; all of these complications were resolved with proper specific treatment; the other three patients with advanced stage were submitted to transmediastinal esophagectomy; two of them presented hydropneumothorax with good evolution, and one of them also presented fistula of the cervical esophagogastric anastomosis, but with spontaneous healing after conservative treatment and nutritional support. The two patients with fistula of the cervical anastomosis progressed to stenosis, with good results after endoscopic dilations. In the medium and long term assessment done in 23 patients, all of them reported improvement in life quality, with return to swallowing. The

Helicobacter pylori infection among patients with liver cirrhosis.

PubMed

Pogorzelska, Joanna; Łapińska, Magda; Kalinowska, Alicja; Łapiński, Tadeusz W; Flisiak, Robert

2017-10-01

Inflammatory changes in the stomach caused by Helicobacter pylori indirectly and directly affect liver function. Moreover, the bacteria may worsen the course of the liver cirrhosis. The study aimed at evaluating the incidence of H. pylori infection among patients with liver cirrhosis, depending on the etiology and injury stage, scored according to Child-Pugh classification. Stage of esophageal varices and endoscopic inflammatory lesions in the stomach were evaluated, depending on the presence of H. pylori infection. The study included 147 patients with liver cirrhosis: 42 were infected with hepatitis C virus, 31 were infected with hepatitis B virus, 56 had alcoholic liver cirrhosis, and 18 had primary biliary cirrhosis. Diagnosis of H. pylori infection was performed based on the presence of immunoglobulin G antibodies in serum. H. pylori infection was found in 46.9% of patients. The incidence of H. pylori infection among patients with postinflammatory liver cirrhosis was significantly higher (P=0.001), as compared with patients with alcoholic liver cirrhosis. Ammonia concentration was significantly higher in patients infected with H. pylori, compared with noninfected individuals (129 vs. 112 μmol/l; P=0.002). Incidence of H. pylori infection in patients without esophageal varices was significantly lower compared with patients with esophageal varices (14 vs. 60%; P<0.001). H. pylori infection is significantly more frequent among patients with postinflammatory liver cirrhosis (infected with hepatitis C virus or hepatitis B virus) than in patients with alcoholic liver cirrhosis or primary biliary cirrhosis. H. pylori infection correlates with elevated concentration of blood ammonia and the incidence of esophageal varices.

[Self-ligating edgewise brackets. An overview].

PubMed

Katsaros, C; Dijkman, J F

2003-01-01

During the last years both the manufactures and the orthodontists seem to show an increased interest in self-ligating brackets. This paper aims to present the history of self-ligating systems, to describe the three mostly used bracketsystems and to review the relevant literature. It seems from the existing data that self-ligating brackets have certain advantages over conventionally ligated brackets. However, the data are still thin and a high need for well designed clinical trials exist.

Endoscopic excavation for the treatment of small esophageal subepithelial tumors originating from the muscularis propria.

PubMed

Ye, Li-ping; Zhu, Lin-hong; Zhou, Xian-bin; Mao, Xin-li; Zhang, Yu

2015-01-01

This study was designed to evaluate the safety and efficacy of endoscopic excavation for esophageal subepithelial tumors originating from the muscularis propria. Forty-five patients with esophageal subepithelial tumors originating from the muscularis propria were treated with endoscopic excavation between January 2010 and June 2012. The key steps were: (1) making several dots around the tumor; (2) incising the mucosa along with the marker dots, and then seperating the tumor from the muscularis propria by using a hook knife or an insulated-tip knife; (3) closing the artificial ulcer with clips after the tumor was removed. The mean tumor diameter was 1.1 ± 0.6 cm. Endoscopic excavation was successfully performed in 43 out of 45 cases (95.6%), the other 2 cases were ligated with nylon rope. During the procedure perforation occurred in 4 (8.9%) patients, who recovered after conservative treatment. No massive bleeding or delayed bleeding occurred. Histologic diagnosis was obtained from 43 (95.6%) patients. Pathological diagnoses of these tumors were leiomyomas (38/43) and gastrointestinal stromal tumors (5/43). Endoscopic excavation is a safe and effective method for the treatment of small esophageal subepithelial tumors originating from the muscularis propria.

Optimizing tubal ligation service delivery: a prospective cohort study to measure the task-sharing experience of Marie Stopes International Ethiopia.

PubMed

Nuccio, Olivia; Sendek, Birhanu; Park, Min Hae; Mesele, Tesfaye; Okello, Francis Ogojo; Gordon-Maclean, Cristin

2017-03-01

The Ethiopian government implements a progressive task-sharing policy for health services as a strategy to address shortages of highly skilled providers and increase access to critical services, such as family planning. Since 2009, Marie Stopes International Ethiopia has trained health officers to provide tubal ligations, a permanent method of family planning, as part of its task-sharing strategy. The objectives of this research were to evaluate task-sharing tubal ligations to health officers at Marie Stopes International Ethiopia, specifically: (a) to investigate safety, as measured by the proportion of major adverse events; (b) to evaluate the feasibility, as measured by adherence to the standard tubal ligation procedure protocol and (c) to investigate acceptability to clients of the tubal ligation procedure provided by health officers. We established a prospective cohort of women aged  ≥18 years presenting for tubal ligation at Marie Stopes International Ethiopia sites in three regions in Ethiopia (March–May 2014). Data on adverse events (incomplete procedure, pain, bleeding, infection, perforation) were collected intra-operatively; peri-operatively (1-h post-procedure); and post-operatively (7 days post-procedure). To measure feasibility, 65% of procedures were selected for ‘audit’, where a nurse observed and scored health officers adherence to standard protocol using an 18-item checklist. To assess acceptability, women were asked about their satisfaction with the procedure. In total, 276 women were enrolled in the study. 97.5% of procedures took place in rural settings. All participants were followed up 7 days post-procedure (100% response rate). The overall proportion of major adverse events was 3% (95% CI 1–6%). The most frequent adverse event was ‘failure to complete the TL’ (2.2%, n = 6). The average score on protocol adherence was 96.9%. Overall, 98.2% (n = 271) of clients would recommend the procedure to a friend. Findings from

Impaired esophageal motor function in eosinophilic esophagitis.

PubMed

Santander, Cecilio; Chavarría-Herbozo, Carlos M; Becerro-González, Irene; Burgos-Santamaría, Diego

2015-10-01

Eosinophilic esophagitis is a chronic immunoallergic inflammatory disease of the esophagus that represents a major cause of digestive morbidity among the pediatric and young adult populations. Despite the fact that key symptoms in adults include dysphagia and food impaction, many patients lack structural changes in the esophagus to account for their complaints, which suggests the presence of underlying motor disorders and esophageal distensibility impairment. In the last few years the esophageal motility of these patients has been studied using various approaches, most particularly high-resolution manometry, ambulatory manometry, and impedance planimetry. This review focuses on the most relevant findings and scientific evidence regarding esophageal motor disorders in eosinophilic esophagitis.

Postoperative esophageal leak management with the Polyflex esophageal stent.

PubMed

Freeman, Richard K; Ascioti, Anthony J; Wozniak, Thomas C

2007-02-01

Leak after esophageal anastomosis or perforation repair prolongs hospitalization, prevents oral hydration and nutrition, and can produce localized infection or sepsis. This investigation reviews our experience treating postoperative esophageal leaks with the Polyflex esophageal stent (Boston Scientific, Natick, Mass). Over a 30-month period, patients with a postoperative esophageal leak were treated with the Polyflex stent for leak occlusion. Leak occlusion was confirmed by means of esophagraphy. Patients were followed until their stent was removed and their esophageal leak had resolved. Twenty-one patients had 27 stents placed for leak occlusion after esophagectomy (n = 5), esophageal perforation (n = 5), surgical (n = 4) or endoscopic (n = 2) antireflux procedure, and esophageal diverticulectomy (n = 3) or myotomy (n = 2). The mean interval between surgical intervention and stent placement was 12 +/- 8 days (range, 3-31 days). Occlusion of the leak occurred in 20 patients. One patient experienced a dehiscence of the surgical esophageal perforation repair requiring esophageal diversion. Stent migration requiring repositioning (n = 3) or replacement (n = 4) occurred in 5 (24%) patients. Twenty (95%) stents were removed without residual leak (mean, 51 +/- 43 days; range, 15-175 days). One patient had a stricture after stent removal that required endoscopic dilatation. One patient in this series died. The Polyflex esophageal stent is an effective method for occluding a postoperative esophageal leak. It rapidly eliminates contamination of the mediastinum, pleura, and peritoneum; allows oral hydration and nutrition; and is easily removable. These stents also offer an appealing alternative to traditional esophageal diversion and subsequent reconstruction in patients with a persistent esophageal leak.

Physical ExeRcise Following Esophageal Cancer Treatment (PERFECT) study: design of a randomized controlled trial.

PubMed

van Vulpen, Jonna K; Siersema, Peter D; van Hillegersberg, Richard; Nieuwenhuijzen, Grard A P; Kouwenhoven, Ewout A; Groenendijk, Richard P R; van der Peet, Donald L; Hazebroek, Eric J; Rosman, Camiel; Schippers, Carlo C G; Steenhagen, Elles; Peeters, Petra H M; May, Anne M

2017-08-18

Following esophagectomy, esophageal cancer patients experience a clinically relevant deterioration of health-related quality of life, both on the short- and long-term. With the currently growing number of esophageal cancer survivors, the burden of disease- and treatment-related complaints and symptoms becomes more relevant. This emphasizes the need for interventions aimed at improving quality of life. Beneficial effects of post-operative physical exercise have been reported in several cancer types, but so far comparable evidence in esophageal cancer patients is lacking. The aim of this study is to investigate effects of physical exercise on health-related quality of life in esophageal cancer patients following surgery. The Physical ExeRcise Following Esophageal Cancer Treatment (PERFECT) study is a multicenter randomized controlled trial including 150 esophageal cancer patients after surgery with curative intent. Patients are randomly allocated to an exercise group or usual care group. The exercise group participates in a 12-week combined aerobic and resistance exercise program, supervised by a physiotherapist near the patient's home-address. In addition, participants in the exercise group are requested to be physically active for at least 30 min per day, every day of the week. Participants allocated to the usual care group are asked to maintain their habitual physical activity pattern. The primary outcome is health-related quality of life (EORTC-QLQ-C30). Secondary outcomes include esophageal cancer specific quality of life, fatigue, anxiety and depression, sleep quality, work-related factors, cardiorespiratory fitness (VO 2peak ), muscle strength, physical activity, malnutrition risk, anthropometry, blood markers, recurrence of disease and survival. All questionnaire outcomes, diaries and accelerometers are assessed at baseline, post-intervention (12 weeks post-baseline) and 24 weeks post-baseline. Physical fitness, anthropometry and blood markers are assessed

Effect of Low-Dose Aspirin on Chronic Acid Reflux Esophagitis in Rats.

PubMed

Masuda, Takahiro; Yano, Fumiaki; Omura, Nobuo; Tsuboi, Kazuto; Hoshino, Masato; Yamamoto, Se Ryung; Akimoto, Shunsuke; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2018-01-01

Clinical role of low-dose aspirin (LDA) in pathogenesis of gastroesophageal reflux disease is by far controversial. This can be attributed to the paucity of basic research detailing the mechanism of LDA-induced esophageal mucosal injury (EI) on underlying chronic acid reflux esophagitis (RE). The aim of this study was to clarify the effect of LDA on chronic RE in rats. Esophagitis was induced in 8-week-old male Wistar rats by ligating the border between forestomach and glandular portion with a 2-0 silk tie and covering the duodenum with a small piece of 18-Fr Nélaton catheter. Seventy-eight chronic RE rat models were divided into five treatment groups, consisting of orally administered vehicle (controls), and aspirin doses of 2, 5, 50 or 100 mg/kg once daily for 28 days. EI was assessed by gross area of macroscopic mucosal injury, severity grade of esophagitis and microscopic depth of infiltration by inflammatory cells. Area of esophagitis in animals with aspirin dose of 100 mg/kg/day showed a 36.5% increase compared with controls, although it failed to achieve statistical significance (p = 0.812). Additionally, the rate of severe EI was increased in animals with aspirin dose of 100 mg/kg/day as compared with controls (p < 0.05). The grade of severity correlated with the depth of inflammation (r s  = 0.492, p < 0.001). Maximal dose aspirin (100 mg/kg/day) contributed in exacerbating preexisting EI. LDA (2 and 5 mg/kg/day), on the other hand, did not affect chronic RE in this model. LDA seems to be safe for use in patients with chronic RE.

Esophageal Reconstruction with the Stomach, a Functional Dilemma?

PubMed

Predescu, Dragoş; Constantinoiu, Silviu

2018-01-01

Background: A few decades ago, esophageal substitution was mainly dedicated particularly in postcaustic esophageal stenosis; currently, the reconstruction has expanded its palette of indications to other areas of benign esophageal pathology (severe motor disorders, esophageal achalasia with multiple relapses, peptic stenosis, etc.) but has also become a quasi-obligatory final time in the esophagectomy for cancer whenever it is possible. The techniques of esophageal reconstruction using the stomach, regardless of the indication and the chosen technical option, remain a valuable and effective method. A number of striking arguments advocate for one or another type of gastric graft: anatomic factors more than convenient (vascularization, sufficient length, a wall structure favorable for suture, etc.) and a sustainable surgical intervention (length, approach, complexity of the surgical steps digestive disorders after surgery, post-therapeutic functionality, etc.). Choosing a technique or another, beyond pathological arguments, should take into account remote functionality, with a clear impact on metabolic status and quality of life. So, according to this criterion, can we functionally justify a type or another of gastric restoration? Finally, the proof of an adequate solution is relatively easy to appreciate: has swallowing been restored and if so, the result has been maintained over time? For oncological cases, the assessment should also take into account the chronological criterion of the postoperative survival rate. Methods: The statistically rated lot ranged from 1981 to 2016 and included 268 patients with surgical interventions for esophageal stenosis, distributed according to etiopathogenesis and indication in 201 reconstructions for post-caustic stenosis, and 67 for post-esophagectomy replacement for neoplasm. The techniques used for remote functional evaluation included: barium swallow, endoscopy + biopsy, and in cases with obvious changes pH measurement/24 h

Diagnosis and management of esophageal achalasia.

PubMed

Stavropoulos, Stavros N; Friedel, David; Modayil, Rani; Parkman, Henry P

2016-09-13

Achalasia is a rare esophageal motility disorder that is usually idiopathic in origin. It is characterized by dysphagia, and patients often have chest pain, regurgitation, weight loss, and an abnormal barium radiograph showing esophageal dilation with narrowing at the gastroesophageal junction. Abnormal or absent esophageal peristalsis and impaired relaxation of the lower esophageal sphincter (LES) are typically seen on esophageal manometry. The advent of high resolution manometry (HRM) has allowed more precise diagnosis of achalasia, subtype designation, and differentiation from other esophageal motor disorders with an initial seminal publication in 2008 followed by further refinements of what has been termed the Chicago classification. Potential treatments include drugs, endoscopic botulinum toxin injection, balloon dilation, traditional surgery (usually laparoscopic Heller myotomy; LHM), and a novel, less invasive, natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy termed peroral endoscopic myotomy (POEM). The first human POEM was performed in 2008, with the first publication appearing in 2010 and evidence now rapidly accumulating showing POEM to be comparable to traditional surgery in terms of clinical success and radiologic and manometric post-therapy outcomes. This review discusses the diagnosis and management of achalasia with particular emphasis on the recent developments of HRM and POEM, which arguably represent the most important advances in the field since the advent of laparoscopic Heller myotomy in the 1990s. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Risk factors for esophageal stenosis after entire circumferential endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma.

PubMed

Miwata, Tomohiro; Oka, Shiro; Tanaka, Shinji; Kagemoto, Kenichi; Sanomura, Yoji; Urabe, Yuji; Hiyama, Toru; Chayama, Kazuaki

2016-09-01

Endoscopic submucosal dissection (ESD) is used to perform en block resection for esophageal squamous cell carcinoma, but it is strongly associated with postoperative stenosis, especially during entire circumferential resection. This study aimed to clarify the risk factors for refractory postoperative stenosis after entire circumferential esophageal ESD. Nineteen patients who underwent entire circumferential esophageal ESD from February 2006 to December 2013 at Hiroshima University Hospital were divided into two groups: refractory postoperative stenosis [≥6 endoscopic balloon dilation (EBD) procedures, 12 lesions in 12 patients] and non-refractory postoperative stenosis (≤5 EBD procedures, 7 lesions in 7 patients). We retrospectively examined the patient factors (age, sex, alcohol consumption, smoking index, and chemoradiation therapy history), tumor factors (location, macroscopic type, fibrosis, and depth), and treatment factors (mean procedure time, entire circumferential resection diameter, muscle layer damage, and steroid administration method) between the two groups. Muscle layer damage (p = 0.019) and ≥5 cm of longitudinal mucosal defect length after entire circumferential esophageal ESD (p = 0.010) were significant factors associated with the refractory group. Regarding the patient and tumor factors, there were no significant differences between the two groups. Our data suggest that refractory post-ESD stenosis occurs after entire circumferential esophageal ESD with muscle layer damage and ≥5 cm of longitudinal mucosal defect length.

Hypotension following patent ductus arteriosus ligation: the role of adrenal hormones

PubMed Central

Clyman, Ronald I.; Wickremasinghe, Andrea; Merritt, T. Allen; Solomon, Tabitha; McNamara, Patrick; Jain, Amish; Singh, Jaideep; Chu, Alison; Noori, Shahab; Sekar, Krishnamurthy; Lavoie, Pascal M.; Attridge, Joshua T.; Swanson, Jonathan R.; Gillam-Krakauer, Maria; Reese, Jeff; DeMauro, Sara; Poindexter, Brenda; Aucott, Sue; Satpute, Monique; Fernandez, Erika; Auchus, Richard J.

2014-01-01

Objective To test the hypothesis that an impaired adrenal response to stress might play a role in the hypotension that follows patent ductus arteriosus (PDA) ligation. Study design We performed a multicenter study of infants born at <32 weeks gestation who were about to undergo PDA ligation. Serum adrenal steroids were measured three times: before and after a cosyntropin (1.0 microgram/kg) stimulation test (performed prior to the ligation), and at 10–12 hours after the ligation. A standardized approach for diagnosis and treatment of postoperative hypotension was followed at each site. A modified Inotrope Score (1 x dopamine (μg/kg/min) + 1 x dobutamine) was used to monitor the catecholamine support an infant received. Infants were considered to have catecholamine-resistant hypotension if their highest Inotrope Score was >15. Results Of 95 infants enrolled, 43 (45%) developed hypotension and 14 (15%) developed catecholamine-resistant hypotension. Low post-operative cortisol levels were not associated with the overall incidence of hypotension following ligation. However, low cortisol levels were associated with the refractoriness of the hypotension to catecholamine treatment. In a multivariate analysis: the odds ratio for developing catecholamine-resistant hypotension was OR=36.6, CI=2.8–476, p=0.006. Low cortisol levels (in infants with catecholamine-resistant hypotension) were not due to adrenal immaturity or impairment; their cortisol precursor concentrations were either low or unchanged and their response to cosyntropin was similar to infants without catecholamine-resistant hypotension. Conclusion Infants with low cortisol concentrations following PDA ligation are likely to develop postoperative catecholamine-resistant hypotension. We speculate that decreased adrenal stimulation, rather than an impaired adrenal response to stimulation, may account for the decreased production. PMID:24636853

Customization of laparoscopic gastric devascularization and splenectomy for gastric varices based on CT vascular anatomy.

PubMed

Kawanaka, Hirofumi; Akahoshi, Tomohiko; Nagao, Yoshihiro; Kinjo, Nao; Yoshida, Daisuke; Matsumoto, Yoshihiro; Harimoto, Norifumi; Itoh, Shinji; Yoshizumi, Tomoharu; Maehara, Yoshihiko

2018-01-01

Laparoscopic gastric devascularization(Lap GDS) and splenectomy (SPL) for gastric varices is technically challenging because of highly developed collateral vessels and bleeding tendency. We investigated the feasibility of customization of Lap GDS and SPL based on CT vascular anatomy. We analyzed 61 cirrhotic patients with gastric varices who underwent Lap GDS and SPL between 2006 and 2014. Lap GDS was customized according to the afferent feeding veins (left gastric vein (LGV) and/or posterior gastric vein (PGV)/short gastric vein (SGV)) and efferent drainage veins (gastrorenal shunt and/or gastrophrenic shunt, or numerous retroperitoneal veins) based on CT imaging. Thirty-four patients with efferent drainage veins suitable for balloon-occluded retrograde transvenous obliteration (B-RTO) underwent B-RTO instead of surgical GDS, with subsequent Lap SPL. Among 27 patients with gastric varices unsuitable for B-RTO, 15 patients with PGV/SGV underwent Lap GDS of the greater curvature and SPL, and 12 patients with LGV or LGV/PGV/SGV underwent Lap GDS of the greater and lesser curvature and SPL. The mean operation time was 294 min and mean blood loss was 198 g. There was no mortality or severe morbidity. Gastric varices were eradicated in all 61 patients, with no bleeding or recurrence during a mean follow-up of 55.9 months. The cumulative 3-, 5-, and 7-year survival rates were 92, 82, and 64%, respectively. Lap GDS and SPL customized based on CT vascular anatomy is a safe and effective procedure for treating gastric varices.

Embolia cutis medicamentosa: an unusual adverse reaction to terlipressin

PubMed Central

Gatos-Gatopoulos, Polychronis; Kostantoudakis, Stephanos; Panayiotides, Ioannis G.; Dimitriadis, George D.; Triantafyllou, Konstantinos

2017-01-01

Terlipressin is a synthetic long-acting analog of vasopressin widely used to control variceal bleeding by lowering portal venous pressure. We report an unusual adverse reaction to terlipressin in a 78-year-old patient with esophageal variceal bleeding who developed skin necrosis soon after treatment initiation. Skin biopsy revealed embolia cutis medicamentosa. PMID:29118569

[Latex ligation in treatment of chronic hemorrhoids].

PubMed

Ektov, V N; Somov, K A

2015-01-01

We analyzed the results of treatment of 432 patients with chronic hemorrhoids using different variants of latex ligation. New technique including ligation of mucosa and submucosa of low-ampullar rectum providing ligation of hemorrhoidalvessels, lifting and recto-anal repair is developed and suggested. This method is advisable to use in case of chronic internal hemorrhoids stages I and II. The authors recommend simultaneous combined ligation of mucosa of low-ampullar rectum and internal hemorrhoids for stages III and IV. Different variants of latex ligation with external hemorrhoids excision were used in 103 patients. Pointed variants of latex ligation preserve important advantages including mini-invasiveness, simplicity and wide availability, low cost. Good remote results were obtained after these procedures in 87.3% of observations. Suggested tactics extends use of latex ligation and increases its effectiveness in treatment of different stages and forms of chronic hemorrhoids.

First bleeding episode from oesophageal varices in cirrhotic patients: a prospective study of endoscopic predictive factors.

PubMed

Colombo, E; Casiraghi, M A; Minoli, G; Prada, A; Terruzzi, V; Bortoli, A; Carnovali, M; Gullotta, R; Imperiali, G; Comin, U

1995-09-01

Two hundred patients affected by liver cirrhosis and oesophageal varices were studied in 9 Gastrointestinal Units in Lombardy (Northern Italy) in order to assess factors possibly related to variceal bleeding. Only patients without any previous episode of gastrointestinal bleeding were included in the prospective evaluation. For each patient demographic data, aetiology of cirrhosis, various clinical and biochemical parameters able to group patients into the three Child-Pugh Classes, endoscopic items for calculation of Beppu's and of NIEC prognostic scores were recorded on computerized cards. Patients were regularly interviewed every three months for one year and underwent an upper gastrointestinal endoscopy at enrollment, after six months and in case of bleeding. Within the twelve-month follow-up period, 29 out of the 200 patients (14%) bled and 52 out of 200 died (26%). In 16 of the 52 patients who died (59% of bleeding patients) death was directly related to gastrointestinal bleeding. Bleeding from oesophageal varices was endoscopically proven in 19/29 patients, in another 9 bleeding was classified as from unknown source and in one patient a bleeding gastric ulcer was diagnosed. Univariate analysis of all the recorded clinical, biochemical and endoscopic parameters, performed by Chi-square method and Fisher exact test showed that the presence of RWM (p < 0.001) was the only factor significantly associated to variceal bleeding within one year. Relationship between size of varices and bleeding was very close to the statistical significance but did not achieve it (p = 0.058).

Bleeding Duodenal: Varices Treatment by TIPS and Transcatheter Embolization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lopera, Jorge E.; Arthurs, Blain; Scheuerman, Christian

2008-03-15

We describe our clinical experience in 4 patients with portal hypertension who presented with bleeding mesenteric varices originating from the superior mesenteric vein with retrograde filling of collaterals draining into the inferior vena cava. The clinical presentation, imaging findings, and potential therapeutic management are discussed.

Prognostic scores in oesophageal or gastric variceal bleeding.

PubMed

Ohmann, C; Stöltzing, H; Wins, L; Busch, E; Thon, K

1990-05-01

Numerous scoring systems have been developed for the prediction of outcome of variceal bleeding; however, only a few have been evaluated adequately. The object of this study was to improve the classical Child-Pugh score (CPS) and to test other scores from the literature. Patients (n = 82) with endoscopically confirmed variceal bleeding and long-term sclerotherapy were included in the study. Linear logistic regression (LR) was applied to different sets of prognostic variables with regard to 30-day mortality. In addition, scores from the literature were evaluated on the data set. Performance was measured by the accuracy and receiver-operating characteristic curves. The application of LR to all five CPS variables (accuracy, 80%) was superior to the classical CPS (70%). LR with selection from the CPS variables or from other sets of variables resulted in no improvement. Compared with CPS only three scores from the literature, mainly based on subsets of the CPS variables, showed an improved accuracy. It is concluded that CPS is still a good scoring system; however, it can be improved by statistical analysis using the same variables.

Clinical Implications and Pathogenesis of Esophageal Remodeling in Eosinophilic Esophagitis

PubMed Central

Hirano, Ikuo; Aceves, Seema S.

2014-01-01

In eosinophilic esophagitis (EoE), remodeling changes are manifest histologically in both the epithelium as well as in the subepithelium where lamina propria (LP) fibrosis, expansion of the muscularis propria and increased vascularity occur. The major clinical symptoms and complications of EoE are largely consequences of esophageal remodeling. Important mediators of the process include IL-5, IL-13, TGFβ1, mast cells, fibroblasts and eosinophils. Methods to detect remodeling effects include upper endoscopy, histopathology, barium esophagram, endoscopic ultrasonography, esophageal manometry, and functional luminal imaging. These modalities provide evidence of organ dysfunction that include focal and diffuse esophageal strictures, expansion of the mucosa and subepithelium, esophageal motor abnormalities and reduced esophageal distensibility. Complications of food impaction and perforations of the esophageal wall have been associated with reduction in esophageal caliber and increased esophageal mural stiffness. The therapeutic benefits of topical corticosteroids and elimination diet therapy in resolving mucosal eosinophilic inflammation of the esophagus are evident. Available therapies, however, have demonstrated variable ability to reverse existing remodeling changes of the esophagus. Systemic therapies that include novel, targeted biologic agents have the potential of addressing subepithelial remodeling. Esophageal dilation remains a useful, adjunctive therapeutic maneuver in symptomatic adults with esophageal stricture. As novel treatments emerge, it is essential that therapeutic endpoints account for the fundamental contributions of esophageal remodeling to overall disease activity. PMID:24813517

Repair of esophageal atresia with proximal fistula using endoscopic magnetic compression anastomosis (magnamosis) after staged lengthening.

PubMed

Dorman, Robert M; Vali, Kaveh; Harmon, Carroll M; Zaritzky, Mario; Bass, Kathryn D

2016-05-01

We describe the treatment of a patient with long-gap esophageal atresia with an upper pouch fistula, mircogastria and minimal distal esophageal remnant. After 4.5 months of feeding via gastrostomy, a proximal fistula was identified by bronchoscopy and a thoracoscopic modified Foker procedure was performed reducing the gap from approximately 7-5 cm over 2 weeks of traction. A second stage to ligate the fistula and suture approximate the proximal and distal esophagus resulted in a gap of 1.5 cm. IRB and FDA approval was then obtained for endoscopic placement of 10-French catheter mounted magnets in the proximal and distal pouches promoting a magnetic compression anastomosis (magnamosis). Magnetic coupling occurred at 4 days and after magnet removal at 13 days an esophagram demonstrated a 10 French channel without leak. Serial endoscopic balloon dilation has allowed drainage of swallowed secretions as the baby learns bottling behavior at home.

Long-term serum bile acid concentrations in 51 dogs after complete extrahepatic congenital portosystemic shunt ligation.

PubMed

Bristow, P; Tivers, M; Packer, R; Brockman, D; Ortiz, V; Newson, K; Lipscomb, V

2017-08-01

To report the long-term bile acid stimulation test results for dogs that have undergone complete suture ligation of a single congenital extrahepatic portosystemic shunt. Data were collected from the hospital records of all dogs that had undergone a complete suture ligation of a single congenital extrahepatic portosystemic shunt. Owners were invited to return to the referral centre or their local veterinarian for repeat serum bile acid measurement. Dogs diagnosed with idiopathic epilepsy and undergoing bile acid stimulation tests were used as a comparison population. Fifty-one study dogs were included, with a mean follow-up time of 62 months. 48 dogs had no evidence of multiple acquired shunts and a significant reduction in the pre- and post-prandial serum bile acid concentrations at long-term follow-up compared with pre-operative measurements. Pre- and post-prandial serum bile acids were statistically significantly greater for dogs that had undergone a full ligation (with no evidence of multiple acquired shunts) at all time points compared to the control dogs (P<0·001 for all comparisons). The results suggest that in dogs treated with complete suture ligation mild increases in serum bile acids are not clinically relevant if there are no physical examination abnormalities, a normal body condition score and no relapse in clinical signs. © 2017 British Small Animal Veterinary Association.

Study Points to Genetic Subtypes of Esophageal Cancer

Cancer.gov

A Cancer Currents blog post about a study by The Cancer Genome Atlas Research Network that identified distinct genetic and molecular changes in esophageal cancers that could improve their classification and identify potential new treatments.

A novel murine model of esophageal nonerosive reflux disease: from inflammation to impairment in mucosal integrity.

PubMed

Silva, Renan O; Oliveira, Francisco Fábio B; Bingana, Rudy D; Arruda, Mailton O; Woodland, Philip; Lee, Chung; Souza, Miguel A N; Soares, Pedro M G; Santos, Armênio A; Sifrim, Daniel; Souza, Marcellus H L P

2017-06-01

Nonerosive reflux disease (NERD) is a highly prevalent phenotype of the gastroesophageal reflux disease. In this study, we developed a novel murine model of NERD in mice with microscopic inflammation and impairment in the epithelial esophageal barrier. Female Swiss mice were subjected to the following surgical procedure: the transitional region between the forestomach and the glandular portion of the stomach was ligated, and a nontoxic ring was placed around the duodenum near the pylorus. The control group underwent sham surgery. The animals were euthanized at 1, 3, 7, and 14 days after surgery. Survival and body weight were monitored daily. Esophageal wet weight, macroscopic lesion, histopathological alterations, myeloperoxidase (MPO) activity, cytokine levels, transepithelial electrical resistance (TEER), and mucosal permeability were evaluated. The survival rate was 78% at 14 days, with mild loss in body weight. Surgery did not induce erosive esophagitis but instead induced microscopic inflammation and increased esophageal wet weight, IL-6, keratinocyte-derived cytokine (KC) levels, and MPO activity with maximal peak between 3 and 7 days and resolution at 14 days postsurgery. Epithelial esophageal barrier was evaluated in operated mice at 7 and 14 days postsurgery; a decrease in TEER and increase in the esophageal epithelial permeability were observed compared with the sham-operated group. In addition, the inhibition of acid secretion with omeprazole significantly prevented the esophageal inflammation and impairment of barrier function at 7 days postsurgery. Thus we established a novel experimental model of NERD in mice, which can contribute to understanding the pathophysiological events associated with NERD. NEW & NOTEWORTHY In this study, we standardized an experimental model of nonerosive reflux disease (NERD) in mice. This model involves an acute inflammatory response followed by impaired esophageal mucosal integrity, even in the absence of inflammation

Two surgical procedures for esophagogastric variceal bleeding in patients with portal hypertension

PubMed Central

Yang, Lin; Yuan, Li-Juan; Dong, Rui; Yin, Ji-Kai; Wang, Qing; Li, Tao; Li, Jiang-Bin; Du, Xi-Lin; Lu, Jian-Guo

2013-01-01

AIM: To determine the clinical value of a splenorenal shunt plus pericardial devascularization (PCVD) in portal hypertension (PHT) patients with variceal bleeding. METHODS: From January 2008 to November 2012, 290 patients with cirrhotic portal hypertension were treated surgically in our department for the prevention of gastroesophageal variceal bleeding: 207 patients received a routine PCVD procedure (PCVD group), and 83 patients received a PCVD plus a splenorenal shunt procedure (combined group). Changes in hemodynamic parameters, rebleeding, encephalopathy, portal vein thrombosis, and mortality were analyzed. RESULTS: The free portal pressure decreased to 21.43 ± 4.35 mmHg in the combined group compared with 24.61 ± 5.42 mmHg in the PCVD group (P < 0.05). The changes in hemodynamic parameters were more significant in the combined group (P < 0.05). The long-term rebleeding rate was 7.22% in the combined group, which was lower than that in the PCVD group (14.93%), (P < 0.05). CONCLUSION: Devascularization plus splenorenal shunt is an effective and safe strategy to control esophagogastric variceal bleeding in PHT. It should be recommended as a first-line treatment for preventing bleeding in PHT patients when surgical interventions are considered. PMID:24409071

Esophageal motor disorders in adults with eosinophilic esophagitis.

PubMed

Moawad, Fouad J; Maydonovitch, Corinne L; Veerappan, Ganesh R; Bassett, John T; Lake, Jason M; Wong, Roy K H

2011-05-01

An association between eosinophilic esophagitis (EoE) and esophageal motility disorders has been described in small studies. The aim of this study was to describe the prevalence of esophageal motor disorders in a large cohort of adults with EoE and examine whether an association exists between esophageal dysmotility and dysphagia. A retrospective review of esophageal manometry studies in adult EoE patients was performed. Tracings were reviewed for abnormalities including nutcracker esophagus and ineffective swallows, defined as low amplitude peristalsis (<30 mmHg) or non-propagating contractions. Ineffective esophageal motility (IEM) was categorized as mild (30-40% ineffective swallows), moderate (50-60% ineffective swallows), and severe (≥70% ineffective swallows). Dysphagia was graded on a 0-3 scale for frequency and severity. Seventy-five tracings from EoE patients were reviewed (85% male, mean age 41 ± 12 years). IEM was identified in 25 patients and categorized as mild (n = 13), moderate (n = 6), and severe (n = 6). Nutcracker esophagus was found in three patients. There was no significant difference in eosinophil count among the motility groups: normal 46.5 ± 3.1, mild IEM 56.9 ± 36.9, moderate IEM 45.5 ± 23.7, severe IEM 34.3 ± 12.6 (P = 0.157). In this cohort of EoE patients, the majority had normal esophageal motility studies, although a subset of these patients had some esophageal dysmotility. It is unlikely that esophageal dysmotility is a major contributing factor to dysphagia, although it is reasonable to consider esophageal manometry testing in EoE patients to identify potential abnormalities of the smooth muscle esophagus.

[Primary esophageal motility disorders; especially about esophageal achalasia].

PubMed

Miyazaki, Tatsuya; Sohda, Makoto; Sakai, Makoto; Tanaka, Naritaka; Suzuki, Shigemasa; Yokobori, Takehiko; Inose, Takanori; Nakajima, Masanobu; Fukuchi, Minoru; Kato, Hiroyuki; Kusano, Motoyasu; Kuwano, Hiroyuki

2011-07-01

Esophageal motility disorders are classified primary and secondary, and primary esophageal motility disorders are classified esophageal achalasia and other diseases by manometry. An esophageal emptying disorder associated with insufficient relaxation of the lower esophageal sphincter (LES) and elimination of peristaltic waves on the esophageal body is the major abnormality of achalasia. Esophagogram, endoscopy, and manometry are used for diagnosis. As pharmacological therapy, administration of a calcium channel blocker or nitrate is useful. The pharmacological therapy is not recommended as long-term basic therapy but as a temporary treatment. At 1st, the balloon dilation method is chosen in treatment of achalasia Surgical treatment is indicated in the following cases: (1) Patients uneffected by balloon dilation, (2) Flask type with grade II to III dilation, and sigmoid type, (3) the gradual progression to the pathophysiological stage, (4) young patients, (5) complicated with esophageal cancer. Laparoscopic Heller-Dor procedure is the most popular surgical procedure, recently. It is somewhat difficult to perform surgical treatment for this functional disease. We should select the most suitable individualized treatment with efficient comprehension of the pathophysiological situation.

Comparative clinical evaluation of Kshara Sutra ligation and hemorrhoidectomy in Arsha (hemorrhoids).

PubMed

Gupta, Meva Lal; Gupta, S K; Bhuyan, Chaturbhuja

2011-04-01

Arsha (hemorrhoids) is engorgement of the hemorrhoidal venous plexus, characterized by bleeding per rectum, constipation, pain, prolapse and discharge. It is manifested due to improper diet, prolonged standing and faulty habits of defecation causing derangement of tridosha, mainly vata dosha. Vitiated dosha localizes in guda vali, pradhana dhamani and mansdhara kala and vitiates twak, mansa, meda and rakta, resulting in the annavaha sroto dushti. Modern management of arsha needs, mainly, a surgical approach, i.e. hemorrhoidectomy, wherein the result was found to be less satisfactory. In this regard, to determine a solution for satisfactory cure, the kshara sutra ligation method in arsha was studied in comparison with hemarrhoidectomy. Kshara sutra ligation in arsha was employed in 35 patients, and 26 patients were dealt with hemorrhoidectomy. The study revealed a better result of the kshara sutra ligation-treated group in comparison with hemorrhoidectomy. The observations revealed that maximum advantages like minimum hospital stay, no bleeding during or after operation, no post-operative anal stenosis, a low cost-effective and more acceptable to different categories of people, etc. were recorded in the kshara sutra-treated group. Statistically, kshara sutra ligation for arsha was found to be highly significant and effective management. No adverse effects were noted during the follow-up period.

Comparative clinical evaluation of Kshara Sutra ligation and hemorrhoidectomy in Arsha (hemorrhoids)

PubMed Central

Gupta, Meva Lal; Gupta, S. K.; Bhuyan, Chaturbhuja

2011-01-01

Arsha (hemorrhoids) is engorgement of the hemorrhoidal venous plexus, characterized by bleeding per rectum, constipation, pain, prolapse and discharge. It is manifested due to improper diet, prolonged standing and faulty habits of defecation causing derangement of tridosha, mainly vata dosha. Vitiated dosha localizes in guda vali, pradhana dhamani and mansdhara kala and vitiates twak, mansa, meda and rakta, resulting in the annavaha sroto dushti. Modern management of arsha needs, mainly, a surgical approach, i.e. hemorrhoidectomy, wherein the result was found to be less satisfactory. In this regard, to determine a solution for satisfactory cure, the kshara sutra ligation method in arsha was studied in comparison with hemarrhoidectomy. Kshara sutra ligation in arsha was employed in 35 patients, and 26 patients were dealt with hemorrhoidectomy. The study revealed a better result of the kshara sutra ligation-treated group in comparison with hemorrhoidectomy. The observations revealed that maximum advantages like minimum hospital stay, no bleeding during or after operation, no post-operative anal stenosis, a low cost-effective and more acceptable to different categories of people, etc. were recorded in the kshara sutra-treated group. Statistically, kshara sutra ligation for arsha was found to be highly significant and effective management. No adverse effects were noted during the follow-up period. PMID:22408307

Esophageal spasm

MedlinePlus

... foods if you get esophageal spasms. Alternative Names Diffuse esophageal spasm; Spasm of the esophagus; Distal esophageal spasm Images Digestive system Throat anatomy Esophagus References Falk GW, Katzka DA. ...

Alternative Treatment for Bleeding Peristomal Varices: Percutaneous Parastomal Embolization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Pabon-Ramos, Waleska M., E-mail: waly.pr@duke.edu; Niemeyer, Matthew M.; Dasika, Narasimham L., E-mail: narasimh@med.umich.edu

2013-10-15

Purpose: To describe how peristomal varices can be successfully embolized via a percutaneous parastomal approach. Methods: The medical records of patients who underwent this procedure between December 1, 2000, and May 31, 2008, were retrospectively reviewed. Procedural details were recorded. Median fluoroscopy time and bleeding-free interval were calculated. Results: Seven patients underwent eight parastomal embolizations. The technical success rate was 88 % (one failure). All embolizations were performed with coils combined with a sclerosant, another embolizing agent, or both. Of the seven successful parastomal embolizations, there were three cases of recurrent bleeding; the median time to rebleeding was 45 daysmore » (range 26-313 days). The remaining four patients did not develop recurrent bleeding during the follow-up period; their median bleeding-free interval was 131 days (range 40-659 days). Conclusion: This case review demonstrated that percutaneous parastomal embolization is a feasible technique to treat bleeding peristomal varices.« less

Single-Session Percutaneous Endovascular Mesocaval Shunt Creation and Balloon-Occluded Retrograde Transvenous Obliteration for the Treatment of Gastric Varices.

PubMed

Srinivasa, Ravi Nara; Majdalany, Bill S; Chick, Jeffrey Forris Beecham; Meadows, J Matthew; Fenlon, Jordan Bruce; Brewerton, Charles; Saad, Wael E

2018-01-01

In the setting of portal hypertension, the body responds by creating portosystemic venous shunts, which may lead to the development of varices. Endoscopic treatment of these varices is often warranted to prevent catastrophic bleeding. During the course of variceal treatment, 1 or more portosystemic shunts may be sacrificed, which may acutely exacerbate portal hypertension and reduce systemic venous return. This report describes percutaneous creation of a mesocaval shunt and balloon-occluded retrograde transvenous obliteration (BRTO) in a patient with cavernous transformation of the portal vein. The patient had previously undergone an unsuccessful attempt at transjugular intrahepatic portosystemic shunt (TIPS) creation with postoperative bleeding requiring splenectomy. As TIPS was not feasible, creation of a percutaneous mesocaval shunt provided an alternate pathway for portosystemic decompression, facilitating safe treatment of gastric varices with BRTO via a gastrorenal shunt. These procedures were performed simultaneously to reduce the risk of variceal bleeding from acute changes in portal venous pressures and redirect blood flow through the shunt to maintain patency. This is the first reported case of combined mesocaval shunt placement and BRTO in a single session. Copyright © 2017 Elsevier Inc. All rights reserved.

Uniportal thoracoscopy combined with laparoscopy as minimally invasive treatment of esophageal cancer

PubMed Central

Caronia, Francesco Paolo; Arrigo, Ettore; Failla, Andrea Valentino; Sgalambro, Francesco; Giannone, Giorgio; Lo Monte, Attilio Ignazio; Cajozzo, Massimo; Santini, Mario

2018-01-01

A 67-year-old man was referred to our attention for management of esophageal adenocarcinoma, localized at the level of the esophagogastric junction and obstructed the 1/3 of the esophageal lumen. Due to the extension of the disease (T3N1M0-Stage IIIA), the patient underwent neo-adjuvant chemo-radiation therapy and he was then scheduled for a minimally invasive surgical procedure including laparoscopic gastroplasty, uniportal thoracoscopic esophageal dissection and intrathoracic end-to-end esophago-gastric anastomosis. No intraoperative and post-operative complications were seen. The patient was discharged in post-operative day 9. Pathological study confirmed the diagnosis of adenocarcinoma (T2N1M0-Stage IIB) and he underwent adjuvant chemotherapy. At the time of present paper, patient is alive and well without signs of recurrence or metastasis. Our minimally approach compared to standard open procedure would help reduce post-operative pain and favours early return to normal activity. However, future experiences with a control group are required before our strategy can be widely used. PMID:29850166

Uniportal thoracoscopy combined with laparoscopy as minimally invasive treatment of esophageal cancer.

PubMed

Caronia, Francesco Paolo; Arrigo, Ettore; Failla, Andrea Valentino; Sgalambro, Francesco; Giannone, Giorgio; Lo Monte, Attilio Ignazio; Cajozzo, Massimo; Santini, Mario; Fiorelli, Alfonso

2018-04-01

A 67-year-old man was referred to our attention for management of esophageal adenocarcinoma, localized at the level of the esophagogastric junction and obstructed the 1/3 of the esophageal lumen. Due to the extension of the disease (T3N1M0-Stage IIIA), the patient underwent neo-adjuvant chemo-radiation therapy and he was then scheduled for a minimally invasive surgical procedure including laparoscopic gastroplasty, uniportal thoracoscopic esophageal dissection and intrathoracic end-to-end esophago-gastric anastomosis. No intraoperative and post-operative complications were seen. The patient was discharged in post-operative day 9. Pathological study confirmed the diagnosis of adenocarcinoma (T2N1M0-Stage IIB) and he underwent adjuvant chemotherapy. At the time of present paper, patient is alive and well without signs of recurrence or metastasis. Our minimally approach compared to standard open procedure would help reduce post-operative pain and favours early return to normal activity. However, future experiences with a control group are required before our strategy can be widely used.

Esophageal motility after peroral endoscopic myotomy for achalasia.

PubMed

Hu, Yue; Li, Meng; Lu, Bin; Meng, Lina; Fan, Yihong; Bao, Haibiao

2016-05-01

Peroral endoscopic myotomy (POEM) has been introduced as a novel endoscopic treatment for achalasia. The aim of this work is to assess the changes in esophageal motility caused by POEM in patients with achalasia. Forty-one patients with achalasia underwent POEM from September 2012 to November 2014. Esophageal motility of all patients was evaluated preoperatively and 1 month after POEM utilizing high-resolution manometry, which was performed with ten water swallows, ten steamed bread swallows, and multiple rapid swallows (MRS). In single swallows, including liquid swallows and bread swallows, all the parameters of lower esophagus sphincter resting pressure (LESP), 4-s integrated relaxation pressure (4sIRP), and intra-bolus pressure (IBP) were decreased between pre- and post-POEM patients (all p < 0.05). Postoperatively, the trend of distal contractile integral (DCI) and distal esophageal peristaltic amplitude declined in subtype II and subtype III (subtype II: p < 0.05; subtype III: p > 0.05), but increased in subtype I (subtype I: p > 0.05). In liquid swallows, the Eckardt score of subtype II patients decreased with DCI, and distal esophageal peristaltic amplitude after POEM was significantly lower compared with those showing increased values of those two parameters (p < 0.05). In MRS, the rate of LES relaxation increased from 66.67 to 95.24%, but without normal response in all achalasia patients. POEM reduces LES pressure in achalasia, and partly restores esophageal motility. POEM displayed varying effect on esophageal motility in patients with different patterns of swallowing. In addition, the changes in parameters associated with esophageal peristalsis correlated with decreases in Eckardt score.

Esophageal Motility after Extensive Circumferential Endoscopic Submucosal Dissection for Superficial Esophageal Cancer.

PubMed

Kuribayashi, Yasutaka; Iizuka, Toshiro; Nomura, Kosuke; Furuhata, Tsukasa; Yamashita, Satoshi; Matsui, Akira; Kikuchi, Daisuke; Mitani, Toshifumi; Kaise, Mitsuru; Hoteya, Shu

2018-06-05

Endoscopic submucosal dissection (ESD) for superficial esophageal cancer is sometimes extensive, and in our experience, patients not infrequently present with dysphagia after ESD even in the absence of esophageal stricture. The aim of this study was to evaluate esophageal motility using high-resolution manometry (HRM) in patients with and without dysphagia after extensive circumferential ESD. HRM was performed in a total of 52 patients who had undergone ESD for superficial esophageal cancer and a mucosal defect after ESD exceeded more than two-thirds of the esophageal circumference. The frequency and type of esophageal dysmotility and the relationship between esophageal motility and dysphagia were evaluated. Esophageal dysmotility was observed in 13 patients (25%): jackhammer esophagus in 4, esophagogastric junction outflow obstruction in 4, absent contractility in 2, and distal esophageal spasm, ineffective esophageal motility, and fragmented peristalsis in 1 patient each. Of the 22 patients with dysphagia after ESD, 9 (41%) had esophageal dysmotility. Of the 30 patients without dysphagia after ESD, 4 (13%) had esophageal dysmotility. The relationship between dysmotility and dysphagia was significant (p = 0.025). Esophageal dysmotility exists in approximately one-quarter of patients after extensive circumferential ESD, which is associated with dysphagia in the absence of esophageal stricture. © 2018 S. Karger AG, Basel.

Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome.

PubMed

Guntipalli, Prathima; Chason, Rebecca; Elliott, Alan; Rockey, Don C

2014-12-01

We have recognized a unique clinical syndrome in patients with upper gastrointestinal bleeding who are found to have severe esophagitis. We aimed to more clearly describe the clinical entity of upper gastrointestinal bleeding in patients with severe esophagitis. We conducted a retrospective matched case-control study designed to investigate clinical features in patients with carefully defined upper gastrointestinal bleeding and severe esophagitis. Patient data were captured prospectively via a Gastrointestinal Bleeding Healthcare Registry, which collects data on all patients admitted with gastrointestinal bleeding. Patients with endoscopically documented esophagitis (cases) were matched with randomly selected controls that had upper gastrointestinal bleeding caused by other lesions. Epidemiologic features in patients with esophagitis were similar to those with other causes of upper gastrointestinal bleeding. However, hematemesis was more common in patients with esophagitis 86% (102/119) than in controls 55% (196/357) (p < 0.0001), while melena was less common in patients with esophagitis 38% (45/119) than in controls 68% (244/357) (p < 0.0001). Additionally, the more severe the esophagitis, the more frequent was melena. Patients with esophagitis had less abnormal vital signs, lesser decreases in hematocrit, and lesser increases in BUN. Both pre- and postRockall scores were lower in patients with esophagitis compared with controls (p = 0.01, and p < 0.0001, respectively). Length of hospital stay (p = 0.002), rebleeding rate at 42 days (p = 0.0007), and mortality were less in patients with esophagitis than controls. Finally, analysis of patients with esophagitis and cirrhosis suggested that this group of patients had more severe bleeding than those without cirrhosis. We have described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. This syndrome is manifest by typical clinical features and is associated with

Advances in esophageal cancer: A new perspective on pathogenesis associated with long non-coding RNAs.

PubMed

Huang, Xiaomei; Zhou, Xi; Hu, Qing; Sun, Binyu; Deng, Mingming; Qi, Xiaolong; Lü, Muhan

2018-01-28

Esophageal cancer is a malignant digestive tract cancer with high mortality. Although studies have found that esophageal cancer is involved in a complex and important gene regulation network, the pathogenesis remains unclear. The recently described long non-coding RNAs (lncRNAs) are one effective part of the gene regulation network. However, in past decades, lncRNAs were thought to be "transcript noise" or "pseudogenes" and were thus ignored. Early studies indicated that lncRNAs play pivotal roles during evolution. However, in recent years, increasing research has revealed that many lncRNAs are associated with tumorigenesis. In particular, lncRNAs may act as important elements for epigenetic regulation, transcription, post-transcriptional regulation and post-translational modification of proteins. Additionally, they may be novel biomarkers for tumors and therapeutic targets in cancer. Here, we summarize the functions of lncRNAs in esophageal cancer, with an emphasis on lncRNA-mediated regulatory mechanisms that affect the biological characteristics of esophageal cancer. Copyright © 2017 Elsevier B.V. All rights reserved.

Sequence-Independent Cloning and Post-Translational Modification of Repetitive Protein Polymers through Sortase and Sfp-Mediated Enzymatic Ligation.

PubMed

Ott, Wolfgang; Nicolaus, Thomas; Gaub, Hermann E; Nash, Michael A

2016-04-11

Repetitive protein-based polymers are important for many applications in biotechnology and biomaterials development. Here we describe the sequential additive ligation of highly repetitive DNA sequences, their assembly into genes encoding protein-polymers with precisely tunable lengths and compositions, and their end-specific post-translational modification with organic dyes and fluorescent protein domains. Our new Golden Gate-based cloning approach relies on incorporation of only type IIS BsaI restriction enzyme recognition sites using PCR, which allowed us to install ybbR-peptide tags, Sortase c-tags, and cysteine residues onto either end of the repetitive gene polymers without leaving residual cloning scars. The assembled genes were expressed in Escherichia coli and purified using inverse transition cycling (ITC). Characterization by cloud point spectrophotometry, and denaturing polyacrylamide gel electrophoresis with fluorescence detection confirmed successful phosphopantetheinyl transferase (Sfp)-mediated post-translational N-terminal labeling of the protein-polymers with a coenzyme A-647 dye (CoA-647) and simultaneous sortase-mediated C-terminal labeling with a GFP domain containing an N-terminal GG-motif in a one-pot reaction. In a further demonstration, we installed an N-terminal cysteine residue into an elastin-like polypeptide (ELP) that was subsequently conjugated to a single chain poly(ethylene glycol)-maleimide (PEG-maleimide) synthetic polymer, noticeably shifting the ELP cloud point. The ability to straightforwardly assemble repetitive DNA sequences encoding ELPs of precisely tunable length and to post-translationally modify them specifically at the N- and C- termini provides a versatile platform for the design and production of multifunctional smart protein-polymeric materials.

Non-invasive prediction of oesophageal varices in cirrhosis

PubMed Central

Sen, Sambit; Griffiths, William JH

2008-01-01

Non-invasive predictors of varices in cirrhosis would reduce the need for screening endoscopies. Platelet count and spleen size have been shown to be useful parameters, in mixed groups of cirrhotics with different aetiologies. We evaluated this in two homogeneous groups with cirrhosis due to hepatitis C and alcohol. Non-invasive predictors appear promising in the former group, but less so in the latter group. PMID:18416480

[New technique for safe removal of impacted foreign bodies in the upper gastrointestinal tract using reusable variceal "cap" (cup, cap or cylinder)].

PubMed

Chávez Rossell, Miguel

2012-01-01

The ingestion of a foreign body is one of the most common endoscopic emergencies. Foreign bodies in the upper gastrointestinal tract should be extracted as soon as possible to avoid serious complications such as perforation o bleeding. However, removals of foreign bodies with sharp edges are very difficult and can develop complications during their removal. Various devices have therefore been developed to prevent mucosal injury from the sharp edges during endoscopic extraction. We report a new technique for the successful foreign body extraction of upper digestive tract using the cap from six shooter variceal banding reused. We present 17 cases (9 males and 8 females). The types of foreign bodies removed were: chicken bones (n:7), fish bones (n:3), denture prosthesis (n:2), food bolus (n:2), long pin (n:1), golden thumb tack (n: 1) and press-through package (n:1). There were no complications. This new technique is safe and effective. Highlights its advantages: enhanced sight pharyngo esophageal junction, foreign bodies disimpact at that level, food bolus suck, avoid sharp object damage mucosal or scope and decrease time removal.

Evaluation of esophageal function in patients with esophageal motor abnormalities using multichannel intraluminal impedance esophageal manometry.

PubMed

Cho, Yu Kyung; Choi, Myung-Gyu; Park, Jae Myung; Oh, Jung Hwan; Paik, Chang Nyol; Lee, Joon Wook; Lee, In Seok; Kim, Sang Woo; Chung, In-Sik

2006-10-21

To evaluate the functional aspect of esophageal motility in healthy subjects and in patients who were referred for esophageal function testing using multichannel intraluminal impedance-esophageal manometry (MII-EM), and to assess the clinical utility of MII-EM. From September 2003 to January 2004, we performed the MII-EM on healthy volunteers and all the patients who were referred for esophageal function testing. Each patient received 10 liquid and 10 viscous swallows. We analyzed the results, the impedance and the manometric findings. Some of the subjects had additional ambulatory 24-h pH study performed to diagnose gastroesophageal reflux disease (GERD). Among 89 studied subjects, the MII-EM findings showed normal esophageal motility in 50 (56.17%), ineffective esophageal motility (IEM) in 17 (19.10%), nutcracker esophagus in 7 (7.86%), achalasia in 4 (4.49%), and scleroderma esophagus in 11 (12.35%) cases. The completeness and the speed of bolus transit were in the order of nutcracker esophagus, normal manometry and IEM. Some of the swallows showing normal manometry and IEM had incomplete transit. In the achalasia and scleroderma esophagus, almost all the swallows had incomplete transit. The body amplitudes were higher for the swallows with complete transit than for the swallows with incomplete transit. There was not a significant difference in the manometric and impedance findings between the subjects with and without GERD. MII-EM is a useful tool in assessing the esophageal function in the patients having esophageal motility abnormality. The primary factors influencing the bolus transit are the amplitude of the esophageal body and normal peristalsis.

Esophageal duplication and congenital esophageal stenosis.

PubMed

Trappey, A Francois; Hirose, Shinjiro

2017-04-01

Esophageal duplication and congenital esophageal stenosis (CES) may represent diseases with common embryologic etiologies, namely, faulty tracheoesophageal separation and differentiation. Here, we will re-enforce definitions for these diseases as well as review their embryology, diagnosis, and treatment. Copyright © 2017. Published by Elsevier Inc.

Gastro-esophageal reflux time parameters and esophagitis in children

DOE Office of Scientific and Technical Information (OSTI.GOV)

Baulieu, F.; Baulieu, J.; Maurage, C.

1985-05-01

The aim of this work was to study the correlation between the reflux timing and the presence of esophagitis, an inconstant but serious complication of gastro-esophageal reflux (GER). The hypothesis was that reflux occurring late after meal can be incriminated more than early reflux in esophagitis genesis. 32 children with GER (mean age = 10.5 months, 2 to 30 months) had esophagoscopy and scintigraphy in the same week. The children were classified in two groups according to esophagoscopy: group 1 (n = 18) no esophagitis, group 2 (n = 14) esophaqgitis. The scintigraphy involved the ingestion of 0.5 mCi Tc-99mmore » sulfur colloid milk mixture, followed by esophageal and gastric activity recording (one image per minute for 1 hour). The reflux was assessed from contrast enhanced images and esophageal time activity curves. Reflux intensity was quantitated by reflux index (Re). Mean reflux time was calculated as the mean esophageal activity peaks time (t-bar). Finally a composite parameter was calculated as the mean reflux time weighted by the relative intensity of each reflux peak (t-barw). Re was not found to be different between the two groups. t-bar was significantly higher in group 2: t-bar = 29.6 +- 3.0 mn (mean +- SD) than in group 1: t-bar = 24.5 +- 6.8 mn; rho <0.02. The difference between the two groups was enhanced by intensity weighting: group 1: t-barw = 16.6 +- 6.3 mn, group 2: t-barw = 33.5 +- 7.1 mn rho <0.001. t-barw value was not correlated to esophagitis grade. These results suggest that late reflux is more likely responsible of esophagitis.« less

Chemoprevention of Barrett's Esophagus and Esophageal Adenocarcinoma.

PubMed

Bresalier, Robert S

2018-06-12

Barrett's esophagus is common in Western countries, but progression to esophageal adenocarcinoma is uncommon. Chemoprevention therefore needs to consider whether benefits outweigh risks given an otherwise healthy population. This will depend on the particular population at risk and the relative safety of a potential preventive agent. Most evidence regarding the potential benefit of chemoprevention of Barrett's esophagus and prevention of progression to esophageal adenocarcinoma is based on observational studies such as case-control and cohort studies. Given the potential benefits and relatively low risks, patients with BE should receive once-daily PPI therapy, but routine use of twice-daily PPI is not recommended unless necessitated by poor control of reflux symptoms or esophagitis. Recent data suggest that the inverse associations between aspirin/NSAID use and esophageal adenocarcinoma may be the result of reducing neoplastic progression (from metaplasia to dysplasia and carcinoma) rather than initiation of Barrett's esophagus. While substantial associative data suggest a potential benefit of aspirin and nonaspirin NSAIDs in reducing the risk of progression of Barrett's esophagus, the low risk of progression and the potential risks (gastrointestinal bleeding, complicated ulcer disease, hemorrhagic stroke) do not warrant routine use, unless dictated by cardiovascular risk. Chemoprevention after mucosal ablation in those at highest risk of post-ablation recurrence (dysplastic Barrett's) is currently under investigation.

Topical hemostatic powder promotes reepithelialization and reduces scar formation after extensive esophageal mucosal resection.

PubMed

Beye, B; Barret, M; Alatawi, A; Beuvon, F; Nicco, C; Pratico, C A; Chereau, C; Chaussade, S; Batteux, F; Prat, F

2016-08-01

The development of techniques for endoscopic resection has provided new strategies for radical conservative treatment of superficial esophageal neoplasms, even those that are circumferential, such as Barrett's neoplasia. However, it is necessary to prevent the formation of scar tissue that can be responsible for esophageal strictures following circumferential resection. Preliminary data have suggested the possible efficacy of a hemostatic powder in the promotion of wound healing. The study aims to assess the effectiveness of Hemospray (Cook Medical) in a swine model of post-endoscopic esophageal stricture. Our prospective controlled study included 21 pigs. A 6-cm circumferential submucosal dissection of the esophagus (CESD) was performed in each pig. Group 1 (n = 11) only underwent CESD and Group 2 (n = 10) had repeated Hemospray applications after CESD. Clinical, endoscopic, and radiological monitoring were performed, blood levels of four inflammatory or pro-fibrotic cytokines were assessed, and histological analysis was performed. Median esophageal diameter was greater in the group treated with Hemospray (2 mm [1-3] vs. 3 mm [2-4], P = 0.01), and the rate of symptomatic esophageal stricture was 100% and 60% in Groups 1 and 2, respectively (P = 0.09). The thicknesses of esophageal fibrosis and inflammatory cell infiltrate were significantly lower in Group 2 than in Group 1 (P = 0.002 and 0.0003, respectively). The length of the neoepithelium was greater in Group 2 than in Group 1 (P = 0.0004). Transforming growth factor-β levels were significantly lower in Group 2 than in Group 1 (P = 0.01). The application of Hemospray after esophageal CESD reduces scar tissue formation and promotes reepithelialization, and therefore is a promising therapeutic approach in the prevention of post-endoscopic esophageal stricture. © 2015 International Society for Diseases of the Esophagus.

Synthesis of histone proteins by CPE ligation using a recombinant peptide as the C-terminal building block.

PubMed

Kawakami, Toru; Yoshikawa, Ryo; Fujiyoshi, Yuki; Mishima, Yuichi; Hojo, Hironobu; Tajima, Shoji; Suetake, Isao

2015-11-01

The post-translational modification of histones plays an important role in gene expression. We report herein on a method for synthesizing such modified histones by ligating chemically prepared N-terminal peptides and C-terminal recombinant peptide building blocks. Based on their chemical synthesis, core histones can be categorized as two types; histones H2A, H2B and H4 which contain no Cys residues, and histone H3 which contains a Cys residue(s) in the C-terminal region. A combination of native chemical ligation and desulphurization can be simply used to prepare histones without Cys residues. For the synthesis of histone H3, the endogenous Cys residue(s) must be selectively protected, while keeping the N-terminal Cys residue of the C-terminal building block that is introduced for purposes of chemical ligation unprotected. To this end, a phenacyl group was successfully utilized to protect endogenous Cys residue(s), and the recombinant peptide was ligated with a peptide containing a Cys-Pro ester (CPE) sequence as a thioester precursor. Using this approach it was possible to prepare all of the core histones H2A, H2B, H3 and H4 with any modifications. The resulting proteins could then be used to prepare a core histone library of proteins that have been post-translationally modified. © The Authors 2015. Published by Oxford University Press on behalf of the Japanese Biochemical Society. All rights reserved.

Esophageal motor disease and reflux patterns in patients with advanced pulmonary disease undergoing lung transplant evaluation.

PubMed

Seccombe, J; Mirza, F; Hachem, R; Gyawali, C P

2013-08-01

Advanced pulmonary disorders are linked to esophageal hypomotility and reflux disease. However, characterization of esophageal function using high resolution manometry (HRM) and ambulatory pH monitoring, segregation by pulmonary pathology, and comparison to traditional reflux disease are all limited in the literature. Over a 4 year period, 73 patients (55.2 ± 1.3 years, 44F) were identified who underwent esophageal function testing as part of lung transplant evaluation for advanced pulmonary disease (interstitial lung disease, ILD = 47, obstructive lung disease, OLD = 24, other = 2). Proportions of patients with motor dysfunction (≥ 80% failed sequences = severe hypomotility) and/or abnormal reflux parameters (acid exposure time, AET ≥ 4%) were determined, and compared to a cohort of 1081 patients (48.4 ± 0.4 years, 613F) referred for esophageal function testing prior to antireflux surgery (ARS). The proportion of esophageal body hypomotility was significantly higher within advanced pulmonary disease categories (35.6%), particularly ILD (44.7%), compared to ARS patients (12.1%, P < 0.0001). Abnormal AET was noted in 56.5%, and was similar between ILD and OLD, but less frequent than in the ARS group (P = 0.04). Post-transplant chronic rejection trended towards association with pretransplant elevated AET in OLD (P = 0.08) but not ILD. Mortality was not predicted by esophageal motor pattern or reflux evidence. Interstitial lung disease has a highly significant association with esophageal body hypomotility. Consequently, prevalence of abnormal esophageal acid exposure is high, but implications for post lung transplant chronic rejection remain unclear. © 2013 John Wiley & Sons Ltd.

Impaired Upper Esophageal Sphincter Reflexes in Patients with Supra-Esophageal Reflux Disease

PubMed Central

Babaei, Arash; Venu, Mukund; Naini, Sohrab Rahimi; Gonzaga, Jason; Lang, Ivan; Massey, Benson; Jadcherla, Sudarshan; Shaker, Reza

2015-01-01

Background & Aims Normal responses of the upper esophageal sphincter (UES) and esophageal body to liquid reflux events prevent esophagopharyngeal reflux and its complications, but abnormal responses have not been characterized. We investigated whether patients with supra-esophageal reflux disease (SERD) have impaired UES and esophageal body responses to simulated reflux events. Methods We performed a prospective study of 25 patients with SERD (19–82 y old, 13 female) and complaints of regurgitation and supra-esophageal manifestations of reflux. We also included 10 patients with gastroesophageal reflux disease (GERD; 32–60 y old, 7 female) without troublesome regurgitation and supra-esophageal symptoms and 24 healthy asymptomatic individuals (controls; 19–49 y old, 13 female). UES and esophageal body pressure responses, along with luminal distribution of infusate during esophageal rapid and slow infusion of air or liquid, were monitored by concurrent high-resolution manometry and intraluminal impedance. Results A significantly smaller proportion of patients with SERD had UES contractile reflexes in response to slow esophageal infusion of acid than controls or patients with GERD. Only patients with SERD had abnormal UES relaxation responses to rapid distension with saline. Diminished esophageal peristaltic contractions resulted in esophageal stasis in patients with GERD or SERD. Conclusions Patients with SERD and complaints of regurgitation have impaired UES and esophageal responses to simulated liquid reflux events. These patterns could predispose them to esophagopharyngeal reflux. PMID:26188682

A Case of Ruptured Aneurysm of the Proper Esophageal Artery with Symptomatic Mediastinal Hematoma

DOE Office of Scientific and Technical Information (OSTI.GOV)

Liu, Jiajia; Sato, Yusuke, E-mail: yusuke@doc.med.akita-u.ac.jp; Takahashi, Satoshi

Mediastinal aneurysms are rare but potentially life-threatening. Among these, bronchial artery aneurysms are most frequently reported, whereas up to now aneurysms of the proper esophageal artery had never been reported. A 69-year-old woman was referred to our hospital for treatment of a massive mediastinal hematoma. Enhanced computed tomography and selective proper esophageal arteriography revealed a 5-mm aneurysm in the proper esophageal artery that arises from the thoracic aorta at the Th8 level and has an anastomotic branch with the bronchial artery peripherally. Transcatheter arterial embolization was successfully performed using a mixture of N-butyl cyanoacrylate and lipiodol (1:3 ratio, 0.3 ml). Post-embolizationmore » angiography showed no filling into the aneurysm. The patient recovered with no complications and was discharged on the 25th post-procedure day.« less

Efficacy of ankaferd blood stopper application on non-variceal upper gastrointestinal bleeding

PubMed Central

Gungor, Gokhan; Goktepe, M Hakan; Biyik, Murat; Polat, Ilker; Tuna, Tuncer; Ataseven, Huseyin; Demir, Ali

2012-01-01

AIM: To prospectively assess the hemostatic efficacy of the endoscopic topical use of ankaferd blood stopper (ABS) in active non-variceal upper gastrointestinal system (GIS) bleeding. METHODS: Endoscopy was performed on 220 patients under suspiciency of GIS bleeding. Patients with active non-variceal upper gastrointestinal bleeding (NVUGIB) with a spurting or oozing type were included. Firstly, 8-10 cc of isotonic saline was sprayed to bleeding lesions. Then, 8 cc of ABS was applied on lesions in which bleeding continued after isotonic saline application. The other endoscopic therapeutic methods were applied on the lesions in which the bleeding did not stop after ABS. RESULTS: Twenty-seven patients had an active NVUGIB with a spurting or oozing type and 193 patients were excluded from the study since they did not have non-variceal active bleeding. 8 cc of ABS was sprayed on to the lesions of 26 patients whose bleeding continued after isotonic saline and in 19 of them, bleeding stopped after ABS. Other endoscopic treatment methods were applied to the remaining patients and the bleeding was stopped with these interventions in 6 of 7 patients. CONCLUSION: ABS is an effective method on NVUGIB, particularly on young patients with no coagulopathy. ABS may be considered as part of a combination treatment with other endoscopic methods. PMID:23293725

Safe and successful endoscopic initial treatment and long-term eradication of gastric varices by endoscopic ultrasound-guided Histoacryl (N-butyl-2-cyanoacrylate) injection.

PubMed

Gubler, Christoph; Bauerfeind, Peter

2014-09-01

Optimal endoscopic treatment of gastric varices is still not standardized nowadays. Actively bleeding varices may prohibit a successful endoscopic injection therapy of Histoacryl® (N-butyl-2-cyanoacrylate). Since 2006, we have treated gastric varices by standardized endoscopic ultrasound (EUS) guided Histoacryl injection therapy without severe adverse events. We present a large single-center cohort over 7 years with a standardized EUS-guided sclerotherapy of all patients with gastric varices. Application was controlled by fluoroscopy to immediately detect any glue embolization. Only perforating veins located within the gastric wall were treated. In the follow up, we repeated this treatment until varices were eradicated. Utmost patients (36 of 40) were treated during or within 24 h of active bleeding. About 32.5% of patients were treated while visible bleeding. Histoacryl injection was always technically successful and only two patients suffered a minor complication. Acute bleeding was stopped in all patients. About 15% (6 of 40) of patients needed an alternative rescue treatment in the longer course. Three patients got a transjugular portosystemic shunt and another three underwent an orthotopic liver transplantation. Mean long-term survival of 60 months was excellent. Active bleeding of gastric varices can be treated successfully without the necessity of gastric rinsing with EUS-guided injection of Histoacryl.

Impact of splenic artery ligation after major hepatectomy on liver function, regeneration and viability.

PubMed

Carrapita, Jorge; Abrantes, Ana Margarida; Campelos, Sofia; Gonçalves, Ana Cristina; Cardoso, Dulce; Sarmento-Ribeiro, Ana Bela; Rocha, Clara; Santos, Jorge Nunes; Botelho, Maria Filomena; Tralhão, José Guilherme; Farges, Olivier; Barbosa, Jorge Maciel

2016-10-11

It was reported that prevention of acute portal overpressure in small-for-size livers by inflow modulation results in a better postoperative outcome. The aim is to investigate the impact of portal blood flow reduction by splenic artery ligation after major hepatectomy in a murine model. Forty-eight rats were subjected to an 85% hepatectomy or 85% hepatectomy and splenic artery ligation. Both groups were evaluated at 24, 48, 72 and 120 post-operative hours: liver function, regeneration and viability. All methods and experiments were carried out in accordance with Coimbra University guidelines. Splenic artery ligation produces viability increase after 24 h, induces a relative decrease in oxidative stress during the first 48 hours, allows antioxidant capacity increment after 24 h, which is reflected in a decrease of half-time normalized liver curve at 48 h and at 72 h and in an increase of mitotic index between 48 h and 72 h. Splenic artery ligation combined with 85% hepatectomy in a murine model, allows portal inflow modulation, promoting an increase in hepatocellular viability and regeneration, without impairing the function, probably by inducing a less marked elevation of oxidative stress at first 48 hours.

The HubBLe trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for haemorrhoids.

PubMed

Tiernan, Jim; Hind, Daniel; Watson, Angus; Wailoo, Allan J; Bradburn, Michael; Shephard, Neil; Biggs, Katie; Brown, Steven

2012-10-25

Haemorrhoids (piles) are a very common condition seen in surgical clinics. After exclusion of more sinister causes of haemorrhoidal symptoms (rectal bleeding, perianal irritation and prolapse), the best option for treatment depends upon persistence and severity of the symptoms. Minor symptoms often respond to conservative treatment such as dietary fibre and reassurance. For more severe symptoms treatment such as rubber band ligation may be therapeutic and is a very commonly performed procedure in the surgical outpatient setting. Surgery is usually reserved for those who have more severe symptoms, as well as those who do not respond to non-operative therapy; surgical techniques include haemorrhoidectomy and haemorrhoidopexy. More recently, haemorrhoidal artery ligation has been introduced as a minimally invasive, non destructive surgical option.There are substantial data in the literature concerning efficacy and safety of 'rubber band ligation including multiple comparisons with other interventions, though there are no studies comparing it to haemorrhoidal artery ligation. A recent overview has been carried out by the National Institute for Health and Clinical Excellence which concludes that current evidence shows haemorrhoidal artery ligation to be a safe alternative to haemorrhoidectomy and haemorrhoidopexy though it also highlights the lack of good quality data as evidence for the advantages of the technique. The aim of this study is to establish the clinical effectiveness and cost effectiveness of haemorrhoidal artery ligation compared with conventional rubber band ligation in the treatment of people with symptomatic second or third degree (Grade II or Grade III) haemorrhoids. A multi-centre, parallel group randomised controlled trial. The primary outcome is patient-reported symptom recurrence twelve months following the intervention. Secondary outcome measures relate to symptoms, complications, health resource use, health related quality of life and cost

Novel strategy for prevention of esophageal stricture after endoscopic surgery.

PubMed

Mizutani, Taro; Tadauchi, Akimitsu; Arinobe, Manabu; Narita, Yuji; Kato, Ryuji; Niwa, Yasumasa; Ohmiya, Naoki; Itoh, Akihiro; Hirooka, Yoshiki; Honda, Hiroyuki; Ueda, Minoru; Goto, Hidemi

2010-01-01

-treated dog compared with the control. 5FLC showed sustained release of 5-FU and decreased cell proliferation in vitro. The clinically relevant canine model demonstrated that local endoscopic injection of 5FLC can prevent post-operative esophageal stricture. These results suggest that our strategy may be useful for preventing post-operative esophageal stricture.

Esophageal dysmotility in children with eosinophilic esophagitis: a study using prolonged esophageal manometry.

PubMed

Nurko, Samuel; Rosen, Rachel; Furuta, Glenn T

2009-12-01

The pathophysiology of dysphagia in patients with eosinophilic esophagitis (EoE) is unknown but may be related to abnormal esophageal motor function. Symptoms rarely occur during stationary esophageal manometry, so it has been difficult to establish an association between symptoms and motor events. Our aim was to evaluate esophageal motor function in children with EoE with the use of stationary manometry and ambulatory prolonged esophageal manometry and pH-metry (PEMP). PEMP was performed in children with EoE and compared with controls and children with gastroesophageal reflux disease (GERD). Peristalsis was considered effective when the esophageal contractions had a normal amplitude and propagation. Results are expressed as mean+/-s.e. Seventeen patients with EoE, 13 with GERD, and 11 controls were studied. Values are expressed as mean+/-s.e. Stationary manometry identified abnormal peristalsis in 41% of children with EoE. During PEMP, children with EoE had an increased number of isolated (16.7+/-3.8 vs. 9.5+/-1.6 vs. 6.5+/-1.1; P<0.03) and high-amplitude contractions (4.1+/-1.2 vs. 1.8+/-0.8 vs. 0.1+/-0.1; P<0.03), and higher percentage ineffective peristalsis both during fasting (70.5%+/-2.5 vs. 57.8%+/-3.0 vs. 53.8%+/-1.9; P<0.05) and during meals (68.4+/-3.4 vs. 55.3+/-2.8 vs. 48.1+/-2.8; P<0.05) when compared with children with GERD and controls. Thirteen patients with EoE experienced 21 episodes of dysphagia, and all correlated with simultaneous abnormal motor function. PEMP allowed the detection of ineffective peristalsis in children with EoE. Symptoms observed in children with EoE may be related to esophageal motor dysfunction.

Association of Oesophageal Varices and Splanchnic Vein Thromboses in Patients with JAK2-Positive Myeloproliferative Neoplasms: Presentation of Two Cases and Data from a Retrospective Analysis

PubMed Central

Link, Cornelia S.; Platzbecker, Uwe; Kroschinsky, Frank; Pannach, Sven; Thiede, Christian; Platzek, Ivan; Ehninger, Gerhard; Schuler, Markus K.

2013-01-01

Background Oesophageal varices and gastrointestinal bleeding are common complications of liver cirrhosis. More rarely, oesophageal varices occur in patients with non-cirrhotic portal hypertension that results from thromboses of portal or splanchnic veins. Case Report We describe 2 young men who initially presented with varices as a result of portal vein thromboses. In the clinical follow-up, both were tested positive for a JAK2 mutation and consequently diagnosed with myeloproliferative neoplasms (MPNs). In an attempt to characterise the frequency of gastrointestinal complications in patients with JAK2-positive MPNs, we retrospectively analysed all known affected patients from our clinic for the diagnosis of portal vein thromboses and oesophageal varices. Strikingly, 48% of those who had received an oesophagogastroduodenoscopy had detectable oesophageal or gastric varices, and 82% of those suffered from portal or splanchnic vein thromboses. Conclusion While the association between JAK2, myeloproliferative disease and thrombotic events is well established, patients with idiopathic oesophageal varices are not regularly tested for JAK2 mutations. However, the occurrence of oesophageal varices may be the first presenting symptom of a MPN with a JAK2 mutation, and affected patients may profit from a close haematological monitoring to assure the early detection of developing MPN. PMID:23898274

Temporary banding of the gastroesophageal junction in the critically ill neonate with esophageal atresia and tracheoesophageal fistula.

PubMed

Fagelman, K M; Boyarsky, A

1985-09-01

Patients with esophageal atresia and a distal tracheoesophageal fistula with associated conditions contributing to decreased pulmonary compliance present special problems in management. In the face of positive pressure ventilation, the fistula acts as a vent preventing adequate ventilatory effort from reaching the lungs. A thoracic approach to ligate or divide the fistula carries with it a high mortality rate. A technique is described whereby a silicone rubber band is applied to the gastroesophageal junction to effectively occlude the esophagus. It is designed so that is can be adjusted or removed, without operative intervention, according to the patient's clinical course and growth.

The Role of Esophageal Hypersensitivity in Functional Esophageal Disorders.

PubMed

Farmer, Adam D; Ruffle, James K; Aziz, Qasim

2017-02-01

The Rome IV diagnostic criteria delineates 5 functional esophageal disorders which include functional chest pain, functional heartburn, reflux hypersensitivity, globus, and functional dysphagia. These are a heterogenous group of disorders which, despite having characteristic symptom profiles attributable to esophageal pathology, fail to demonstrate any structural, motility or inflammatory abnormalities on standard clinical testing. These disorders are associated with a marked reduction in patient quality of life, not least considerable healthcare resources. Furthermore, the pathophysiology of these disorders is incompletely understood. In this narrative review we provide the reader with an introductory primer to the structure and function of esophageal perception, including nociception that forms the basis of the putative mechanisms that may give rise to symptoms in functional esophageal disorders. We also discuss the provocative techniques and outcome measures by which esophageal hypersensitivity can be established.

Evaluation of embolization for periuterine varices involving chronic pelvic pain secondary to pelvic congestion syndrome.

PubMed

Siqueira, Flavio Meirelles; Monsignore, Lucas Moretti; Rosa-E-Silva, Julio Cesar; Poli-Neto, Omero Benedicto; Castro-Afonso, Luis Henrique de; Nakiri, Guilherme Seizem; Muglia, Valdair Francisco; Abud, Daniel Giansante

2016-12-01

To evaluate the clinical response and success rate after periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome and to report the safety of endovascular treatment and its rate of complications. Retrospective cohort of patients undergoing endovascular treatment of pelvic congestion syndrome in our department from January 2012 to November 2015. Data were analyzed based on patient background, imaging findings, embolized veins, rate of complications, and clinical response as indicated by the visual analog pain scale. We performed periuterine varices embolization in 22 patients during the study, four of which required a second embolization. Seventeen patients reported a reduction in pelvic pain after the first embolization and three patients reported a reduction in pelvic pain after the second embolization. Minor complications were observed in our patients, such as postural hypotension, postoperative pain, and venous perforation during the procedure, without clinical repercussion. Periuterine varices embolization in patients with chronic pelvic pain secondary to pelvic congestion syndrome appears to be an effective and safe technique.

Proteomic profiling of fetal esophageal epithelium, esophageal cancer, and tumor-adjacent esophageal epithelium and immunohistochemical characterization of a representative differential protein, PRX6

PubMed Central

Guo, Jun-Hui; Xing, Guo-Lan; Fang, Xin-Hui; Wu, Hui-Fang; Zhang, Bo; Yu, Jin-Zhong; Fan, Zong-Min; Wang, Li-Dong

2017-01-01

AIM To understand the molecular mechanism of esophageal cancer development and provide molecular markers for screening high-risk populations and early diagnosis. METHODS Two-dimensional electrophoresis combined with mass spectrometry were adopted to screen differentially expressed proteins in nine cases of fetal esophageal epithelium, eight cases of esophageal cancer, and eight cases of tumor-adjacent normal esophageal epithelium collected from fetuses of different gestational age, or esophageal cancer patients from a high-risk area of esophageal cancer in China. Immunohistochemistry (avidin-biotin-horseradish peroxidase complex method) was used to detect the expression of peroxiredoxin (PRX)6 in 91 cases of esophageal cancer, tumor-adjacent normal esophageal tissue, basal cell hyperplasia, dysplasia, and carcinoma in situ, as well as 65 cases of esophageal epithelium from fetuses at a gestational age of 3-9 mo. RESULTS After peptide mass fingerprint analysis and search of protein databases, 21 differential proteins were identified; some of which represent a protein isoform. Varying degrees of expression of PRX6 protein, which was localized mainly in the cytoplasm, were detected in adult and fetal normal esophageal tissues, precancerous lesions, and esophageal cancer. With the progression of esophageal lesions, PRX6 protein expression showed a declining trend (P < 0.05). In fetal epithelium from fetuses at gestational age 3-6 mo, PRX6 protein expression showed a declining trend with age (P < 0.05). PRX6 protein expression was significantly higher in well-differentiated esophageal cancer tissues than in poorly differentiated esophageal cancer tissues (P < 0.05). CONCLUSION Development and progression of esophageal cancer result from interactions of genetic changes (accumulation or superposition). PRX6 protein is associated with fetal esophageal development and cancer differentiation. PMID:28293090

Proteomic profiling of fetal esophageal epithelium, esophageal cancer, and tumor-adjacent esophageal epithelium and immunohistochemical characterization of a representative differential protein, PRX6.

PubMed

Guo, Jun-Hui; Xing, Guo-Lan; Fang, Xin-Hui; Wu, Hui-Fang; Zhang, Bo; Yu, Jin-Zhong; Fan, Zong-Min; Wang, Li-Dong

2017-02-28

To understand the molecular mechanism of esophageal cancer development and provide molecular markers for screening high-risk populations and early diagnosis. Two-dimensional electrophoresis combined with mass spectrometry were adopted to screen differentially expressed proteins in nine cases of fetal esophageal epithelium, eight cases of esophageal cancer, and eight cases of tumor-adjacent normal esophageal epithelium collected from fetuses of different gestational age, or esophageal cancer patients from a high-risk area of esophageal cancer in China. Immunohistochemistry (avidin-biotin-horseradish peroxidase complex method) was used to detect the expression of peroxiredoxin (PRX)6 in 91 cases of esophageal cancer, tumor-adjacent normal esophageal tissue, basal cell hyperplasia, dysplasia, and carcinoma in situ , as well as 65 cases of esophageal epithelium from fetuses at a gestational age of 3-9 mo. After peptide mass fingerprint analysis and search of protein databases, 21 differential proteins were identified; some of which represent a protein isoform. Varying degrees of expression of PRX6 protein, which was localized mainly in the cytoplasm, were detected in adult and fetal normal esophageal tissues, precancerous lesions, and esophageal cancer. With the progression of esophageal lesions, PRX6 protein expression showed a declining trend ( P < 0.05). In fetal epithelium from fetuses at gestational age 3-6 mo, PRX6 protein expression showed a declining trend with age ( P < 0.05). PRX6 protein expression was significantly higher in well-differentiated esophageal cancer tissues than in poorly differentiated esophageal cancer tissues ( P < 0.05). Development and progression of esophageal cancer result from interactions of genetic changes (accumulation or superposition). PRX6 protein is associated with fetal esophageal development and cancer differentiation.

Evaluation of Micro-organism in Ligated Metal and Self-ligating Brackets using Scanning Electron Microscopy: An In Vivo Study.

PubMed

Sunil, P C; Michael, Tony; Raju, Aravind S; Paul, Renji K; Mamatha, J; Ebin, T M

2015-07-01

The objective of the study was to determine the sites of plaque accumulation and to compare the plaque accumulated with metal and self-ligating orthodontic brackets in order to know which bracket type had a higher plaque retaining capacity. The study was done on 20 subjects who were scheduled for orthodontic treatment including extraction of four premolars and fixed orthodontic appliances. Mesh-backed edgewise metal brackets ligated with steel ligatures and self-ligating brackets were bonded to the premolars to be extracted using composite (Transbond XT, 3M). The subjects were told to continue their normal oral hygiene regimen. Teeth were extracted at 1, 2, and 3 weeks after bracket bonding. Plaque attached to the buccal surfaces was stained using plaque disclosing agent. The teeth were then immersed in fixative containing 4% formaldehyde and 1% glutaraldehyde in phosphate buffer for 24 h, followed by 0.1 M phosphate buffer for 12 h. The specimens were then mounted on aluminum stubs, and sputter coated with gold prior to Scanning electron microscopy examination. The results showed that increased retention of plaque in metal brackets ligated with steel ligatures and comparatively less in self-ligating brackets at the base of the brackets. This study highlights that higher retention of plaque in metal brackets ligated with steel ligatures and comparatively less plaque retention in self-ligating brackets. Excess composite around the bracket base is the critical site of plaque accumulation associated with fixed appliances due to its rough surface texture.

Esophageal motor abnormalities in eosinophilic esophagitis identified by high-resolution manometry.

PubMed

Martín Martín, Leticia; Santander, Cecilio; Lopez Martín, Mari Carmen; Espinoza-Ríos, Jorge; Chavarría-Herbozo, Carlos; Gisbert, Javier P; Moreno-Otero, Ricardo

2011-09-01

Esophageal motility abnormalities, as measured by conventional manometry (CM), are non-specific in the majority of patients with eosinophilic esophagitis (EoE). Moreover, the study of CM is limited by poor interobserver agreement. The aims of the present study were: (i) to assess the esophageal patterns in EoE by a topographic analysis of high-resolution manometry (HRM) data; and (ii) to establish a relationship between motility abnormalities and symptoms of EoE, such as dysphagia and bolus impaction. All adult patients with EoE diagnosed according to histological criteria, and controls with gastroesophageal reflux disease symptoms and dysphagia, were included. HRM was done in EoE patients and controls. For the analysis of data, the Chicago classification was followed. HRM was performed in 21 patients with EoE, as well as in 21 controls. Of the 21 patients with EoE, 10 (48%) showed pan-esophageal pressurization, six (28%) showed peristaltic dysfunction, and in five cases (24%), HRM was normal. There was no pan-esophageal pressurization in controls. Nine of 10 patients with pan-esophageal pressurization required endoscopic bolus removal (P < 0.05); none had obstructive endoscopy findings. The most frequent esophageal motor abnormality measured by HRM was a pan-esophageal pressurization. Bolus impaction in patients with EoE was associated with pan-esophageal pressurization. © 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.

Variceal bleeding in cirrhotic patients: What is the best prognostic score?

PubMed

Mohammad, Asmaa N; Morsy, Khairy H; Ali, Moustafa A

2016-09-01

To find the most accurate, suitable, and applicable scoring system for the prediction of outcome in cirrhotic patients with bleeding varices. A prospective study was conducted comprising 120 cirrhotic patients with acute variceal bleeding who were admitted to Tropical Medicine and Gastroenterology Department in Sohag University Hospital, over a 1-year period (1/2015 to 1/2016). The clinical, laboratory, and endoscopic parameters were studied. Child-Turcotte-Pugh (CTP) classification score, Model for end-stage liver disease (MELD) score, acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure assessment (SOFA) score, and AIMS65 score were calculated for all patients. Univariate and multivariate analyses were performed for all the measured parameters and scores. Of the 120 patients (92 male) admitted during the study period, eight patients (6.67%) died in the hospital. Advanced age, the presence of encephalopathy, rebleeding, and higher serum bilirubin were independent factors associated with higher hospital mortality. The largest area under the receiver operator curve (AUROC) was obtained for the AIMS65 score and SOFA score, followed by the MELD score and APACHEII score, then CTP score, all of which achieved very good performance (AUROC>0.8). AIMS65 score showed the best sensitivity, specificity, and negative and positive predictive values. Although the AIMS65 score was not significantly different from the MELD, SOFA, and APACHEII scores, it was the optimum among them in terms of the prediction of mortality. AIMS65 score is the best simple and applicable scoring system for independently predicting mortality in cirrhotic patients with acute variceal bleeding.

Esophageal replacement.

PubMed

Kunisaki, Shaun M; Coran, Arnold G

2017-04-01

This article focuses on esophageal replacement as a surgical option for pediatric patients with end-stage esophageal disease. While it is obvious that the patient׳s own esophagus is the best esophagus, persisting with attempts to retain a native esophagus with no function and at all costs are futile and usually detrimental to the overall well-being of the child. In such cases, the esophagus should be abandoned, and the appropriate esophageal replacement is chosen for definitive reconstruction. We review the various types of conduits used for esophageal replacement and discuss the unique advantages and disadvantages that are relevant for clinical decision-making. Copyright © 2017 Elsevier Inc. All rights reserved.

Assessing the short- and long-term prognosis of patients with cirrhosis and acute variceal bleeding.

PubMed

Sempere, L; Palazón, J M; Sánchez-Payá, J; Pascual, S; de Madaria, E; Poveda, M J; Carnicer, F; Zapater, P; Pérez-Mateo, M

2009-04-01

to evaluate the efficacy of various indicators in predicting short- and long-term survival in patients with cirrhosis and acute variceal bleeding. prognostic indicators were calculated for a cohort of 201 cirrhotic patients with acute variceal bleeding hospitalized in our center, a third-level teaching hospital. The studied variables were: age, sex, etiology of cirrhosis, endoscopic findings, previous variceal bleeding episodes, human immunodeficiency virus (HIV) infection, hepatocellular carcinoma (HCC), infection during episode, and Child-Turcotte-Pugh (CTP) and Model for End-stage Liver Disease (MELD) scores within 24 hours of bleeding onset. Patients were followed up for at least 6 months until death, liver transplantation, or end of observation. median follow-up was 66.85 weeks (range 0-432.4). The 6-week, 3-month, 12-month and 36-month mortality rates were 22.9, 24.9, 34.3, and 39.8%, respectively. Age >= 65 years, presence of HCC, CTP score >=10, and MELD score >= 18 were the variables associated with mortality in the multivariate analysis. The accuracy of MELD scores as predictors of 6-week, 3-month, 12-month, and 36-month mortality was better than that of CTP scores (c-statistics: 6 week MELD 0.804, CTP 0.762; 3-month MELD 0.794, CTP 0.760; 12-month MELD 0.766, CTP 0.741; 36 month MELD 0.737, CTP 0.717). MELD and CTP scores together with age and a diagnosis of hepatocellular carcinoma are useful indicators to assess the short- and long-term prognosis of patients with acute variceal bleeding.

Second Generation TQ-Ligation for Cell Organelle Imaging.

PubMed

Zhang, Xiaoyun; Dong, Ting; Li, Qiang; Liu, Xiaohui; Li, Lin; Chen, She; Lei, Xiaoguang

2015-07-17

Bioorthogonal ligations play a crucial role in labeling diverse types of biomolecules in living systems. Herein, we describe a novel class of ortho-quinolinone quinone methide (oQQM) precursors that show a faster kinetic rate in the "click cycloaddition" with thio-vinyl ether (TV) than the first generation TQ-ligation in both chemical and biological settings. We further demonstrate that the second generation TQ-ligation is also orthogonal to the widely used strain-promoted azide-alkyne cycloaddition (SPAAC) both in vitro and in vivo, revealing that these two types of bioorthogonal ligations could be used as an ideal reaction pair for the simultaneous tracking of multiple elements within a single system. Remarkably, the second generation TQ-ligation and SPAAC are effective for selective and simultaneous imaging of two different cell organelles in live cells.

TIPS versus endoscopic therapy for variceal rebleeding in cirrhosis: A meta-analysis update.

PubMed

Zhang, Hu; Zhang, Hui; Li, Hui; Zhang, Heng; Zheng, Dan; Sun, Chen-Ming; Wu, Jie

2017-08-01

Endoscopic therapy (ET) is most common method for preventing variceal bleeding in cirrhosis, but the outcomes are not perfect. Recently, transjugular intrahepatic portosystemic shunt (TIPS) is introduced into clinical practice. However, the beneficial effects of TIPS compared to ET on cirrhotic patients is unknown. The aim of this study was to evaluate and compare the effects of TIPS with those of the most frequently used ET for prevention of variceal rebleeding (VRB) in liver cirrhosis. The Pub-Med, EMBASE, and Cochrane Library databases were searched from inception to February 2017. The primary study outcomes included the incidence of VRB, all-cause mortality, bleeding-related death, and the incidence of post-treatment hepatic encephalopathy (PTE). The odds ratios (ORs) with 95% confidence intervals (CI) were pooled for dichotomous variables. Subgroup analyses were performed. Twenty-four studies were eligible and they included 1120 subjects treated with TIPS and 1065 subjects treated with ET. Although there was no significant difference in survival and PTE, TIPS was superior to ET in decreasing the incidence of VRB (OR=0.27; 95% CI, 0.19-0.39, P<0.00001), and decreasing the incidence of bleeding-related death (OR=0.21; 95% CI, 0.13-0.32, P<0.00001). Subgroup analysis found a lower mortality (OR=0.48; 95% CI, 0.23-0.97; P=0.04) without any increased incidence of PTE (OR=1.37; 95% CI, 0.75-2.50; P=0.31) in the studies of a greater proportion (≥40%) of patients with Child-Pugh class C cirrhosis receiving TIPS, and TIPS with covered stent did not increase the risk of PTE compared to ET (OR=1.52, 95% CI =0.82-2.80, P=0.18). It was concluded that TIPS with covered stent might be considered the preferred choice of therapy in patients with severe liver disease for secondary prophylaxis.

Evaluation of Micro-organism in Ligated Metal and Self-ligating Brackets using Scanning Electron Microscopy: An In Vivo Study

PubMed Central

Sunil, P C; Michael, Tony; Raju, Aravind S; Paul, Renji K; Mamatha, J; Ebin, T M

2015-01-01

Background: The objective of the study was to determine the sites of plaque accumulation and to compare the plaque accumulated with metal and self-ligating orthodontic brackets in order to know which bracket type had a higher plaque retaining capacity. Materials and Methods: The study was done on 20 subjects who were scheduled for orthodontic treatment including extraction of four premolars and fixed orthodontic appliances. Mesh-backed edgewise metal brackets ligated with steel ligatures and self-ligating brackets were bonded to the premolars to be extracted using composite (Transbond XT, 3M). The subjects were told to continue their normal oral hygiene regimen. Teeth were extracted at 1, 2, and 3 weeks after bracket bonding. Plaque attached to the buccal surfaces was stained using plaque disclosing agent. The teeth were then immersed in fixative containing 4% formaldehyde and 1% glutaraldehyde in phosphate buffer for 24 h, followed by 0.1 M phosphate buffer for 12 h. The specimens were then mounted on aluminum stubs, and sputter coated with gold prior to Scanning electron microscopy examination. Results: The results showed that increased retention of plaque in metal brackets ligated with steel ligatures and comparatively less in self-ligating brackets at the base of the brackets. Conclusions: This study highlights that higher retention of plaque in metal brackets ligated with steel ligatures and comparatively less plaque retention in self-ligating brackets. Excess composite around the bracket base is the critical site of plaque accumulation associated with fixed appliances due to its rough surface texture. PMID:26229372

Ligation site in proteins recognized in silico

PubMed Central

Brylinski, Michal; Konieczny, Leszek; Roterman, Irena

2006-01-01

Recognition of a ligation site in a protein molecule is important for identifying its biological activity. The model for in silico recognition of ligation sites in proteins is presented. The idealized hydrophobic core stabilizing protein structure is represented by a three-dimensional Gaussian function. The experimentally observed distribution of hydrophobicity compared with the theoretical distribution reveals differences. The area of high differences indicates the ligation site. Availability http://bioinformatics.cm-uj.krakow.pl/activesite PMID:17597871

Upper non-variceal gastrointestinal bleeding - review the effectiveness of endoscopic hemostasis methods

PubMed Central

Szura, Mirosław; Pasternak, Artur

2015-01-01

Upper non-variceal gastrointestinal bleeding is a condition that requires immediate medical intervention and has a high associated mortality rate (exceeding 10%). The vast majority of upper gastrointestinal bleeding cases are due to peptic ulcers. Helicobacter pylori infection, non-steroidal anti-inflammatory drugs and aspirin are the main risk factors for peptic ulcer disease. Endoscopic therapy has generally been recommended as the first-line treatment for upper gastrointestinal bleeding as it has been shown to reduce recurrent bleeding, the need for surgery and mortality. Early endoscopy (within 24 h of hospital admission) has a greater impact than delayed endoscopy on the length of hospital stay and requirement for blood transfusion. This paper aims to review and compare the efficacy of the types of endoscopic hemostasis most commonly used to control non-variceal gastrointestinal bleeding by pooling data from the literature. PMID:26421105

The impact of a dedicated patent ductus arteriosus ligation team on neonatal health-care outcomes.

PubMed

Resende, M H F; More, K; Nicholls, D; Ting, J; Jain, A; McNamara, P J

2016-06-01

The decision to perform patent ductus arteriosus (PDA) ligation is controversial. Patient selection is oftentimes poorly standardized, leading to delays in referral and inappropriate intervention. A system for PDA ligation categorization and triaging process was introduced in 2006 at a quaternary hospital in Canada to streamline referrals and enhance perioperative care. We aimed to evaluate the impact of this dedicated PDA ligation triaging system comparing pre- and postimplementation of this system. We performed a retrospective chart review. Demographic and cardiorespiratory data of neonates ⩽30 weeks gestation age at birth, who were referred for and/or had a PDA ligation performed during two distinct epochs (EPOCH 1 (2003 to 2005) and EPOCH 2 (2010 to 2012)), were analyzed. All surgeries were performed at The Hospital for Sick Children, the regional referral center for PDA ligation. The primary outcome was incidence of PDA ligation and procedural cancellations. Secondary outcomes included postoperative need for cardiovascular or respiratory support. Subgroup analysis was performed in neonates <1000 vs >1000 g at the time of surgery during both epochs. A total of 198 neonates underwent surgery with no difference in baseline demographics between epochs. The incidence of PDA ligation as a proportion of total live births under 30 weeks in Central East Region of Ontario was lower in the second epoch (EPOCH 1: 117/1092 (10.7%) vs EPOCH 2: 81/1520 (5.3%)). During the second epoch, 24% of referrals for surgery were canceled after review by our PDA ligation team. There were no overall differences in the proportion of neonates with oxygenation failure, ventilation failure or Post-Ligation Cardiac Syndrome (PLCS), after surgery, between epochs. The proportion of neonates who developed systemic hypotension was higher in patients <1000 g (n=34 (34%) vs n=17 (17.4%), P=0.01) at the time of surgery. In addition, we identified a reduction in the proportion of neonates

Relationship between symptom response and esophageal pH level on standard dose of esomeprazole treatment for gastroesophageal reflux disease.

PubMed

Peng, Sui; Xiong, Li-shou; Xiao, Ying-lian; Wang, An-jiang; Lin, Jin-kun; Hu, Pin-jin; Chen, Min-hu

2010-08-05

The relationship between symptom elimination and normalization of esophageal acid level of gastroesophageal reflux disease (GERD) on proton-pump inhibitor (PPI) therapy has been questioned. This study aimed to evaluate the relationship between symptom response and gastro-esophageal acidity control in Chinese patients with GERD on esomeprazole therapy, and to assess the role of 24-hour esophageal pH-metry after therapy in GERD patients. GERD patients with typical reflux symptoms were enrolled and received esomeprazole 40 mg once daily for 4 weeks. Patients with positive baseline 24-hour esophageal pH-metry were divided into two groups depending on an additional dual-channel 24-hour pH-metry after treatment. The pH- group achieved normalization of esophageal pH level whereas the pH+ group did not. Of the 80 patients studied, 76 had abnormal baseline esophageal pH levels. Of these, 90% (52/58) of symptom-free patients and 67% (12/18) of symptom-persistent patients achieved esophageal pH normalization after therapy (P = 0.030). The mean post-therapy gastric nocturnal percent time of pH < 4.0 was significantly higher in pH+ group than that in pH- group (P < 0.001) after therapy. The multivariate regression analysis identified hiatus hernia (P < 0.001) and persistent reflux symptom (P = 0.004) were two independent factors predicting the low post-therapy esophageal pH level. Symptom elimination is not always accompanied by esophageal pH normalization, and vice verse. Esophageal pH-metry is recommended for GERD patients with hiatus hernia or with persistent reflux symptoms after PPI therapy.

Esophageal stenosis associated with tumor regression in radiotherapy for esophageal cancer: frequency and prediction.

PubMed

Atsumi, Kazushige; Shioyama, Yoshiyuki; Arimura, Hidetaka; Terashima, Kotaro; Matsuki, Takaomi; Ohga, Saiji; Yoshitake, Tadamasa; Nonoshita, Takeshi; Tsurumaru, Daisuke; Ohnishi, Kayoko; Asai, Kaori; Matsumoto, Keiji; Nakamura, Katsumasa; Honda, Hiroshi

2012-04-01

To determine clinical factors for predicting the frequency and severity of esophageal stenosis associated with tumor regression in radiotherapy for esophageal cancer. The study group consisted of 109 patients with esophageal cancer of T1-4 and Stage I-III who were treated with definitive radiotherapy and achieved a complete response of their primary lesion at Kyushu University Hospital between January 1998 and December 2007. Esophageal stenosis was evaluated using esophagographic images within 3 months after completion of radiotherapy. We investigated the correlation between esophageal stenosis after radiotherapy and each of the clinical factors with regard to tumors and therapy. For validation of the correlative factors for esophageal stenosis, an artificial neural network was used to predict the esophageal stenotic ratio. Esophageal stenosis tended to be more severe and more frequent in T3-4 cases than in T1-2 cases. Esophageal stenosis in cases with full circumference involvement tended to be more severe and more frequent than that in cases without full circumference involvement. Increases in wall thickness tended to be associated with increases in esophageal stenosis severity and frequency. In the multivariate analysis, T stage, extent of involved circumference, and wall thickness of the tumor region were significantly correlated to esophageal stenosis (p = 0.031, p < 0.0001, and p = 0.0011, respectively). The esophageal stenotic ratio predicted by the artificial neural network, which learned these three factors, was significantly correlated to the actual observed stenotic ratio, with a correlation coefficient of 0.864 (p < 0.001). Our study suggested that T stage, extent of involved circumference, and esophageal wall thickness of the tumor region were useful to predict the frequency and severity of esophageal stenosis associated with tumor regression in radiotherapy for esophageal cancer. Copyright © 2012 Elsevier Inc. All rights reserved.

Chemical Ligation Reactions of Oligonucleotides for Biological and Medicinal Applications.

PubMed

Abe, Hiroshi; Kimura, Yasuaki

2018-01-01

Chemical ligation of oligonucleotides (ONs) is the key reaction for various ON-based technologies. We have tried to solve the problems of RNA interference (RNAi) technology by applying ON chemical ligation to RNAi. We designed a new RNAi system, called intracellular buildup RNAi (IBR-RNAi), where the RNA fragments are built up into active small-interference RNA (siRNA) in cells through a chemical ligation reaction. Using the phosphorothioate and iodoacetyl groups as reactive functional groups for the ligation, we achieved RNAi effects without inducing immune responses. Additionally, we developed a new chemical ligation for IBR-RNAi, which affords a more native-like structure in the ligated product. The new ligation method should be useful not only for IBR-RNAi but also for the chemical synthesis of biofunctional ONs.

Alcohol Abuse Increases Rebleeding Risk and Mortality in Patients with Non-variceal Upper Gastrointestinal Bleeding.

PubMed

Kärkkäinen, Jussi M; Miilunpohja, Sami; Rantanen, Tuomo; Koskela, Jenni M; Jyrkkä, Johanna; Hartikainen, Juha; Paajanen, Hannu

2015-12-01

No current data are available on rebleeding and mortality risk in patients who use alcohol excessively and are admitted for non-variceal upper gastrointestinal bleeding (NVUGIB). This information could help in planning interventions and follow-up protocols for these patients. This study provides contemporary data on the long-term outcome after first-time NVUGIB in alcohol abusers (AAs) compared to non-abusers (NAs). Consecutive patients hospitalized for their first acute gastrointestinal bleeding from 2009 through 2011 were retrospectively recorded and categorized as AA or NA. Risk factors for one-year mortality and rebleeding were identified, and patients were further monitored for long-term mortality until 2015. Alcohol abuse was identified in 19.7% of patients with NVUGIB (n = 518). The one-year rebleeding rate was 16.7% in AAs versus 9.1% in NAs (P = 0.027). Alcohol abuse was associated with a twofold increase in rebleeding risk (P = 0.025); the risk especially increased 6 months after the initial bleeding. The study groups did not differ significantly in 30-day (6.0%) or one-year mortality rates (20.5%). However, there was a tendency for higher overall mortality in AAs than NAs after adjustment of comorbidities. AAs with NVUGIB are at high risk of rebleeding, and mortality is increased in AA patients. A close follow-up strategy and long-term proton pump inhibitor therapy are recommended for AA patients with peptic ulcer or esophagitis.

Effects of Morinda citrifolia aqueous fruit extract and its biomarker scopoletin on reflux esophagitis and gastric ulcer in rats.

PubMed

Mahattanadul, Sirima; Ridtitid, Wibool; Nima, Sawpheeyah; Phdoongsombut, Narubodee; Ratanasuwon, Pranee; Kasiwong, Srirat

2011-03-24

The present study was carried out to evaluate the effect of dried mature unripe Morinda citrifolia L. (Rubiaceae) fruit, commonly known as "Noni", in an aqueous extract preparation (AFE) as used in Thai traditional medicine and its biomarker scopoletin on gastro-esophageal inflammatory models that are related to the claimed pharmacological properties of AFE and/or resembled the human esophagitis or gastric ulcer. The powder of dried mature unripe Noni fruit was boiled in water until it became a sticky paste and was then dried into a powder by lyophilization. The pharmacological activity of AFE and pure scopoletin at the same equivalent dose present in AFE was investigated in rat on gastro-esophageal inflammatory models (acid reflux esophagitis, acute gastritis induced by ethanol and serotonin, and chronic gastric ulcer induced by acetic acid); gastric biochemical parameters and gastrointestinal motility. AFE (0.63-2.50 g/kg) significantly prevented the formation of acid reflux esophagitis, reduced the formation of ethanol-induced acute gastric lesions, suppressed the development of gastric lesions in response to serotonin, and accelerated the healing of acetic acid-induced chronic gastric ulcer in rats with equal potency to those obtained by standard antisecretory agents (ranitidine and lansoprazole). AFE also significantly inhibited gastric acid secretion and pepsin activity in pylorus ligated rats. Additionally, AFE strongly increased the gastrointestinal transit of charcoal meal with a higher potency than cisapride. Pure scopoletin, when compared at the same equivalent dose containing in AFE, possessed similar antiulcer and antisecretory properties to that of AFE although it exerted a less prokinetic activity than AFE. The findings indicated that AFE as well as its biomarker: scopoletin may be beneficial as a potential preventive and therapeutic agent for gastro-esophageal inflammatory diseases, mainly through its antisecretory and prokinetic activities

Tetrazine ligation for chemical proteomics.

PubMed

Kang, Kyungtae; Park, Jongmin; Kim, Eunha

2016-01-01

Determining small molecule-target protein interaction is essential for the chemical proteomics. One of the most important keys to explore biological system in chemical proteomics field is finding first-class molecular tools. Chemical probes can provide great spatiotemporal control to elucidate biological functions of proteins as well as for interrogating biological pathways. The invention of bioorthogonal chemistry has revolutionized the field of chemical biology by providing superior chemical tools and has been widely used for investigating the dynamics and function of biomolecules in live condition. Among 20 different bioorthogonal reactions, tetrazine ligation has been spotlighted as the most advanced bioorthogonal chemistry because of their extremely faster kinetics and higher specificity than others. Therefore, tetrazine ligation has a tremendous potential to enhance the proteomic research. This review highlights the current status of tetrazine ligation reaction as a molecular tool for the chemical proteomics.

Efficient Ligation of the Schistosoma Hammerhead Ribozyme †

PubMed Central

Canny, Marella D.; Jucker, Fiona M.; Pardi, Arthur

2011-01-01

The hammerhead ribozyme from Schistosoma mansoni is the best characterized of the natural hammerhead ribozymes. Biophysical, biochemical, and structural studies have shown that the formation of the loop-loop tertiary interaction between stems I and II alters the global folding, cleavage kinetics, and conformation of the catalytic core of this hammerhead, leading to a ribozyme that is readily cleaved under physiological conditions. This study investigates the ligation kinetics and the internal equilibrium between cleavage and ligation for the Schistosoma hammerhead. Single turnover kinetic studies on a construct where the ribozyme cleaves and ligates substrate(s) in trans showed up to 23% ligation when starting from fully cleaved products. This was achieved by a ~2,000-fold increase in the rate of ligation compared to a minimal hammerhead without the loop-loop tertiary interaction, yielding an internal equilibrium that ranges from 2–3 at physiological Mg2+ ion concentrations (0.1 –1 mM). Thus, the natural Schistosoma hammerhead ribozyme is almost as efficient at ligation as it is at cleavage. The results here are consistent with a model where formation of the loop-loop tertiary interaction leads to a higher population of catalytically active molecules, and where formation of this tertiary interaction has a much larger effect on the ligation than the cleavage activity of the Schistosoma hammerhead ribozyme. PMID:17319693

Genetic variations in MTHFR and esophageal squamous cell carcinoma susceptibility in Chinese Han population.

PubMed

Tang, Weifeng; Zhang, Sheng; Qiu, Hao; Wang, Lixin; Sun, Bin; Yin, Jun; Gu, Haiyong

2014-05-01

Esophageal cancer is the sixth most common cancer worldwide. Esophageal squamous cell carcinoma (ESCC) is a fatal malignancy associated with low 5-year survival rate. The aim of this study was to assess the association between methylenetetrahydrofolate reductase (MTHFR) tagging single nucleotide polymorphisms (SNPs) rs1801133 C>T, rs3753584 A>G, rs4845882 G>A, rs4846048 A>G and rs9651118 T>C genotypes and ESCC susceptibility in a hospital-based case-control study. We conducted genotyping analyses for these five SNPs with 629 ESCC cases and 686 controls in a Chinese Han population. Ligation detection reaction method was used to identify genotypes of these MTHFR SNPs. Our results demonstrated that MTHFR rs1801133 C>T was associated with the risk of ESCC; however, MTHFR rs4845882 G>A and rs4846048 A>G SNPs were associated with the decreased risk of ESCC, and MTHFR rs3753584 A>G and rs9651118 T>C SNPs were not associated with ESCC risk. Our findings suggests that MTHFR rs1801133 C>T, rs4845882 G>A and rs4846048 A>G SNPs may be genetic modifiers for developing ESCC in Chinese Han population.

Esophageal Dysmotility, Gastro-esophageal Reflux Disease, and Lung Transplantation: What Is the Evidence?

PubMed

Wood, Richard K

2015-12-01

Lung transplantation is an effective and life-prolonging therapy for patients with advanced lung disease (ALD). However, long-term patient survival following lung transplantation is primarily limited by development of an inflammatory and fibrotic process involving the lung allograft known as bronchiolitis obliterans syndrome (BOS). Although the precise cause of BOS remains uncertain and is likely multifactorial, chronic aspiration of gastro-duodenal contents is one possible contributing factor. Multiple small, cross-sectional studies performed over the past two decades have reported a high prevalence of gastro-esophageal reflux disease (GERD) and esophageal dysmotility in the ALD population and several investigations suggest the prevalence may increase following lung transplantation. More recent studies evaluating the direct effect of gastro-duodenal contents on airways have demonstrated a possible biologic link between GERD and BOS. Despite the recent advances in our understanding of BOS, further investigations are needed to establish GERD as a causative factor in its development. This review will discuss the existing literature that has identified an association of GERD with ALD and post-transplant populations, with a focus on recent advances in the field.

Risk factors of electrocoagulation syndrome after esophageal endoscopic submucosal dissection

PubMed Central

Ma, Dae Won; Youn, Young Hoon; Jung, Da Hyun; Park, Jae Jun; Kim, Jie-Hyun; Park, Hyojin

2018-01-01

AIM To investigate post endoscopic submucosal dissection electrocoagulation syndrome (PEECS) of the esophagus. METHODS We analyzed 55 consecutive cases with esophageal endoscopic submucosal dissection for superficial esophageal squamous neoplasms at a tertiary referral hospital in South Korea. Esophageal PEECS was defined as “mild” meeting one of the following criteria without any obvious perforation: fever (≥ 37.8 °C), leukocytosis (> 10800 cells/μL), or regional chest pain more than 5/10 points as rated on a numeric pain intensity scale. The grade of PEECS was determined as “severe” when meet two or more of above criteria. RESULTS We included 51 cases without obvious complications in the analysis. The incidence of mild and severe esophageal PEECS was 47.1% and 17.6%, respectively. Risk factor analysis revealed that resected area, procedure time, and muscle layer exposure were significantly associated with PEECS. In multivariate analysis, a resected area larger than 6.0 cm2 (OR = 4.995, 95%CI: 1.110-22.489, P = 0.036) and muscle layer exposure (OR = 5.661, 95%CI: 1.422-22.534, P = 0.014) were independent predictors of esophageal PEECS. All patients with PEECS had favorable outcomes with conservative management approaches, such as intravenous hydration or antibiotics. CONCLUSION Clinicians should consider the possibility of esophageal PEECS when the resected area exceeds 6.0 cm2 or when the muscle layer exposure is noted. PMID:29563758

Esophageal culture

MedlinePlus

... page: //medlineplus.gov/ency/article/003764.htm Esophageal culture To use the sharing features on this page, please enable JavaScript. Esophageal culture is a laboratory test that checks for infection- ...

Transcatheter arterial embolization for endoscopically unmanageable non-variceal upper gastrointestinal bleeding.

PubMed

Lee, Han Hee; Park, Jae Myung; Chun, Ho Jong; Oh, Jung Suk; Ahn, Hyo Jun; Choi, Myung-Gyu

2015-07-01

Transcatheter arterial embolization (TAE) is a therapeutic option for endoscopically unmanageable upper gastrointestinal (GI) bleeding. We aimed to assess the efficacy and clinical outcomes of TAE for acute non-variceal upper GI bleeding and to identify predictors of recurrent bleeding within 30 days. Visceral angiography was performed in 66 patients (42 men, 24 women; mean age, 60.3 ± 12.7 years) who experienced acute non-variceal upper GI bleeding that failed to be controlled by endoscopy during a 7-year period. Clinical information was reviewed retrospectively. Outcomes included technical success rates, complications, and 30-day rebleeding and mortality rates. TAE was feasible in 59 patients. The technical success rate was 98%. Rebleeding within 30 days was observed in 47% after an initial TAE and was managed with re-embolization in 8, by endoscopic intervention in 5, by surgery in 2, and by conservative care in 12 patients. The 30-day overall mortality rate was 42.4%. In the case of initial endoscopic hemostasis failure (n = 34), 31 patients underwent angiographic embolization, which was successful in 30 patients (96.8%). Rebleeding occurred in 15 patients (50%), mainly because of malignancy. Two factors were independent predictors of rebleeding within 30 days by multivariate analysis: coagulopathy (odds ratio [OR] = 4.37; 95% confidence interval [CI]: 1.25-15.29; p = 0.021) and embolization in ≥2 territories (OR = 4.93; 95% CI: 1.43-17.04; p = 0.012). Catheterization-related complications included hepatic artery dissection and splenic embolization. TAE controlled acute non-variceal upper GI bleeding effectively. TAE may be considered when endoscopic therapy is unavailable or unsuccessful. Correction of coagulopathy before TAE is recommended.

Validation of prognostic scores for clinical outcomes in cirrhotic patients with acute variceal bleeding.

PubMed

Motola-Kuba, Miguel; Escobedo-Arzate, Angélica; Tellez-Avila, Félix; Altamirano, José; Aguilar-Olivos, Nancy; González-Angulo, Alberto; Zamarripa-Dorsey, Felipe; Uribe, Misael; Chávez-Tapia, Norberto C

Background. The Rockall, Glasgow-Blatchford, and AIMS65 are useful and validated scoring systems for predicting the outcomes of patients with nonvariceal gastrointestinal bleeding. However, there are no validated evidence for using them to predict outcomes on variceal bleeding. The aim of this study was to evaluate and compare the prognostic accuracy of different nonvariceal bleeding scores with other liver-specific scoring systems in cirrhotic patients. A retrospective multicenter study that included 160 cirrhotic patients with acute variceal bleeding. The AUROC's to predict in-hospital mortality, and rebleeding, were analyzed for each scoring system. Overall in-hospital mortality occurred in 13% and in-hospital rebleeding in 12% of patients. The systems with the best AUROC value for predicting mortality were MELD (0.828; 95% CI 0.748-0.909), and AIMS65 (0.817; 95% CI 0.724-0.909). The best score systems for predicting rebleeding were Glasgow-Blatchford (0.756; 95% CI 0.640- 0.827), and Rockall (0.691; 95% CI 0.580-0.802). In addition to liver-specific scores, the AIMS65 score is accurate for predicting in-hospital mortality in cirrhotic patients with acute variceal bleeding. Other scoring systems might be useful for predicting significant clinical outcomes in these patients.

Balloon-Occluded Antegrade Transvenous Sclerotherapy to Treat Rectal Varices: A Direct Puncture Approach to the Superior Rectal Vein Through the Greater Sciatic Foramen Under CT Fluoroscopy Guidance

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ono, Yasuyuki, E-mail: onoyasy@hirakata.kmu.ac.jp; Kariya, Shuji, E-mail: kariyas@hirakata.kmu.ac.jp; Nakatani, Miyuki, E-mail: nakatanm@hirakata.kmu.ac.jp

Rectal varices occur in 44.5 % of patients with ectopic varices caused by portal hypertension, and 48.6 % of these patients are untreated and followed by observation. However, bleeding occurs in 38 % and shock leading to death in 5 % of such patients. Two patients, an 80-year-old woman undergoing treatment for primary biliary cirrhosis (Child-Pugh class A) and a 63-year-old man with class C hepatic cirrhosis (Child-Pugh class A), in whom balloon-occluded antegrade transvenous sclerotherapy was performed to treat rectal varices are reported. A catheter was inserted by directly puncturing the rectal vein percutaneously through the greater sciatic foramen under computed tomographic fluoroscopymore » guidance. In both cases, the rectal varices were successfully treated without any significant complications, with no bleeding from rectal varices after embolization.« less

Clinical significance of the correlation between PLCE 1 and PRKCA in esophageal inflammation and esophageal carcinoma

PubMed Central

Ma, Ming; Zhang, Shanshan; Zhang, Yongmeng; Yuan, Ming; Liu, Bing; Yang, Yiqiong; Cui, Wen; Ansong, Emmanuel; Dong, Huali; Macias, Virgilia; Yang, Wancai

2017-01-01

Esophagitis and Barrett's esophagus are linked to esophageal squamous cell carcinoma and adenocarcinoma, respectively. However, the underlying mechanisms are still unclear. This study analyzed the expression levels of and correlation between PLCE1 and PRKCA in human esophagitis, carcinogen NMBA-induced rat esophagus, PLCE1 genetic deficient mouse esophageal epithelial tissues and human esophageal cancer cell line, integrated with Online oncology data sets. We found that the expression levels of both PLCE1 and PRKCA were significantly elevated in human esophagitis, esophageal squamous cell carcinoma, Barrett's esophagus, esophageal adenocarcinoma and in NMBA-treated rat esophageal epithelia. However, PRKCA and cytokines were significantly downregulated in PLCE1-deficient mouse esophageal epithelia, and knockdown of PLCE1 in human esophageal cancer cells led to reduction of PRKCA and cytokines. Finally, high expression of both PLCE1 and PRKCA is significantly associated with poor outcomes of the patients with esophageal cancers. In conclusion, this study defined the initiation and progression of esophageal inflammation and malignant transformation, in which the positive correlation of PLCE1 and PRKCA exhibits critical clinical significance. PMID:28402280

Prevalence of Eosinophilic Esophagitis and Lymphocytic Esophagitis in Adults with Esophageal Food Bolus Impaction.

PubMed

Truskaite, Kotryna; Dlugosz, Aldona

2016-01-01

Background. The relation of esophageal food bolus impaction (FBI) to eosinophilic esophagitis (EoE) and lymphocytic esophagitis (LyE) is unclear. The aim of this study was to determine the prevalence of EoE and LyE among adults with FBI. Methods. In this retrospective study we analyzed data from all patients referred for gastroscopy during the past 5 years, because of a present or recent episode of FBI. Results. We found 238 patients with FBI (median age 51 (17-96), 71% males). Endoscopic therapy was required in 143 patients. Esophageal biopsies were obtained in 185 (78%) patients. All biopsies were assessed for numbers of eosinophils and lymphocytes. EoE was found in 18% of patients who underwent biopsy. We found 41 patients (22%) who fulfilled the criteria for both EoE and LyE (EoE/LyE). LyE was found in the 9% of patients with FBI. EoE together with EoE/LyE was the leading cause of FBI in patients ≤50 years (64%). GERD was the leading cause of FBI among patients older than 50 years (42%). Conclusions. Our study showed that EoE was the leading cause of FBI in particular among young adults. Our study highlights the need for esophageal biopsies in any patient with FBI.

Ligation with Nucleic Acid Sequence–Based Amplification

PubMed Central

Ong, Carmichael; Tai, Warren; Sarma, Aartik; Opal, Steven M.; Artenstein, Andrew W.; Tripathi, Anubhav

2012-01-01

This work presents a novel method for detecting nucleic acid targets using a ligation step along with an isothermal, exponential amplification step. We use an engineered ssDNA with two variable regions on the ends, allowing us to design the probe for optimal reaction kinetics and primer binding. This two-part probe is ligated by T4 DNA Ligase only when both parts bind adjacently to the target. The assay demonstrates that the expected 72-nt RNA product appears only when the synthetic target, T4 ligase, and both probe fragments are present during the ligation step. An extraneous 38-nt RNA product also appears due to linear amplification of unligated probe (P3), but its presence does not cause a false-positive result. In addition, 40 mmol/L KCl in the final amplification mix was found to be optimal. It was also found that increasing P5 in excess of P3 helped with ligation and reduced the extraneous 38-nt RNA product. The assay was also tested with a single nucleotide polymorphism target, changing one base at the ligation site. The assay was able to yield a negative signal despite only a single-base change. Finally, using P3 and P5 with longer binding sites results in increased overall sensitivity of the reaction, showing that increasing ligation efficiency can improve the assay overall. We believe that this method can be used effectively for a number of diagnostic assays. PMID:22449695

Esophageal Cancer

MedlinePlus

... from your throat to your stomach. Early esophageal cancer usually does not cause symptoms. Later, you may ... You're at greater risk for getting esophageal cancer if you smoke, drink heavily, or have acid ...

Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders.

PubMed

van Hoeij, Froukje B; Bredenoord, Albert J

2016-01-31

Esophageal high-resolution manometry (HRM) is replacing conventional manometry in the clinical evaluation of patients with esophageal symptoms, especially dysphagia. The introduction of HRM gave rise to new objective metrics and recognizable patterns of esophageal motor function, requiring a new classification scheme: the Chicago classification. HRM measurements are more detailed and more easily performed compared to conventional manometry. The visual presentation of acquired data improved the analysis and interpretation of esophageal motor function. This led to a more sensitive, accurate, and objective analysis of esophageal motility. In this review we discuss how HRM changed the way we define and categorize esophageal motility disorders. Moreover, we discuss the clinical applications of HRM for each esophageal motility disorder separately.

Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders

PubMed Central

van Hoeij, Froukje B; Bredenoord, Albert J

2016-01-01

Esophageal high-resolution manometry (HRM) is replacing conventional manometry in the clinical evaluation of patients with esophageal symptoms, especially dysphagia. The introduction of HRM gave rise to new objective metrics and recognizable patterns of esophageal motor function, requiring a new classification scheme: the Chicago classification. HRM measurements are more detailed and more easily performed compared to conventional manometry. The visual presentation of acquired data improved the analysis and interpretation of esophageal motor function. This led to a more sensitive, accurate, and objective analysis of esophageal motility. In this review we discuss how HRM changed the way we define and categorize esophageal motility disorders. Moreover, we discuss the clinical applications of HRM for each esophageal motility disorder separately. PMID:26631942

Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit.

PubMed

Jairath, Vipul; Rehal, Sunita; Logan, Richard; Kahan, Brennan; Hearnshaw, Sarah; Stanworth, Simon; Travis, Simon; Murphy, Michael; Palmer, Kelvin; Burroughs, Andrew

2014-05-01

Despite advances in treatment, acute variceal haemorrhage remains life-threatening. To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality. Multi-centre clinical audit conducted in 212 UK hospitals. In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01). Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support. Copyright © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

The potential of photodynamic therapy to treat esophageal candidiasis coexisting with esophageal cancer.

PubMed

Qiu, Haixia; Mao, Yongping; Gu, Ying; Zhu, Jianguo; Wang, Ying; Zeng, Jing; Huang, Naiyan; Liu, Qingsen; Yang, Yunsheng

2014-01-05

Photodynamic therapy (PDT) has been used in recent years to deal with fungal infections because of the prevalence of fungi resistance to drugs. However, PDT for gastrointestinal fungal infection has not been reported. This study was conducted to assess the potential of PDT to deal with esophageal candidiasis. Two male patients with histological evidence of esophageal candidiasis coexisting with esophageal cancer were included in this retrospective study. Both patients were treated with PDT. This treatment was repeated at least 1month after the initial PDT if the patient still had residual cancer or esophageal candidiasis. Short-term efficacy was evaluated on the basis of endoscopy and histology findings. Further follow-up data were obtained from endoscopy results or telephone conversation. The esophageal candidiasis located 21-24cm and 25-28cm from the incisors of case 1 reached complete remission after one and two PDT sessions, respectively. The esophageal cancer coexisting with esophageal candidiasis located 21-24cm from the incisors reached complete remission after two PDT sessions. No recurrence was found at a 14-month follow-up. The esophageal cancer located 30-35cm from the incisors reached partial response after three PDT sessions. Both of the esophageal candidiasis and the coexisting esophageal cancer at 23-26cm from the incisors of case 2 reached complete remission and the esophageal cancer at 34-37cm from the incisors reached complete remission after one PDT session. No recurrence was found at a 24-month follow-up. There were no serious adverse events found in either of the two cases. Results of this preliminary study indicate that PDT may be a potential method to deal with esophageal candidiasis. Copyright © 2013 Elsevier B.V. All rights reserved.

Preventive Effect on Post-Operative Pneumonia of Oral Health Care among Patients Who Undergo Esophageal Resection: A Multi-Center Retrospective Study.

PubMed

Soutome, Sakiko; Yanamoto, Souichi; Funahara, Madoka; Hasegawa, Takumi; Komori, Takahide; Oho, Takahiko; Umeda, Masahiro

2016-08-01

Post-operative pneumonia is a frequent and possibly fatal complication of esophagectomy and is likely caused by aspiration of oropharyngeal fluid that contains pathogenic micro-organisms. We conducted a multi-center retrospective study to investigate the preventive effect of oral health care on post-operative pneumonia among patients with esophageal cancer who underwent esophagectomy. A total of 280 patients underwent esophagectomy at three university hospitals. These patients were divided retrospectively into those who received pre-operative oral care from dentists and dental hygienists (oral care group; n = 173) and those who did not receive such care (control group; n = 107). We evaluated the correlations between the occurrence of post-operative pneumonia and 18 predictive variables (patient factors, tumor factors, treatment factors, and pre-operative oral care) using the χ(2) test and logistic regression analysis. The differences of mean hospital days and mortality rate in both groups were analyzed by the Student t-test. Age, post-operative dysphagia, and absence of pre-operative oral care were correlated significantly with post-operative pneumonia in the univariable analysis. Multivariable analysis revealed that diabetes mellitus, post-operative dysphagia, and the absence of pre-operative oral care were independent risk factors for post-operative pneumonia. The mean hospital stay and mortality rate did not differ between the oral care and control groups. Pre-operative oral care may be an effective and easy method to prevent post-operative pneumonia in patients who are undergoing esophagectomy.

Esophagitis with eosinophil infiltration associated with congenital esophageal atresia and stenosis.

PubMed

Yamada, Yoshiyuki; Nishi, Akira; Kato, Masahiko; Toki, Fumiaki; Yamamoto, Hideki; Suzuki, Norio; Hirato, Junko; Hayashi, Yasuhide

2013-01-01

The esophagus is physiologically devoid of eosinophils, so their presence would suggest some underlying pathology. The prevalence of eosinophilic esophagitis (EoE) has steadily increased in Western countries. Previous studies have described EoE in association with congenital esophageal atresia (CEA), which is the most common congenital anomaly of the esophagus. However, the association remains unclear. We performed a retrospective histological analysis examining for eosinophil infiltration in the esophagus of patients with CEA following surgical repair or congenital esophageal stenosis (CES) who underwent esophageal biopsy or surgical resection in our hospital between 2005 and 2012. There were 6 patients with CEA following surgical repair or CES who had eosinophil-dominant infiltration in the esophagus. All had associated allergic disorders, including food allergies in 4. Moreover, all except for one fulfilled the histological criteria of EoE. Impairment of eosinophil infiltration and symptomatic improvement were observed in those treated with a proton pump inhibitor (PPI), either alone or in combination with steroids after esophageal dilatation. These findings suggest that CEA repair or CES in conjunction with allergic conditions and coexisting gastroesophageal reflux disease (GERD) may induce greater esophageal eosinophilic inflammation. In addition, esophageal dilatation followed by PPI treatment, alone or with steroids, may be a therapeutic strategy that can provide symptomatic relief by reducing eosinophilic inflammation in esophageal strictures or GERD associated with CEA or CES. Copyright © 2013 S. Karger AG, Basel.

Fully covered self-expanding metallic stent placement for benign refractory esophageal strictures.

PubMed

Kahalekar, Vinit; Gupta, Deepak Trilokinath; Bhatt, Pratin; Shukla, Akash; Bhatia, Shobna

2017-05-01

Treatment options for benign refractory esophageal stricture are limited. We retrospectively analyzed data of 11 patients who underwent fully covered self-expanding metallic stent (FC-SEMS) placement for refractory benign esophageal stricture at our institute. Refractory benign esophageal stricture was defined as inability to dilate a stricture to a diameter of 14 mm after a minimum of five sessions at 2-week intervals or inability to maintain diameter of 14 mm for at least 4 weeks. Eleven patients with refractory benign esophageal stricture (corrosive-6, peptic-3, and post-sclerotherapy-2) underwent FC-SEMS placement. The stent was removed after 4-6 weeks as per manufacturer's recommendation. Patients were followed up for 1 year. Three patients with peptic strictures [length of stricture 2, 3, and 3 cm] and two patients with post-sclerotherapy stricture [length 2 and 1.5 cm] had complete response. Two of 6 patients with corrosive stricture (10 cm, 12 cm) developed recurrence of symptoms within 1 month of stent removal, and two after 2 months (8 cm, 3 cm). One patient with corrosive stricture (6 cm) had recurrence after 6 months, and responded to single session of dilatation. One patient with corrosive stricture was asymptomatic for last 12 months. Four stents were migrated. Four patients developed severe retrosternal pain following stent placement, which was managed with analgesics. There were no serious adverse events after placement of stent and removal of stent. Fully covered SEMS is safe and effective for refractory benign non-corrosive esophageal strictures.

Diagnosis and therapy of non-variceal upper gastrointestinal bleeding

PubMed Central

Biecker, Erwin

2015-01-01

Non-variceal upper gastrointestinal bleeding (UGIB) is defined as bleeding proximal to the ligament of Treitz in the absence of oesophageal, gastric or duodenal varices. The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock. Causes of UGIB are peptic ulcers, Mallory-Weiss lesions, erosive gastritis, reflux oesophagitis, Dieulafoy lesions or angiodysplasia. After admission to the hospital a structured approach to the patient with acute UGIB that includes haemodynamic resuscitation and stabilization as well as pre-endoscopic risk stratification has to be done. Endoscopy offers not only the localisation of the bleeding site but also a variety of therapeutic measures like injection therapy, thermocoagulation or endoclips. Endoscopic therapy is facilitated by acid suppression with proton pump inhibitor (PPI) therapy. These drugs are highly effective but the best route of application (oral vs intravenous) and the adequate dosage are still subjects of discussion. Patients with ulcer disease are tested for Helicobacter pylori and eradication therapy should be given if it is present. Non-steroidal anti-inflammatory drugs have to be discontinued if possible. If discontinuation is not possible, cyclooxygenase-2 inhibitors in combination with PPI have the lowest bleeding risk but the incidence of cardiovascular events is increased. PMID:26558151

Advances in esophageal motor disorders.

PubMed

Smout, André Jpm

2008-07-01

Esophageal motor disorders, often leading to dysphagia and chest pain, continue to pose diagnostic and therapeutic problems. In the past 12 months important new information regarding esophageal motor disorders was published. This information will be reviewed in this paper. A number of studies have addressed the issue of heterogeneity in achalasia, the best defined esophageal motility disorder. The spastic esophageal motility disorders nutcracker esophagus and diffuse esophageal spasm may coexist with gastroesophageal reflux disease, which has consequences for the management of patients with these disorders. The entity labelled ineffective esophageal motility is associated with reflux esophagitis, but also with morbid obesity. For the detection of disordered transit caused by ineffective esophageal motility, application of intraluminal impedance monitoring in conjunction with manometry leads to improved diagnosis. New data on the effect of Nissen fundoplication on esophageal motility were published during the last year. Recent knowledge on the heterogeneity of achalasia and the association of spastic esophageal motor disorders and ineffective motility with reflux disease will help the clinician in the management of patients with these disorders.

Varic acid analogues from fungus as PTP1B inhibitors: Biological evaluation and structure-activity relationships.

PubMed

Sun, Wenlong; Zhuang, Chunlin; Li, Xia; Zhang, Bowei; Lu, Xinhua; Zheng, Zhihui; Dong, Yuesheng

2017-08-01

Protein tyrosine phosphatase 1B (PTP1B) inhibitors as potential therapies for diabetes and obesity have attracted much attention in recent years. Six varic acid analogues were isolated from two strains of fungi and evaluated for PTP1B inhibition activities. The structure-activity relationships were also characterized and predicted by molecular modeling. Further kinetic studies indicated the reversible and competitive inhibition manner of varic acid analogues. Trivaric acid showed insulin-sensitizing effect not only in vitro but also in vivo, representing a promising lead compound for further optimization. Copyright © 2017 Elsevier Ltd. All rights reserved.

Esophageal tissue engineering: A new approach for esophageal replacement

PubMed Central

Totonelli, Giorgia; Maghsoudlou, Panagiotis; Fishman, Jonathan M; Orlando, Giuseppe; Ansari, Tahera; Sibbons, Paul; Birchall, Martin A; Pierro, Agostino; Eaton, Simon; De Coppi, Paolo

2012-01-01

A number of congenital and acquired disorders require esophageal tissue replacement. Various surgical techniques, such as gastric and colonic interposition, are standards of treatment, but frequently complicated by stenosis and other problems. Regenerative medicine approaches facilitate the use of biological constructs to replace or regenerate normal tissue function. We review the literature of esophageal tissue engineering, discuss its implications, compare the methodologies that have been employed and suggest possible directions for the future. Medline, Embase, the Cochrane Library, National Research Register and ClinicalTrials.gov databases were searched with the following search terms: stem cell and esophagus, esophageal replacement, esophageal tissue engineering, esophageal substitution. Reference lists of papers identified were also examined and experts in this field contacted for further information. All full-text articles in English of all potentially relevant abstracts were reviewed. Tissue engineering has involved acellular scaffolds that were either transplanted with the aim of being repopulated by host cells or seeded prior to transplantation. When acellular scaffolds were used to replace patch and short tubular defects they allowed epithelial and partial muscular migration whereas when employed for long tubular defects the results were poor leading to an increased rate of stenosis and mortality. Stenting has been shown as an effective means to reduce stenotic changes and promote cell migration, whilst omental wrapping to induce vascularization of the construct has an uncertain benefit. Decellularized matrices have been recently suggested as the optimal choice for scaffolds, but smart polymers that will incorporate signalling to promote cell-scaffold interaction may provide a more reproducible and available solution. Results in animal models that have used seeded scaffolds strongly sug- gest that seeding of both muscle and epithelial cells on scaffolds

Esophageal tissue engineering: a new approach for esophageal replacement.

PubMed

Totonelli, Giorgia; Maghsoudlou, Panagiotis; Fishman, Jonathan M; Orlando, Giuseppe; Ansari, Tahera; Sibbons, Paul; Birchall, Martin A; Pierro, Agostino; Eaton, Simon; De Coppi, Paolo

2012-12-21

A number of congenital and acquired disorders require esophageal tissue replacement. Various surgical techniques, such as gastric and colonic interposition, are standards of treatment, but frequently complicated by stenosis and other problems. Regenerative medicine approaches facilitate the use of biological constructs to replace or regenerate normal tissue function. We review the literature of esophageal tissue engineering, discuss its implications, compare the methodologies that have been employed and suggest possible directions for the future. Medline, Embase, the Cochrane Library, National Research Register and ClinicalTrials.gov databases were searched with the following search terms: stem cell and esophagus, esophageal replacement, esophageal tissue engineering, esophageal substitution. Reference lists of papers identified were also examined and experts in this field contacted for further information. All full-text articles in English of all potentially relevant abstracts were reviewed. Tissue engineering has involved acellular scaffolds that were either transplanted with the aim of being repopulated by host cells or seeded prior to transplantation. When acellular scaffolds were used to replace patch and short tubular defects they allowed epithelial and partial muscular migration whereas when employed for long tubular defects the results were poor leading to an increased rate of stenosis and mortality. Stenting has been shown as an effective means to reduce stenotic changes and promote cell migration, whilst omental wrapping to induce vascularization of the construct has an uncertain benefit. Decellularized matrices have been recently suggested as the optimal choice for scaffolds, but smart polymers that will incorporate signalling to promote cell-scaffold interaction may provide a more reproducible and available solution. Results in animal models that have used seeded scaffolds strongly suggest that seeding of both muscle and epithelial cells on scaffolds

Doppler-guided hemorrhoidal artery ligation does not offer any advantage over suture ligation of grade 3 symptomatic hemorrhoids.

PubMed

Gupta, P J; Kalaskar, S; Taori, S; Heda, P S

2011-12-01

Doppler-guided ligation of hemorrhoidal vessels is being proposed as a treatment of grade 2 and 3 hemorrhoids. Many researchers are coupling this procedure with mucopexy or lifting of hemorrhoids to control the prolapse more effectively. The present study was conducted in patients with 3rd-degree hemorrhoids to determine the usefulness of Doppler-guided hemorrhoidal artery ligation compared to mucopexy of prolapsing hemorrhoids and to compare it with mere mucopexy of the hemorrhoids. A double-blind, randomized controlled study was conducted on 48 consecutive patients with grade III hemorrhoids requiring surgery. The patients were randomized into two groups. Half of them were treated with ligation and mucopexy [SL], while the remaining patients underwent a Doppler-guided hemorrhoidal artery ligation followed by ligation and mucopexy [DSL]. The patients were examined by a blinded independent observer at 2, 4, and 6 weeks and at the end of 1 year after the operation to evaluate postoperative pain scores, amount of analgesics consumed, and complications encountered. The observer also assessed recurrence of hemorrhoids after 1 year. Operative time was significantly longer in the DSL group (31 min vs. 9 min P < 0.003). The postoperative pain score was significantly higher in the Doppler group [4.4 vs. 2.2, P < 0.002 (visual analogue scale)]. The mean total analgesic dose and duration of pain control using analgesics were greater and longer for the Doppler group than for the SL group (17 vs. 11 tablets, and 13 days vs. 9 days, respectively; P < 0. 01). Complications were similar in both the groups. At 1-year follow-up, the recurrence of hemorrhoids was not statistically significant in either group (4 patients in SL group and 3 patients in DSL group; P < 0.93). Suture ligation of hemorrhoids is a simple, cost-effective, and convenient modality for treating grade 3 hemorrhoids. Doppler assistance in ligating the hemorrhoidal vessels prior to hemorrhoidal

Esophageal cancer

MedlinePlus

... old. There are two main types of esophageal cancer: squamous cell carcinoma and adenocarcinoma. These two types look different from each other under the microscope. Squamous cell esophageal cancer is linked to smoking and drinking too much ...

Recursive Directional Ligation Approach for Cloning Recombinant Spider Silks.

PubMed

Dinjaski, Nina; Huang, Wenwen; Kaplan, David L

2018-01-01

Recent advances in genetic engineering have provided a route to produce various types of recombinant spider silks. Different cloning strategies have been applied to achieve this goal (e.g., concatemerization, step-by-step ligation, recursive directional ligation). Here we describe recursive directional ligation as an approach that allows for facile modularity and control over the size of the genetic cassettes. This approach is based on sequential ligation of genetic cassettes (monomers) where the junctions between them are formed without interrupting key gene sequences with additional base pairs.

Esophageal lichen planus.

PubMed

Oliveira, Janine Pichler de; Uribe, Natalia Caballero; Abulafia, Luna Azulay; Quintella, Leonardo Pereira

2015-01-01

Lichen planus is a chronic inflammatory disease that affects the skin, mucous membranes, nails and scalp. Esophageal lichen planus is a rarely reported manifestation of lichen planus, presenting itself commonly in middle-aged women, with symptoms such as dysphagia. We report a case of esophageal lichen planus in a 54-year-old woman associated with oral, cutaneous and ungual lichen planus. Although lichen planus is a disorder well known by dermatologists, reports of esophageal lichen planus are rare in dermatologic literature. The esophageal lichen planus is little known and underdiagnosed, with a significant delay between the onset of symptoms and diagnosis.

[Friction: self-ligating brackets].

PubMed

Thermac, Guilhem; Morgon, Laurent; Godeneche, Julien

2008-12-01

The manufacturers of self-ligating brackets advertise a reduction of the friction engendered between the wire and the bracket, which is an essential parameter for treatment's speed and comfort. We have compared the friction obtained with four types of self-ligating brackets - In-Ovation R, Damon 3, Smart Clip and Quick - with that of a standard bracket Omniarch associated with an elastomeric ligature. All bracket were tested on a bench of traction with three types of wires: steel .019"x.025", TMA .019"x.025" and NEO sentalloy F300 .020"x.020". The results confirm a clear friction reduction for all tested wire.

Long-term esophageal motility changes after thyroidectomy: associations with aerodigestive disorders.

PubMed

Scerrino, G; Inviati, A; Di Giovanni, S; Paladino, N C; Di Giovanni, S; Paladino, N C; Di Paola, V; Raspanti, C; Melfa, G I; Cupido, F; Mazzola, S; Porrello, C; Bonventre, S; Gullotta, G

2017-01-01

Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months. The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again. After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p<0,001). Our study confirms that aerodigestive disorders after uncomplicated thyroidectomy, largely transient, are strictly connected with upper esophageal motility changes. In this viewpoint, the innervation of upper aerodigestive anatomical structures (larynx, pharynx, upper esophagus) and its variations should be focused.

Esophageal luminal stenosis is an independent prognostic factor in esophageal squamous cell carcinoma.

PubMed

Yang, Yu-Shang; Hu, Wei-Peng; Ni, Peng-Zhi; Wang, Wen-Ping; Yuan, Yong; Chen, Long-Qi

2017-06-27

Predictive value of preoperative endoscopic characteristic of esophageal tumor has not been fully evaluated. The aim of this study is to investigate the impact of esophageal luminal stenosis on survival for patients with resectable esophageal squamous cell carcinoma (ESCC). The clinicopathologic characteristics of 623 ESCC patients who underwent curative resection as the primary treatment between January 2005 and April 2009 were retrospectively reviewed. The esophageal luminal stenosis measured by endoscopy was defined as a uniform measurement preoperatively. The impact of esophageal luminal stenosis on patients' overall survival (OS) and relation with other clinicopathological features were assessed. A Cox regression model was used to identify prognostic factors. The results showed that OS significantly decreased in patients with manifest stenotic tumor compared with patients without luminal obstruction (P<0.05). Considerable esophageal luminal stenosis was associated with a higher T stage, longer tumor length, and poorer differentiation (all P<0.05). In multivariate survival analysis, esophageal luminal stenosis remained as an independent prognostic factor for OS (P= 0.036). Esophageal luminal stenosis could have a significant impact on the OS in patients with resected ESCC and may provide additional prognostic value to the current staging system before any cancer-specific treatment.

Minimally invasive surgery for esophageal achalasia.

PubMed

Chen, Huan-Wen; Du, Ming

2016-07-01

Esophageal achalasia is due to the esophagus of neuromuscular dysfunction caused by esophageal functional disease. Its main feature is the lack of esophageal peristalsis, the lower esophageal sphincter pressure and to reduce the swallow's relaxation response. Lower esophageal muscular dissection is one of the main ways to treat esophageal achalasia. At present, the period of muscular layer under the thoracoscope esophagus dissection is one of the treatment of esophageal achalasia. Combined with our experience in minimally invasive esophageal surgery, to improved incision and operation procedure, and adopts the model of the complete period of muscular layer under the thoracoscope esophagus dissection in the treatment of esophageal achalasia.

Minimally invasive surgery for esophageal achalasia

PubMed Central

Chen, Huan-Wen

2016-01-01

Esophageal achalasia is due to the esophagus of neuromuscular dysfunction caused by esophageal functional disease. Its main feature is the lack of esophageal peristalsis, the lower esophageal sphincter pressure and to reduce the swallow’s relaxation response. Lower esophageal muscular dissection is one of the main ways to treat esophageal achalasia. At present, the period of muscular layer under the thoracoscope esophagus dissection is one of the treatment of esophageal achalasia. Combined with our experience in minimally invasive esophageal surgery, to improved incision and operation procedure, and adopts the model of the complete period of muscular layer under the thoracoscope esophagus dissection in the treatment of esophageal achalasia. PMID:27499977

Esophageal Helicobacter pylori colonization aggravates esophageal injury caused by reflux

PubMed Central

Chu, Yun-Xiang; Wang, Wei-Hong; Dai, Yun; Teng, Gui-Gen; Wang, Shu-Jun

2014-01-01

AIM: To investigate esophageal Helicobacter pylori (H. pylori) colonization on esophageal injury caused by reflux and the related mechanisms. METHODS: An esophagitis model, with acid and bile reflux, was surgically produced in male rats. The rats were randomly divided into either: (1) an esophagogastroduodenal anastomosis (EGDA) group; (2) an EGDA with H. pylori infection group; (3) a pseudo-operation with H. pylori infection group; or (4) a pseudo-operation group. All rats were kept for 36 wk. Based on the location of H. pylori colonization, the EGDA rats with H. pylori infection were subdivided into those with concomitant esophageal H. pylori colonization or those with only gastric H. pylori colonization. The esophageal injuries were evaluated grossly and microscopically. The expressions of CDX2 and MUC2 were determined by real-time polymerase chain reaction (RT-PCR) and immunohistochemistry. Ki-67 antigen expression was determined by immunohistochemistry. The mRNA levels of cyclin D1, c-Myc, Bax and Bcl-2 were determined by RT-PCR. Cell apoptosis was evaluated using the TdT-mediated dUTP nick-end labeling method. RESULTS: Esophagitis, Barrett’s esophagus (BE), and esophageal adenocarcinoma (EAC) developed in rats that underwent EGDA. When comparing rats with EGDA and concomitant esophageal H. pylori colonization to EGDA-only rats, the severity of injury (87.9 ± 5.2 vs 77.2 ± 8.6, macroscopically, 92.5 ± 8.0 vs 83.8 ± 5.5, microscopically, both P < 0.05) and the incidences of BE (80.0% vs 33.3%, P = 0.055) and EAC (60.0% vs 11.1%, P < 0.05) were increased. These increases were associated with upregulation of CDX2 and MUC2 mRNA (10.1 ± 5.4 vs 3.0 ± 2.9, 8.4 ± 4.6 vs 2.0 ± 3.2, respectively, Ps < 0.01) and protein (8.1 ± 2.3 vs 3.3 ± 3.1, 7.3 ± 4.0 vs 1.8 ± 2.7, respectively, all P < 0.05). The expression of Ki-67 (8.9 ± 0.7 vs 6.0 ± 1.7, P < 0.01) and the presence of apoptotic cells (8.3 ± 1.1 vs 5.3 ± 1.7, P < 0.01) were also increased

Liquid nitrogen spray cryotherapy for dysphagia palliation in patients with inoperable esophageal cancer.

PubMed

Kachaamy, Toufic; Prakash, Ravi; Kundranda, Madappa; Batish, Raman; Weber, Jeffrey; Hendrickson, Scott; Yoder, Leon; Do, Hannah; Magat, Theresa; Nayar, Rajeev; Gupta, Digant; DaSilva, Trisha; Sangal, Ashish; Kothari, Shivangi; Kaul, Vivek; Vashi, Pankaj

2018-05-08

Dysphagia is a debilitating symptom in patients with inoperable esophageal cancer contributing to poor quality of life and worsening nutritional status. The 2 most commonly used palliative modalities for dysphagia are radiation therapy (RT) and esophageal stent placement. However, RT is limited by adverse events (AEs) and total dose, and stent placement has a high rate of AEs including reflux, migration, and chest pain. A relatively new modality of liquid nitrogen endoscopic spray cryotherapy has been described as salvage when other options have been exhausted and when patients are no longer receiving systemic therapy. We evaluated the safety and efficacy of cryotherapy as the primary modality for relieving dysphagia in inoperable esophageal cancer including patients receiving systemic cancer therapy. This is a retrospective multicenter consecutive case series of 49 inoperable esophageal cancer patients undergoing palliative endoscopic cryotherapy at 4 specialized cancer centers from May 2014 to May 2016. The primary outcomes were change in dysphagia scores between pre- and post-cryotherapy and AE. Dysphagia was measured using a 4-point Likert scale: 0, no dysphagia; 1, dysphagia to solids; 2, dysphagia to semi-solids; 3, dysphagia to liquids; 4, dysphagia to saliva. There were 39 males and 10 females with a mean age of 58 years who underwent a total of 120 cryotherapy treatments. The mean dysphagia score improved significantly from 2.4 pre-cryotherapy to 1.7 post-cryotherapy (improvement of 0.7 points; p<0.001). Minor AE were seen in 6/120 (5.0%) cryotherapy treatments (1 intra-procedural and 5 post-procedural). In addition, one patient developed a severe intra-procedural AE of dilation-related perforation whereas another patient developed a benign stricture requiring dilation. This preliminary retrospective study suggests that liquid nitrogen spray cryotherapy may be safe and effective for dysphagia palliation in inoperable esophageal cancer. Large prospective

Prevention and Treatment of Esophageal Stenosis after Endoscopic Submucosal Dissection for Early Esophageal Cancer

PubMed Central

Wen, Jing; Lu, Zhongsheng; Liu, Qingsen

2014-01-01

Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions is associated with a risk of esophageal stenosis, especially for near-circumferential or circumferential esophageal mucosal defects. Here, we review historic and modern studies on the prevention and treatment of esophageal stenosis after ESD. These methods include prevention via pharmacological treatment, endoscopic autologous cell transplantation, endoscopic esophageal dilatation, and stent placement. This short review will focus on direct prevention and treatment, which may help guide the way forward. PMID:25386186

Optimizing the time-frame for the definition of bleeding-related death after acute variceal bleeding in cirrhosis.

PubMed

Merkel, C; Gatta, A; Bellumat, A; Bolognesi, M; Borsato, L; Caregaro, L; Cavallarin, G; Cielo, R; Cristina, P; Cucci, E; Donada, C; Donadon, V; Enzo, E; Martin, R; Mazzaro, C; Sacerdoti, D; Torboli, P

1996-01-01

To identify the best time-frame for defining bleeding-related death after variceal bleeding in patients with cirrhosis. Prospective long-term evaluation of a cohort of 155 patients admitted with variceal bleeding. Eight medical departments in seven hospitals in north-eastern Italy. Non-linear regression analysis of a hazard curve for death, and Cox's multiple regression analyses using different zero-time points. Cumulative hazard plots gave two slopes, the first corresponding to the risk of death from acute bleeding, the second a baseline risk of death. The first 30 days were outside the confidence limits of the regression curve for the baseline risk of death. Using Cox's regression analysis, the significant predictors of overall mortality risk were balanced between factors related to severity of bleeding and those related to severity of liver disease. If only deaths occurring after 30 days were considered, only predictors related to the severity of liver disease were found to be of importance. Thirty days after bleeding is considered to be a reasonable time-frame for the definition of bleeding-related death in patients with cirrhosis and variceal bleeding.

Fully covered Alimaxx esophageal metal stents in the endoscopic treatment of benign esophageal diseases.

PubMed

Senousy, Bahaa E; Gupte, Anand R; Draganov, Peter V; Forsmark, Chris E; Wagh, Mihir S

2010-12-01

Expandable esophageal stents are widely used for the palliation of dysphagia in patients with esophageal cancer and are also beginning to be used in patients with benign esophageal diseases such as refractory strictures and fistulas. There is concern regarding the increased risk of migration of the fully covered Alimaxx metal esophageal stent and experience with this stent in benign esophageal pathology has been reported in only a small series of patients. To evaluate the technical success in placement and removal, efficacy and complications of the Alimaxx esophageal stent for benign esophageal diseases. Our endoscopy database was retrospectively reviewed from 1/2003 to 2/2009 to identify patients with Alimaxx esophageal stent placement for benign diseases. Chart review was performed for age, gender, indication, site of the lesion, success of placement, outcome, and incidence of complications. Twenty-eight stents were successfully placed in 14 patients with benign esophageal diseases (mean: two stents/patient; range 1-7). Indications included esophageal fistula in seven (50%) and benign strictures in 7/14 (50%). Dysphagia improved in all patients while the fistula resolved in 6/7 (85.8%) patients. Complications related to stents included pain (2/28, 7%), stent related gastric ulcer (1/28, 4%), nausea and vomiting (3/21, 11%) and stent migration (11/28, 39%). All migrated stents were successfully endoscopically retrieved. The fully covered and removable Alimaxx stent is effective in the endoscopic management of benign esophageal strictures or fistulas, despite its relatively high rate of migration. Stent migration was successfully managed endoscopically without complications.

Risk Factors for Esophageal Fistula Associated With Chemoradiotherapy for Locally Advanced Unresectable Esophageal Cancer

PubMed Central

Tsushima, Takahiro; Mizusawa, Junki; Sudo, Kazuki; Honma, Yoshitaka; Kato, Ken; Igaki, Hiroyasu; Tsubosa, Yasuhiro; Shinoda, Masayuki; Nakamura, Kenichi; Fukuda, Haruhiko; Kitagawa, Yuko

2016-01-01

Abstract Esophageal fistula is a critical adverse event in patients treated with chemoradiotherapy (CRT) for locally advanced esophageal cancer. However, risk factors associated with esophageal fistula formation in patients receiving CRT have not yet been elucidated. We retrospectively analyzed data obtained from 140 patients who were enrolled in a phase II/III trial comparing low-dose cisplatin with standard-dose cisplatin administered in combination with 5-flurouracil and concomitant radiotherapy. Inclusion criteria were performance status (PS) 0 to 2 and histologically proven thoracic esophageal cancer clinically diagnosed as T4 and/or unresectable lymph node metastasis for which definitive CRT was applicable. Risk factors for esophageal fistula were examined with univariate analysis using Fisher exact test and multivariate analysis using logistic regression models. Esophageal fistula was observed in 31 patients (22%). Of these, 6 patients developed fistula during CRT. Median time interval between the date of CRT initiation and that of fistula diagnosis was 100 days (inter quartile range, 45–171). Esophageal stenosis was the only significant risk factor for esophageal fistula formation both in univariate (P = 0.026) and in multivariate analyses (odds ratio, 2.59; 95% confidence interval, 1.13–5.92, P = 0.025). Other clinicopathological factors, namely treatment arm, age, sex, PS, primary tumor location, T stage, lymph node invasion to adjacent organs, blood cell count, albumin level, and body mass index, were not risk factors fistula formation. Esophageal stenosis was a significant risk factor for esophageal fistula formation in patients treated with CRT for unresectable locally advanced thoracic esophageal squamous cell carcinoma. PMID:27196482

Comparison of Hi-C results using in-solution versus in-nucleus ligation.

PubMed

Nagano, Takashi; Várnai, Csilla; Schoenfelder, Stefan; Javierre, Biola-Maria; Wingett, Steven W; Fraser, Peter

2015-08-26

Chromosome conformation capture and various derivative methods such as 4C, 5C and Hi-C have emerged as standard tools to analyze the three-dimensional organization of the genome in the nucleus. These methods employ ligation of diluted cross-linked chromatin complexes, intended to favor proximity-dependent, intra-complex ligation. During development of single-cell Hi-C, we devised an alternative Hi-C protocol with ligation in preserved nuclei rather than in solution. Here we directly compare Hi-C methods employing in-nucleus ligation with the standard in-solution ligation. We show in-nucleus ligation results in consistently lower levels of inter-chromosomal contacts. Through chromatin mixing experiments we show that a significantly large fraction of inter-chromosomal contacts are the result of spurious ligation events formed during in-solution ligation. In-nucleus ligation significantly reduces this source of experimental noise, and results in improved reproducibility between replicates. We also find that in-nucleus ligation eliminates restriction fragment length bias found with in-solution ligation. These improvements result in greater reproducibility of long-range intra-chromosomal and inter-chromosomal contacts, as well as enhanced detection of structural features such as topologically associated domain boundaries. We conclude that in-nucleus ligation captures chromatin interactions more consistently over a wider range of distances, and significantly reduces both experimental noise and bias. In-nucleus ligation creates higher quality Hi-C libraries while simplifying the experimental procedure. We suggest that the entire range of 3C applications are likely to show similar benefits from in-nucleus ligation.

[Comparison of predictive factors related to the mortality and rebleeding caused by variceal bleeding: Child-Pugh score, MELD score, and Rockall score].

PubMed

Lee, Ja Young; Lee, Jin Heon; Kim, Soo Jin; Choi, Dae Rho; Kim, Kyung Ho; Kim, Yong Bum; Kim, Hak Yang; Yoo, Jae Young

2002-12-01

The first episode of variceal bleeding is one of the most frequent causes of death in patients with liver cirrhosis. The Child-Pugh(CP) scoring system has been widely accepted for prognostic assessment. Recently, MELD has been known to be better than the CP scoring system for predicting mortality in patients with end-stage liver diseases. The Rockall risk scoring system was developed to predict the outcome of upper GI bleeding including variceal bleeding. The aim of this study was to investigate the mortality rate of first variceal bleeding and the predictability of each scoring system. We evaluated the 6-week mortality rate, rebleeding rate, and 1-year mortality rate of all the 136 patients with acute variceal bleeding without previous episode of hemorrhage between January 1, 1998 and December 31, 2000. The CP score, MELD score, and Rockall score were estimated and analyzed. Among 136 patients, 35 patients with hepatoma and 8 patients with follow-up loss were excluded. Six-week mortality rate, 1-year mortality rate, and rebleeding rate of first variceal bleeding were 24.7%, 35.5%, and 12.9%, respectively. The c-statistics of CP, MELD, and Rockall score for predicting 6-week mortality rate were 0.809 (p<0.001, 95% CI, 0.720-0.898), 0.804 (p<0.001, 95% CI, 0.696-0.911), 0.787 (p<0.001, 95% CI, 0.683-0.890), respectively. For 1-year mortality rate, c-statistics were 0.765 (p<0.005, 95% CI, 0.665-0.865), 0.780 (p<0.005, 95% CI, 0.676-0.883), 0.730 (p<0.01, 95% CI, 0.627-0.834), respectively. The CP, MELD, and Rockall scores were reliable measures of mortality risk in patients with first variceal bleeding. The CP classification is useful in its easy applicability.

Elastomeric-ligated vs self-ligating appliances: a pilot study examining microbial colonization and white spot lesion formation after 1 year of orthodontic treatment.

PubMed

Buck, Tyson; Pellegrini, Peter; Sauerwein, Rebecca; Leo, Michael C; Covell, David A; Maier, Tom; Machida, Curtis A

2011-01-01

To (1) evaluate the use of adenosine triphosphate (ATP)-driven bioluminescence for quantification of total plaque bacteria in orthodontic patients, (2) compare plaque bacteria amounts at the bracket-tooth interface with use of elastomeric-ligated and self-ligating brackets after 1 year of orthodontic treatment, and (3) analyze formation of white spot lesions by photographic evaluation and laser-light fluorescence (DIAGNOdent). Thirteen subjects had fixed orthodontic appliances placed where lateral incisors were bonded with either elastomeric-ligated or self-ligating brackets. Plaque bacteria were collected from incisor surfaces after 1 year and quantified using plating methods and ATP-driven bioluminescence. White spot lesions were evaluated by photographic and DIAGNOdent determinations. A 2 x 2 x 2 mixed-design ANOVA was conducted to determine differences in plaque retention between elastomeric-ligated and self-ligating brackets. ATP-driven bioluminescence values correlated to numbers of total plaque bacteria (r = 0.80). However, unlike findings published in the original pilot study, which described increased plaque retention with elastomeric-ligated brackets at 5 weeks postbonding, there were no significant differences in bacterial numbers or ATP-driven bioluminescence values surrounding the elastomeric-ligated vs self-ligating brackets after 1 year of orthodontic treatment. Based on photographic and DIAGNOdent determinations, white spot lesions were found relatively equally on teeth bonded with either bracket type. DIAGNOdent measurements were found to have moderate sensitivity (0.71) and good specificity (0.88) when compared to white spot lesions determined using photographic evaluation. ATP-driven bioluminescence can be used as an accurate assessment of total plaque bacteria in orthodontic patients. After 1 year of orthodontic treatment for patients in this pilot study, there appeared to be no differences in retention of plaque bacteria or white spot lesions

Esophageal luminal stenosis is an independent prognostic factor in esophageal squamous cell carcinoma

PubMed Central

Yang, Yu-Shang; Hu, Wei-Peng; Ni, Peng-Zhi; Wang, Wen-Ping; Yuan, Yong; Chen, Long-Qi

2017-01-01

Background Predictive value of preoperative endoscopic characteristic of esophageal tumor has not been fully evaluated. The aim of this study is to investigate the impact of esophageal luminal stenosis on survival for patients with resectable esophageal squamous cell carcinoma (ESCC). Methods The clinicopathologic characteristics of 623 ESCC patients who underwent curative resection as the primary treatment between January 2005 and April 2009 were retrospectively reviewed. The esophageal luminal stenosis measured by endoscopy was defined as a uniform measurement preoperatively. The impact of esophageal luminal stenosis on patients’ overall survival (OS) and relation with other clinicopathological features were assessed. A Cox regression model was used to identify prognostic factors. Results The results showed that OS significantly decreased in patients with manifest stenotic tumor compared with patients without luminal obstruction (P<0.05). Considerable esophageal luminal stenosis was associated with a higher T stage, longer tumor length, and poorer differentiation (all P<0.05). In multivariate survival analysis, esophageal luminal stenosis remained as an independent prognostic factor for OS (P= 0.036). Conclusions Esophageal luminal stenosis could have a significant impact on the OS in patients with resected ESCC and may provide additional prognostic value to the current staging system before any cancer-specific treatment. PMID:28118615

Esophageal Cancer.

PubMed

Short, Matthew W; Burgers, Kristina G; Fry, Vincent T

2017-01-01

Esophageal cancer has a poor prognosis and high mortality rate, with an estimated 16,910 new cases and 15,910 deaths projected in 2016 in the United States. Squamous cell carcinoma and adenocarcinoma account for more than 95% of esophageal cancers. Squamous cell carcinoma is more common in nonindustrialized countries, and important risk factors include smoking, alcohol use, and achalasia. Adenocarcinoma is the predominant esophageal cancer in developed nations, and important risk factors include chronic gastroesophageal reflux disease, obesity, and smoking. Dysphagia alone or with unintentional weight loss is the most common presenting symptom, although esophageal cancer is often asymptomatic in early stages. Physicians should have a low threshold for evaluation with endoscopy if any symptoms are present. If cancer is confirmed, integrated positron emission tomography and computed tomography should be used for initial staging. If no distant metastases are found, endoscopic ultrasonography should be performed to determine tumor depth and evaluate for nodal involvement. Localized tumors can be treated with endoscopic mucosal resection, whereas regional tumors are treated with esophagectomy, neoadjuvant chemotherapy, chemoradiotherapy, or a combination of modalities. Nonresectable tumors or tumors with distant metastases are treated with palliative interventions. Specific prevention strategies have not been proven, and there are no recommendations for esophageal cancer screening.

Thoracoscopic Surgery in a Patient with Multiple Esophageal Carcinomas after Surgery for Esophageal Achalasia.

PubMed

Yamasaki, Yuki; Tsukada, Tomoya; Aoki, Tatsuya; Haba, Yusuke; Hirano, Katsuhisa; Watanabe, Toshifumi; Kaji, Masahide; Shimizu, Koichi

2017-01-01

We present a case in which we used a thoracoscopic approach for resection of multiple esophageal carcinomas diagnosed 33 years after surgery for esophageal achalasia. A 68-year-old Japanese man had been diagnosed with esophageal achalasia and underwent surgical treatment 33 years earlier. He was examined at our hospital for annual routine checkup in which upper gastrointestinal endoscopy showed a "0-IIb+IIa" lesion in the middle esophagus. Iodine staining revealed multiple irregularly shaped iodine-unstained areas, the diagnosis of which was esophageal carcinoma. Thoracoscopic subtotal esophagectomy was performed. Esophageal carcinoma may occur many years after surgery for esophageal achalasia, even if the passage symptoms have improved. So, long-term periodic follow-up is necessary for detection of carcinoma at an earlier stage.

Thoracoscopic Surgery in a Patient with Multiple Esophageal Carcinomas after Surgery for Esophageal Achalasia

PubMed Central

Tsukada, Tomoya; Aoki, Tatsuya; Haba, Yusuke; Hirano, Katsuhisa; Watanabe, Toshifumi; Kaji, Masahide; Shimizu, Koichi

2017-01-01

We present a case in which we used a thoracoscopic approach for resection of multiple esophageal carcinomas diagnosed 33 years after surgery for esophageal achalasia. A 68-year-old Japanese man had been diagnosed with esophageal achalasia and underwent surgical treatment 33 years earlier. He was examined at our hospital for annual routine checkup in which upper gastrointestinal endoscopy showed a “0-IIb+IIa” lesion in the middle esophagus. Iodine staining revealed multiple irregularly shaped iodine-unstained areas, the diagnosis of which was esophageal carcinoma. Thoracoscopic subtotal esophagectomy was performed. Esophageal carcinoma may occur many years after surgery for esophageal achalasia, even if the passage symptoms have improved. So, long-term periodic follow-up is necessary for detection of carcinoma at an earlier stage. PMID:28951795

Clinical and dosimetric factors of radiation-induced esophageal injury: radiation-induced esophageal toxicity.

PubMed

Qiao, Wen-Bo; Zhao, Yan-Hui; Zhao, Yan-Bin; Wang, Rui-Zhi

2005-05-07

To analyze the clinical and dosimetric predictive factors for radiation-induced esophageal injury in patients with non-small-cell lung cancer (NSCLC) during three-dimensional conformal radiotherapy (3D-CRT). We retrospectively analyzed 208 consecutive patients (146 men and 62 women) with NSCLC treated with 3D-CRT. The median age of the patients was 64 years (range 35-87 years). The clinical and treatment parameters including gender, age, performance status, sequential chemotherapy, concurrent chemotherapy, presence of carinal or subcarinal lymph nodes, pretreatment weight loss, mean dose to the entire esophagus, maximal point dose to the esophagus, and percentage of volume of esophagus receiving >55 Gy were studied. Clinical and dosimetric factors for radiation-induced acute and late grade 3-5 esophageal injury were analyzed according to Radiation Therapy Oncology Group (RTOG) criteria. Twenty-five (12%) of the two hundred and eight patients developed acute or late grade 3-5 esophageal injury. Among them, nine patients had both acute and late grade 3-5 esophageal injury, two died of late esophageal perforation. Concurrent chemotherapy and maximal point dose to the esophagus > or =60 Gy were significantly associated with the risk of grade 3-5 esophageal injury. Fifty-four (26%) of the two hundred and eight patients received concurrent chemotherapy. Among them, 25 (46%) developed grade 3-5 esophageal injury (P = 0.0001<0.01). However, no grade 3-5 esophageal injury occurred in patients who received a maximal point dose to the esophagus <60 Gy (P = 0.0001<0.01). Concurrent chemotherapy and the maximal esophageal point dose > or =60 Gy are significantly associated with the risk of grade 3-5 esophageal injury in patients with NSCLC treated with 3D-CRT.

Formation of oligonucleotide-PNA-chimeras by template-directed ligation

NASA Technical Reports Server (NTRS)

Koppitz, M.; Nielsen, P. E.; Orgel, L. E.; Bada, J. L. (Principal Investigator)

1998-01-01

DNA sequences have previously been reported to act as templates for the synthesis of PNA, and vice versa. A continuous evolutionary transition from an informational replicating system based on one polymer to a system based on the other would be facilitated if it were possible to form chimeras, that is molecules that contain monomers of both types. Here we show that ligation to form chimeras proceeds efficiently both on PNA and on DNA templates. The efficiency of ligation is primarily determined by the number of backbone bonds at the ligation site and the relative orientation of template and substrate strands. The most efficient reactions result in the formation of chimeras with ligation junctions resembling the structures of the backbones of PNA and DNA and with antiparallel alignment of both components of the chimera with the template, that is, ligations involving formation of 3'-phosphoramidate and 5'-ester bonds. However, double helices involving PNA are stable both with antiparallel and parallel orientation of the two strands. Ligation on PNA but not on DNA templates is, therefore, sometimes possible on templates with reversed orientation. The relevance of these findings to discussions of possible transitions between genetic systems is discussed.

Esophageal Cancer—Patient Version

Cancer.gov

The most common types of esophageal cancer are adenocarcinoma and squamous cell carcinoma. These forms of esophageal cancer develop in some parts of the esophagus and are driven by genetic changes. Start here to find information on esophageal cancer treatment, causes and prevention, screening, research, and statistics.

Clinical application of oral meglumine diatrizoate esophagogram in screening esophageal fistula during radiotherapy for esophageal cancer.

PubMed

Geng, Lidan; Wu, Rong; Hu, He; Zhao, Yu; Fan, Lingli; Zhao, Zhenhua; Liao, Dongbiao; Li, Musheng; Xiang, Miao; Ma, Ying; Du, Xiaobo

2018-05-01

Esophageal fistula is a serious and common complication of radiotherapy for esophageal cancer. Therefore, early diagnosis and treatment is necessary. Because of side effect of barium esophagography, it cannot be used to screening esophageal fistula during radiotherapy. Meglumine diatrizoate is an ionic contrast agent, its adverse reactions were rarely seen when it was used in the body cavity. The purpose of this trial is identified the sensitivity and specificity of oral meglumine diatrizoate in an esophagogram for screening esophageal fistula during radiotherapy. This trial was a prospective, multicenter, diagnostic clinical trial. A total of 105 patients with esophageal cancer will swallowed meglumine diatrizoate and underwent a radiographic examination weekly during radiotherapy, medical personnel observed the esophageal lesions to determine whether an esophageal fistula formed. If an esophageal fistula was observed, esophagofiberoscopy and/or computer tomography was used to further confirm the diagnosis. And the sensitivity and specificity of meglumine diatrizoate should be calculated for screening esophageal fistula during radiotherapy. To our knowledge, this study protocol is the first to identify the sensitivity and specificity of oral meglumine diatrizoate in an esophagogram for screening esophageal fistula during radiotherapy. If oral meglumine diatrizoate can be used to screening esophageal fistula, more patients will benefit from early detection and treatment.

Esophageal hypermotility: cause or effect?

PubMed

Crespin, O M; Tatum, R P; Yates, R B; Sahin, M; Coskun, K; Martin, A V; Wright, A; Oelschlager, B K; Pellegrini, C A

2016-07-01

Nutcracker esophagus (NE), Jackhammer esophagus (JHE), distal esophageal spasm (DES), and hypertensive lower esophageal sphincter (HTLES) are defined by esophageal manometric findings. Some patients with these esophageal motility disorders also have abnormal gastroesophageal reflux. It is unclear to what extent these patients' symptoms are caused by the motility disorder, the acid reflux, or both. The aim of this study was to determine the effectiveness of laparoscopic Nissen fundoplication (LNF) on esophageal motility disorders, gastroesophageal reflux, and patient symptoms. Between 2007 and 2013, we performed high-resolution esophageal manometry on 3400 patients, and 221 patients were found to have a spastic esophageal motility disorder. The medical records of these patients were reviewed to determine the manometric abnormality, presence of gastroesophageal symptoms, and amount of esophageal acid exposure. In those patients that underwent LNF, we compared pre- and postoperative esophageal motility, gastroesophageal symptom severity, and esophageal acid exposure. Of the 221 patients with spastic motility disorders, 77 had NE, 2 had JHE, 30 had DES, and 112 had HTLES. The most frequently reported primary and secondary symptoms among all patients were: heartburn and/or regurgitation, 69.2%; respiratory, 39.8%; dysphagia, 35.7%; and chest pain, 22.6%. Of the 221 patients, 192 underwent 24-hour pH monitoring, and 103 demonstrated abnormal distal esophageal acid exposure. Abnormal 24-hour pH monitoring was detected in 62% of patients with heartburn and regurgitation, 49% of patients with respiratory symptoms, 36.8 % of patients with dysphagia, and 32.6% of patients with chest pain. Sixty-six of the 103 patients with abnormal 24-hour pH monitoring underwent LNF. Thirty-eight (13NE, 2JHE, 6 DES, and 17 HTLES) of these 66 patients had a minimum of 6-month postoperative follow-up that included clinical evaluation, esophageal manometry, and 24-hour pH monitoring

Effects of Age on Esophageal Motility: Use of High-resolution Esophageal Impedance Manometry

PubMed Central

Shim, Young Kwang; Kim, Nayoung; Park, Yo Han; Lee, Jong-Chan; Sung, Jihee; Choi, Yoon Jin; Yoon, Hyuk; Shin, Cheol Min; Park, Young Soo; Lee, Dong Ho

2017-01-01

Background/Aims Disturbances of esophageal motility have been reported to be more frequent the aged population. However, the physiology of disturbances in esophageal motility during aging is unclear. The aim of this study was to evaluate the effects of age on esophageal motility using high-resolution esophageal impedance manometry (HRIM). Methods Esophageal motor function of 268 subjects were measured using HRIM in 3 age groups, < 40 years (Group A, n = 32), 40–65 years (Group B, n = 185), and > 65 years (Group C, n = 62). Lower esophageal sphincter (LES) and upper esophageal sphincter (UES) pressures, integrated relaxation pressure, distal contractile integral, contractile front velocity, distal latency, and pressures and duration of contraction on 4 positions along the esophagus, and complete bolus transit were measured. Results Basal UES pressure was lower in Group C (P < 0.001) but there was no significant difference in the LES pressure among groups. Contractile duration on position 3 (10 cm from proximal LES high pressure zone) was longer in Group C (P = 0.001), and the contractile amplitude on position 4 (5 cm from proximal LES high pressure zone) was lower in Group C (P = 0.005). Distal contractile integral was lower in Group C (P = 0.037). Contractile front velocity (P = 0.015) and the onset velocity (P = 0.040) was lower in Group C. There was no significant difference in impedance values. Conclusions The decrease of UES pressure, distal esophageal motility, and peristaltic velocity might be related with esophageal symptoms in the aged population. PMID:28163259

The effect of n-3/n-6 polyunsaturated fatty acids on acute reflux esophagitis in rats.

PubMed

Zhuang, Ze-Hao; Xie, Jing-Jing; Wei, Jing-Jing; Tang, Du-Peng; Yang, Li-Yong

2016-10-04

Polyunsaturated fatty acids (PUFAs) play various roles in inflammation. However, the effect of PUFAs in the development of reflux esophagitis (RE) is unclear. This study is to investigate the potential effect of n-3/n-6 PUFAs on acute RE in rats along with the underlying protective mechanisms. Forty Sprague Dawley rats were randomly divided into four groups (n = 10 in each group). RE model was established by pyloric clip and section ligation. Fish oil- and soybean oil-based fatty emulsion (n-3 and n-6 groups), or normal saline (control and sham operation groups) was injected intraperitoneally 2 h prior to surgery and 24 h postoperatively (2 mL/kg, respectively). The expressions of interleukin (IL)-1β, IL-8, IL-6 and myeloid differentiation primary response gene 88 (MyD88) in esophageal tissues were evaluated by Western blot and immunohistochemistry after 72 h. The malondialdehyde (MDA) and superoxide dismutase (SOD) expression in the esophageal tissues were determined to assess the oxidative stress. The mildest macroscopic/microscopic esophagitis was found in the n-3 group (P < 0.05). The expression of IL-1β, IL-8, IL-6 and MyD88 were increased in all RE groups, while the lowest and highest expression were found in n-3 and n-6 group, respectively (P < 0.05). The MDA levels were increased in all groups (P < 0.05), in an ascending trend from n-3, n-6 groups to control group. The lowest and highest SOD levels were found in the control and n-3 group, respectively (P < 0.05). n-3 PUFAs may reduce acute RE in rats, which may be due to inhibition of the MyD88-NF-kB pathway and limit oxidative damage.

Successful Embolization of Bleeding Ileal Varices with N-butyl Cyanoacrylate via a Recanalized Paraumbilical Vein.

PubMed

Onishi, Yasuyuki; Kimura, Hiroyuki; Kanagaki, Mitsunori; Oka, Shojiro; Fukumoto, Genki; Otani, Tomoaki; Matsubara, Naoko; Kawabata, Kazuna; Namikawa, Mio; Matsumura, Takeshi; Kimura, Toshiyuki

2018-04-23

A 48-year-old woman with alcoholic liver cirrhosis was admitted to our hospital because of hematochezia and severe anemia. She had been hospitalized many times over the past year for hematochezia of unknown etiology. Contrast-enhanced CT demonstrated ileal varices, which were fed by several ileal veins. These feeding veins were selectively embolized with N-butyl cyanoacrylate (NBCA) via a recanalized paraumbilical vein. The paraumbilical vein instead of the portal vein was punctured to decrease the risk of bleeding complications because she had coagulopathy and ascites. We consider antegrade embolization of ileal varices with NBCA to be a feasible and effective treatment. Access via a paraumbilical vein is an alternative to the transhepatic approach.Level of Evidence Level V, case report.

Long-term safety of left renal vein division and ligation to expedite complex abdominal aortic surgery.

PubMed

Samson, Russell H; Lepore, Michael R; Showalter, David P; Nair, Deepak G; Lanoue, Julien B

2009-09-01

Left renal vein division and ligation (LRVDAL) is performed to facilitate complex abdominal aortic surgery. Surgeons restore continuity of the vein due to concern that ligation could cause renal compromise or hematuria. However, we report the short and long-term safety of left renal vein division and ligation. Between 1992 and 2007, we divided the left renal vein in 56 patients (40 males, 16 females) ages 57 to 84 (average 74-years-old) who were treated for aortic occlusive disease (9) or abdominal aortic aneurysm (47). Patients requiring concomitant renal artery reconstruction were excluded from this review. Suprarenal cross-clamp was used in 51 patients with temporary vessel-loop control of the renal arteries. Creatinine (Cr) and glomerular filtration rates (eGFR) were measured pre-, post-, and long-term after surgery. Outpatient records of all patients that had survived more than 12 months were also reviewed in order to evaluate the late effects on renal function or symptoms possibly related to LRVDAL. Median procedure duration was 157 (61-375) minutes. Median cross-clamp time was 16 (10-45) minutes. Median intensive care unit (ICU) and hospital length of stays were 2 (1-11) days and 7 (4-58) days, respectively. There were no deaths. There were no complications directly related to renal vein ligation. Hematuria, seen in 2 patients, was a result of traumatic insertion of a Foley catheter. Median pre-op and discharge Cr levels were 1.1 mg/dL (0.7-2.4 mg/dL) and 1.1 mg/dL (0.6-2.1 mg/dL), respectively (P < .5). Median change in Cr was 0.0 mg/dL and only increased in 14 patients (maximum increase 0.9 mg/dL). Median pre-op and discharge eGFR was 61 mL/minute (28-137 mL/minute/1.73 m2) and 67 mL/minute (32-138 mL/minute/1.73 m2), respectively (P < .5). Cr and eGFR in the 2 patients with a Cr of >2.0 mg/dL remained unchanged post-op. Only 2 patients with a Cr of <2.0 mg/dL had a post-op Cr >2.0 mg/dL and both returned to normal by day 3 post-op. Thirty-six patients

An observational European study on clinical outcomes associated with current management strategies for non-variceal upper gastrointestinal bleeding (ENERGIB-Turkey).

PubMed

Mungan, Zeynel

2012-01-01

This observational, retrospective cohort study assessed outcomes of the current management strategies for nonvariceal upper gastrointestinal bleeding in several European countries (Belgium, Greece, Italy, Norway, Portugal, Spain, and Turkey) (NCT00797641; ENERGIB). Turkey contributed 23 sites to this study. Adult patients (≥18 years old) consecutively admitted to hospital and who underwent endoscopy for overt non-variceal upper gastrointestinal bleeding (hematemesis, melena or hematochezia, with other clinical/laboratory evidence of acute upper GI blood loss) were included in the study. Data were collected from patient medical records regarding bleeding continuation, re-bleeding, pharmacological treatment, surgery, and mortality during a 30-day follow-up period. A total of 423 patients (67.4% men; mean age: 57.8 ± 18.9 years) were enrolled in the Turkish study centers, of whom 96.2% were admitted to hospital with acute non-variceal upper gastrointestinal bleeding. At admission, the most common symptom was melena (76.1%); 28.6% of patients were taking aspirin, 19.9% were on non-steroidal anti-inflammatory drugs, and 7.3% were on proton pump inhibitors. The most common diagnoses were duodenal (45.2%) and gastric (27.7%) ulcers and gastritis/gastric erosions (26.2%). Patients were most often managed in general medical wards (45.4%). A gastrointestinal team was in charge of treatment in 64.8% of cases. Therapeutic procedures were performed in 32.4% of patients during endoscopy. After the endoscopy, most patients (94.6%) received proton pump inhibitors. Mean (SD) hospital stay was 5.36 ± 4.91 days. The cumulative proportions of continued bleeding/re-bleeding, complications and mortality within 30 days of the non-variceal upper gastrointestinal bleeding episode were 9.0%, 5.7% and 2.8%, respectively. In the Turkish sub-group of patients, the significant risk factors for bleeding continuation or re-bleeding were age >65 years, presentation with hematemesis or shock

Esophageal stricture - benign

MedlinePlus

Esophageal stricture can be caused by: Gastroesophageal reflux (GERD). Eosinophilic esophagitis. Injuries caused by an endoscope . Long-term use of a nasogastric (NG) tube (tube through the nose into the ...

Ineffective esophageal motility phenotypes following fundoplication in gastroesophageal reflux disease.

PubMed

Mello, M D; Shriver, A R; Li, Y; Patel, A; Gyawali, C P

2016-02-01

Ineffective esophageal motility (IEM) is associated with reflux disease, but its natural history is unclear. We evaluated patients undergoing repeat esophageal high resolution manometry (HRM) for symptomatic presentations after antireflux surgery (ARS) to understand the progression of IEM. Patients with repeat HRM after ARS were included. Ineffective esophageal motility was diagnosed if ≥5 sequences had distal contractile integral (DCI) <450 mmHg cm s. Augmentation of DCI following multiple rapid swallows (MRS) was assessed. The esophagogastric junction (EGJ) was interrogated using the EGJ contractile integral (EGJ-CI). Esophageal motor function was compared between patients with and without IEM. Sixty-eight patients (53.9 ± 1.8 years, 66.2% female) had pre- and post-ARS HRM studies 2.1 ± 0.19 years apart. Esophagogastric junction-CI augmented by a mean of 26.3% following ARS. Four IEM phenotypes were identified: 14.7% had persistent IEM, 8.8% resolved IEM after ARS, 19.1% developed new IEM, and 57.4% had no IEM at any point. Patients with IEM had a lower DCI pre- and post-ARS, lower pre-ARS EGJ CI, and lower pre-ARS-integrated relaxation pressure (p ≤ 0.02 for all comparisons); presenting symptoms and other EGJ metrics were similar (p ≥ 0.08 for all comparisons). The IEM phenotypes could be predicted by MRS DCI response patterns (p = 0.008 across groups); patients with persistent IEM had the least DCI augmentation (p = 0.007 compared to no IEM), while those who resolved IEM had DCI augmentation comparable to no IEM (p = 0.08). Distinct phenotypes of IEM exist among symptomatic reflux patients following ARS. Provocative testing with MRS may help identify these phenotypes pre-ARS. © 2015 John Wiley & Sons Ltd.

Esophageal stent placement as a therapeutic option for iatrogenic esophageal perforation in children.

PubMed

Ahmad, Alsafadi; Wong Kee Song, Louis M; Absah, Imad

2016-01-01

Iatrogenic esophageal perforation (IEP) is a potentially serious adverse event of interventional endoscopy. The approach to IEP varies from surgical repair for large perforations to conservative treatment for small contained perforations. We report a case of an 18-month-old girl with congenital esophageal stenosis suffering a large esophageal perforation after a trial of stricture dilatation, which was successfully managed by the placement of fully covered stent. Hence, in selected cases, esophageal stent placement is a feasible alternative to invasive surgery in managing IEP.

[Rubber band ligation in treatment of hemorrhoids: our experience].

PubMed

Gaj, F; Biviano, I; Sportelli, G; Candeloro, L

2015-01-01

Hemorrhoids are a very common condition. The treatment depends upon persistence and severity of symptoms. For hemorrhoids of II and III grade the rubber band ligation may be therapeutic. Our aim is to report the outcomes of rubber band ligation of hemorrhoids, with a follow up of 6 months. A total of 50 patients underwent rubber band ligation for symptomatic hemorrhoids (grade II and III) without prolapse, between June 2012 and June 2014. All patients underwent plug test to rule out presence of rectal mucosal prolapse and were classified according to PATE classification (1). Each hemorrhoid was ligated with one rubber band through a ligator. All patients were evaluated immediately at the end of the procedure, after ten days and six months after the treatment. Patient's demographic and operative data were collected and analyzed. The mean patients age was 47.6±12.3 years (range 24-72). All procedures were performed without complications. Before rubber band ligation, 42 patients had rectal bleeding, 38 had perineal discomfort and 27 had itching. Ten days after the treatment, 12 patients presented self-limited rectal bleeding, but 10 of these had more hemorrhoids and underwent a second rubber band ligation. No patients complained perineal discomfort, and 8 patients had itching; 78% and 16% of patients respectively, experienced feeling of a foreign body inside the canal anal and anal pain. After 6 months, only 13 patients were occasionally symptomatic: 4 patients had rectal bleeding, 2 had perineal discomfort and 4 had itching. Three more patients presented both perineal discomfort and hitching. None had the feeling of a foreign body in anal canal or anal pain. Rubber band ligation is an efficacious, cost-effective and simple treatment for the second and third degree hemorrhoids without rectal mucosal prolapsed. In our hands, no severe complications developed and minor complications could be handled with ease.

Chest closure without drainage after open patent ductus arteriosus ligation in Ugandan children: A non blinded randomized controlled trial.

PubMed

Kebba, Naomi; Mwambu, Tom; Oketcho, Michael; Izudi, Jonathan; Obuku, Ekwaro A

2016-09-29

There is clinical equipoise regarding post-operative management of patients with patent ductus arteriosus (PDA) without insertion of a chest drain. This study evaluated post operative outcomes of chest closure with or without a drain following Patent Ductus Arteriosus ligation among childen at Uganda Heart Instritute (UHI). This was an open label randomized controlled trial of 62 children 12 years of age and below diagnosed with patent ductus arteriosus at Mulago National Teaching and Referral Hospital, Uganda. Participants were randomized in the ratio of 1:1 with surgical ligation of patent ductus arteriosus to either thoracotomy closure with a chest tube or without a chest tube. All participants received standard care and were monitored hourly for 24 hours then until hospital discharge. The combined primary endpoint consisted of significant pleural space accumulation of fluid or air, higher oxygen need or infection of the surgical site. Analysis was conducted by multivariable logistic regression analysis at 5 % significance level. We enrolled 62 participants, 46 (74 %) of whom were females. Their median age was 12 months (IQR: 8-36). Participants in the no-drain arm significantly had less post-operative complications compared to the drain arm (Unadjusted odds ratio [uOR]: 0.21, 95 % CI: 0.06-0.73, p = 0.015). This "protective effect" remained without statistical significance in the multivariable regression model (Adjusted odds ratio [aOR]: 0.07, 95 % CI: 0.00-2.50, p = 0.144). Children aged below 6 years with patent ductus arterious can safely and effectively have thoracotomy closure without using a drain in uncomplicated surgical ligation of the PDA. Chest drain was associated with post-operative complications. The trial was registered in the Pan African Clinical Trials registry on 1st/July/2012, retrospectively registered. Identifier number PACTR201207000395469 .

Persistent Dysphagia After Induction Chemotherapy in Patients with Esophageal Adenocarcinoma Predicts Poor Post-Operative Outcomes.

PubMed

McNamara, Michael J; Adelstein, David J; Allende, Daniela S; Bodmann, Joanna W; Ives, Denise I; Murthy, Sudish C; Raymond, Daniel; Raja, Siva; Rodriguez, Cristina P; Sohal, Davendra; Stephans, Kevin L; Videtic, Gregory M M; Rybicki, Lisa A

2017-06-01

Preoperative therapy is frequently employed in the management of esophageal adenocarcinoma. However, many patients are found to have advanced pathologic stage and have poor outcomes. A prognostic factor which identifies this patient population before surgery would be desirable, as alternative treatment strategies may be warranted. Between 2/08 and 1/12, 60 evaluable patients with locally advanced esophageal adenocarcinoma enrolled in single-arm phase II trial of induction chemotherapy, surgery, and post-operative adjuvant chemo-radiotherapy (CRT). A clinical stage of T3, N1, or M1a (AJCC 6th) was required for eligibility. Induction chemotherapy with epirubicin 50 mg/m 2 d1, oxaliplatin 130 mg/m 2 d1, and fluorouracil 200 mg/m 2 /day continuous infusion for 3 weeks, was given every 21 days for 3 cycles and was followed by surgical resection. Adjuvant CRT consisted of 50-55 Gy @ 1.8-2.0 Gy/day and 2 cycles of cisplatin (20 mg/m 2 /day) and fluorouracil (1000 mg/m 2 /day) given as 96-h infusions during weeks 1 and 4 of radiotherapy. Dysphagia was assessed at baseline and after induction chemotherapy. Persistent dysphagia was associated with worse distant metastatic control [HR 3.48 (1.43-8.43), p = 0.006], recurrence free survival [HR 3.04 (1.34-6.92), p = 0.008], and overall survival [HR 3.31 (1.43-7.66), p = 0.005]. Persistent dysphagia was associated with more advanced pathologic T descriptor (pT) (p = 0.048) and N descriptor (pN) (p = 0.002), a greater median number of involved lymph nodes (3 v 1, p = 0.003), and greater residual tumor viability (p = 0.05). No patients with persistent dysphagia had pT0-T2 or pN0 disease. Persistent dysphagia after induction chemotherapy is associated with more advanced pathologic stage and inferior outcomes.

One-Pot/Sequential Native Chemical Ligation Using Photocaged Crypto-thioester.

PubMed

Aihara, Keisuke; Yamaoka, Kosuke; Naruse, Naoto; Inokuma, Tsubasa; Shigenaga, Akira; Otaka, Akira

2016-02-05

A practical and efficient methodology for the chemical synthesis of peptides/proteins using a one-pot/sequential ligation is described. It features the use of photocleavable S-protection on an N-sulfanylethylaniline moiety. Removal of the S-protecting ligated materials under UV irradiation provides a readily usable mixture for subsequent native chemical ligation.

Genito-Urinary Function and Quality of Life after Elective Totally Laparoscopic Sigmoidectomy after at Least One Episode of Complicated Diverticular Disease According to Two Different Vascular Approaches: the IMA Low Ligation or the IMA Preservation.

PubMed

Mari, Giulio; Crippa, Jacopo; Costanzi, Andrea; Mazzola, Michele; Magistro, Carmelo; Ferrari, Giovanni; Maggioni, Dario

2017-01-01

The arterial ligation during elective laparoscopic sigmoidectomy for diverticular disease can affect genito-urinary function injuring the superior hypogastric plexus, and can weaken the distal colonic stump arterial perfusion. Ligation of the inferior mesenteric artery distal to the left colic artery or the complete preservation of the inferior mesenteric artery can therefore be compared in terms of preservation of the descending sympathetic fibres running along the aorta to the rectum resulting in a different post operative genito urinary function. From January 2015 to March 2016, 66 patients underwent elective laparoscopic sigmoidectomy for diverticular disease among two enrolling hospitals. In one centre 35 patients underwent laparoscopic sigmoidectomy with the ligation of the inferior mesenteric artery distal to the left colic artery (low ligation). In the other centre 31 patient were operated on the same procedure with complete inferior mesenteric artery preservation (IMA preservation). There was no difference in terms of major complication occurred, first passage of stool and length of hospital stay between the two groups. Time of surgery was significantly shorter in LL group compared to IMA preserving group and intra operative blood loss was significantly lower in the LL group. There were no differences in the genito urinary function between the two group pre operatively, at 1 and 9 months post operatively. Genito urinary function did not significantly change across surgery in each groups. The low ligation and the IMA preserving vascular approach are safe end feasible techniques in elective laparoscopic sigmoidectomy for diverticular disease. They both prevent from genito-urinary post-operative disfunction and allow good post operative quality of life. The low ligation approach is related to shorter operative time and slower intra operative blood loss. Celsius.

[Effects of peroral endoscopic myotomy on esophageal dynamics in patients with esophageal achalasia].

PubMed

Zhong, Yun-shi; Li, Liang; Zhou, Ping-hong; Xu, Mei-dong; Ren, Zhong; Zhu, Bo-qun; Yao, Li-qing

2012-07-01

To investigate the effects of peroral endoscopic myotomy(POEM) on esophageal dynamics in patients with esophageal achalasia. From September 2011 to November 2011, 20 cases with esophageal achalasia received POEM at the Endoscopic Center in the Zhongshan Hospital of Fudan University. Pre-operation esophageal dynamics of all the patients were evaluated by high resolution manometry(HRM) system and 3 days after operation the test was repeated. Lower esophagus sphincter resting pressure(LESP), 4-second integrated relaxation pressure(4sIRP), lower esophagus sphincter relax rate(LESRR), lower esophagus sphincter length(LESL), and esophageal manometry were analyzed. After POEM, LESP decreased from(29.1±17.0) mm Hg to(14.6±4.9) mm Hg, and decrease rate was 49.8%(P<0.01). However, the decreases in LESRR and LESL were not statistically significant(P>0.05). Esophageal peristaltic contraction was absent in all the 20 patients preoperatively. After POEM, changes in the esophageal contraction were seen in 7 patients, and peristalsis was noticed but was below normal level. There were no significant changes in peristalsis in the remaining 13 patients. POEM can significantly reduce LESP and 4sIRP in patients with achalasia, but can not affect the contraction of the esophagus.

Classification of esophageal motor findings in gastro-esophageal reflux disease: Conclusions from an international consensus group.

PubMed

Gyawali, C P; Roman, S; Bredenoord, A J; Fox, M; Keller, J; Pandolfino, J E; Sifrim, D; Tatum, R; Yadlapati, R; Savarino, E

2017-12-01

High-resolution manometry (HRM) has resulted in new revelations regarding the pathophysiology of gastro-esophageal reflux disease (GERD). The impact of new HRM motor paradigms on reflux burden needs further definition, leading to a modern approach to motor testing in GERD. Focused literature searches were conducted, evaluating pathophysiology of GERD with emphasis on HRM. The results were discussed with an international group of experts to develop a consensus on the role of HRM in GERD. A proposed classification system for esophageal motor abnormalities associated with GERD was generated. Physiologic gastro-esophageal reflux is inherent in all humans, resulting from transient lower esophageal sphincter (LES) relaxations that allow venting of gastric air in the form of a belch. In pathological gastro-esophageal reflux, transient LES relaxations are accompanied by reflux of gastric contents. Structural disruption of the esophagogastric junction (EGJ) barrier, and incomplete clearance of the refluxate can contribute to abnormally high esophageal reflux burden that defines GERD. Esophageal HRM localizes the LES for pH and pH-impedance probe placement, and assesses esophageal body peristaltic performance prior to invasive antireflux therapies and antireflux surgery. Furthermore, HRM can assess EGJ and esophageal body mechanisms contributing to reflux, and exclude conditions that mimic GERD. Structural and motor EGJ and esophageal processes contribute to the pathophysiology of GERD. A classification scheme is proposed incorporating EGJ and esophageal motor findings, and contraction reserve on provocative tests during HRM. © 2017 John Wiley & Sons Ltd.

Esophageal manometric characteristics and outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication for epiphrenic diverticula.

PubMed

Melman, Lora; Quinlan, Jessica; Robertson, Brian; Brunt, L M; Halpin, Valerie J; Eagon, J C; Frisella, Margaret M; Matthews, Brent D

2009-06-01

The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean +/- standard deviation (SD). An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 +/- 4.2 years, body mass index (BMI) of 28.1 +/- 1.9 kg/m2 and American Society of Anesthesiologists (ASA) 2.2 +/- 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 +/- 15.1 min and mean length of stay (LOS) was 2.8 +/- 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 +/- 3.0 months (range 3-36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. The majority of patients

Necrotizing fasciitis following saphenofemoral junction ligation with long saphenous vein stripping: a case report.

PubMed

Smith, Stella Ruth; Aljarabah, Moayad; Ferguson, Graeme; Babar, Zahir

2010-05-27

Necrotizing fasciitis is a rare condition with a mortality rate of around 34%. It can be mono- or polymicrobial in origin. Monomicrobial infections are usually due to group A streptococcus and their incidence is on the rise. They normally occur in healthy individuals with a history of trauma, surgery or intravenous drug use. Post-operative necrotizing fasciitis is rare but accounts for 9 to 28% of all necrotizing fasciitis. The incidence of wound infection following saphenofemoral junction ligation and vein stripping is said to be less than 3%, although this complication is probably under-reported. We describe a case of group A streptococcus necrotizing fasciitis following saphenofemoral junction ligation and vein stripping. A 39-year-old woman presented three days following a left sided saphenofemoral junction ligation with long saphenous vein stripping at another institution. She had a three day history of fever, rigors and swelling of the left leg. She was pyrexial and shocked. She had a very tender, swollen left groin and thigh, with a small blister anteriorly and was in acute renal failure. She was prescribed intravenous penicillin and diagnosed with necrotizing fasciitis. She underwent extensive debridement of her left thigh and was commenced on clindamycin and imipenem. Post-operatively, she required ventilatory and inotropic support with continuous veno-venous haemofiltration. An examination 12 hours after surgery showed no requirement for further debridement. A group A streptococcus, sensitive to penicillin, was isolated from the debrided tissue. A vacuum assisted closure device was fitted to the clean thigh wound on day four and split-skin-grafting was performed on day eight. On day 13, a wound inspection revealed that more than 90% of the graft had taken. Antibiotics were stopped on day 20 and she was discharged on day 22. Necrotizing fasciitis is a very serious complication for a relatively minor, elective procedure. To the best of our knowledge, this

Necrotizing fasciitis following saphenofemoral junction ligation with long saphenous vein stripping: a case report

PubMed Central

2010-01-01

Introduction Necrotizing fasciitis is a rare condition with a mortality rate of around 34%. It can be mono- or polymicrobial in origin. Monomicrobial infections are usually due to group A streptococcus and their incidence is on the rise. They normally occur in healthy individuals with a history of trauma, surgery or intravenous drug use. Post-operative necrotizing fasciitis is rare but accounts for 9 to 28% of all necrotizing fasciitis. The incidence of wound infection following saphenofemoral junction ligation and vein stripping is said to be less than 3%, although this complication is probably under-reported. We describe a case of group A streptococcus necrotizing fasciitis following saphenofemoral junction ligation and vein stripping. Case Presentation A 39-year-old woman presented three days following a left sided saphenofemoral junction ligation with long saphenous vein stripping at another institution. She had a three day history of fever, rigors and swelling of the left leg. She was pyrexial and shocked. She had a very tender, swollen left groin and thigh, with a small blister anteriorly and was in acute renal failure. She was prescribed intravenous penicillin and diagnosed with necrotizing fasciitis. She underwent extensive debridement of her left thigh and was commenced on clindamycin and imipenem. Post-operatively, she required ventilatory and inotropic support with continuous veno-venous haemofiltration. An examination 12 hours after surgery showed no requirement for further debridement. A group A streptococcus, sensitive to penicillin, was isolated from the debrided tissue. A vacuum assisted closure device was fitted to the clean thigh wound on day four and split-skin-grafting was performed on day eight. On day 13, a wound inspection revealed that more than 90% of the graft had taken. Antibiotics were stopped on day 20 and she was discharged on day 22. Conclusion Necrotizing fasciitis is a very serious complication for a relatively minor, elective

Primary Esophageal Motility Disorders: Beyond Achalasia.

PubMed

Schlottmann, Francisco; Patti, Marco G

2017-06-30

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders. The Chicago classification introduced new manometric parameters and better defined esophageal motility disorders. Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis). The aim of this study was to review the current diagnosis and management of esophageal motility disorders other than achalasia.

Primary Esophageal Motility Disorders: Beyond Achalasia

PubMed Central

Schlottmann, Francisco; Patti, Marco G.

2017-01-01

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders. The Chicago classification introduced new manometric parameters and better defined esophageal motility disorders. Motility disorders beyond achalasia with the current classification are: esophagogastric junction outflow obstruction, major disorders of peristalsis (distal esophageal spasm, hypercontractile esophagus, absent contractility) and minor disorders of peristalsis (ineffective esophageal motility, fragmented peristalsis). The aim of this study was to review the current diagnosis and management of esophageal motility disorders other than achalasia. PMID:28665309

Convergent synthesis of proteins by kinetically controlled ligation

DOEpatents

Kent, Stephen; Pentelute, Brad; Bang, Duhee; Johnson, Erik; Durek, Thomas

2010-03-09

The present invention concerns methods and compositions for synthesizing a polypeptide using kinetically controlled reactions involving fragments of the polypeptide for a fully convergent process. In more specific embodiments, a ligation involves reacting a first peptide having a protected cysteyl group at its N-terminal and a phenylthioester at its C-terminal with a second peptide having a cysteine residue at its N-termini and a thioester at its C-termini to form a ligation product. Subsequent reactions may involve deprotecting the cysteyl group of the resulting ligation product and/or converting the thioester into a thiophenylester.

Evaluation of the Friction of Self-Ligating and Conventional Bracket Systems

PubMed Central

Tecco, Simona; Di Iorio, Donato; Nucera, Riccardo; Di Bisceglie, Beatrice; Cordasco, Giancarlo; Festa, Felice

2011-01-01

Objectives: This in vitro study evaluated the friction (F) generated by aligned stainless steel (SS) conventional brackets, self-ligating Damon MX© brackets (SDS Ormco, Glendora, California, USA), Time3© brackets (American Orthodontics, Sheboygan, Wisconsin, USA), Vision LP© brackets (American Orthodontics), and low-friction Slide© ligatures (Leone, Firenze, Italy) coupled with various SS, nickel-titanium (NiTi), and beta-titanium (TMA) archwires. Methods: All brackets had a 0.022-inch slot, and the orthodontic archwires were 0.014-inch, 0.016-inch, 0.014×0.025-inch, 0.018×0.025-inch, and 0.019×0.025-inch NiTi; 0.017×0.025-inch TMA; and 0.019×0.025-inch SS. Each bracket-archwire combination was tested 10 times. In the test, 10 brackets of the same group were mounted in alignment on a metal bar. The archwires moved through all the 10 brackets at a crosshead speed of 0.5 mm/min (each run lasted approximately 5 min). The differences among 5 groups of brackets were analyzed through the Kruskal-Wallis test, and a Mann-Whitney test was calculated as post hoc analysis. The P value was set at 0.05. Results: Coupled with 0.014-inch NiTi and 0.016-inch NiTi, Victory Series© brackets generated the greatest F, while Damon MX© and Vision LP© brackets generated the lowest (P<.05); no significant differences were observed between Time3© brackets and Slide© ligatures. Coupled with all the rectangular archwires, Victory Series© brackets, Slide© ligatures, and Vision LP© self-ligating brackets generated significantly lower F than did Time3© and Damon MX© self-ligating brackets (P<.05). Conclusions: These findings suggest that self-ligating brackets are a family of brackets that, in vitro, can generate different levels of F when coupled with thin or thick, rectangular, or round archwires. Clinical conclusions based on our results are not possible due to the limitations of the experimental conditions. PMID:21769273

Disulfide bond exchanges in integrins αIIbβ3 and αvβ3 are required for activation and post-ligation signaling during clot retraction.

PubMed

Mor-Cohen, Ronit; Rosenberg, Nurit; Averbukh, Yulia; Seligsohn, Uri; Lahav, Judith

2014-05-01

Integrin αIIbβ3 mediates platelet adhesion, aggregation and fibrin clot retraction. These processes require activation of αIIbβ3 and post-ligation signaling. Disulfide bond exchanges are involved in αIIbβ3 and αvβ3 activation. In order to investigate the role of integrin activation and disulfide bond exchange during αIIbβ3- and αvβ3-mediated clot retraction, we co-expressed in baby hamster kidney cells wild-type (WT) human αIIb and WT or mutated human β3 that contain single or double cysteine substitutions disrupting C523-C544 or C560-C583 bonds. Flow cytometry was used to measure surface expression and activation state of the integrins. Time-course of fibrin clot retraction was examined. Cells expressed WT or mutated human αIIbβ3 as well as chimeric hamster/human αvβ3. The αIIbβ3 mutants were constitutively active and the thiol blocker dithiobisnitrobenzoic acid (DTNB) did not affect their activation state. WT cells retracted the clot and addition of αvβ3 inhibitors decreased the retraction rate. The active mutants and WT cells activated by anti-LIBS6 antibody retracted the clot faster than untreated WT cells, particularly in the presence of αvβ3 inhibitor. DTNB substantially inhibited clot retraction by WT or double C523S/C544S mutant expressing cells, but minimally affected single C523S, C544S or C560S mutants. Anti-LIBS6-enhanced clot retraction was significantly inhibited by DTNB when added prior to anti-LIBS6. Both αIIbβ3 and αvβ3 contribute to clot retraction without prior activation of the integrins. Activation of αIIbβ3, but not of αvβ3 enhances clot retraction. Both αIIbβ3 activation and post-ligation signaling during clot retraction require disulfide bond exchange. Copyright © 2014 Elsevier Ltd. All rights reserved.

Esophageal stenosis with sloughing esophagitis: A curious manifestation of graft-vs-host disease.

PubMed

Trabulo, Daniel; Ferreira, Sara; Lage, Pedro; Rego, Rafaela Lima; Teixeira, Gilda; Pereira, A Dias

2015-08-14

We report a case of a 56-year-old woman with a history of allogenic bone marrow transplantation for two years, complaining with dysphagia and weight loss. Upper endoscopy revealed esophageal stenosis and extensive mucosa sloughing. Biopsies confirmed the diagnosis of graft-vs-host disease (GVHD). Balloon dilation, corticosteroids and cyclosporin resulted in marked clinical improvement. Gastrointestinal tract is involved in the majority of patients with chronic GVHD. Esophageal manifestations are rare and include vesiculobullous disease, ulceration, esophageal webs, casts or strictures. Sloughing esophagitis along with severe stenosis requiring endoscopic dilation has never been reported in this context.

Esophageal motility pattern and gastro-esophageal reflux in chronic obstructive pulmonary disease.

PubMed

Gadel, Abil Ali; Mostafa, Mohamed; Younis, Ahmed; Haleem, Magdy

2012-01-01

The association of esophageal motility and gastroesophageal reflux symptoms with respiratory symptoms is not well established in patients with chronic obstructive pulmonary disease (COPD). The aim of this work is to study the abnormalities of esophageal function in COPD patients and study its relation to smoking index, body mass index and indices of hyperinflation. This study included 40 male COPD patients and 10 healthy controls. The patients and controls were subjected to spirometry, body plethysmography, esophageal manometry and 24hr pH-metry. Upper gastrointestinal symptoms were found in 55% of patients, hypotensive upper esophageal sphincter pressure in 65% of patients and hypotensive lower esophageal sphincter pressure in 52.5% of patients. Pathological acid reflux was found in 35% of patients. The severity of GERD increased with increased age, smoking index and body mass index, p<0.005. There was negative correlation between LESP and UESP compared with indices of hyperinflation, p<0.001. There was high prevalence of esophageal motility disorders in COPD patients, LESP and UESP were significantly negatively correlated to indices of hyperinflation. There was a high prevalence of GERD in COPD patents especially elderly, severe stage of COPD, high smoking index and high body mass index (BMI).

Delayed onset pulmonary glue emboli in a ventilated patient: a rare complication following endoscopic cyanoacrylate injection for gastric variceal haemorrhage

PubMed Central

Chew, Joyce Ruo Yi; Balan, Anu; Griffiths, William; Herre, Jurgen

2014-01-01

Cyanoacrylate injection is a recognised endoscopic treatment option for variceal haemorrhage. We describe a 34-year old man with hepatitis B cirrhosis who presented to the hospital with upper gastrointestinal haemorrhage from gastric and oesophageal varices. Haemostasis was achieved via cyanoacrylate injection sclerotherapy and banding. Ten days later, the patient developed acute hypoxia and fever. His chest radiograph showed wide-spread pulmonary shadowing. A non-contrast CT scan confirmed multiple emboli of injected glue material from the varix with parenchymal changes either suggesting acute lung injury or pulmonary oedema. He gradually recovered with supportive treatment and was discharged home. On follow-up, he remained asymptomatic from a chest perspective. This case report discusses the rare complication of pulmonary embolisation of cyanoacrylate glue from variceal injection sites and the diagnostic dilemmas involved. Emphasis is placed on the importance of maintaining high index of clinical suspicion when assessing patients with possible procedure related complications. PMID:25320260

Ligation versus no ligation of spontaneous portosystemic shunts during liver transplantation: Audit of a prospective series of 66 consecutive patients.

PubMed

Gomez Gavara, Concepcion; Bhangui, Prashant; Salloum, Chady; Osseis, Michael; Esposito, Francesco; Moussallem, Toufic; Lahat, Eylon; Fuentes, Liliana; Compagnon, Philippe; Ngongang, Norbert; Lim, Chetana; Azoulay, Daniel

2018-04-01

The management of large spontaneous portosystemic shunt (SPSS) during liver transplantation (LT) is a matter of debate. The aim of this study is to compare the short-term and longterm outcomes of SPSS ligation versus nonligation during LT, when both options are available. From 2011 to 2017, 66 patients with SPSS underwent LT: 56 without and 10 with portal vein thrombosis (PVT), all of whom underwent successful thrombectomy and could have portoportal reconstruction. The SPSS were either splenorenal (n = 40; 60.6%), left gastric (n = 16; 24.2%), or mesenterico-iliac (n = 10; 15.1%). Following portoportal anastomosis, the SPSS was ligated in 36 (54.4%) patients and left in place in 30 (45.5%) patients, based on the effect of the SPSS clamping/unclamping test on portal vein flow during the anhepatic phase. Intraoperatively, satisfactory portal flow was obtained in both groups. Primary nonfunction (PNF) and primary dysfunction (PDF) rates did not differ significantly between the 2 groups. Nonligation of SPSS was significantly associated with a higher rate of postoperative encephalopathy (P < 0.001) and major postoperative morbidity (P = 0.02). PVT occurred in 0 and 3 patients in the ligated and nonligated shunt group, respectively (P = 0.08). A composite end point, which included the relevant complications in the setting of SPSS in LT (ie, PNF and PDF, PVT, and encephalopathy) was present in 16 (44.4%) and 22 (73.3%) patients of the ligated and nonligated shunt group, respectively (P = 0.02). Patient (P = 0.05) and graft (P = 0.02) survival rates were better in the ligated shunt group. In conclusion, the present study supports routine ligation of large SPSS during LT whenever feasible. Liver Transplantation 24 505-515 2018 AASLD. © 2018 by the American Association for the Study of Liver Diseases.

Indwelling esophageal balloon catheter for benign esophageal stenosis in infants and children.

PubMed

van der Zee, David; Hulsker, Caroline

2014-04-01

Balloon dilatation of benign esophageal strictures is an established mode of therapy in adults and children. There remains a group of patients with refractory stenosis despite dilatation at regular intervals. An indwelling balloon catheter may offer an alternative. This is a retrospective study of 19 children who underwent esophagoscopy between 2004 and 2012 with placement of an indwelling balloon catheter for refractory esophageal stenosis. Total number of endoscopies, number of endoscopies with indwelling balloon catheter, as well as complications, reoperations, and mortality due to use of the balloon catheter were studied. Patient age ranged from 4 weeks to 15 years. The indwelling balloon catheter was used to treat refractory stenosis after corrective surgery of long gap esophageal atresia (n = 5), esophageal atresia with distal fistula (n = 2), refractory esophageal stenosis due to caustic esophageal burns (n = 7), reflux (n = 2), and stenosis of unknown cause (n = 3). With the indwelling balloon catheter in place, the mean number of endoscopies equalled four. Complications were restenosis after a symptom-free period for which a new indwelling balloon catheter was necessary (n = 3). Two others needed two to five additional dilations: balloon leakage requiring replacement (n = 7 in 5 patients), sputum retention (n = 1), and dislodgement (n = 5 in 4 patients). More importantly, there was no mortality or the need for any patient to undergo a surgical resection. The indwelling balloon catheter is safe to use and can be used by parents at home. More importantly it obviates the need for rethoracotomy/-scopy or esophageal replacement.

Supersonic shear imaging for the diagnosis of liver fibrosis and portal hypertension in liver diseases: a meta-analysis.

PubMed

Deng, Han; Qi, Xingshun; Zhang, Tiansong; Qi, Xiaolong; Yoshida, Eric M; Guo, Xiaozhong

2018-01-01

The meta-analysis aimed to summarize the technical success rate of supersonic shear imaging (SSI) and to evaluate the diagnostic performance of liver and spleen stiffness measurement (LSM and SSM) with SSI for the detection of liver fibrosis, portal hypertension, and gastroesophageal varices in liver diseases. PubMed, EMBASE, and Cochrane Library databases were searched. Technical success rate of SSI was pooled. Area under curve (AUC), sensitivity, and specificity with corresponding 95% confidence interval (CI) were calculated. Included studies regarding the diagnostic performance of SSI for liver fibrosis, portal hypertension, and esophageal varices numbered 28, 4, and 4 respectively. The pooled technical success rates of LSM and SSM were 95.3% and 75.5%, respectively. The AUC, sensitivity, and specificity of LSM/SSM for different stages of liver fibrosis were 0.85-0.94, 0.7-0.89, and 0.82-0.92, respectively. The AUC, sensitivity, and specificity of LSM were 0.84 (95%CI = 0.8-0.86), 0.79 (95%CI = 0.7-0.85), and 0.82 (95%CI = 0.72-0.88) for clinically significant portal hypertension, 0.85 (95%CI = 0.82-0.88), 0.8 (95%CI = 0.68-0.88), and 0.8 (95%CI = 0.6-0.92) for any varices, and 0.86 (95%CI = 0.83-0.89), 0.86 (95%CI = 0.76-0.92), and 0.61 (95%CI = 0.35-0.83) for high-risk varices, respectively. LSM with SSI had a high diagnostic accuracy for liver fibrosis, but a moderate diagnostic accuracy for portal hypertension and esophageal varices.

Upper Gastrointestinal Symptoms Predictive of Candida Esophagitis and Erosive Esophagitis in HIV and Non-HIV Patients

PubMed Central

Takahashi, Yuta; Nagata, Naoyoshi; Shimbo, Takuro; Nishijima, Takeshi; Watanabe, Koji; Aoki, Tomonori; Sekine, Katsunori; Okubo, Hidetaka; Watanabe, Kazuhiro; Sakurai, Toshiyuki; Yokoi, Chizu; Mimori, Akio; Oka, Shinichi; Uemura, Naomi; Akiyama, Junichi

2015-01-01

Abstract Upper gastrointestinal (GI) symptoms are common in both HIV and non-HIV-infected patients, but the difference of GI symptom severity between 2 groups remains unknown. Candida esophagitis and erosive esophagitis, 2 major types of esophagitis, are seen in both HIV and non-HIV-infected patients, but differences in GI symptoms that are predictive of esophagitis between 2 groups remain unknown. We aimed to determine whether GI symptoms differ between HIV-infected and non-HIV-infected patients, and identify specific symptoms of candida esophagitis and erosive esophagitis between 2 groups. We prospectively enrolled 6011 patients (HIV, 430; non-HIV, 5581) who underwent endoscopy and completed questionnaires. Nine upper GI symptoms (epigastric pain, heartburn, acid regurgitation, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia) were evaluated using a 7-point Likert scale. Associations between esophagitis and symptoms were analyzed by the multivariate logistic regression model adjusted for age, sex, and proton pump inhibitors. Endoscopy revealed GI-organic diseases in 33.4% (2010/6.011) of patients. The prevalence of candida esophagitis and erosive esophagitis was 11.2% and 12.1% in HIV-infected patients, respectively, whereas it was 2.9% and 10.7 % in non-HIV-infected patients, respectively. After excluding GI-organic diseases, HIV-infected patients had significantly (P < 0.05) higher symptom scores for heartburn, hunger cramps, nausea, early satiety, belching, dysphagia, and odynophagia than non-HIV-infected patients. In HIV-infected patients, any symptom was not significantly associated with CD4 cell count. In multivariate analysis, none of the 9 GI symptoms were associated with candida esophagitis in HIV-infected patients, whereas dysphagia and odynophagia were independently (P < 0.05) associated with candida esophagitis in non-HIV-infected patients. However, heartburn and acid regurgitation were independently (P < 0

[Three cases of the malignant esophageal stenosis successfully treated with the Niti-S™ esophageal stent].

PubMed

Isohata, Noriyuki; Naritaka, Yoshihiko; Asaka, Shinichi; Shimakawa, Takeshi; Miyaki, Akira; Yamaguchi, Kentaro; Murayama, Minoru; Katsube, Takao; Ogawa, Kenji

2011-11-01

We herein report three cases of the malignant esophageal stenosis successfully treated with the Niti-S™ esophageal stent. CASE 1: The hilar lung cancer and its mediastinal lymph node metastasis pressed the esophagus extramurally and caused the marked stenosis. CASE 2: A metastatic lymph node along the left laryngeal nerve caused the stenosis of the trachea. A primary esophageal lesion located at the middle thoracic esophagus also caused the marked stenosis. At first, tracheal stent was placed because of dyspnea, and two weeks later, we placed an esophageal stent. Case 3: Esophageal cancer at lower thoracic esophagus after definitive radiation therapy caused the marked stenosis. Because of the stenosis of esophago-gastric junction( EGJ), we used an esophageal stent with a long cover in order to prevent a reflux into the esophagus. This new Niti-STM esophageal stent was easy to place at the stenosis without difficulty using a conventional device. The symptom was improved immediately for each case. We hope this new device will be used widely.

Esophageal manometry in gastroesophageal reflux disease.

PubMed

Mello, Michael; Gyawali, C Prakash

2014-03-01

High-resolution manometry (HRM) allows nuanced evaluation of esophageal motor function, and more accurate evaluation of lower esophageal sphincter (LES) function, in comparison with conventional manometry. Pathophysiologic correlates of gastroesophageal reflux disease (GERD) and esophageal peristaltic performance are well addressed by this technique. HRM may alter the surgical decision by assessment of esophageal peristaltic function and exclusion of esophageal outflow obstruction before antireflux surgery. Provocative testing during HRM may assess esophageal smooth muscle peristaltic reserve and help predict the likelihood of transit symptoms following antireflux surgery. HRM represents a continuously evolving new technology that compliments the evaluation and management of GERD. Copyright © 2014 Elsevier Inc. All rights reserved.

Recovery of normal esophageal function in a kitten with diffuse megaesophagus and an occult lower esophageal stricture.

PubMed

Schneider, Jaycie; Ames, Marisa; DiCicco, Michael; Savage, Mason; Atkins, Clarke; Wood, Michael; Gookin, Jody L

2015-06-01

An 8-week-old male domestic shorthair was presented to the Internal Medicine Service at North Carolina State University for regurgitation. Radiographic diagnosis of generalized esophageal dilation and failure of esophageal peristalsis were compatible with diagnosis of congenital megaesophagus. Endoscopic examination of the esophagus revealed a fibrous stricture just orad to the lower esophageal sphincter. Conservative management to increase the body condition and size of the kitten consisted of feeding through a gastrostomy tube, during which time the esophagus regained normal peristaltic function, the stricture orifice widened in size and successful balloon dilatation of the stricture was performed. Esophageal endoscopy should be considered to rule out a stricture near the lower esophageal sphincter in kittens with radiographic findings suggestive of congenital megaesophagus. Management of such kittens by means of gastrostomy tube feeding may be associated with a return of normal esophageal motility and widening of the esophageal stricture, and facilitate subsequent success of interventional dilation of the esophageal stricture. © ISFM and AAFP 2014.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding.

PubMed

Fujishiro, Mitsuhiro; Iguchi, Mikitaka; Kakushima, Naomi; Kato, Motohiko; Sakata, Yasuhisa; Hoteya, Shu; Kataoka, Mikinori; Shimaoka, Shunji; Yahagi, Naohisa; Fujimoto, Kazuma

2016-05-01

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research. © 2016 Japan Gastroenterological Endoscopy Society.

Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience.

PubMed

Monsanto, Pedro; Almeida, Nuno; Rosa, Albano; Maçôas, Fernanda; Lérias, Clotilde; Portela, Francisco; Amaro, Pedro; Ferreira, Manuela; Gouveia, Hermano; Sofia, Carlos

2013-07-01

Endoscopic injection of N-butyl-2-cyanoacrylate is the current recommended treatment for gastric variceal bleeding. Despite the extensive worldwide use, there are still differences related to the technique, safety, and long term-results. We retrospectively evaluated the efficacy and safety of cyanoacrylate in patients with gastric variceal bleeding. Between January 1998 and January 2010, 97 patients with gastric variceal bleeding underwent endoscopic treatment with a mixture of N-butyl-2-cyanoacrylate and Lipiodol(TM). Ninety-one patients had cirrhosis and 6 had non-cirrhotic portal hypertension. Child-Pugh score at presentation for cirrhotic patients was A-12.1 %; B-53.8 %; C-34.1 % and median MELD score at admission was 13 (3-26). Successful hemostasis, rebleeding rate and complications were reviewed. Median time of follow up was 19 months (0.5-126). A median mixture volume of 1.5 mL (0.6 to 5 mL), in 1 to 8 injections, was used, with immediate hemostasis rate of 95.9 % and early rebleeding rate of 14.4 %. One or more complications occurred in 17.5 % and were associated with the use of Sengstaken-Blakemore tube before cyanoacrylate and very early rebleeding (p < 0.05). Hospital mortality rate during initial bleeding episode was 9.3 %. Very early rebleeding was a strong and independent predictor for in-hospital mortality (p < 0.001). Long-term mortality rate was 58.8 %, in most of the cases secondary to hepatic failure. N-butyl-2-cyanoacrylate is a rapid, easy and highly effective modality for immediate hemostasis of gastric variceal bleeding with an acceptable rebleeding rate. Patients with very early rebleeding are at higher risk of death.

Transcatheter recanalization of ligated main pulmonary artery.

PubMed

Bhole, Vinay; Wright, John G C; Stumper, Oliver

2007-04-01

A 12.5-year-old boy with tricuspid atresia and quadriplegic cerebral palsy presented with increasing cyanosis after previous palliation with a cavopulmonary shunt and ligation of the main pulmonary artery (MPA). Because of severe physical disabilities he was not considered suitable for Fontan completion. He underwent successful transcatheter stent recanalization of the ligated MPA. This re-established anterograde flow to the pulmonary arteries resulting in marked improvement in saturations.

A novel laparoscopic approach for severe esophageal stenosis due to reflux esophagitis: how to do it.

PubMed

Tsuboi, Kazuto; Omura, Nobuo; Yano, Fumiaki; Hoshino, Masato; Yamamoto, Se Ryung; Akimoto, Shunsuke; Kashiwagi, Hideyuki; Yanaga, Katsuhiko

2015-02-01

We herein report our technique for laparoscopic esophageal myotomy combined with Collis gastroplasty and Nissen fundoplication for severe esophageal stenosis. Our patient had experienced vomiting since childhood, and his dysphagia had gradually worsened. He was referred to our department for surgery because of resistance to pneumatic dilation. He was diagnosed with a short esophagus based on the findings of a preoperative upper gastrointestinal series and GI endoscopy. After exposing the abdominal esophagus, esophageal myotomy around the esophago-gastric junction (EGJ) was undertaken to introduce an esophageal bougie into the stomach. Then, stapled wedge gastroplasty was performed, and a short and loose Nissen fundoplication was performed. In addition, the bulging mucosa after myotomy was patched using the Dor method. The patient's postoperative course was uneventful. Most patients with esophageal stricture require subtotal esophagectomy. Laparoscopic surgery for patients with benign esophageal stricture refractory to repeated pneumatic dilation is challenging. However, our current procedure might abrogate the need for invasive esophagectomy for the surgical management of severe esophageal stenosis.

Gastrointestinal hemorrhage from adhesion-related mesenteric varices.

PubMed Central

Moncure, A C; Waltman, A C; Vandersalm, T J; Linton, R R; Levine, F H; Abbott, W M

1976-01-01

As a result of this retrospective analysis of hemorrhage from a porta-systemic venous shunt occurring within the small intestine, we believe that the early diagnosis of the syndrome is strongly suggested by the presence of varices in unusual locations demonstrated by the venous phase of mesenteric arteriography. In all patients portal hypertension was present, and in all the affected bowel was adherent to postoperative adhesions on old suture lines. The syndrome was treated variously with lysis of adhesions, bowel resection, or portal-systemic shunt. Those patients with excellent hepatic reserve survived and had no further gastrointestinal bleeding. Images Fig. 1a. Fig. 1b. Fig. 1c. Fig. 2. Fig. 3. Fig. 4a. Fig. 4b. Fig. 5. PMID:1082310

Predicting outcome of acute non-variceal upper gastrointestinal haemorrhage without endoscopy using the clinical Rockall Score.

PubMed

Tham, T C K; James, C; Kelly, M

2006-11-01

The Rockall risk scoring system uses clinical criteria and endoscopy to identify patients at risk of adverse outcomes after acute upper gastrointestinal haemorrhage. A clinical Rockall score obtained using only the clinical criteria may be able to predict outcome without endoscopy. To validate the clinical Rockall Score in predicting outcome after acute non-variceal upper gastrointestinal haemorrhage. A retrospective observational study of consecutive patients who were admitted with non-variceal acute upper gastrointestinal haemorrhage was undertaken. Medical records were abstracted using a standardised form. 102 cases were identified (51 men and 51 women; mean age 59 years). 38 (37%) patients considered to be at low risk of adverse outcomes (clinical Rockall Score 0) had no adverse outcomes and did not require transfusion. Patients with a clinical Rockall Score of 1-3 had no adverse outcomes, although 13 of 45 (29%) patients required blood transfusions. Clinical Rockall Scores >3 (n = 19) were associated with adverse outcomes (rebleeding in 4 (21%), surgery in 1 (5%) and death in 2 (10%)). The clinical Rockall Score without endoscopy may be a useful prognostic indicator in this cohort of patients with acute non-variceal upper gastrointestinal haemorrhage. This score may reduce the need for urgent endoscopy in low-risk patients, which can instead be carried out on a more elective outpatient basis.

Esophageal Dysmotility in Patients following Total Laryngectomy.

PubMed

Zhang, Teng; Maclean, Julia; Szczesniak, Michal; Bertrand, Paul P; Quon, Harry; Tsang, Raymond K; Wu, Peter I; Graham, Peter; Cook, Ian J

2018-02-01

Objectives Dysphagia is common in total laryngectomees, with some symptoms suggesting esophageal dysmotility. Tracheoesophageal (TE) phonation requires effective esophagopharyngeal air passage. Hence, esophageal dysmotility may affect deglutition or TE phonation. This study aimed to determine (1) the characteristics of esophageal dysmotility in laryngectomees, (2) whether clinical history is sensitive in detecting esophageal dysmotility, and (3) the relationship between esophageal dysmotility and TE prosthesis dysfunction. Study Design Multidisciplinary cross-sectional study. Setting Tertiary academic hospital. Subjects and Methods For 31 participants undergone total laryngectomy 1 to 12 years prior, clinical histories were taken by a gastroenterologist and a speech pathologist experienced in managing dysphagia. Esophageal high-resolution manometry was performed and analyzed using Chicago Classification v3.0. Results Interpretable manometric studies were obtained in 23 (1 normal manometry). Esophageal dysmotility patterns included achalasia, esophagogastric junction outflow obstruction, diffuse esophageal spasm, and other major (30%) and minor (50%) peristaltic disorders. The sensitivity of predicting any esophageal dysmotility was 28%, but it is noteworthy that patients with achalasia and diffuse esophageal spasm (DES) were predicted. Two of 4 participants with TE puncture leakage had poor esophageal clearance. Of 20 TE speakers, 12 had voice problems, no correlation between poor voice, and any dysmotility pattern. Conclusions Peristaltic and lower esophageal sphincter dysfunction are common in laryngectomees. Clinical history, while not predictive of minor motor abnormalities, predicted correctly cases with treatable spastic motor disorders. Dysmotility was not associated with poor phonation, although TE puncture leakage might be linked to poor esophageal clearance. Esophageal dysmotility should be considered in the laryngectomees with persisting dysphagia or

Esophageal motor disorders: recent advances.

PubMed

Dogan, Ibrahim; Mittal, Ravinder K

2006-07-01

The aim of this article is to highlight literature published during the last year in the context of previous knowledge. A number of novel techniques - high-resolution manometry, esophageal electrical impedance and intra-luminal ultrasound imaging - have improved our understanding of esophageal function in health and disease. Several studies address the function of longitudinal muscle layer of the esophagus in normal subjects and patients with motor disorders of the esophagus. Esophageal electrical impedance recordings reveal abnormal transit in patients with diffuse esophageal spasm, achalasia and patients with normal manometry. Loss of the mammalian Sprouty2 gene leads to enteric neuronal hyperplasia and esophageal achalasia. Several studies showed excellent long-term results of medical and surgical treatment of achalasia of the esophagus. For the first time, mechanisms of gastroesophageal reflux in critically ill mechanically ventilated patients are reported. Novel pharmacologic strategies in the treatment of reflux disease are highlighted. Several novel techniques, perfected during recent years, have improved our understanding of esophageal function and dysfunction. A number of important observations, reviewed here, provide important insight into the pathogenesis of esophageal motor disorders and treatment of gastroesophageal reflux disease.

Chemoselective ligation and antigen vectorization.

PubMed

Gras-Masse, H

2001-01-01

The interest in cocktail-lipopeptide vaccines has now been confirmed by phase I clinical trials: highly diversified B-, T-helper or cytotoxic T-cell epitopes can be combined with a lipophilic vector for the induction of B- and T-cell responses of predetermined specificity. With the goal of producing an improved vaccine that should ideally induce a multispecific response in non-selected populations, increasing the diversity of the immunizing mixture represents one of the most obvious strategies.The selective delivery of antigens to professional antigen-presenting cells represents another promising approach for the improvement of vaccine efficacy. In this context, the mannose-receptor represents an attractive entry point for the targeting to dendritic cells of antigens linked to clustered glycosides or glycomimetics. In all cases, highly complex but fully characterized molecules must be produced. To develop a modular and flexible strategy which could be generally applicable to a large set of peptide antigens, we elected to explore the potentialities of chemoselective ligation methods. The hydrazone bond was found particularly reliable and fully compatible with sulphide ligation. Hydrazone/thioether orthogonal ligation systems could be developed to account for the nature of the antigens and the solubility of the vector systems. Copyright 2001 The International Association for Biologicals.

Esophageal Cancer Screening

MedlinePlus

... decrease the risk of dying from cancer. Scientists study screening tests to find those with the fewest risks and ... stage . There is no standard or routine screening test for esophageal cancer. Screening for esophageal cancer is under study with screening clinical trials taking place in many ...

Template-Directed Ligation of Peptides to Oligonucleotides

NASA Technical Reports Server (NTRS)

Bruick, Richard K.; Dawson, Philip E.; Kent, Stephen BH; Usman, Nassim; Joyce, Gerald F.

1996-01-01

Synthetic oligonucleotides and peptides have enjoyed a wide range of applications in both biology and chemistry. As a consequence, oligonucleotide-peptide conjugates have received considerable attention, most notably in the development of antisense constructs with improved pharmacological properties. In addition, oligonucleotide-peptide conjugates have been used as molecular tags, in the assembly of supramolecular arrays and in the construction of encoded combinatorial libraries. To make these chimeric molecules more accessible for a broad range of investigations, we sought to develop a facile method for joining fully deprotected oligonucleotides and peptides through a stable amide bond linkage. Furthermore, we wished to make this ligation reaction addressable, enabling one to direct the ligation of specific oligonucleotide and peptide components.To confer specificity and accelerate the rate of the reaction, the ligation process was designed to be dependent on the presence of a complementary oligonucleotide template.

Successful bypass operation for esophageal obstruction after acute esophageal necrosis: a case report.

PubMed

Sakatoku, Yayoi; Fukaya, Masahide; Miyata, Kazushi; Nagino, Masato

2017-12-01

Acute esophageal necrosis (AEN) is a rare clinical disorder. Esophageal stenosis or obstruction is one of severe complications, but there are a few reports about surgical treatments. In such a situation, it still remains controversial which to choose, esophagectomy or bypass operation. A 61-year-old woman was admitted to the local hospital for septic shock with diabetic ketoacidosis due to necrotizing fasciitis of the right thigh. Three days later, she had hematemesis, and gastrointestinal endoscopy revealed black mucosal coloration throughout the entire esophagus. She was diagnosed as having AEN. Her general condition improved after intensive care, debridement, and treatment with antibiotics and a proton pump inhibitor; the esophageal mucosal color recovered. However, an esophageal stricture developed after 1 month, and the patient underwent gastrostomy to remove an esophageal obstruction after 3 months. She was referred to our hospital for surgical treatment 1 year and 4 months after the occurrence of AEN because of her strong desire for oral intake. Her medical condition was poor, and she could not walk due to generalized muscle weakness. After rehabilitation for 8 months, we performed an esophageal bypass using a gastric conduit via the percutaneous route rather than esophagectomy because of her multiple severe comorbidities including walking difficulty, chronic hepatitis C, cerebrovascular disease, and chronic renal failure. Minor leakage of the esophagogastrostomy occurred and was resolved with conservative treatment. The patient began oral intake on postoperative day 34 and was discharged on day 52. Esophageal obstruction after AEN was successfully treated by esophageal bypass using a gastric conduit in a high-risk patient. Because the majority of patients with AEN have multiple severe comorbidities, assessing the medical condition of the patient adequately is important prior to choosing either an esophagectomy or bypass surgery.

Assessment and protection of esophageal mucosal integrity in patients with heartburn without esophagitis.

PubMed

Woodland, Philip; Lee, Chung; Duraisamy, Yasotha; Duraysami, Yasotha; Farré, Ricard; Dettmar, Peter; Sifrim, Daniel

2013-04-01

Intact esophageal mucosal integrity is essential to prevent symptoms during gastroesophageal reflux events. Approximately 70% of patients with heartburn have macroscopically normal esophageal mucosa. In patients with heartburn, persistent functional impairment of esophageal mucosal barrier integrity may underlie remaining symptoms. Topical protection of a functionally vulnerable mucosa may be an attractive therapeutic strategy. We aimed to evaluate esophageal mucosal functional integrity in patients with heartburn without esophagitis, and test the feasibility of an alginate-based topical mucosal protection. Three distal esophageal biopsies were obtained from 22 patients with heartburn symptoms, and 22 control subjects. In mini-Ussing chambers, the change in transepithelial electrical resistance (TER) of biopsies when exposed to neutral, weakly acidic, and acidic solutions was measured. The experiment was repeated in a further 10 patients after pretreatment of biopsies with sodium alginate, viscous control, or liquid control "protectant" solutions. Biopsy exposure to neutral solution caused no change in TER. Exposure to weakly acidic and acidic solutions caused a greater reduction in TER in patients than in controls (weakly acid -7.2% (95% confidence interval (CI) -9.9 to -4.5) vs. 3.2% (-2.2 to 8.6), P<0.05; acidic -22.8% (-31.4 to 14.1) vs. -9.4% (-17.2 to -1.6), P<0.01). Topical pretreatment with alginate but not with control solutions prevented the acid-induced decrease in TER (-1% (-5.9 to 3.9) vs. -13.5 (-24.1 to -3.0) vs. -13.2 (-21.7 to -4.8), P<0.05). Esophageal mucosa in patients with heartburn without esophagitis shows distinct vulnerability to acid and weakly acidic exposures. Experiments in vitro suggest that such vulnerable mucosa may be protected by application of an alginate-containing topical solution.