Endoscopy clips for treatment of complicated gastric and esophageal varices in patients with cirrhosis

We describe the feasibility and outcomes of endoclipping in the treatment of complicated variceal bleeding (four gastric and two esophageal) in six cirrhotic patients (mean age 62.33, range 36 – 82), by performing a mechanical closure of the variceal wall rupture. In all patients, previous endoscopic treatments had been performed in other centers and failure to control bleeding was observed in accordance with BAVENO V definitions and criteria [1]. Hemodynamic stabilization was performed, and intravenous treatments with fresh frozen plasma, vitamin K at 30 mg/d, octreotide (bolus of 50 µg followed by 25 µg/h), albumin, antibiotic, and proton pump inhibitor (40 mg/d) were administered. After approval by the ethics committee of our institution and completion of written informed consents, the procedures were carried out using a standard endoscope (EG-2990i HD, Pentax, Japan) and endoclips (EZ-clip Olympus, Japan) ([Fig. 1]; [Video 1] and [Video 2]). The technique was successful in all cases and no acute complication or rebleeding was observed in the follow-up period (mean 15 months). The patients were discharged from the critical care unit after 24 hours, and discharged from hospital 72 hours later.

Fig. 1 a Endoscopic view of the gastric varice with disrupted wall. b, c Placement of clips to close the disrupted wall. d Control endoscopy 4 months after the treatment.

Placement of endoclips to close the disrupted wall of a gastric varix.

Placement of endoclips to close the disrupted wall of an esophageal varix.

Endoscopic treatments for variceal bleeding are band ligation (esophageal) and cyanoacrylate injection (gastric fundal varices). However, in cases of variceal wall rupture, it could be difficult to apply these treatments.

Endoclips are used in the treatment of nonvariceal gastrointestinal bleeding [2]. They offer a mechanical closure of the disrupted wall and achieve hemostasis by compression. There is one study comparing this treatment with band ligation in esophageal varices, and demonstrating its effectiveness [3]. In addition, there is one case report of successful endoclip placement in a gastric fundal varix in a patient with portal hypertension as a result of schistosomiasis [4]. Application of endoclips was feasible and safe in our series, and it could be a viable alternative for these cases.

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Competing interests: None

• References

• 1 De Franchis R. Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53: 762-768
• 2 Conway JD, Adler DJ, Diehl DL et al. Endoscopic hemostatic devices: technology report. Gastrointest Endosc 2009; 69: 987-996
• 3 Yol S, Belviranli M, Toprak S et al. Endoscopic clipping versus band ligation in the management of bleeding esophageal varices. Surg Endosc 2003; 17: 38-42
• 4 Arantes V, Albuquerque W. Fundal variceal hemorrhage treated by endoscopy clips. Gastrointest Endosc 2005; 61: 732