Management of Gastric and Ectopic Varices: The Endoscopist's Perspective

Abstract

Gastric and Ectopic varices are a rare complication of portal hypertension and represent a complex, heterogeneous system of vascular shunts. Bleeding from these shunts can be severe and life-threatening, with poorly standardized treatment algorithms to follow in their management. When bleeding occurs, it is important to follow standard diagnostic procedures for portal hypertensive bleeding and always obtain imaging of the underlying vascular anatomy to help guide therapy. Potential treatment methods will depend on these imaging findings as well as the location of the varix within the gastrointestinal tract. While gastric varices have more data to support specific treatment options, duodenal and rectal varices have only case reports and case series to guide their care. In addition, stomal varices are a very rare complication of portal hypertension and have limited data to support any one treatment modality. Gastric and ectopic varices are best approached in a multidisciplinary fashion after discussion with hepatologists and interventional radiologists to overcome the uncertainty in choosing a definitive therapy.

Keywords

gastric varices - ectopic varices - rectal varices - duodenal varices - stomal varices - endoscopic cyanoacrylate injection - endoscopic band ligation - transjugular intrahepatic portosystemic shunt - balloon-occluded retrograde transvenous obliteration

• References

• 1 Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16 (06) 1343-1349
• 2 Henry ZH. Treatment of gastro-fundal varices (including a discussion of BRTO). Curr Hepatol Rep 2018; 17 (03) 184-192
• 3 Kim T, Shijo H, Kokawa H. , et al. Risk factors for hemorrhage from gastric fundal varices. Hepatology 1997; 25 (02) 307-312
• 4 Orr DW, Harrison PM, Devlin J. , et al. Chronic mesenteric venous thrombosis: evaluation and determinants of survival during long-term follow-up. Clin Gastroenterol Hepatol 2007; 5 (01) 80-86
• 5 Spaander VM, van Buuren HR, Janssen HL. Review article: the management of non-cirrhotic non-malignant portal vein thrombosis and concurrent portal hypertension in adults. Aliment Pharmacol Ther 2007; 26 (Suppl. 02) 203-209
• 6 Spaander MC, Darwish Murad S, van Buuren HR, Hansen BE, Kuipers EJ, Janssen HL. Endoscopic treatment of esophagogastric variceal bleeding in patients with noncirrhotic extrahepatic portal vein thrombosis: a long-term follow-up study. Gastrointest Endosc 2008; 67 (06) 821-827
• 7 Trudeau W, Prindiville T. Endoscopic injection sclerosis in bleeding gastric varices. Gastrointest Endosc 1986; 32 (04) 264-268
• 8 Ryan BM, Stockbrugger RW, Ryan JM. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices. Gastroenterology 2004; 126 (04) 1175-1189
• 9 Pagliaro L, D'Amico G, Pasta L. , et al. Portal hypertension in cirrhosis: natural history. In: Bosch J, Groszmann RJ. , eds. Portal Hypertension: Pathophysiology and Treatment. Oxford, UK: Blackwell Scientific; 1994: 72-92
• 10 Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc 2007; 65 (01) 82-88
• 11 Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology 1998; 28 (04) 1154-1158
• 12 Henry Z, Uppal D, Saad W, Caldwell S. Gastric and ectopic varices. Clin Liver Dis 2014; 18 (02) 371-388
• 13 Helmy A, Al Kahtani K, Al Fadda M. Updates in the pathogenesis, diagnosis and management of ectopic varices. Hepatol Int 2008; 2 (03) 322-334
• 14 Kinkhabwala M, Mousavi A, Iyer S, Adamsons R. Bleeding ileal varicosity demonstrated by transhepatic portography. AJR Am J Roentgenol 1977; 129 (03) 514-516
• 15 Stephan G, Miething R. X-ray diagnosis of varicose duodenal changes in poratal hypertension [in German]. Radiologe 1968; 8 (03) 90-95
• 16 Ganguly S, Sarin SK, Bhatia V, Lahoti D. The prevalence and spectrum of colonic lesions in patients with cirrhotic and noncirrhotic portal hypertension. Hepatology 1995; 21 (05) 1226-1231
• 17 Chawla Y, Dilawari JB. Anorectal varices--their frequency in cirrhotic and non-cirrhotic portal hypertension. Gut 1991; 32 (03) 309-311
• 18 Misra SP, Dwivedi M, Misra V, Dharmani S, Kunwar BK, Arora JS. Colonic changes in patients with cirrhosis and in patients with extrahepatic portal vein obstruction. Endoscopy 2005; 37 (05) 454-459
• 19 McCormack TT, Bailey HR, Simms JM, Johnson AG. Rectal varices are not piles. Br J Surg 1984; 71 (02) 163
• 20 Shudo R, Yazaki Y, Sakurai S, Uenishi H, Yamada H, Sugawara K. Clinical study comparing bleeding and nonbleeding rectal varices. Endoscopy 2002; 34 (03) 189-194
• 21 Wilson SE, Stone RT, Christie JP, Passaro Jr E. Massive lower gastrointestinal bleeding from intestinal varices. Arch Surg 1979; 114 (10) 1158-1161
• 22 Saad WE, Lippert A, Saad NE, Caldwell S. Ectopic varices: anatomical classification, hemodynamic classification, and hemodynamic-based management. Tech Vasc Interv Radiol 2013; 16 (02) 158-175
• 23 Hashizume M, Tanoue K, Ohta M. , et al. Vascular anatomy of duodenal varices: angiographic and histopathological assessments. Am J Gastroenterol 1993; 88 (11) 1942-1945
• 24 Lebrec D, Benhamou JP. Ectopic varices in portal hypertension. Clin Gastroenterol 1985; 14 (01) 105-121
• 25 Itzchak Y, Glickman MG. Splenic vein thrombosis in patients with a normal size spleen. Invest Radiol 1977; 12 (02) 158-163
• 26 Adson MA, Fulton RE. The ileal stoma and protal hypertension: an uncommon site of variceal bleeding. Arch Surg 1977; 112 (04) 501-504
• 27 Fucini C, Wolff BG, Dozois RR. Bleeding from peristomal varices: perspectives on prevention and treatment. Dis Colon Rectum 1991; 34 (12) 1073-1078
• 28 Wiesner RH, LaRusso NF, Dozois RR, Beaver SJ. Peristomal varices after proctocolectomy in patients with primary sclerosing cholangitis. Gastroenterology 1986; 90 (02) 316-322
• 29 Spier BJ, Fayyad AA, Lucey MR. , et al. Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 2008; 6 (03) 346-352
• 30 Sarin SK, Kumar A. Gastric varices: profile, classification, and management. Am J Gastroenterol 1989; 84 (10) 1244-1249
• 31 Hashizume M, Kitano S, Yamaga H, Koyanagi N, Sugimachi K. Endoscopic classification of gastric varices. Gastrointest Endosc 1990; 36 (03) 276-280
• 32 North-Italian Endoscopic Club for the Study and Treatment of Esophageal Varices . Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. N Engl J Med 1988; 319: 983-989
• 33 Saad WE, Saad NE, Koizumi J. Stomal varices: management with decompression tips and transvenous obliteration or sclerosis. Tech Vasc Interv Radiol 2013; 16 (02) 176-184
• 34 Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017; 65 (01) 310-335
• 35 de Franchis R. ; Baveno VI Faculty. Expanding consensus in portal hypertension: report of the Baveno VI Consensus Workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752
• 36 European Association for the Study of the Liver. Electronic address. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69 (02) 406-460
• 37 Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F. , et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review. Aliment Pharmacol Ther 2011; 34 (05) 509-518
• 38 Villanueva C, Colomo A, Bosch A. , et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 2013; 368 (01) 11-21
• 39 Wells M, Chande N, Adams P. , et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35 (11) 1267-1278
• 40 Sarin SK. Long-term follow-up of gastric variceal sclerotherapy: an eleven-year experience. Gastrointest Endosc 1997; 46 (01) 8-14
• 41 Tan PC, Hou MC, Lin HC. , et al. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation. Hepatology 2006; 43 (04) 690-697
• 42 Lo GH, Lai KH, Cheng JS, Chen MH, Chiang HT. A prospective, randomized trial of butyl cyanoacrylate injection versus band ligation in the management of bleeding gastric varices. Hepatology 2001; 33 (05) 1060-1064
• 43 Arantes V, Albuquerque W. Fundal variceal hemorrhage treated by endoscopic clip. Gastrointest Endosc 2005; 61 (06) 732
• 44 Holster IL, Poley JW, Kuipers EJ, Tjwa ET. Controlling gastric variceal bleeding with endoscopically applied hemostatic powder (Hemospray™). J Hepatol 2012; 57 (06) 1397-1398
• 45 Heneghan MA, Byrne A, Harrison PM. An open pilot study of the effects of a human fibrin glue for endoscopic treatment of patients with acute bleeding from gastric varices. Gastrointest Endosc 2002; 56 (03) 422-426
• 46 Yang WL, Tripathi D, Therapondos G, Todd A, Hayes PC. Endoscopic use of human thrombin in bleeding gastric varices. Am J Gastroenterol 2002; 97 (06) 1381-1385
• 47 Panés J, Terés J, Bosch J, Rodés J. Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices. Results in 151 consecutive episodes. Dig Dis Sci 1988; 33 (04) 454-459
• 48 Ortiz AM, Garcia CJ, Othman MO, Zuckerman MJ. Innovative technique for endoscopic placement of sengstaken-blakemore tube. South Med J 2018; 111 (05) 307-311
• 49 Saad WE. Vascular anatomy and the morphologic and hemodynamic classifications of gastric varices and spontaneous portosystemic shunts relevant to the BRTO procedure. Tech Vasc Interv Radiol 2013; 16 (02) 60-100
• 50 Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices. Part 1. Anatomic classification. Radiographics 2003; 23 (04) 911-920
• 51 Kang EJ, Jeong SW, Jang JY. , et al. Long-term result of endoscopic Histoacryl (N-butyl-2-cyanoacrylate) injection for treatment of gastric varices. World J Gastroenterol 2011; 17 (11) 1494-1500
• 52 Caldwell SH, Hespenheide EE, Greenwald BD, Northup PG, Patrie JT. Enbucrilate for gastric varices: extended experience in 92 patients. Aliment Pharmacol Ther 2007; 26 (01) 49-59
• 53 Rajoriya N, Forrest EH, Gray J. , et al. Long-term follow-up of endoscopic Histoacryl glue injection for the management of gastric variceal bleeding. QJM 2011; 104 (01) 41-47
• 54 Soehendra N, Nam VC, Grimm H, Kempeneers I. Endoscopic obliteration of large esophagogastric varices with bucrylate. Endoscopy 1986; 18 (01) 25-26
• 55 Ríos Castellanos E, Seron P, Gisbert JP, Bonfill Cosp X. Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. Cochrane Database Syst Rev 2015; (05) CD010180
• 56 Rengstorff DS, Binmoeller KF. A pilot study of 2-octyl cyanoacrylate injection for treatment of gastric fundal varices in humans. Gastrointest Endosc 2004; 59 (04) 553-558
• 57 Caldwell S. Gastric varices: is there a role for endoscopic cyanoacrylates, or are we entering the BRTO era?. Am J Gastroenterol 2012; 107 (12) 1784-1790
• 58 Cheng LF, Wang ZQ, Li CZ, Lin W, Yeo AE, Jin B. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol 2010; 8 (09) 760-766
• 59 Lee YT, Chan FK, Ng EK. , et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc 2000; 52 (02) 168-174
• 60 Binmoeller KF, Weilert F, Shah JN, Kim J. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74 (05) 1019-1025
• 61 Bhat YM, Weilert F, Fredrick RT. , et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 2016; 83 (06) 1164-1172
• 62 Watanabe K, Kimura K, Matsutani S, Ohto M, Okuda K. Portal hemodynamics in patients with gastric varices. A study in 230 patients with esophageal and/or gastric varices using portal vein catheterization. Gastroenterology 1988; 95 (02) 434-440
• 63 Sanyal AJ, Freedman AM, Luketic VA. , et al. The natural history of portal hypertension after transjugular intrahepatic portosystemic shunts. Gastroenterology 1997; 112 (03) 889-898
• 64 Tripathi D, Therapondos G, Jackson E, Redhead DN, Hayes PC. The role of the transjugular intrahepatic portosystemic stent shunt (TIPSS) in the management of bleeding gastric varices: clinical and haemodynamic correlations. Gut 2002; 51 (02) 270-274
• 65 Kanagawa H, Mima S, Kouyama H, Gotoh K, Uchida T, Okuda K. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996; 11 (01) 51-58
• 66 Kim DJ, Darcy MD, Mani NB. , et al. Modified balloon-occluded retrograde transvenous obliteration (BRTO) techniques for the treatment of gastric varices: vascular plug-assisted retrograde transvenous obliteration (PARTO)/coil-assisted retrograde transvenous obliteration (CARTO)/balloon-occluded antegrade transvenous obliteration (BATO). Cardiovasc Intervent Radiol 2018; 41 (06) 835-847
• 67 LaBerge JM, Ring EJ, Gordon RL. , et al. Creation of transjugular intrahepatic portosystemic shunts with the wallstent endoprosthesis: results in 100 patients. Radiology 1993; 187 (02) 413-420
• 68 Rössle M, Haag K, Ochs A. , et al. The transjugular intrahepatic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994; 330 (03) 165-171
• 69 Saad WE, Kitanosono T, Koizumi J. Balloon-occluded antegrade transvenous obliteration with or without balloon-occluded retrograde transvenous obliteration for the management of gastric varices: concept and technical applications. Tech Vasc Interv Radiol 2012; 15 (03) 203-225
• 70 Lo GH, Liang HL, Chen WC. , et al. A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding. Endoscopy 2007; 39 (08) 679-685
• 71 Procaccini NJ, Al-Osaimi AM, Northup P, Argo C, Caldwell SH. Endoscopic cyanoacrylate versus transjugular intrahepatic portosystemic shunt for gastric variceal bleeding: a single-center U.S. analysis. Gastrointest Endosc 2009; 70 (05) 881-887
• 72 Saad WE, Darcy MD. Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the management of gastric varices. Semin Intervent Radiol 2011; 28 (03) 339-349
• 73 Sabri SS, Swee W, Turba UC. , et al. Bleeding gastric varices obliteration with balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam. J Vasc Interv Radiol 2011; 22 (03) 309-316 , quiz 316
• 74 Imai Y, Nakazawa M, Ando S, Sugawara K, Mochida S. Long-term outcome of 154 patients receiving balloon-occluded retrograde transvenous obliteration for gastric fundal varices. J Gastroenterol Hepatol 2016; 31 (11) 1844-1850
• 75 Park JK, Saab S, Kee ST. , et al. Balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices: review and meta-analysis. Dig Dis Sci 2015; 60 (06) 1543-1553
• 76 Choi YS, Lee JH, Sinn DH. , et al. Effect of balloon-occluded retrograde transvenous obliteration on the natural history of coexisting esophageal varices. J Clin Gastroenterol 2008; 42 (09) 974-979
• 77 Tanihata H, Minamiguchi H, Sato M. , et al. Changes in portal systemic pressure gradient after balloon-occluded retrograde transvenous obliteration of gastric varices and aggravation of esophageal varices. Cardiovasc Intervent Radiol 2009; 32 (06) 1209-1216
• 78 Ibukuro K, Sugihara T, Tanaka R. , et al. Balloon-occluded retrograde transvenous obliteration (BRTO) for a direct shunt between the inferior mesenteric vein and the inferior vena cava in a patient with hepatic encephalopathy. J Vasc Interv Radiol 2007; 18 (1 Pt 1): 121-125
• 79 Mukund A, Rajesh S, Arora A, Patidar Y, Jain D, Sarin SK. Efficacy of balloon-occluded retrograde transvenous obliteration of large spontaneous lienorenal shunt in patients with severe recurrent hepatic encephalopathy with foam sclerotherapy: initial experience. J Vasc Interv Radiol 2012; 23 (09) 1200-1206
• 80 Ishikawa T, Sasaki R, Nishimura T. , et al. Comparison of patients with hepatic encephalopathy and those with gastric varices before and after balloon-occluded retrograde transvenous obliteration. Hepatol Res 2018; 48 (12) 1020-1030
• 81 Saad WE, Wagner CC, Al-Osaimi A. , et al. The effect of balloon-occluded transvenous obliteration of gastric varices and gastrorenal shunts on the hepatic synthetic function: a comparison between Child-Pugh and model for end-stage liver disease scores. Vasc Endovascular Surg 2013; 47 (04) 281-287
• 82 Gimm G, Chang Y, Kim HC. , et al. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for the management of gastric variceal bleeding. Gut Liver 2018; 12 (06) 704-713
• 83 Hong CH, Kim HJ, Park JH. , et al. Treatment of patients with gastric variceal hemorrhage: endoscopic N-butyl-2-cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 2009; 24 (03) 372-378
• 84 Wang YB, Zhang JY, Gong JP, Zhang F, Zhao Y. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for treatment of gastric varices due to portal hypertension: a meta-analysis. J Gastroenterol Hepatol 2016; 31 (04) 727-733
• 85 Coelho-Prabhu N, Baron TH, Kamath PS. Endoscopic band ligation of rectal varices: a case series. Endoscopy 2010; 42 (02) 173-176
• 86 Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Suga T. The value of the endoscopic therapies in the treatment of rectal varices: a retrospective comparison between injection sclerotherapy and band ligation. Hepatol Res 2006; 34 (04) 250-255
• 87 Yamanaka T, Shiraki K, Ito T. , et al. Endoscopic sclerotherapy (ethanolamine oleate injection) for acute rectal varices bleeding in a patient with liver cirrhosis. Hepatogastroenterology 2002; 49 (46) 941-943
• 88 Chen WC, Hou MC, Lin HC, Chang FY, Lee SD. An endoscopic injection with N-butyl-2-cyanoacrylate used for colonic variceal bleeding: a case report and review of the literature. Am J Gastroenterol 2000; 95 (02) 540-542
• 89 Ryu SH, Moon JS, Kim I, Kim YS, Lee JH. Endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate in a patient with massive rectal variceal bleeding: a case report. Gastrointest Endosc 2005; 62 (04) 632-635
• 90 Sharma M, Somasundaram A. Massive lower GI bleed from an endoscopically inevident rectal varices: diagnosis and management by EUS (with videos). Gastrointest Endosc 2010; 72 (05) 1106-1108
• 91 Connor EK, Duran-Castro OL, Attam R. Therapy for recurrent bleeding from rectal varices by EUS-guided sclerosis. Gastrointest Endosc 2015; 81 (05) 1280-1281
• 92 Mukkada RJ, Mathew PG, Francis Jose V, Paul Chettupuzha A, Antony R, Koshy A. EUS-guided coiling of rectal varices. VideoGIE 2017; 2 (08) 208-210
• 93 Kochar N, Tripathi D, McAvoy NC, Ireland H, Redhead DN, Hayes PC. Bleeding ectopic varices in cirrhosis: the role of transjugular intrahepatic portosystemic stent shunts. Aliment Pharmacol Ther 2008; 28 (03) 294-303
• 94 Vangeli M, Patch D, Terreni N. , et al. Bleeding ectopic varices--treatment with transjugular intrahepatic porto-systemic shunt (TIPS) and embolisation. J Hepatol 2004; 41 (04) 560-566
• 95 Shibata D, Brophy DP, Gordon FD, Anastopoulos HT, Sentovich SM, Bleday R. Transjugular intrahepatic portosystemic shunt for treatment of bleeding ectopic varices with portal hypertension. Dis Colon Rectum 1999; 42 (12) 1581-1585
• 96 Nayar M, Saravanan R, Rowlands PC. , et al. TIPSS in the treatment of ectopic variceal bleeding. Hepatogastroenterology 2006; 53 (70) 584-587
• 97 Sugano S, Nishio M, Makino H, Suzuki T. Relationship of portal pressure and colorectal vasculopathy in patients with cirrhosis. Dig Dis Sci 1999; 44 (01) 149-154
• 98 Anan A, Irie M, Watanabe H. , et al. Colonic varices treated by balloon-occluded retrograde transvenous obliteration in a cirrhotic patient with encephalopathy: a case report. Gastrointest Endosc 2006; 63 (06) 880-884
• 99 Abdel-Aal AK, Dawoud N, Moustafa AS, Hamed MF, Saddekni S. Percutaneous transhepatic embolization of bleeding rectal varices using a new embolic and sclerotic mixture augmented by Amplatzer vascular plug 2. J Radiol Case Rep 2016; 10 (09) 44-51
• 100 Hashimoto N, Akahoshi T, Kamori M. , et al. Treatment of bleeding rectal varices with transumbilical venous obliteration of the inferior mesenteric vein. Surg Laparosc Endosc Percutan Tech 2013; 23 (03) e134-e137
• 101 Yoshida Y, Imai Y, Nishikawa M. , et al. Successful endoscopic injection sclerotherapy with N-butyl-2-cyanoacrylate following the recurrence of bleeding soon after endoscopic ligation for ruptured duodenal varices. Am J Gastroenterol 1997; 92 (07) 1227-1229
• 102 Shiraishi M, Hiroyasu S, Higa T, Oshiro S, Muto Y. Successful management of ruptured duodenal varices by means of endoscopic variceal ligation: report of a case. Gastrointest Endosc 1999; 49 (02) 255-257
• 103 Seo YS, Kwon YD, Park S. , et al. Complete eradication of duodenal varices after endoscopic injection sclerotherapy with ethanolamine oleate: a case report. Gastrointest Endosc 2008; 67 (04) 759-762
• 104 Liu Y, Yang J, Wang J. , et al. Clinical characteristics and endoscopic treatment with cyanoacrylate injection in patients with duodenal varices. Scand J Gastroenterol 2009; 44 (08) 1012-1016
• 105 Rai R, Panzer SW, Miskovsky E, Thuluvath PJ. Thrombin injection for bleeding duodenal varices. Am J Gastroenterol 1994; 89 (10) 1871-1873
• 106 Kinzel J, Pichetshote N, Dredar S, Aslanian H, Nagar A. Bleeding from a duodenal varix: a unique case of variceal hemostasis achieved using EUS-guided placement of an embolization coil and cyanoacrylate. J Clin Gastroenterol 2014; 48 (04) 362-364
• 107 Kimura G, Hashimoto Y, Ikeda M. Successful obliteration of bleeding duodenal varices by EUS-guided injection of N-butyl-2-cyanoacrylate. VideoGIE 2017; 2 (11) 317-319
• 108 Illuminati G, Smail A, Azoulay D, Castaing D, Bismuth H. Association of transjugular intrahepatic portosystemic shunt with embolization in the treatment of bleeding duodenal varix refractory to sclerotherapy. Dig Surg 2000; 17 (04) 398-400
• 109 Almeida JR, Trevisan L, Guerrazzi F. , et al. Bleeding duodenal varices successfully treated with TIPS. Dig Dis Sci 2006; 51 (10) 1738-1741
• 110 Saad WE, Lippert A, Schwaner S, Al-Osaimi A, Sabri S, Saad N. Management of bleeding duodenal varices with combined TIPS decompression and trans-TIPS transvenous obliteration utilizing 3% sodium tetradecyl sulfate foam sclerosis. J Clin Imaging Sci 2014; 4: 67
• 111 Ohta M, Yasumori K, Saku M, Saitsu H, Muranaka T, Yoshida K. Successful treatment of bleeding duodenal varices by balloon-occluded retrograde transvenous obliteration: a transjugular venous approach. Surgery 1999; 126 (03) 581-583
• 112 Zamora CA, Sugimoto K, Tsurusaki M. , et al. Endovascular obliteration of bleeding duodenal varices in patients with liver cirrhosis. Eur Radiol 2006; 16 (01) 73-79
• 113 Haruta I, Isobe Y, Ueno E. , et al. Balloon-occluded retrograde transvenous obliteration (BRTO), a promising nonsurgical therapy for ectopic varices: a case report of successful treatment of duodenal varices by BRTO. Am J Gastroenterol 1996; 91 (12) 2594-2597
• 114 Copelan A, Chehab M, Dixit P, Cappell MS. Safety and efficacy of angiographic occlusion of duodenal varices as an alternative to TIPS: review of 32 cases. Ann Hepatol 2015; 14 (03) 369-379
• 115 Tsynman DN, DeCross AJ, Maliakkal B, Ciufo N, Ullah A, Kaul V. Novel use of EUS to successfully treat bleeding parastomal varices with N-butyl-2-cyanoacrylate. Gastrointest Endosc 2014; 79 (06) 1007-1008 , discussion 1008
• 116 Thouveny F, Aubé C, Konaté A, Lebigot J, Bouvier A, Oberti F. Direct percutaneous approach for endoluminal glue embolization of stomal varices. J Vasc Interv Radiol 2008; 19 (05) 774-777
• 117 Chong VH, Tan KK, Sharif F. Successful treatment of parastomal varices bleeding with percutaneous N-butyl-2-cyanoacrylate glue injection. Surg Laparosc Endosc Percutan Tech 2008; 18 (05) 520-522
• 118 Deipolyi AR, Kalva SP, Oklu R, Walker TG, Wicky S, Ganguli S. Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices. AJR Am J Roentgenol 2014; 203 (03) 668-673
• 119 Minami S, Okada K, Matsuo M, Kamohara Y, Sakamoto I, Kanematsu T. Treatment of bleeding stomal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol 2007; 42 (01) 91-95
• 120 Teo TK, Sabri SS, Turba UC, Saad WE, Angle JF. Obliteration of bleeding peristomal varices with balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam. J Vasc Interv Radiol 2011; 22 (07) 1049-1051
• 121 Mishra SR, Sharma BC, Kumar A, Sarin SK. Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: a randomized controlled trial. J Hepatol 2011; 54 (06) 1161-1167
• 122 Mishra SR, Chander Sharma B, Kumar A, Sarin SK. Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial. Gut 2010; 59 (06) 729-735
• 123 Chen WC, Hsin IF, Chen PH. , et al. Addition of carvedilol to gastric variceal obturation does not decrease recurrence of gastric variceal bleeding in patients with cirrhosis. Clin Gastroenterol Hepatol 2019; 17 (11) 2356-2363.e2