PREDICTORS OF MORTALITY WITHIN 8 WEEKS AFTER ENDOSCOPIC TREATMENT OF GASTRIC VARICEAL BLEED WITH N-BUTYL 2-CYANOACRYLATE IN CIRRHOTIC PATIENTS

Objective: To assess the predictors associated with mortality within 8 weeks in patients undergoing endoscopic N-butyl-2- cyanoacrylate treatment. Study Design: Prospective comparative study. Place and Duration of Study: Department of Gastroenterology, Services Institute of Medical Sciences, Lahore Pakistan, from Mar 2018 to Mar 2019. Methodology: A total of 106 patients of gastric variceal bleed were enrolled in the study. Tissue glue was injected into the varix endoscopically and mortality within 8 weeks after endoscopic intervention was noted. Results: Among the enrolled patients, 65 (61.3%) were male and 41(38.7%) were female. Mortality was noted in 19 (17.9%) patients within 8 weeks after endoscopic therapy. Chi-square analysis showed creatinine >1.5, Child Pugh score >9, MELD score >18, re-bleeding within 7 days, low blood pressure <90/60 at presentation and hepatic encephalopathy as significant predictors of mortality (p<0.005). Conclusion: Cirrhotic patients undergoing endoscopic injection of gastric varix with N-butyl 2-cyanoacrylate after gastric variceal bleed have high risk of death within 8 weeks.

A226 INCIDENTAL FINDING OF A LARGE GASTRIC VARIX ASSOCIATED WITH NEONATAL UMBILICAL VEIN CANALIZATION

Results A 41-year old Asian male, who immigrated to Canada many years ago, and who had previously been successfully treated for Helicobacter pylori infection underwent gastroscopy for investigation of dyspepsia. His gastroscopy was normal except for a large subepithelial abnormality that was noted close to the gastroesophageal junction. Routine gastric biopsies from the antrum and body were normal. Subsequent endoscopic ultrasound revealed flow through the anechoic tortuous lesion and confirmed it was a very large isolated gastric varix type 1. Abdominal CT scan revealed chronic occlusion of the portal vein, splenic vein, and the portal confluence with extensive collateralization in the upper abdomen. There was complete cavernous transformation of the portal vein. Of the numerous varices in the upper abdomen, a very large varix drained into the left renal vein and indented into the posterior wall of the fundus of the stomach which accounted for the endoscopic finding. Multiple mesenteric veins were identified that connected to varices adjacent to the inferior aspect of the pancreas and duodenum. Notably, there was no evidence of cirrhosis or chronic pancreatitis. Liver enzymes, albumin, and INR were normal. Further collateral history revealed that he was hospitalized as a neonate for pneumonia with catheterization of the umbilical vein, which is known to be associated with thrombosis of the portal vein. Conclusions Detection of congenital absence of the portal vein (CAPV) is recognized more often due to advances in diagnostic imaging. Radiologically, the absence of the portal vein in CAPV is distinguished from portal vein thrombosis by the lack of venous collaterals or sequalae of portal hypertension, such as ascites or splenomegaly. A more gradual thrombosis of the portal vein may permit collaterals to develop without acute changes and is not equivalent to portal vein aplasia or agenesis as intrahepatic bile ducts are normal. The gold standard for diagnosis of CAPV is histologic absence of the portal vein in the liver on catheter angiography. CAPV is associated with abnormal embryologic development of the portal vein and frequently presents with complications of portal hypertension or portosystemic encephalopathy or the sequalae of venous shunts, hepatic or cardiac abnormalities found on imaging. Our case is an incidentally discovered absence of the portal venous system due to chronic thrombosis with extensive collateralization and an enlarged gastric varix protruding into the proximal stomach. It is well documented that canalization of the umbilical vein in infancy is associated with portal vein thrombosis, with incidences up to 68%. This case highlights the importance of eliciting a childhood hospitalization history in cases of non-cirrhotic portal hypertension. Funding Agencies None

Balloon-Occluded Retrograde Transvenous Obliteration (BRTO): A Novel Method of Obliterating Gastric Varices. Report of Six Cases and Review of Literature

Portal hypertension results in various complications, gastroesophageal varices being one of them. Although less common than esophageal varices, gastric varices are difficult to obliterate and carry a higher mortality rate when bleeding occurs. They are less amenable to sclerotherapy, endoscopic variceal ligation. Balloon-Occluded Retrograde Transvenous Obliteration (BRTO) has been developed as a minimal invasive procedure to obliterate gastric varices. BRTO is an endovascular procedure where a balloon catheter is inserted into a draining vein of gastric varix, and the sclerosant can be injected into the varices through the catheter during balloon occlusion. We report six cases where BRTO was done for gastric varices obliteration.

Unexpected diagnosis in a patient with a liver mass: A case report

Sarcoidosis is a rare inflammatory disease. It is characterized by granulomatous formation. The liver is the second most common site of involvement after the lung. Sarcoidosis of the liver is usually asymptomatic. Symptomatic cases can present with jaundice, itching, elevated liver enzymes, and in rare situations, the development of portal hypertension. We, at this moment, submit a case of liver sarcoidosis in a patient with liver cirrhosis that presented with upper gastrointestinal bleeding. Upper digestive endoscopy revealed gastric varices. Ultrasonography of the abdomen revealed a liver mass that was suspicious for hepatocellular carcinoma. There is no nay cause of gastric varix in this patient apart from hepatic sarcoidosis (portal hypertension). Treatment of the patient with corticosteroids leads to the complete disappearance of the liver mass. Despite the high incidence of HCC in Egypt due to the high prevalence of HCV infection, it is crucial to search for the rare causes of hepatic masses. Keywords: liver mass; sarcoidosis, gastric varix

Current Approaches to the Treatment of Gastric Varices: Glue, Coil Application, TIPS, and BRTO

Gastric varices are less common than esophageal varices, and their treatment is quite challenging. Gastric varix bleedings (GVB) occur less frequently than esophageal varix (EV) bleedings and represent 10% to 30% of all variceal bleedings. They are; however, more severe and are associated with high mortality. Re-bleeding may occur in 35% to 90% of cases after spontaneous hemostasis. GV bleedings represent a serious clinical problem compared with esophageal varices due to their location. Sclerotherapy and band ligation, in particular, are less effective. Based on the anatomic site and location, treatment differs from EV and is categorized into two groups (i.e., endoscopic or radiologic treatment). Surgical management is used less frequently. Balloon-occluded retrograde transvenous obliteration (BRTO) and cyanoacrylate are safe but there is a high risk of re-bleeding. Portal pressure elevates following BRTO and leads to worsening of esophageal varix pressure. Other significant complications may include hemoglobinuria, abdominal pain, fever, and pleural effusion. Shock and atrial fibrillation are major complications. New and efficient treatment modalities will be possible in the future.

Rescue Therapy of Delayed Gastric Perforation Caused by an External Drainage Using an Over-the-Scope Clip

This case reports a iatrogenic gastric fistula due to external draining successfully closed by using an over- the-scope clip. A 50-year old patient with a history of acute pancreatitis, segmental portal hypertension and splenectomy for splenic rupture, with long-term external drainage for a low volume pancreatic fistula, was referred to our hospital. The patient noticed the occurrence of a sudden increase of the drain flow and the immediate drainage of ingested liquid, with no fever or pain. An upper gastrointestinal endoscopy evidenced the gastric fistula with the presence of the drain inside the stomach near a gastric varix. The surgical approach was inappropriate due to bleeding risk. An over-the-scop clip was placed succeeding to stop the gastric flow. The external fistula closed one week later.