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Aim: To evaluate retrospectively the hemodynamics of esophageal varices before and after endoscopic injection sclerotherapy (EIS) using endoscopic color Doppler ultrasonography (ECDUS). Methods: The study included 306 patients whose esophageal varices had been treated with EIS. The underlying pathologies of portal hypertension in these 306 patients included liver cirrhosis (193), cirrhosis associated with hepatocellular carcinoma (102), primary biliary cirrhosis (6), idiopathic portal hypertension (4) and extrahepatic portal vein obstruction (1). ECDUS was used for the examination of all 306 cases before EIS and 3–5 months after EIS. ECDUS was performed to evaluate flow in the left gastric vein, paraesophageal veins, perforating veins and cardiac intramural veins. Results: The patients were divided into three groups according to time of esophageal variceal recurrence: early recurrence within one year (Group A, n = 16), no recurrence over three years (Group B, n = 12), and recurrence between one and three years (Group C, n = 278). Before EIS, the frequency of detection of perforating veins and the inflowing type of perforating veins using ECDUS was significantly higher for Group A than Groups B or C. After EIS, the frequency of detection of cardiac intramural veins, perforating veins and the inflowing type of perforating veins using ECDUS was significantly higher in Group A than Groups B or C. Conclusion: Endoscopic ultrasonographic evaluation of the hemodynamics in esophageal varices before and after EIS enables prediction of early variceal recurrence. [ABSTRACT FROM AUTHOR]

Background: Endoscopic injection sclerotherapy (EIS) is an effective procedure for the treatment of esophageal varices. In the present study, the pathogenesis of gastric ulcer after EIS for esophageal varices was investigated. Methods: EIS for esophageal varices was performed for 610 patients in our department, and the frequency and clinical course of gastric ulcer after EIS were investigated retrospectively. EIS was performed using 5% ethanolamine oleate with iopamidol, which was injected intermittently under fluoroscopy. Results: Gastric ulcer after EIS for esophageal varices was observed in 14 of the 610 (2.3%) patients. These were located around the cardia of the stomach from the fornix to the gastric body. Gastric ulcer extended from the stomach lining into the esophagus in 11 of the 14 cases. Severe chest pain was observed, and dark purple mucosal changes of the esophagus and stomach were detected endoscopically at the time of injection in all 14 cases. All cases received dripping therapy, and prescription of a proton pump inhibitor. Gastric ulcer after EIS was refractory, and almost 2 months was required until the healing stage was reached. Conclusion: Gastric ulcer after EIS for esophageal varices is a rare but important complication of EIS. [ABSTRACT FROM AUTHOR]

Abstract: Gastric antral vascular ectasia (GAVE) is a rare cause of chronic gastrointestinal bleeding. The aim of this study was to evaluate the relationship between GAVE with cirrhotic patients and liver dysfunction, portal hypertension and the safety and efficacy of argon plasma coagulation (APC) in treating GAVE with cirrhotic patients. Eight cirrhotic patients with the characteristic endoscopic findings of GAVE were registered. In this study, APC was performed for GAVE in all eight patients. The patients-liver function was classified by Child-Pugh classification and classifications were: two class A, five class B and one class C (mean score: 7.8). Five patients had previously received prophylactic endoscopic injection sclerotherapy for esophageal varices and one had esophageal varices. Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices had been performed in other one patient. Portal hypertensive gastropathy (PHG) was recognized in only one case. APC was performed in all eight patients and one to three treatment sessions were needed (mean: 1.8 sessions). No complications were observed in the initial treatment. During follow-up, endoscopies revealed the recurrence of GAVE in two patients requiring further treatment by APC (recurrence rate: 25%). After APC treatment, the recurrence of GAVE was not observed with endoscopy in the other six patients. The results suggest that GAVE is related to severe liver damage and portal hypertension in cirrhotic patients. APC is a safe and effective treatment against GAVE. [Copyright &y& Elsevier]

Endoscopic color Doppler ultrasonography (ECDUS) is a method for obtaining color flow images in blood vessels. In the present study, we evaluated the usefulness of three-dimensional endoscopic color Doppler ultrasonography (3D-ECDUS) using electronic radial ECDUS.Five patients with esophageal varices were studied. The technique of ECDUS was performed using a Pentax EG3630-UR (forward-view) with a distal tip diameter of 12 mm. The instrument (electronic radial array) has a curved array scanning transducer with variable frequency (5.0, 7.5, 10.0 MHz) and B mode/color Doppler/power Doppler capability. A Hitachi EUB 8500 was used for the display, which provided a 270° image. We monitored the color flow images of esophageal varices, paraesophageal veins and perforating veins. Scanning was performed from the cardiac part of the stomach to the distal esophagus by moving the instrument. After completing the examination, 3D-ECDUS images were reconstructed.Color flow images of esophageal varices and paraesophageal veins were obtained in five of the five patients. Color flow images of perforating veins were obtained in five of the five patients with 3D-ECDUS. 3D-ECDUS clearly delineated the continuity of vessels from the cardiac varices to the esophageal varices, and between the perforating veins and esophageal varices. Furthermore, 3D-ECDUS clearly showed the continuity of vessels from the anterior branch of the left gastric vein to the esophageal varices and from the posterior branch of the left gastric vein to the paraesophageal veins.3D-ECDUS more clearly provides visualization of vessel continuity in esophageal varices, which allows for better understanding of the hemodynamics of esophageal variceal cases. [ABSTRACT FROM AUTHOR]

Case 1: A 75-year-old woman was admitted to our department in February 1996 with tarry stool. At 71 years of age, she had been diagnosed with idiopathic myelofibrosis (IMF) based upon laboratory data and a biopsy of iliac bone marrow. Fibergastroscopic examination on admission revealed esophageal varices graded as Ls, F2, Cb, and red color (RC)(+ +). Esophageal varices were considered the most likely cause of the bleeding. Computed tomography (CT) showed a markedly enlarged spleen and large collateral veins (left gastric vein, spleno-renal shunt). We performed endoscopic injection sclerotherapy (EIS) twice weekly using 5% ethanolamine oleate with iopamidol (5% EOI), the total amount of sclerosant was 13 mL. No further variceal bleeding occurred until she died in June 1996. Case 2: A 67-year-old man was admitted to our hospital in February 1992 with anemia and leukocytosis after a health check. He was diagnosed with IMF based upon laboratory data and a biopsy of iliac bone marrow. Screening upper gastrointestinal endoscopy demonstrated esophageal varices graded as Ls, F3, Cb, and red color (RC)(+) and gastric varices graded as Lg–cf, F2, and RC(–). CT showed a markedly enlarged spleen and large collateral veins (left gastric vein, short gastric vein). We performed EIS four times weekly using 5% EOI, the total amount of sclerosant was 32 mL. Two weeks after EIS the varices were graded as F1, RC(–). This patient experienced esophageal varix recurrence up to 1 year later, and EIS was performed twice using 5% EOI. [ABSTRACT FROM AUTHOR]

Endoscopic color Doppler ultrasonography (ECDUS) is a useful modality for obtaining color flow images of esophageal varices. The direction of blood flow in passageways is fundamentally hepatofugal flow according to ECDUS. The present study is designed to evaluate the alternate direction of color flow image of passageways via ECDUS in esophageal variceal patients. The study involved 125 patients with esophageal varices using ECDUS. The grades of red color (RC) were as follows: RC(+) in 79 cases, RC(+ +) in 35 cases, and RC(+ + +) in 11 cases. We investigated the alternate direction on color flow images of the left gastric vein, the palisade vein, and the perforating veins via ECDUS. Color flow images of the esophageal varices and the left gastric vein were obtained in all 125 (100%) patients by ECDUS. Color flow images of the perforating veins were obtained in 90 (72.0%) of the 125 patients. Vessel images of the palisade veins were detected in 33 (26.4%) of the 125 patients. The alternate direction on color flow images was detected in seven (5.6%) of the 125 patients with ECDUS: in three patients, left gastric vein; in three patients, perforating veins; and in one patients, left gastric vein and palisade veins. This phenomenon was observed periodically at regular intervals. The endoscopic findings were RC(+) in all seven patients. The alternate direction of blood flow in the passageways was observed in a few cases of RC(+) esophageal varices. We can observe the hemodynamics of esophageal varices non-invasively and in real time with ECDUS, and clarify the frequencies of the alternate direction of blood flow in RC-positive esophageal variceal patients. [ABSTRACT FROM AUTHOR]

A 72-year-old man with type C cirrhosis was admitted to our hospital for refractory esophageal varices. Prophylactic endoscopic injection sclerotherapy (EIS) was performed twice in August 2000 for high-risk esophageal varices at an outside hospital. However, a therapeutic effect was not attained. Endoscopic finding revealed F1, Cb, RC (–) at the gastroesophageal junction to approximately a 5-cm oral site, and F3, Cb, RC (+) varices at the upper site from the 5-cm oral site of the gastroesophageal junction. Color flow images were obtained of the posterior branch of the left gastric vein and revealed an inflow-type perforating vein about a site 5 cm oral from the gastroesophageal junction. Color flow images of esophageal varices were detected with endoscopic color Doppler ultrasonography. Color flow images of out-flowing-type perforating veins were discerned in the middle esophagus. The vessel images of intramural esophageal varices were clearly delineated via an ultrasonic microprobe and showed a perforating vein with a diameter of 4 mm. We performed EIS with an attached balloon to occlude the out-flowing-type perforating veins with 5% ethanolamine oleate with iopamidol. Seven days after the first EIS, thromboses were observed in the intramural esophageal varices and in the inflow type-perforating veins via ultrasonic microprobe. We exchanged the hemodynamics of this esophageal variceal case with blockade of the inflow-type perforating vein. Next, we successfully performed EIS, and achieved the blockade of passageways, including the palisade veins. Forty days after EIS, endoscopic findings revealed disappearance of the esophageal varices. [ABSTRACT FROM AUTHOR]

Background Methods. We compared vessel images detected prior to the use of contrast with those detected by enhanced ECDUS in 29 patients with recurrent esophageal varices. After the pre-contrast ECDUS examination, all 29 patients received Levovist intravenously, at a concentration of 300 mg/ml. A 7.5-ml dose of the contrast agent was injected at a slow infusion rate, of 1 ml/min. The perforating veins detected by ECDUS were classified, according to flow direction, into three different types. Type 1 showed inflow from the paraesophageal veins to the esophageal varices. Type 2 showed outflow from the esophageal varices to the paraesophageal veins, while type 3 was a mixed type with both inflow and outflow. For comparison, 26 patients without recurrent esophageal varices were studied. Results. Color flow images of perforating veins were obtained in 9 (31.0%) of the 29 patients with recurrent esophageal varices with pre-contrast ECDUS. The detection rate of perforating veins in the patients with recurrent esophageal varices (31.0%) was significantly higher than that in patients without recurrent esophageal varices (0 of 26; 0%) with pre-contrast ECDUS. Color flow images of perforating veins were detected in 22 (75.9%) of the 29 patients with recurrent esophageal varices after Levovist contrast. On the other hand, color flow images of perforating veins were not detected in any of the 26 patients without recurrent esophageal varices after Levovist contrast. Type 1 perforating veins were recognized in 6 (20.7%) of the 29 patients, type 2 in 2 (6.9%) of the 29, and type 3 in 1 (3.4%) of the 29 prior to the use of contrast. After the enhanced ECDUS, type 1 perforating veins were recognized in 13 (44.8%) of the 29 patients, type 2 in 6 (20.7%) of the 29, and type 3 in 3 (10.3%) of the 29. All color-flow images detected with pre-contrast ECDUS were enhanced after Levovist contrast. Conclusions. Perforating veins can be detected at a high rate by ECDUS with Levovist in patients with recurrent esophageal varices after endoscopic therapy. We evaluated the usefulness of endoscopic color Doppler ultrasonography (ECDUS) with Levovist, a galactose-based contrast agents, for detecting perforating veins in the esophageal wall in patients with recurrent esophageal varices after endoscopic therapies. [ABSTRACT FROM AUTHOR]

Background: Endoscopic color Doppler ultrasonography (ECDUS) is a method for detecting color flow images in blood vessels. In the present study, electronic radial ECDUS in cases of esophageal varices is described. Methods: Thirteen patients with esophageal varices were studied. The technique of ECDUS was performed using a Pentax EG3630-UR (forward-view) with a distal tip diameter of 12 mm. The instrument (electronic radial array) has a curved array scanning transducer with variable frequency (5.0, 7.5, 10.0 MHz) and B mode/color Doppler/power Doppler capability. A Hitachi EUB 6500 was used for the display, providing a 270° image. We monitored the color flow images of esophageal varices, paraesophageal veins and perforating veins using this technique. Results: Color flow images of esophageal varices and paraesophageal veins were obtained in 13 of the 13 patients, whereas color flow images of perforating veins were obtained in four of the 13 patients (30.8%). The 13 esophageal varices exhibited velocities ranging between 3.0 and 11.7 cm/s (mean = 6.3 cm/ s). The forward-viewing optics facilitated insertion, but the stiffness of the distal tip limited the flexibility of the scope, especially when attempting J- or U-turn views. Conclusion: Electronic radial ECDUS provides color flow images similar in quality to those of convex-type ECDUS with the additional advantages of forward-view optics and extended 270° views. [ABSTRACT FROM AUTHOR]

Background: Endoscopic color Doppler ultrasonography (ECDUS) is a useful modality for obtaining color flow images of esophageal varices. Levovist is a microbubble echo-enhancing agent that improves Doppler ultrasound examination. This study is designed to evaluate the usefulness of ECDUS using Levovist in diagnosing palisade veins of esophageal varices. Methods: The study involved 67 patients with esophageal varices using ECDUS. All 67 patients received Levovist intravenously at a concentration of 300 mg/mL. A 7.5-mL dose of the contrast agent was injected at a slow infusion rate of 1 mL/min. We compared vessel images detected with precontrast with those detected by enhanced ECDUS. Results: Color flow images of palisade veins were obtained in 16 (23.9%) of the 67 patients with precontrast ECDUS. Vessel images of palisade veins were detected in 15 of 61 F2 type varices (24.6%) and in one of six F3 varices (16.7%). The color flows of these vessels showed a continuous wave on fast-Fourier transform analysis. Sixteen palisade veins had velocities in the 3.3 cm/s-11.6 cm/s range. Color flow images of palisade veins were obtained in 27 (40.3%) of the 67 cases by enhanced ECDUS using Levovist. Palisade veins could be delineated after Levovist contrast in 11 patients who could not be detected on precontrast ECDUS. After Levovist contrast, color flow images detected with precontrast ECDUS were enhanced in all patients. Conclusion: Endoscopic color Doppler ultrasonography with Levovist contrast can improve the diagnostic quality of the palisade veins in esophageal varices. [ABSTRACT FROM AUTHOR]

Endoscopic color Doppler ultrasonography (ECDUS) is a useful modality for obtaining color flow images of esophageal varices. Levovist is a microbubble echo-enhancing agent, which improves Doppler ultrasound examination. In this paper, we compared vessel images detected with pre-contrast with those detected by enhanced ECDUS using Levovist in 62 patients with esophageal varices. Color flow images of esophageal varices and paraesophageal veins by pre-contrast ECDUS were obtained in 62 (100%) of the 62 patients. Vessel images of perforating veins were obtained in 48 (77.4%) of the 62 patients with pre-contrast ECDUS. The perforating veins were classified into three types according to the flow direction. Type 1 showed in-flow from the paraesophageal veins to the esophageal varices, Type 2 showed out-flow from the esophageal varices to the paraesophageal veins, and Type 3 was a mixed type showing both in-flow and out-flow. After Levovist contrast, color flow images detected with pre-contrast ECDUS were improved in all patients. Color flow images of perforating veins were obtained in 60 (96.8%) of the 62 patients by enhanced ECDUS using Levovist. Pre-contrast-diagnosed Type 2 patterns had been re-diagnosed as Type 3 in five patients, and three cases with Type 1 had been relabeled as Type 3 pattern using Levovist. The use of Levovist contrast can improve the diagnostic quality of ECDUS examinations of esophageal variceal patients, yielding a much clearer picture of the hemodynamics. [Copyright &y& Elsevier]

Background: There is little information in the literature on the diagnosis of esophagogastric varices via ultrasonic microprobe (UMP). Methods: Twenty-one patients with esophageal varices (five cases F3; 16 cases F2) were studied. First, ultrasonographic observation of the cardiac area using deaerated water through the biopsy channel (the water repletion method) was performed followed by the balloon sheath method using MH-246R (3.2 mm in diameter; Olympus, Tokyo, Japan). Results: The vessel images of intramural gastric varices were delineated in all 21 patients with both the water repletion method and the balloon sheath method. The overall features of perigastric collateral veins were obtained in 14 of 21 patients (66.7%) using the water repletion method and in 18 of 21 patients (85.7%) with the balloon sheath method. Vessel images of communicating veins were obtained in 10 of 21 patients (47.6%) with the water repletion method and in 17 of 21 patients (81.0%) with the balloon sheath method. Conclusion: We conclude that detailed evaluation of esophageal varix hemodynamics in the cardia is most successfully accomplished by using the balloon sheath method of UMP in conjunction with the water repletion method. [ABSTRACT FROM AUTHOR]

Recurrent varices located in the middle esophagus are considered to be rare. We could find no scientific reports on this type of recurrent varices. We report herein on five cases diagnosed by endoscopy and endoscopic color Doppler ultrasonography (ECDUS). Endoscopic findings revealed the disappearance of varices in the lower esophagus and F2 type recurrent varices in the middle esophagus. Color flow images of the left gastric vein and the developed para-esophageal vein, and the perforating vein of inflow type from para-esophageal veins to esophageal varices in the middle esophagus were produced using ECDUS. One of the five cases had red color (RC)-positive recurrent varices located in the middle esophagus and was admitted to our hospital with hematemesis. In such cases, where the recurrent varices show a high-risk sign, rupture is probable. [ABSTRACT FROM AUTHOR]

A 53-year-old man was admitted to our hospital in August 1997 with enlarged gastric varices. Computed tomography (CT) showed splenic vein occlusion, gastric varices, and extra-gastric wall collateral veins. Color flow images of gastric varices were clearly visualized, and the velocity in the gastric varices was 19.6 cm/s via endoscopic color Doppler ultrasonography (ECDUS). The patient was diagnosed with gastric varices according to angiographic findings of splenic vein occlusion, and splenic arterial embolization was performed. Two weeks after the splenic arterial embolization, CT showed peripheral areas of low attenuation in the spleen, due to splenic infarction, with 70% of the spleen volume showing low attenuation. Eight months after the splenic arterial embolization, ECDUS revealed a decrease in gastric variceal color flow images, with the velocity in the gastric varices being 10.3 cm/s. [ABSTRACT FROM AUTHOR]