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Abstract Background HCV infection is a major worldwide cause of chronic liver diseases. Esophageal and gastric varices are common in cirrhotic patients due to concomitant portal hypertension. Variceal hemorrhage is a major decompensating event with high morbidity and mortality. Endothelial dysfunction, occurring in cirrhosis, facilitates the development of liver cirrhosis, portal hypertension and contributes to increased intrahepatic vascular resistance..VEGF family members are major regulators of blood vessel development and function. Results The study was conducted on 90 subjects admitted to Tropical Medicine Department, Alexandria Main University Hospital: 30 cirrhotic patients with endoscopically proven varices (group A), 30 cirrhotic patients without varices (group B), and 30 healthy controls (group C). All patients was subjected to detailed history taking and thorough clinical examination, laboratory investigations, ultrasound abdomen, upper gastrointestinal endoscopy, and genotyping for VEGF C(+405)G (rs2010963) by 5′ nuclease assay. The VEGF C(+405)G (rs2010963) GG genotype was associated with higher prevalence of esophageal and gastric varices and higher bleeding risk. Conclusion VEGF C(+405)G (rs2010963) is an important genetic determinant of esophageal varices, gastric varices, and correlates with variceal bleeding risk. Genetic testing of this SNP would be useful in prediction of esophageal and gastric varices and bleeding risk.

Pelvic venous disorders (PeVD), sometimes referred to as pelvic congestion syndrome (PCS), widely impact affected patients–mainly young women’s quality of life, causing puzzling, uncomfortable symptoms sometimes requiring months or years to get an explanation, while simply remaining undiagnosed in other cases. Because pelvic pain is a non-specific symptom, an appropriate diagnosis requires a careful patient workup, including a correlation between history and non-invasive imaging. Invasive imaging is frequently required to confirm the diagnosis and plan treatment. Current therapeutic approaches principally rely on minimally invasive techniques delivered through endovascular access. However, while comprehensive descriptive classifications such as the symptoms-varices-pathophysiology (SVP) classification exist, universally accepted guidelines regarding therapy to apply for each SVP category are still lacking. This review strongly focuses on PeVD imaging and discusses available therapeutic approaches with regard to pathophysiological mechanisms. It proposes a new classification scheme assisting clinical decision-making about endovascular management to help standardize the link between imaging findings and treatment.

Objectives: Objective assessments of esophageal varices (EVs) are inadequate. The recurrence of variceal bleeding after endoscopic variceal ligation (EVL) is associated with residual blood flow underlying EVL or incomplete treatment of a perforating vein by EVL. We aimed to assess our novel through‐the‐scope endoscopic Doppler probe method (DOP) for the evaluation and management of EVs. Methods: This study included 20 patients (54 varices) with a history of esophageal variceal rupture from June 2019 to May 2021 who underwent DOP at a tertiary hospital. Variceal velocities were compared based on the size and endoscopic variceal findings. Additionally, we performed EVL assisted by DOP (EVL + DOP) in nine patients. Results: Doppler imaging of EVs was observed in all 20 patients. The velocity of varices was significantly higher in EVs with a larger size, greater form, blue color, and red color sign positive. Perforating veins connecting to the EVs were identified in six out of nine patients who underwent EVL + DOP. Eight out of nine patients underwent repeat EVL. Repeat EVL was performed until the variceal velocity reached absent. No recurrence of variceal bleeding occurred during the follow‐up period (mean 8.7 ± 3.2 months). No adverse events associated with DOP were observed. Conclusion: The evaluation of EVs using DOP is feasible and accurate. EV velocities are related to the variceal size, form, blue color, and red color sign. EVL + DOP may be a more reliable treatment for EVs. Further large‐scale, long‐term comparative studies are warranted. [ABSTRACT FROM AUTHOR]

Background: The incidence of, risk factors for, and outcomes after the development of ascites are poorly described for contemporary patients with cirrhosis.Methods: We examined data for a 20% random sample of US Medicare enrollees with cirrhosis and Part D prescription coverage from 2008 to 2019, excluding patients with heart failure and diuretic use prior to cirrhosis. Among 63,364 persons with cirrhosis, we evaluated the incidence of ascites using an Aalen-Johansen estimator. We evaluated risk factors for ascites, mortality, and mortality after ascites using multistate modeling. We determined the associations with each outcome for an array of medication exposures including nonselective beta-blockers, antiviral therapy, statins, rifaximin, anticoagulants, and metformin.Results: The cumulative incidence of ascites was 5.1%, 9.5%, and 10.7% and 1, 3, and 5 years overall. The corresponding data for ascites requiring paracentesis were 1%, 2.1%, and 2.4%. Persons aged < 65 years, with alcohol-related cirrhosis, varices, or HE, are most likely to develop ascites. The risk of ascites was higher for persons taking any NSBB (including carvedilol) but lower for those taking atorvastatin (but not other statins) and antiviral therapy for Hepatitis C. Incident ascites was associated with increased risk of death, HR 27.6 95%CI(21.7-35.1). Survival following ascites was 1.08 years (interquartile range, IQR, 0.26-2.75), 0.38 years (IQR0.1-1.3) for those requiring paracentesis. Lipophilic statins were the only medications associated with lower mortality after ascites requiring paracentesis.Conclusions: Ascites is associated with a high risk of death. Very few candidate therapies are associated with the reduction in the risk of ascites and mortality after ascites development. [ABSTRACT FROM AUTHOR]

Simple Summary: This study aims to evaluate sinistral portal hypertension (SPH) development and its clinical impact on the long-term outcomes of patients with pancreatic cancer who underwent surgical resection with splenic vein (SV) ligation. Data from 94 consecutive patients who underwent pancreatoduodenectomy (PD) with vascular resection for pancreatic cancer were divided into two groups according to SV ligation, and the groups were compared. Variceal score in the SV ligation group was significantly higher than that in the SV saving group at the same postoperative periods, and clinically relevant variceal bleeding was noted in one patient from the SV ligation group. In survival analysis, there was no significant difference between the two groups. These results showed that although SV ligation induced SPH during PD for pancreatic cancer, it did not lead to clinically significant long-term complications. In addition, it did not impact the long-term survival of patients with resected pancreatic head cancer. Background: This study aims to evaluate sinistral portal hypertension (SPH) development and its clinical impact on the long-term outcomes of patients with pancreatic cancer who underwent surgical resection with splenic vein (SV) ligation. Methods: Data from 94 consecutive patients who underwent pancreatoduodenectomy (PD) with vascular resection for pancreatic cancer from 2008 to 2019 were retrospectively collected. The patients were divided into two groups according to whether the SV was preserved or ligated during the surgery. Their computed tomography images were serially reviewed (preoperative, 6-, 12-, and 24-months postoperative) with clinical parameters. The degree of variceal formation (variceal score) and splenomegaly were assessed, and the oncologic outcomes were compared between the two groups. Variceal score in the SV ligation group was significantly higher than that in the SV saving group at the same postoperative periods (SV saving vs. ligation: 12 months, 0.9 ± 1.3 vs. 3.5 ± 2.2, p < 0.001; 24 months, 1.4 ± 1.8 vs. 4.0 ± 3.4, p = 0.009). Clinically relevant variceal bleeding was noted in one patient from the SV ligation group (SV saving vs. ligation: 0.0% vs. 3.1%, p = 0.953). In survival analysis, there was no significant difference between the two groups (DFS; SV saving vs. ligation: 13.0 (11.1–14.9) months vs. 13.0 (10.4–15.6) months, p = 0.969, OS; SV saving vs. ligation: 35.0 (19.9–50.1) months vs. 27.0 (11.6–42.4) months, p = 0.417). Although SV ligation induced SPH during PD for pancreatic cancer, it did not lead to clinically significant long-term complications. In addition, it did not impact the long-term survival of patients with resected pancreatic head cancer. [ABSTRACT FROM AUTHOR]

Background: The role of esophagogastroduodenoscopy (EGD) in screening for varices in patients with cirrhosis is well established. However, it is unknown how insurance status impacts the rate of variceal screening. Therefore, we examined an at-risk population to determine the effect of insurance status on the rate of variceal screening. Results: Data were available on 111 patients who had an EGD ordered for variceal screening over this 18-month period. Analysis showed that six of sixteen (37.5%) uninsured patients versus sixty-three of ninety-five (66.4%) insured patients underwent EGD for screening purposes. Comparing these rates revealed a significant difference (p < 0.05, 95% CI 0.0841, 1.034). There were no significant differences comparing gender or ethnicity among the two groups. The unadjusted odds ratio (OR) of completing screening dependent on insurance status was 3.28 (95% CI 1.09–9.84, p = 0.03). These findings suggest that lack of insurance negatively affects EGD completion rates among the cirrhotic patient population. Conclusions: This analysis suggests that lack of insurance adversely impacts variceal screening rates among patients with cirrhosis. Recognition of this disparity is an important first step in finding methods to deliver appropriate care to these patients, reduce avoidable adverse outcomes and decrease the high cost of hospitalization associated with this pathology. [ABSTRACT FROM AUTHOR]

Background and aims: Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC). Methods: Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB). Results: Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age—46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27–40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age—44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24–40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00–28.00] vs. 17.00 [15.00–21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03–9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2–2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1–2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort. Conclusion: Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF. [ABSTRACT FROM AUTHOR]

Background: Screening endoscopy for varices may be deferred when the calculated EVendo score is ≤3.90. This novel score has not been validated in an external cohort. This study aimed to assess the performance of the EVendo score and compare it with the Baveno VI criteria. Methods: We identified and calculated this score in all cirrhotic patients who underwent screening endoscopy for the first time with laboratory tests and liver stiffness measurements within 6 months of the endoscopy date. Results: In total, 103 patients were included. An EVendo score of ≤3.90 identified patients with no gastroesophageal varices (GEV) and varices needing treatment (VNT) with sensitivities of 82% and 83% and specificities of 57% and 34%, respectively. The negative predictive value for VNT was 94%. A comparison with the Baveno VI criteria in Child–Turcotte–Pugh-A patients showed spared endoscopy and missed VNT rates with EVendo score cutoffs of ≤3.9 and ≤4.5 and the Baveno VI criteria of 25%, 33%, and 16.6% and 1.7%, 1.7%, and 0%, respectively. Conclusions: EVendo score is reliable in clinical practice for predicting GEV and VNT. The number of spared endoscopies was higher than that with the Baveno VI criteria; however, there were more missed VNT cases. [ABSTRACT FROM AUTHOR]

Resumen Contexto Las várices son una condición altamente prevalente en la población general, generando motivos variables de consulta que pueden alterar la calidad de vida del paciente, con prevalencia y factores asociados variando en diferentes series. Objetivos Describir el perfil epidemiológico de pacientes que consultaron por várices, evaluando los principales síntomas y las variables asociadas. Métodos Entre 2019 y 2020, se evaluaron a 1.136 pacientes que asistieron a una consulta de cirugía vascular en un centro ambulatorio especializado. Se registraron variables demográficas, sintomatología, complicaciones y factores asociados, como índice de masa corporal, paridad e historia familiar. Resultados Se evaluaron 1.136 pacientes (79,8% mujeres y 20,2% hombres), con edad media de 53,51 años. La presencia de síntomas fue similar en hombres y mujeres; las complicaciones más frecuentes fueron úlcera, varicorragia y trombosis venosa superficial. La mayoría de los pacientes presentaba CEAP 1, 2 o 3 (n = 909), y más de la mitad tenía sobrepeso u obesidad (n = 679), con predominancia de los clasificados como C4. Sesenta y nueve por ciento tenían historia familiar positiva de várices. No hubo diferencia entre la severidad de las varices y el tiempo laborado de pies o sentado, pero hubo mayor presencia de úlcera C5 o C6 en pacientes que permanecían de pies por más de 4 horas. Conclusiones La descripción de las características de la población con várices ayuda a entender la enfermedad y a concentrar los esfuerzos en aquellos más susceptibles. Los resultados de esta investigación son semejantes a los de otras poblaciones.

Abstract Background and Aim Gastric antral vascular ectasia (GAVE) is observed in patients with liver cirrhosis and portal hypertension. The exact pathophysiologic mechanism that underlies this condition is unknown. In our study, we estimate the prevalence of GAVE in hepatitis C virus (HCV) cirrhosis and attempted to determine if any of the hepatocellular manifestations, liver functions, serum gastrin, abdominal ultrasound and endoscopic picture have a relation to, or could predict, the occurrence of GAVE in cirrhotic patients. Methods This study includes 500 HCV‐related liver cirrhosis patients. According to endoscopic assessment, we detected 30 patients with GAVE (Group 2). From the 470 patients without GAVE, we randomly selected 120 patients (Group 1), to avoid statistical bias, for comparison with Group 2. Comparison included clinical manifestations, laboratory findings, serum gastrin, ultrasound findings, and endoscopic findings (esophageal and/or gastric varices and gastropathy). Results The percentage of GAVE in HCV‐related liver cirrhosis is 0.06%. We can predict GAVE by platelets, palmer erythema, diabetes mellitus (DM), marked ascites > with area under the curve of 0.67, 75.5, 0.62, and 0.40%, and accuracy of 82.5, 72, 70.7, and 79.3%, respectively. There was no correlation found between occurrence of GAVE and endoscopic findings. Also, there was no correlation found between occurrence of GAVE and serum gastrin levels, which reflect another pathophysiology, and we found no statistically significant correlation with GAVE. Conclusions Palmer erythema, low platelets, DM, and ascites might help in the prediction of GAVE. GAVE is not linked to the presence, type or grade of varices, and gastropathy.

Background: There have been several reports of seasonal variations in the incidence of esophageal variceal bleeding but the data available from this part of the world is scanty. Aims and Objective: We aimed to study whether monthly and seasonal climatic changes during the year have an influence on the incidence of variceal bleeding in our setting and whether a particular time in the year can be defined as a high-risk period for variceal bleed. Materials and Methods: Data of all the patients with diagnosis of acute variceal upper gastrointestinal bleed who presented to our endoscopy centre from January 2010 to December 2019 was retrieved and analysed. The demographic data, clinical presentations and seasonal and monthly variation was analysed. Results: Out of a total of 10200 patients presenting with upper gastrointestinal bleed during the study time period, 530 patients had a diagnosis of variceal bleed after esophagogastroduodenoscopy (EGD). The majority of variceal bleed patients (48.5%) were seen between May to August months of the year. Conclusions: Contrary to the most of the literature which shows increased frequency of variceal bleed during winters, our patients bleed more during the months of May and August. This could be explained on the basis of unique socio-cultural and demographic pattern of this part of the world.

Nonselective beta-adrenergic blocker (NSBB) therapy for the prevention of initial and recurrent gastrointestinal bleeding in cirrhotic patients with gastroesophageal varices has been used for the past four decades. NSBB therapy is considered the cornerstone of treatment for varices, and has become the standard of care. However, a 2010 study from the group that pioneered β-blocker therapy suggested a detrimental effect of NSBBs in decompensated cirrhosis, especially in patients with refractory ascites. Since then, numerous additional studies have incompletely resolved whether NSBBs are deleterious, although more recent evidence weighs against a harmful effect. The possibility of a “therapeutic window” has also been raised. We aimed to review the literature to analyze the pros and cons of using NSBBs in patients with cirrhosis, not only with respect to bleeding or mortality but also to other potential benefits and risks. β-blockers are highly effective in preventing first bleeding and recurrent bleeding. Furthermore, NSBBs improve congestion/ischemia of the gut mucosa, decrease intestinal permeability, and therefore indirectly alleviate systemic inflammation. β-blockers shorten the electrocardiographic prolonged QTc interval and may also decrease the incidence of hepatocellular carcinoma. On the other hand, the possibility of deleterious effects in cirrhosis has not been completely eliminated. NSBBs may be associated with an increased risk of portal vein thrombosis, although this could be correlational artifact. Overall, we conclude that β-blockers in cirrhosis are much more of a friend than enemy.

Objective: To determine the spectrum of findings in patients presenting for upper gastrointestinal (UGI) endoscopy and investigate role of age and gender. Study Design: Cross-sectional study. Place and Duration of Study: Department of Gastroenterology & Internal Medicine, Combined Military Hospital Kharian, from Jul 2017 to Mar 2019. Methodology: The data regarding 638 consecutive patients who underwent upper gastrointestinal endoscopy in the department were collected from the computer-based database and patients were stratified into two groups according to their age: ≤50 and >50 years. Results: The mean age was 50.2 ± 17.4 (range: 7-100) years. There were 431 males and 207 females. The commonest presenting complaint was decompensated chronic liver disease (CLD) 162 (25.4%). The upper gastrointestinal endoscopy was normal in 306 (48%) and abnormal in 332 (52%) patients. The commonest abnormality seen on upper gastrointestinal endoscopy was esophageal varices seen in 167 (26.2%) followed by non-specific gastropathy, and hiatal hernia seen in 28 (4.4%) and 21 (3.3%) patients respectively. No significant differences were observed among males and females for a positive upper gastrointestinal endoscopy. Significantly large number of patients of age >50 years had an abnormal upper gastrointestinal endoscopy (p

Abstract Background and Aim Acute variceal bleeding (AVB) is a serious complication associated with high mortality. The aim of our study was to investigate mortality predictors and to develop a new simplified prognostic model among cirrhotic patients with AVB. Methods A simplified prognostic model was developed using multiple logistic regression after identifying significant predictors of 6‐week mortality. Results A total of 713 consecutive patients with AVB were enrolled. The 6‐week overall mortality rate was 18%. Multivariate analysis showed that shock, model for end‐stage liver disease (MELD) score, high‐risk stigmata of esophageal varices on endoscopic finding, and Glasgow Blatchford score were independent predictors of mortality. A new logistic model using these variables was developed. This model (cutoff value ≥ 4) area under the receiver operating characteristics (AUROC) was 0.93 and significantly higher than that of MELD score alone (0.74). Two validation analyses showed that the AUROC of our model was consistently high. The 6‐week rebleeding rate was 25.3%. Multivariate analysis showed that MELD score, Glasgow Blatchford score, history of upper GI bleeding, shock, and alcohol use were independent predictors of rebleeding. Conclusion Our new simplified model accurately and consistently predicted 6‐week mortality among patients with AVB using objective variables measured at admission. Patients with higher MELD scores should be closely monitored due to the higher probability of 6‐week rebleeding.

Recently, a combined regimen of atezolizumab and bevacizumab (AB) treatment has been approved as a first-line treatment in patients with advanced hepatocellular carcinoma (HCC), contributing to prolonged survival. However, we often encounter cases where treatment must be discontinued due to the occurrence of adverse events. One of these events, which is often fatal, is gastrointestinal bleeding. To clarify the clinical effects of gastrointestinal bleeding after AB treatment, we evaluated patients with HCC who were treated with AB at our institution. Of the 105 patients, five treated with AB developed gastrointestinal bleeding, necessitating treatment discontinuation. Additionally, we encountered two cases where exacerbation of varicose veins was observed, and AB therapy could be continued by preventive treatment of varices. In conclusion, an appropriate follow-up is required during treatment with AB to prevent possible exacerbation of varicose veins. [ABSTRACT FROM AUTHOR]

Background: Esophageal varices (OVs) are common side effects of liver cirrhosis that can be life-threatening. Esophago-gastroduodenoscopy (EGD) is the gold standard for detecting OVs. In spite of this, it is intrusive and expensive. Objective: The aim of the current work was to evaluate albumin-Bilirubin Score (ALBI), AST/ALT ratio, aspartate to platelet count ratio index (APRI), Child-Pugh Score, albumin-bilirubin grade, platelets (ALBI-PLT score) and platelet count/spleen diameter ratio as noninvasive laboratory markers for prediction of OVs in cirrhotic patients. Patients and Methods: Two hundred and sixty patients with liver cirrhosis were screened for OVs. CBC, liver and kidney profiles and abdominal ultrasonography were done, ALBI, ALBI-PLT score, AST/ALT ratio, APRI, a Child-Pugh Score and platelet count/spleen diameter ratio were measured for all patients. Also, EGDs were performed by one professional endoscopist for all patients. Results: ALBI, ALBI-PLT, Platelet count/spleen diameter ratio and Child-Pugh Score were reliable indicators of esophageal varices. The best one was ALBI-PLT where at cut-off >2, may predict OVs with sensitivity 96.48 and specificity 87.76 (P< 0.001). Using ALBI at a cutoff >-2.6. may predict OVs with sensitivity of 83.77% and specificity of 53.26% (P = 0.001). Also, these noninvasive markers could help in detecting OV's size (P <0.001). Conclusion: It could be concluded that the combined albumin-bilirubin and platelet grade (ALBI-PLT) and the albumin- bilirubin ratio (ALBI), Platelet count/spleen diameter ratio and Child-Pugh Score could be used as noninvasive markers for detecting esophageal varices and grading them. [ABSTRACT FROM AUTHOR]

Cirrhosis consists of two main stages: compensated (asymptomatic) and decompensated, the latter with a higher mortality. Variceal hemorrhage, together with ascites or encephalopathy, or both, are events that define cirrhosis decompensation and are driven by portal hypertension. The approach and management of patients with compensated cirrhosis has been mostly focused on preventing variceal hemorrhage in those who have high-risk varices on endoscopy. Recent studies suggest a paradigm shift aimed at preventing all decompensating events, not only variceal hemorrhage, in patients with cirrhosis and clinically significant portal hypertension identified via noninvasive measures such as liver stiffness and platelet count. In these patients, nonselective beta-blockers have been shown to prevent ascites (the most common decompensating event) and variceal growth. Variceal hemorrhage has a high mortality rate and even though advances in diagnostic approach and standard of care over the past decades have led to a decrease in mortality, it is still high with a 6-week mortality rate of 15–20%. Survival has improved with the preemptive placement of the transjugular intrahepatic portosystemic shunt in patients at high risk of failing standard therapy. In this review, we provide an overview of the pathophysiology and bases for therapy of portal hypertension and varices, the diagnostic approach and management of compensated cirrhosis with clinically significant portal hypertension, and the management of acute variceal hemorrhage as well as prevention strategies for variceal hemorrhage recurrence. [ABSTRACT FROM AUTHOR]

• Des radiculalgies peuvent être dues à des stases veineuses au sein des ganglions spinaux. • Des sciatiques tronculaires peuvent résulter de stases veineuses dans les vasa-nervorum. • Les tractions sur les racines/nerfs contribuent beaucoup à ce défaut de vidange veineux. • Des obstructions/thromboses de la veine cave ou varices péridurales peuvent se révéler par des sciatiques. • Des stases veineuses dans le pelvis et la cuisse peuvent induire des sciatiques. Les compressions des racines/nerfs ne génèrent pas forcément de douleurs, comme le démontrent l'indolence de nombreuses sténoses lombaires et certains conflits disco-radiculaires. Les radiculalgies et douleurs des syndromes canalaires pourraient, donc, surtout résulter d'œdèmes induits par des stases veineuses autour des ganglions spinaux, racines et nerfs, peu ou non visibles sur l'imagerie. Cette revue recense les arguments en faveur de cette congestion des vasa-nervorum dans la pathogénie des radiculalgies, tant dans le contexte des sténoses lombaires et hernies discales obstruant les veines radiculaires, mais aussi du fait d'autres sources de stase dans les plexus veineux intra- et péri-rachidiens (grossesse, atrésie ou thrombose de la veine cave, hypertension portale, varices épidurales, fistules artérioveineuses, hémangiomes vertébraux). Sont également évoquées les stases veineuses autour du tronc du sciatique (syndromes nutcracker et de May–Thurner, veines glutéales supérieures et inférieures). La prise de conscience que des stases veineuses peuvent suffire à induire des radiculalgies/plexopathies/névralgies : i) remet en question la notion que les compressions sont indispensables à leur induction, une simple traction durable par adhérences du nerf dans deux sites s'écartant trop pouvant aussi suffire à oblitérer les vasa-nervorum ; ii) incite à optimiser des techniques d'IRM permettant de visualiser aussi bien ces vaisseaux que le faisaient les phlébographies lombaires ; iii) pourrait inciter à prévenir les adhérences/arachnoïdites secondaires à la fuite de fibrine survenant lors des stases veineuses aiguës ; iv) fait espérer que des traitements comme des injections hyper-sélectives d'activateur du plasminogène puissent à l'avenir prévenir ou faire régresser les microthromboses survenant dans les veines épidurales/intradurales. [ABSTRACT FROM AUTHOR]

Abstract Background Post-variceal band ligation bleeding ulcer is a severe complication with considerable mortality. We tried evaluating self-expandable metallic stent (SEMS) with concern to the ulcer morphology not well studied. Results We did a retrospective analysis of patients with bleeding post-band ulcers and treated by SEMS with concern to control bleeding and 6 weeks survival. Twenty-eight patients studied had their age (mean ± S.D.) 57.8 ± 8.6 years, and 85.7% were males. The Child-Pugh score range was 5–12]. Control of bleeding by SEMS was achieved in 23 (82.1%) patients, and overall, 6-week survival was 75%. Both post-band ulcer types B (oozing blood and type C (active spurted) were a risk for 6 weeks mortality (P = 0.04, OR 1.58, CI 95% 1.12–2.23). Conclusion SEMS is considered an excellent choice to control esophageal post-banding ulcer bleeding and a definite treatment bridge.

Several studies have indicated that the oral and gut microbiota may exhibit differences in patients with cirrhosis. Less is known about the microbiota in the stomach, which is located between the oral cavity and the intestinal tract. In this study, the gastric mucosal microbiota of patients with liver cirrhosis and controls were analyzed with 16S ribosomal RNA (rRNA) pyrosequencing. Cirrhotic patients had significantly lower Helicobacter pylori (H. pylori) infection rates, as confirmed by both the histological method and the pyrosequencing method. In H. pylori-negative subjects, gastric bacterial communities of healthy and cirrhosis cohorts were clustered into four clusters based on bacterial compositions: Cluster_1 and Cluster_2 (mostly cirrhosis), Cluster_3 (mostly healthy), and Cluster_4 (around half of each). Compositional and functional differences were observed among these different clusters. At the genus level, Cluster_1 and Cluster_2 showed enrichment of Neisseria and Streptococcus, respectively. Functionally, Cluster_2 was characterized as depleted of genetic information processing, as well as of modules related to glycan biosynthesis and metabolism. Patients in Cluster_2 had more severe gastrointestinal symptoms and a higher rate of previous endoscopic variceal ligation (EVL) therapy than patients in other clusters. Our findings suggest that the colonization of both H. pylori and non-H. pylori is influenced in liver cirrhosis. Although the H. pylori-negative gastric mucosal microbiota showed considerable heterogeneity, associations between specific gastric microbiota and clinical characteristics could be observed. Previous EVL therapy might lead to a distinct structure of the gastric mucosal microbiota, thus aggravating the gastrointestinal symptoms in H. pylori-negative cirrhotic patients.

Background & Aims: Benzodiazepines are associated with an increased risk of harm in patients with cirrhosis. However, stopping benzodiazepines must be done with care to avoid withdrawal or other unintended consequences. The impact of deprescribing on patients with cirrhosis is unknown. Methods: We emulated a hypothetical 3-year trial of benzodiazepine deprescription among Medicare enrollees with compensated cirrhosis who lacked other life-limiting diagnoses. All received continuous benzodiazepine prescriptions for the 6-months prior to their diagnosis of cirrhosis. During a 90-day landmark period following their diagnosis of cirrhosis, patients were classified as complete deprescribers (no benzodiazepines dispensed), continuous users, or partial deprescribers. We used inverse probability treatment weighting to compare complete deprescribers to continuous users of traditional benzodiazepines and zolpidem. Outcomes accounted for competing risk of mortality and included incident decompensation (hepatic encephalopathy, ascites, or variceal bleeding), fractures, falls, and alcohol-related hospitalizations. Results: There were 1,651 and 1,463 continuous users of traditional benzodiazepines and zolpidem, respectively, and 728 complete deprescribers. Patients were aged a median of 68 years, 24% had alcohol-related cirrhosis. There was no difference in the risk of death or decompensation for continuous users and deprescribers. Among deprescribers of traditional benzodiazepines, there was no improvement in the risk of falls or fractures. However, compared to continuous zolpidem users, deprescribers had a lower risk of falls (23.2% vs. 31%, p = 0.04) and fractures (21% vs. 29%, p = 0.02). Conclusions: Deprescribing zolpidem reduces the risk of falls and fractures. However, deprescribing benzodiazepines does not improve the risk of decompensation. Efforts to safely address the indications for benzodiazepines such as insomnia and anxiety are urgently needed. Lay summary: Many people with cirrhosis have anxiety, depression, and sleep disorders. Increasingly, patients with cirrhosis are treated with sedating medications called benzodiazepines, including valium, alprazolam (‘Xanax’), clonopin, and the sleep-aid zolpidem (‘Ambien’), which can cause falls, broken bones, and maybe other brain disorders. For this reason, many researchers are interested in trials of ‘deprescribing’ (stopping) benzodiazepines. However, no trials have been performed. We used health record data to simulate a trial of deprescribing. We found that stopping benzodiazepines may reduce the chance of falls or broken bones, but it does not improve survival or liver health.

Objective: To assess the non-invasive biomarkers of fibrosis for predicting varices-needing-treatment in patients with cirrhosis secondary to chronic-hepatitis-C. Study Design: Cross sectional comparative study. Place and Duration of Study: Department of Gastroenterology, Pak Emirates Military Hospital Rawalpindi, from Jan 2017 to Dec 2017. Methodology: A total of 153 patients aged 18-79 with cirrhosis, whether compensated or decompensated, secondary to chronic-hepatitis-C were enrolled. Relevant serum tests were used to calculate non-invasive fibrosis indices and their diagnostic performance to predict the presence of varices and varices-needing-treatment was calculated. Results: King’s score showed the best performance in detecting varices due to high positive predictive value of 96.4% and positive likelihood ratio of 2.4. Overall, all the non-invasive fibrosis indices exhibited good performance with positive predictive value >85% but none could rule out the presence of varices with adequate reliability due to low negative-predictive-value (

Abstract Background and Aim Hepatic venous pressure gradient (HVPG), although an important determinant in predicting rebleeding after an episode of acute variceal bleed (AVB), is seldom utilized in clinical practice. We aimed to study the role of liver stiffness measurement (LSM) after variceal bleeding as a potential noninvasive predictor of rebleed. Methods This was a post hoc analysis of clinical trial of patients undergoing HVPG (postbleed HVPG) and LSM (postbleed LSM) assessment within 3–5 days of index AVB. HVPG response was assessed after 4 weeks of pharmacotherapy. Comparative assessment of long‐term rebleeding rates stratified using postbleed LSM, postbleed HVPG, and HVPG response was performed. Decision curve analysis (DCA) was conducted to identify the most appropriate tool for routine use. Results Long‐term clinical and HVPG response data were available for 48 patients post‐AVB, of whom 45 patients had valid postbleed LSM. Rebleeding occurred in 13 (28%) patients over a median follow‐up of 4 years with no early rebleeds. Postbleed LSM >30 kPa and baseline HVPG >15 mm Hg were optimal cutoffs for identifying patients at high risk of rebleeding. Time‐dependent receiver operating characteristic curves and competing risk analysis accounting for death showed similar discriminative values for all three stratification tools. At usual risk thresholds, HVPG response had maximum benefit on DCA followed by postbleed LSM. On DCA, 50–60 additional HVPGs were required to detect one additional patient at high risk of rebleed. Conclusion Liver stiffness measurement during AVB can potentially be used as an alternative to portal pressure indices in decompensated cirrhosis to identify those at high risk of late‐onset rebleed.

Abstract Background Proprotein convertase subtilisin/kexin type 9 (PCSK9) is of particular importance in cholesterol metabolism with high levels contributing to hypercholesterolemia. Cholesterol and sphingolipids are low in patients with liver cirrhosis. Purpose of this study was to find associations of plasma PCSK9 with circulating cholesterol and sphingolipid species and measures of liver disease severity in patients with liver cirrhosis. Methods PCSK9 protein levels were determined by ELISA in systemic vein (SVP), hepatic vein (HVP) and portal vein plasma of patients with mostly alcoholic liver cirrhosis. PCSK9 and LDL-receptor protein expression were analysed in cirrhotic and non-cirrhotic liver tissues. Results Serum PCSK9 was reduced in patients with liver cirrhosis in comparison to non-cirrhotic patients. In liver cirrhosis, plasma PCSK9 was not correlated with Child-Pugh score, Model for End-Stage Liver Disease score, bilirubin or aminotransferases. A negative association of SVP PCSK9 with albumin existed. PCSK9 protein in the liver did not change with fibrosis stage and was even positively correlated with LDL-receptor protein levels. Ascites volume and variceal size were not related to PCSK9 levels. Along the same line, transjugular intrahepatic shunt to lower portal pressure did not affect PCSK9 concentrations in the three blood compartments. Serum cholesterol, sphingomyelin and ceramide levels did not correlate with PCSK9. Stratifying patients by high versus low PCSK9 levels using the median as cut-off, several cholesteryl ester species were even low in the subgroup with high PCSK9 levels. A few sphingomyelin species were also reduced in the patients with PCSK9 levels above the median. PCSK9 is highly expressed in the liver but systemic, portal and hepatic vein levels were similar. PCSK9 was not correlated with the inflammatory proteins C-reactive protein, IL-6, galectin-3, resistin or pentraxin 3. Of note, HVP PCSK9 was positively associated with HVP chemerin and negatively with HVP adiponectin levels. Conclusions In the cohort of patients with liver cirrhosis mostly secondary to alcohol consumption high PCSK9 was associated with low levels of certain cholesteryl ester and sphingomyelin species. Positive correlations of PCSK9 and LDL-receptor protein in the liver of patients with chronic liver injury are consistent with these findings.

Summary: Background: The presence of esophageal varices is considered a relative contraindication to transesophageal echocardiography (TEE) by cardiology professional societies, so gastroenterologists are often consulted to perform upper endoscopy prior to TEE in patients with cirrhosis. Aim: To perform a systematic review to quantify the risk of bleeding complications in patients with cirrhosis following TEE. Methods: Two reviewers searched Ovid MEDLINE, MEDLINE In‐Process and EMBASE databases from January 1992 to May 2021 for studies reporting bleeding complications from TEE in patients with cirrhosis. We calculated the pooled incidence rate of bleeding events using the metaprop command with a random effect model. Results: We identified 21 studies comprising 4050 unique patients with cirrhosis; 9 studies (n = 3015) assessed the risk of intraoperative TEE during liver transplant (LT) and 12 studies (n = 1035) assessed bleeding risk in patients undergoing TEE for other indications. The pooled incidence of bleeding post‐TEE was 0.37% (95% CI 0.04–0.94%) across all studies. Bleeding complications were low among patients undergoing TEE during LT as well as those undergoing TEE for other diagnostic reasons (0.97% vs. 0.004%) and among studies with mean MELD >18 compared to those with mean MELD <18 (0.43% vs. 0.08%). Few studies had a comparator arm, and data on patient‐level factors impacting bleeding complications (including degree of liver dysfunction and coagulopathy) were limited across studies. Conclusions: The risk of bleeding complications following TEE is low in patients with cirrhosis, suggesting TEE is safe and risk stratification with upper endoscopy may not be necessary. [ABSTRACT FROM AUTHOR]

Background: Left‐sided portal hypertension (LSPH) caused by splenic vein (SV) division in pancreaticoduodenectomy (PD) with portal vein (PV) resection remains challenging. The current study aimed to investigate the efficacy of splenic artery (SA) ligation in preventing LSPH. Methods: One‐hundred thirty patients who underwent PD with PV resection for pancreatic ductal adenocarcinoma were classified into SV and SA preservation (SVP, n = 30), SV resection and SA preservation (SVR, n = 59), and SV resection and SA ligation (SAL, n = 41). The postoperative incidence of LSPH was assessed. Results: The incidence of variceal formation in SVP, SVR, and SAL were 4.8%, 53.2%, and 46.4% at 3 mo, 13.0%, 71.2%, and 62.5% at 6 mo, and 25.0%, 87.5%, and 87.1% at 12 mo, respectively. The rate was significantly higher in SVR at 3 and 6 mo (P =.001 and P <.001, respectively) and in SVR and SAL (P <.001) at 12 mo. Variceal hemorrhage occurred only in SVR (n = 4). The platelet count ratio at 3, 6, and 12 mo began to significantly decrease from 3 mo in SVR (0.77, 0.67, and 0.60, respectively; P <.001) and 6 mo in SAL (0.91, 0.73, and 0.69, respectively; P <.001). The spleen volume ratio also showed significant increase from 3 mo in SVR (1.24, 1.34, and 1.42, respectively; P <.001) and 6 mo in SAL (1.31, 1.32, and 1.34, respectively; P <.001). SVR and SAL were significant risk factors for variceal formation at 12 mo (odds ratio, 21.0 and 20.3, respectively). Conclusion: In PD with PV resection, SAL delayed LSPH but could not prevent its occurrence. [ABSTRACT FROM AUTHOR]

Chronic venous insufficiency (CVI) is a frequent vascular pathology in the elderly and generates difficulties in its diagnosis and treatment due to the presence of comorbidities. A narrative review was carried out from the search in five databases: PubMed, Scielo, Lilacs, Clinical Key (Elsevier) and Ebsco. In the geriatric population, more severe stages of the disease occur, such as edema and trophic changes in the leg, due to the pre-existence of chronic venous disease. The main risk factors for disease progression are obesity, limited mobility and comorbidities. Diagnosis is based on clinical suspicion and confirmation with venous echo Doppler of the lower limbs. Systemic causes of lower limb edema such as heart failure, renal or hepatic dysfunction, and the use of hypertensive medications should be considered in the differential diagnosis. Other differential diagnoses are lymphedema, subclinical venous thrombosis, and chronic lower limb pain. Treatment includes patient education, compression stockings, medical and surgical treatment. In conclusion, chronic venous insufficiency is a frequent and more severe disease in elderly patients. Obesity, poor mobility and comorbidities are the risk factors associated with the progression of the disease. Patient education, use of compression stockings, and phlebotonics are effective in treatment. Surgical / endovenous treatment has good effectiveness in elderly patients suffering from CVI. [ABSTRACT FROM AUTHOR]

Non-alcoholic steatohepatitis has become a leading cause of cirrhosis. The prognostic value of (HVPG)-guided NSBB prophylaxis remains to be investigated in the setting of NASH cirrhosis. Patients with NASH cirrhosis and varices undergoing HVPG-guided NSBB therapy were included. HVPG-response to NSBBs was evaluated within a median 52 (IQR:28–71) days after baseline measurement. HVPG-Response was defined as a decrease of ≥10% from baseline or below <12 mmHg. The composite endpoint was defined as variceal bleeding, decompensation, and liver-related death. Thirtyeight patients were included: Child-A/B:33(87%), Child-C:5(13%) median HVPG:19.7 ± 4.7 mmHg. 21(55.3%) patients achieved HVPG-response to NSBB. Presence of diabetes(aOR:0.16, p = 0.038) and arterial blood pressure (aOR:1.07, p = 0.044) were independently associated with NSBB-response. While NSBB-HVPG-responders showed fewer decompensations within 90 days (n = 1(5%) vs. n = 3(29%), p = 0.172), only Child-Pugh stage B/C (p = 0.001), MELD ≥ 15(p = 0.021) and HVPG ≥ 20 mmHg(p = 0.011) predicted the composite endpoint at 90 days. Similarly, after 2years of follow-up, only Child-Pugh stage (B: p = 0.001, C: p < 0.001), MELD ≥ 15 (p = 0.021), HVPG≥20 mmHg (p = 0.011) predicted the composite endpoint. Importantly, all bleeding events occurred in HVPG-NSBB non-responders. HVPG-response to NSBB was achieved in 55.3% of NASH patients with varices and this seemed to protect from variceal bleeding. However, only baseline HVPG ≥ 20 mmHg, Child-Pugh stage B/C and MELD ≥ 15 were predictors of decompensation/death in patients with NASH cirrhosis and varices. [ABSTRACT FROM AUTHOR]

Se realizan consideraciones etiopatogénicas sobre el linfedema. Se destaca, la función· de válvula en el sentido linfodinámico de la corriente linfática de los linfonódulos y de la cisterna de Pecquet. Se distingue el reflujo del quilo del reflujo linfático pélvico. Bajo este concepto se plantea el tratamiento medicoquirúrgico de esta afección. Se destaca la importancia de la linfografía en el diagnóstico de esa enfermedad. Se presenta un caso de nuestra casuística y los resultados obtenidos hasta los tres meses de operado.

Se analiza un tipo especial· de linfoedema primario no obstructivo de los miembros inferiores, caracterizado por gruesas várices tronculares linfáticas en las region es subcisternales del abdomen y de los miembros inferiores uni o bilateral, asociado a una agenesia ganglionar inguinoiliolumboaórtica y colectores avalvulados. Se resalta el valor fundamental de la cisterna chili y de los ganglios linfáticos escalonados en el sistema, que evitan el reflujo de la linfa en su ascenso antigravitacional. Cuando faltan ls ganglios y existen los colectores, se produce el síndrome del reflujo del quilo hacia los miembros inferiores. De acuerdo a esta etiopatogenia y a los trastornos fisiopatológicos provocados, es lógica la operación propuesta por E. Tosatti de la ligadura suprainguinal de los troncos para evitar el reflujo. Se presenta el primer caso de reflujo del quilo de nuestro país, diagnosticado linfográficamente y operado de acuerdo a la técnica de Tosatti (Dr. J. Mañana), en un paciente masculino de 15 años de edad, que comenzó con un linfoedema del miembro inferior derecho a los 12 años lución. La existencia de ganglios inguinales izquierdos impidió el reflujo y el linfoedema del otro miembro. La evolución postoperatoria inmediata fue excelente.

Abstract Background Cirrhosis is a rapidly increasing cause of global mortality. To improve cirrhosis care, the Veterans Health Administration (VHA) developed the Hepatic Innovation Team (HIT) Collaborative to support VA Medical Centers (VAMCs) to deliver evidence-based cirrhosis care. This randomized HIT program evaluation aims to develop and assess a novel approach for choosing and applying implementation strategies to improve the quality of cirrhosis care. Methods Evaluation aims are to (1) empirically determine which combinations of implementation strategies are associated with successful implementation of evidence-based practices (EBPs) for Veterans with cirrhosis, (2) manualize these “data-driven” implementation strategies, and (3) assess the effectiveness of data-driven implementation strategies in increasing cirrhosis EBP uptake. Aim 1 will include an online survey of all VAMCs’ use of 73 implementations strategies to improve cirrhosis care, as defined by the Expert Recommendations for Implementing Change taxonomy. Traditional statistical as well as configurational comparative methods will both be employed to determine which combinations of implementation strategies are associated with site-level adherence to EBPs for cirrhosis. In aim 2, semi-structured interviews with high-performing VAMCs will be conducted to operationalize successful implementation strategies for cirrhosis care. These data will be used to inform the creation of a step-by-step guide to tailoring and applying the implementation strategies identified in aim 1. In aim 3, this manualized implementation intervention will be assessed using a hybrid type III stepped-wedge cluster randomized design. This evaluation will be conducted in 12 VAMCs, with four VAMCs crossing from control to intervention every 6 months, in order to assess the effectiveness of using data-driven implementation strategies to improve guideline-concordant cirrhosis care. Discussion Successful completion of this innovative evaluation will establish the feasibility of using early evaluation data to inform a manualized, user-friendly implementation intervention for VAMCs with opportunities to improve care. This evaluation will provide implementation support tools that can be applied to enhance the implementation of other evidence-based practices. Trial registration This project was registered at ClinicalTrials.Gov ( NCT04178096 ) on 4/29/20.

Se da cuenta de los muy buenos resultados obtenidos en el tratamiento de las úlceras varicosas de pierna, mediante la utilización del vendaje hidrostático de Wood, en nueve pacientes sin solución medicoquirúrgica satisfactoria, y se hace mención especial de dos casos particularmente graves.

Background and Aim Esophagogastroduodenoscopy (EGD) is the gold standard tool in both screening/diagnosis and management of varices in cirrhotic patients; however, its invasive nature may be uncomfortable to some patients, and in addition, it may be unavailable in some centers that cannot afford it. Therefore, to decrease the economic and physical burden on patients, multiple noninvasive clinical, laboratory, and radiological parameters are evaluated as triage screening predictors of varices before patients' referral to endoscopy. In this respect, we tried to evaluate the validity of portal vein velocity (PVV) as a noninvasive screening tool of esophageal varices (EV). Methods One hundred thirty‐five cirrhotic patients were consecutively enrolled in this cross‐sectional study. All patients were evaluated independently and blindly by EGD as the gold standard and then by Doppler ultrasound on portal vein (PV). Results Univariate regression showed significant coefficients for PVV, platelet (PLT), albumin, bilirubin, international normalized ratio (INR), portal vein diameter, and ascites; however, multivariable regression showed significant coefficients only for PVV, PLT, and albumin; (P = 0.000, 0.000, and 0.006, respectively). Area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, LR+, and LR− values were then calculated and validated using bootstrap analysis. PVV was more accurate than other evaluated parameters (AUROC: 0.927 and P = 0.000). The most accurate rule out cutoff value for PVV was ≥19 cm/s with the sensitivity of 97% and LR− of 0.05. Conclusion PVV may be useful as a noninvasive triage test for selection of the high‐risk cirrhotic patients who should be referred to and could benefit from EGD. We could highlight using PVV to rule out EV at a cutoff value ≥19 cm/s, reserving EGD only for patients with the PVV value

Las várices colónicas son una enfermedad poco común del colon que, de forma general, suelen manifestarse con la presencia de hemorragia digestiva inferior, y motivan siempre esfuerzos en la búsqueda subyacente de su etiología. En la mayoría de los casos se producen en el contexto de una hipertensión portal secundaria a cirrosis o trombosis de la vena porta. Sin embargo diversos estudios han demostrado que aun con la presencia de cirrosis hepática su prevalencia es muy baja. Feldman, en un estudio reportado sobre 2.912 cadáveres de pacientes fallecidos con cirrosis hepática encontró, en dos autopsias, este tipo de lesión o de alteración en la vascularización del colon y estimó su prevalencia en un 0.0007% según los resultados. Existen otras causas, tales como trombosis de la vena mesentérica, insuficiencia cardiaca, malformaciones arteriovenosas y pancreatitis crónica. La presencia de varices colónicas en ausencia de cualquiera de las etiologías antes mencionadas es extremadamente rara y se pueden clasificar como varices colónicas idiopáticas, constituyendo una causa infrecuente de hemorragia digestiva inferior. La importancia de un correcto diagnóstico deriva de una grave complicación asociada a las várices colónicas, el sangrado gastrointestinal bajo severo, podría poner en peligro la vida del paciente y representa una urgencia médica, por tal motivo se debe tomar en consideración al momento de plantear posibles diagnósticos

Parastomal varices are an uncommon but significant source of hemorrhage in patients with portal hypertension, often posing diagnostic and therapeutic challenges. We report the case of a 73-year-old male with a history of alcoholic liver disease and a urostomy following cystoprostatectomy for bladder cancer. The patient presented with profuse bleeding from his urostomy site. Imaging revealed dilated vessels within the ileal conduit and associated mesentery and peri esophageal varices, suggesting possible underlying portal hypertension. This case highlights the importance of considering parastomal varices in patients with stomas and liver disease who present with bleeding., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Desouky et al.)

Background: Commercial single-use endoscopic multiband ligators, used for esophageal variceal band ligation (EVL), are prohibitively expensive. To enable greater access to EVL, we used disruptive innovation to develop a novel endoscopic multiband ligator., Methods: We designed and tested a prototype handle 'ENDOhandle' using computer-aided design modeling and exported a cap, trigger cord and latex to form a functional banding unit., Results: The cost of the banding unit was US$4.80 compared with several hundred US dollars for commercially available devices in the USA., Conclusions: Disruptive innovation technology developed an inexpensive ligator for resource-challenged health settings., (© The Author(s) 2024. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

The article presents a case study of a 72-year-old male with longstanding varicose veins in the left forearm, emphasizing the rarity of upper extremity varicose veins and exploring their diagnosis and management, including surgical interventions. Topics discussed include the etiology of upper limb varicose veins, differential diagnosis, and various treatment options, such as surgical procedures and lifestyle modifications.

Duodenal varices (DVs) are ectopic gastrointestinal varices (ECVs) associated with portal hypertension (PH). We present the case of an 82‐year‐old woman who presented with symptomatic anemia secondary to DV hemorrhage diagnosed on oesophagogastroduodenoscopy. This lesion was treated with endoscopic adrenaline injection and clip application. The patient re‐presented on multiple occasions with bleeding recurrence localized to the duodenum, which was managed with intramuscular octreotide and oral beta‐blockade resulting in sustained remission of bleeding. This case highlights a rare cause of upper gastrointestinal hemorrhage and highlights the value of somatostatin analogues for conservative treatment of DVs. [ABSTRACT FROM AUTHOR]

This paper seeks to give a broad overview of pediatric upper gastrointestinal (GI) pathologies that we are now able to treat endoscopically, acquired or congenital, and we hope this delivers the reader an impression of what is increasingly available to pediatric endoscopists and their patients.

Introduction: Despite intensive research, reliable blood-derived parameters to detect clinically significant portal hypertension (CSPH) in patients with cirrhosis are lacking. As altered homeostasis of cyclic guanosine monophosphate (cGMP), the central mediator of vasodilatation, is an essential factor in the pathogenesis of portal hypertension, the aim of our study was to evaluate plasma cGMP as potential biomarker of cirrhotic portal hypertension.Methods: Plasma cGMP was analyzed in cirrhotic patients with CSPH (ascites, n = 39; esophageal varices, n = 31), cirrhotic patients without CSPH (n = 21), patients with chronic liver disease without cirrhosis (n = 11) and healthy controls (n = 8). cGMP was evaluated as predictor of CSPH using logistic regression models. Further, the effect of transjugular intrahepatic portosystemic shunt (TIPS) placement on plasma cGMP was investigated in a subgroup of cirrhotic patients (n = 13).Results: Plasma cGMP was significantly elevated in cirrhotic patients with CSPH compared to cirrhotic patients without CSPH [78.1 (67.6–89.2) pmol/ml vs. 39.1 (35.0–45.3) pmol/l, p < 0.001]. Of note, this effect was consistent in the subgroup of patients with esophageal varices detected at screening endoscopy who had no prior manifestations of portal hypertension (p < 0.001). Cirrhotic patients without CSPH displayed no significant elevation of plasma cGMP compared to patients without cirrhosis (p = 0.347) and healthy controls (p = 0.200). Regression analyses confirmed that cGMP was an independent predictor of CSPH (OR 1.042, 95% CI 1.008–1.078, p = 0.016). Interestingly, portal decompression by TIPS implantation did not lead to normalization of plasma cGMP levels (p = 0.101).Conclusions: Plasma cGMP is a promising biomarker of CSPH in patients with cirrhosis, especially with respect to screening for esophageal varices. The lacking normalization of plasma cGMP after portal decompression suggests that elevated plasma cGMP in cirrhotic portal hypertension is mainly a correlate of systemic and splanchnic vasodilatation, as these alterations have been shown to persist after TIPS implantation.