Esophageal varices managment� the role of interventional radiology

Dr Rabaa Alghalayini

Gastroenterology resident at Ibn alnafees hospital

Welcome!!

Introduction :

50%

Of patients with cirrhosis have EV

25%

May bleed

25%

The mortality rate

Detection of Esophageal varices

Upper gastrointestinal endoscopy

is the gold standard for diagnosing the presence of varices

Pre-primary and primary prophylaxis for (EV)�

No EV

Small EV

Without red sign

Child A

Small EV

With red sign

Child B, C

Cause treatment

Monitoring endoscopy every 2-3 y

No need for NSBB

Cause treatment

Monitoring endoscopy every 1-2y

+ - NSBB

​

NSBB

Monitoring endoscopy

Medium to large EV

NSBB

or

EVL with monitoring endoscopy

To do endoscopy or not to do.. It’s a challenge !

The Baveno VI criteria

Combines transient elastography TE and platelet count

Liver stiffness as measured bytransient elastography (TE)

considering the well-established relationship between fibrosis, portal hypertension, and EV

Artificial

Intelligence !

Machine learning model.

Non Invasive diagnosis of esophageal�varices in liver cirrhosis

proposed that patients with liver cirrhosis with a lower liver stiffness measurement (LSM) (< 20 kPa) and a higher platelet count (> 150,000/μl) can avoid unnecessary endoscopy for the surveillance of VNT

the LSM (< 25 kPa) and platelet count value (> 110,000/μl)

Baveno VI guidelines

expanded Baveno VI criteria

sensitivity for high-risk varices was 97%, specificity was low 41%

sensitivity and specificity of the Expanded Baveno VI criteria for high-risk varices was 90% and 51%,

• Performance of Baveno VI and Expanded Baveno VI Criteria for Excluding High-Risk Varices in Patients With Chronic Liver Diseases: A Systematic Review and Meta-analysis

Algorithm for the management of acute EV bleeding

Endoscopic therapies

EIS

endoscopic injection sclerotherapy

By using a standard endoscope with a 6-cm oral side and a 23- or 25-gauge injection. Under fluoroscopic guidance, intravariceal injections of 5% ethanolamine oleate (EO) were administered that filled the varices and the supplying vessels. The injections were repeated for multiple varices until the maximum amount of EO (0.4 mL/kg) was injected Usually, sclerotherapy alone was performed weekly until the injectable varices had almost disappeared, then band ligation was undertaken at the injection sites during the final EIS session.

EVL

Esophageal varices ligament

using a standard endoscope attached to a pneumoactivat-ed EVL device, which was introduced along a flexible overtube. The varices were ligated sequentially from the most distallesion EVL was repeated weekly until the varices were completely eradicated; this usually requi-red two or three sessions.

Doppler endoscopic probe

• Its ability to evaluate blood flow and anatomy of perforating veins can assist in monitoring treatment and predicting recurrence
• The DEP is a disposable probe which can be inserted into the working channel of the gastroscope

​

• Review. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes

Is it the end ? What's about re-bleeding?

interventional radiology (IVR) therapies

IVR procedures for EVs uncontrollable by endoscopic treatment (ET) alone include two methods: embolization of the collateral vessels and varices, such as via percutaneous transhepatic obliteration (PTO) , and decompression of the portal venous pressure, such as via partial splenic embolization (PSE) and transjugular intrahepatic portosystemic shunt .

partial splenic embolization (PSE)

• A novel therapeutic strategy for esophageal varices using endoscopic treatment combined with splenic artery embolization according to the Child-Pugh classification

PSE reduced the hepatic venous pressure gradient and markedly lowered the ChildPugh score.

PSE is recommended for these high-risk patients with splenomegaly when platelet counts of < 50000/μL persist in three consecutive blood samples.

percutaneous transhepatic obliteration (PTO)

(A) Percutaneus transhepatic portography shows from the left gastric vein to the collateral veins including paraesophageal vein, which caused esophageal varices hemorrhage. (B) The feeding veins were embolized with microcoils and a sclerosing agent. (C) Percutaneous transhepatic portography after treatment showing that the varix and its feeder were embolized.

A Case Report / The First Transileocolic Obliteration for Refractory Esophageal Varices.

• a transileocolic approach is indicated for cases in which percutaneous transhepatic operation is impossible/difficult due to severe liver atrophy, ascites, and tumorous lesions in the liver.
• A 34-year-old who achieved eradication of hepatitis
• C virus previously, come wiith liver cirrhosis and F2 esophageal varices, EVL was performed twice were repeated for recurrence of esophageal varices ,EIS was performed ,too.
• abdominal CT showed not only submucosal venous dilation but also traffic with dilated paraesophageal veins through penetrating blood vessels.

transileocolic obliteration (TIO)

transileocolic obliteration (TIO)

(A, B) Dynamic contrast-enhanced computed tomography (CT) showing a large paraesophageal vein (arrows). (C, D) Follow-up CT after 12 months showing the diminished paraesophageal vein.

transileocolic obliteration (TIO)

(A) Catheterization of the ileocolic vein through the catheter introducer under laparotomy.

(B) Portography showing a large paraesophageal vein before embolization. (C) Portography showing an improved portal vein blood flow in the left lobe of the liver after embolization.

transileocolic obliteration (TIO)

(A) Esophagogastroduodenoscopy showing esophageal varices before the transileocolic obliteration (TIO) procedure. (B) Esophagogastroduodenoscopy six months after TIO showing the shrunken esophageal varices.

Transjugular intrahepatic portosystemic shunt (TIPS)

CONCLUSION

ET is the first therapeutic line for patients with EVs; however, for those with refractory diseases that are resistant to ET, broad knowledge and advanced technology with alternative treatment options, namely IVR therapies, may lead not only to prevention of variceal hemorrhaging but also improvement in the hepatic function and prognosis.

Thank you