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Background: Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative., Objectives: To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability., Design: Retrospective analysis of a prospectively maintained database., Setting: Multicenter study, tertiary referral centers., Patients and Interventions: Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment., Results: There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P < .01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding., Limitations: Nonrandomized; EUS expertise necessary., Conclusions: EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data., (Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Bleeding from gastric varices can be challenging because of its high mortality and recurrent bleeding rates. Endoscopic therapy with tissue adhesives can control acute hemorrhage, but recurrent bleeding could appear if obliteration is not achieved, and endoscopic vision could be troublesome in the case of massive hemorrhage. The glue injected could be responsible for embolic phenomena and local complications. EUS has proved useful in minimizing the risk of recurrent bleeding from gastric varices, accurately showing if they are obturated or not. The presence of perforating veins detected by EUS has been reported as a risk factor for recurrent bleeding from esophageal varices., Objective: To assess the efficacy of EUS-guided cyanoacrylate injection in gastric varices at the entrance of the perforating veins to obtain variceal obturation., Design: Open-basis case series study., Setting: Tertiary care, academic medical center, Seville, Spain., Patients: Five consecutive patients with gastric varices were enrolled from May 2005 through May 2006., Interventions: We injected cyanoacrylate-lipiodol in gastric varices with 22-gauge needles by EUS guidance., Main Outcome Measurements: To analyze the obliteration of gastric varices, the recurrent bleeding rate, and safety of EUS-guided cyanoacrylate-lipiodol injection., Results: EUS-guided injection of the perforating veins by using cyanoacrylate-lipiodol was successful in eradicating gastric varices in the 5 patients treated, without recurrent bleeding or other complications during the study follow-up., Limitation: This is a single-center nonrandomized study., Conclusions: EUS-guided injection of cyanoacrylate at the level of the perforating veins in the treatment of gastric varices seems to be a safe, efficient, and accurate approach. Further controlled studies are warranted.

Background and Aims: There are several treatment options for gastroesophageal variceal hemorrhage. In severe cases, bleeding persists and is associated with a dismal outcome. The coagulation disorders might be correlated with risk of bleeding in patients with portal hypertension. The administration of activated recombinant factor VII corrects prothrombin time transiently in nonbleeding patients with cirrhosis as well as in bleeding ones. The aim of this study was to assess the hemostatic efficacy of activated recombinant factor VII in bleeding esophageal varices., Methods: Between May 2001 and September 2002, 112 patients with cirrhosis and an episode of acute esophageal variceal bleeding were admitted. On an open basis with a single intravenous dose of 4.8 mg of recombinant factor VII, we treated 8 patients experiencing severe and active hemorrhage from esophageal varices unresponsive to pharmacologic therapy, endoscopic therapy, or balloon tamponade., Results: Eight (7%) of 112 patients met entry criteria. Hemostasis was achieved in all the cases after recombinant activated factor VII therapy. Rebleeding and mortality rates were 25% and 50% (2 and 4 patients), respectively., Conclusions: In our experience, recombinant activated factor VII achieves hemostasis in bleeding esophageal varices unresponsive to standard treatment.

Duodenal varices are uncommon and are frequently diagnosed late. However, they are a potential cause of massive bleeding, with tendency to relapse. We would like to offer as an example a case diagnosed by means of an endoscopy. A patient without oesophageal varices and with obstruction of the splenic-portal axis and venous calcifications is reported. A diminution in the volume of the duodenal varices with inspiratory movements may help in the differential diagnosis during endoscopy. We emphasize the need of avoiding incorrect maneuvers during endoscopy and the value of ultrasonography and CAT scan to confirm the diagnosis. Sclerotherapy appears to be the best therapeutic approach. Percutaneous embolization and surgery are therapeutic alternatives if sclerosis is not effective. However, in some cases with self-limited bleeding and a low tendency to relapse, as with the patient described herein, a conservative attitude should be selected.