Clinical Endoscopy

Evaluation of Non-invasive Fibrosis Markers in Predicting Esophageal Variceal Bleeding: Sami Cifci, Nergiz Ekmen; Clin Endosc 2021;54(6):857-863. Published online May 26, 2021; DOI: https://doi.org/10.5946/ce.2021.028

Background
/Aims: Esophageal variceal bleeding (EVB) is an important cause of mortality and morbidity in liver cirrhosis. In this study, we aimed to predict the possibility of EVB in patients with cirrhosis using a non-invasive score.
Methods
A total of 359 patients with cirrhosis were divided into two groups based on the presence or absence of EVB. ChildTurcotte-Pugh (CTP) score, a model for end-stage liver disease, aspartate aminotransferase to alanine aminotransferase ratio, aspartate aminotransferase to platelet ratio index (APRI), fibrosis-4-index (FIB-4), aspartate aminotransferase to alanine aminotransferase ratio/platelet ratio index (AARPRI), and S-index were measured for all participants. Receiver operating characteristic curves were obtained for all parameters, and the optimal cut-off value was determined in predicting EVB.
Results
In patients with EVB, the number of platelets (PLT) were low (p<0.001) and APRI, AARPRI, FIB-4, and S-index were significantly higher than those in patients without EBV. APRI, AARPRI, FIB-4, PLT, and S-index were statistically significant predictors of EVB (p<0.05).
Conclusions
FIB-4 and AARPRI, which are non-invasive markers of fibrosis, can be used to predict EVB. In addition, the 66.5 10⁹/L cut-off value for PLT is important for EVB.

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Prognostic model for esophagogastric variceal rebleeding after endoscopic treatment in liver cirrhosis: A Chinese multicenter study
Jun-Yi Zhan, Jie Chen, Jin-Zhong Yu, Fei-Peng Xu, Fei-Fei Xing, De-Xin Wang, Ming-Yan Yang, Feng Xing, Jian Wang, Yong-Ping Mu
World Journal of Gastroenterology.2025;[Epub] CrossRef
Non-invasive Fibrosis Markers for Predicting Esophageal Varices: A Potential Alternative to Endoscopic Screening
Kunza Ali, Saad Slah-Ud-Din, Mishal Afzal, Mah R Tariq, Tallha Waheed, Haroon Yousuf
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Current and Future Use of Esophageal Capsule Endoscopy: Junseok Park, Young Kwan Cho, Ji Hyun Kim; Clin Endosc 2018;51(4):317-322. Published online July 31, 2018; DOI: https://doi.org/10.5946/ce.2018.101

Abstract PDF PubReader ePub

Capsule endoscopy can be a diagnostic option for patients with esophageal diseases who cannot tolerate esophagogastroduodenoscopy.Functional modifications of the capsule allow for thorough examination of the esophagus. Esophageal capsule endoscopy has so farfailed to show sufficient performance to justify the replacement of traditional endoscopy for the diagnosis of esophageal diseasesbecause the esophagus has a short transit time and common pathologies appear near the esophagogastric junction. However,technological improvements are being introduced to overcome the limitations of capsule endoscopy, which is expected to become agood alternative to conventional endoscopy.

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Prevention and Management of Gastroesophageal Variceal Hemorrhage: Soung Won Jeong, M.D., Joo Young Cho, M.D., Sung Jae Shin, M.D.*, Moon Young Kim, M.D.^†, Byung Seok Lee, M.D.^‡, Tae Hee Lee, M.D.^§, Jae Young Jang, M.D., Yeon Seok Seo, M.D.^∥, Hoon Jai Chu; Korean J Gastrointest Endosc 2010;40(2):71-83. Published online February 27, 2010

Abstract PDF: Gastroesophageal variceal hemorrhage involving increased portal pressure is the most common fatal complication of liver cirrhosis. Gastroesophageal varices are present in approximately 50% of patients with liver cirrhosis. Although acute variceal hemorrhage-related mortality has decreased significantly over the last decade, it still is at least 20% at 6 weeks after variceal bleeding even with optimal management. In patients with medium and large varices that have not bled but have a high risk of hemorrhage, nonselective Ղ-blockers or endoscopic variceal ligation may be recommended for the prevention of first variceal hemorrhage. Acute variceal hemorrhage requires intravascular volume support and blood transfusions with vasoconstrictive agents and prophylactic antibiotics. Endoscopic variceal ligation and nonselective Ղ-blockers are standard secondary prophylaxis therapies for variceal bleeding. Patients whose hepatic venous pressure gradient decreases to ＜12 mmHg or at least 20% from baseline levels after treatment with nonselective Ղ-blockers can reduce the probability of recurrent variceal hemorrhage. In gastric fundal varices, endoscopic variceal obturation using cyanoacrylate is preferred. For failures of medical therapy, a transjugular intrahepatic portosystemic shunt or surgically created shunts are salvage procedures. (Korean J Gastrointest Endosc 2010;40:71-83)

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식도정맥류 경화요법 후 좌위 및 단위정맥의 변화: Korean J Gastrointest Endosc 2003;27(5):401-401. Published online November 20, 2003

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식도 정맥류 출혈을 동반한 원발성 골수섬유증 1예 ( A Case of Idiopathic Myelofibrosis Causing an Esophageal Variceal Hemorrhage ): Korean J Gastrointest Endosc 2000;21(1):549-553. Published online November 30, 1999

Abstract PDF: Idiopathic Myelofibrosis (IMF), a clonal disorder of a multipotent hemtopoietic progenitor cell of unknown etiology, is characterized by massive splenomegaly, leukoerythroblastic blood changes, and bone marrow fibrosis. Portal hypertension occurs in approximately 10% of patients with IMF. Alsom there mey be bleeding from esophageal varices. A 59-year-old woman was admitted with intermittent abdominal distension and melena. An esophagogastroduodenoscopy revealed extensive esophageal varices with red colored signs, and subsequently esophageal variceal ligation was performed. Marked splenomegaly and ascites was observed through abdominal US and MRI scan. Bone marrow biopsy revealed an increase in reticulin and fibrosis. Extramedullary hematopoiesis and sinusoidal change were observed in the liver biopsy specimen. This case of IMF causing an esophageal variceal hemorrhage is herein reported. (Korean J Gastrointest Endosc 2000;21:549-553)

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식도정맥류에 있어서 새로운 소형 박리성계제 결찰용범 ( Mini-detachable snare ligation ) 의 임상적 유용성 ( Clinical Usefulness of the Newly Designed Mini-Detachable Snare Ligation on Esophageal Varices ): Korean J Gastrointest Endosc 2000;20(4):245-253. Published online November 30, 1999

Abstract PDF: Background
/Aims : At present, various methods of endoscopic esophageal variceal treatment have been developed. But a superlative method has yet not been developed for endoscopic esophageal variceal treatment. For overcoming various disadvantages of endoscopic esophageal variceal treatment. We manufactured and reported the usefulness of a newly designed mini-detachable snare (stainless steel) in the treatment of esophageal varices. Methods : In this randomized trial, we performed mini-detachable snare ligation (MDL) on 46 patients who had esophageal varices and we compared the results with the group of multiple band ligation (MBL) performed on 57 patients in the aspects of urgent hemostatic rate, rebleeding rate, eradication rate and recurrence rate etc. from March, 1997 to present. Results: 6 of 7 patients (86%) in mini-detachable snare ligation group and 11 of 13 patients (85%) in multiple band ligation group were successfully controlled by urgent hemostasis. Rebleeding following initiation occured in 2 (5.5%) in MDL group and 3 (5.3%) in MBL group. Esophageal varices were eradicated or reduced to grade I in 96% and 98% by 2-7 snares and 3-10 ligation/one session in 3-9 and 3-8 session (mean+ SD: 4.8±2.1 and 4.5±1.9 session) in the MDL group and MBL group respectively. The recurrence rate was 5 (11%) and 6 (11%) in MDL group and MBL group respectively during 6 to 16 months follow up period. The mean procedure time taken during 5 snares or 5 bands was 4.07±3.8 min and 3.23±1.2 min in MDL group and MBL group respectively. No serious complications occurred in both groups. Conclusions : The mini-detachable snare ligation may be considered as a new and relatively safe, and effective therapeutic modality in the treatment for esophageal varices, Also the mini-detachable snare system is much cheaper than other multi-fire ligation devices but further clinical evaluation and more technical improvements in mini-detachable snare ligation will be needed. (Korean J Gastrointest Endosc 2000;20:245-253)

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식도정맥류에 대한 내시경적 결찰술과β차단제의 병합치료효과 (Combined Therapy of Endoscopic Variceal Ligation andβ-Blocker for Esophageal Varices ): Korean J Gastrointest Endosc 1999;19(2):165-170. Published online November 30, 1998

Abstract PDF: Background
/Aims: Endoscopic variceal ligation (EVL) has been accepted as safe and useful treatment for esophageal varices. However, the main problem is the recurrence after eradication of varices.β-blockers have been shown to be effective for prevention of vari-ceal bleeding. We evaluate the efficacy of the combined therapy of EVL and β-blocker against recurrence of esophageal varices. Methods: 39 patients followed from October 1992 through February 1998 after eradication of esophageal varices by EVL were divided into two groups: group 1; 20 patients received EVL alone, group 2; 19 patients received EVL and propranolol for follow-up periods. The rate of recurrence and rebleeding were observed in two groups. Results: Follow-up periods in group 1 and 2 after an initial eradication of esophageal varices were 1039.6 (291-1499) and 928.3 (448-1793) days, re-spectively. During follow-up periods, the recurrence rate was lower in group 2 (27.8%) than group 1 (60.0%) (p ＜0.05). The periods from last session to recurrence were 609.1 (128-1460) and 666.2 (405-1007) days in group 1 and 2, respectively. The rebleeding and mortality rates were 15.0% and 25.0% in group 1. Conclusions: Combined therapy of EVL and β-blocker could decrease the recurrence rate after eradication of esophageal varices, as compared with EVL alone. The further large, long-term study should be re-quired.(Korean J Gastrointest Endosc 19: 165 ∼170, 1999)

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식도정맥류에 대한 내시경적 정맥류 결찰요법 후 재출혈 및 재발과 연관된 위험인자들 ( Risk Factors Associated with Rebleeding and Recurrence Following Endoscopic Variceal Ligation ): Korean J Gastrointest Endosc 1999;19(1):1-8. Published online November 30, 1998

Abstract PDF: the first EVL was associated with rebleeding (p=0.01); whereas, age, Child class, grade and extent of varices, presence of gastric varices and/or portal hypertensive gastropathy, total number of bands and sessions for successful EVL were not (p ＞0.05). Persistence of esophageal ulcer at 2 weeks after the first EVL was associated with rebleeding also in multivariate analysis (relative risk 5.87, p=0.01). 3) In univariate analysis, grade (p=0.01) and extent (p=0.01) of varices were related to recurrence; whereas, age, Child class, presence of gastric varices and/or portal hypertensive gastropathy, total number of bands and sessions for successful EVL were not (p ＞0.05). In multivariate analysis, grade of varices was the only risk factor associated with recurrence (relative risk 3.76, p=0.01). Conclusions: 1) Persistence of esophageal ulcer at second week after the first EVL was associated with rebleeding. 2) Frequent follow-up endoscopic examinations are necessary in patients who present with high grade of varices since risk of recurrence is high even after successful EVL. (Korean J Gastrointest Endosc 19: 1 ∼8, 1999)

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원저 : 식도 위장관 ; 식도정맥류에 대한 내시경적 결찰요법의 치료효과 및 장기 추적관찰 ( Original Articles : Esophagus , Stomach & Intestine ; Efficacy and Longterm Follow-up of Endoscopic Variceal Ligation on Esophageal Varix Bleeding ): Korean J Gastrointest Endosc 1996;16(5):707-714. Published online November 30, 1995

Abstract PDF: Hemorrhage from esophageal varices is a catastrophic complication of portal hypertension. Endoscopic variceal ligation(EVL) is a newly developed technique that may replace Endoscopic injection sclerotherapy(EIS). But there are a few reports of longterm follow-up of EVL in Korea. We analysed 42 patients to evaluate longterm effect of EVL for esophageal varices. Total 689 variceal ligations were performed during 117 separate EVL sessions. Control rate of acute bleeding was 90.5%(38 of 42 patients). Four patients who were failed on control of acute bleeding were taken EIS with successful bleeding control. The eradication rate of esophageal varix was 76.2%(32 of 42 patients), the mean session for eradication of varix was 3,0(2-6), the number of bands per person was 16.0(5-41), and the number of bands per session was 6.0(4-11). Rebleeding after initiation of EVL occured in 1l of 42 patient(26,2%). 81.8% of rebleeding occurred 6 months later after EVL was done. The mortality rate and survival rate after varix eradication during follow-up period(after 6-45 months, mean: 15.5 months) was each 14.3%(6/42) and 85.7%(36/ 42). The causes of death were hepatic failure (3/6), esophageal variceal bleeding(2/ 6) and hepatic encephalopathy(l/6). After EVL, the~re were no serious treatment-re lated complications: except mild complications: mild chest pain in 5 patient(12.0%), mild substernal pain in 7 patients(16.6%). These results suggest that EVL is a safe and effective method for treatment of variceal bleeding control and eradication of esophageal varices with least serious complication. But regular periodic examination(interval of 4-6 months) and repeat EVL after eradication of varices should be required becuse of recurrence of varix and rebleeding. (Korean J Gaatrointest Endosc 16: 707~714, 1996)

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원저 : 식도 위장관 ; 출혈위험성이 높은 식도정맥류에 대한 예방적인 내시경적 정맥류 결찰요법 ( Original Articles : Esophagus , Stomach & Intestine ; Prophylactic Endoscopic Variceal Ligation for Esophageal Varices with High - risk of Hemorrhage ): Korean J Gastrointest Endosc 1996;16(4):561-567. Published online November 30, 1995

Abstract PDF: Prophylactic treatment of varices is an appealing concept because 50% of patients who experience variceal bleeding will die within the first 6 weeks of the first bleeding. However, the majority of trials which have evaluated prophylactic therapy gave failed to demonstrate advantage, We tried prophylactic endoscopic variceal ligation(EVL) in 10 patients, to evaluate the safety and effect of prophylactic EVL for esophageal varices with high-risk of hemorrhage. The eradication rate was 100% without bleeding and mortality, the mean session for eradication of varices 1.9, the number of bands per person 16.9 and the number of bands per session 8.9. Although mild chest pain(5.3%) and chest discomfortness(31.6%) were observed, no serious complication related with EVL resulted from 19 EVL sessions. The patients were followed for a mean of 327.0 days(85-708), during which recurrent esophagea1 varices were found in a case at 260 days from last session, but no bleeding nor death was occured. No late complication of EVL was documented. In conclusion, prophylactic EVL is safe and may be effective for esophageal varices with high-risk of hemorrhage. But, the large controlled-trial should be required, (Korean J Gastrointest Endosc 16: 561~567, 1996)

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원저 : 식도 위장관 ; 식도정맥류 출혈에 있어서 내시경적 다연발 정맥류 결찰요법의 임상적 의의 ( Original Articles : Esophagus , Stomach & Intestine ; Clinical Significance of Multi - Band Ligation for Esophageal Variceal Bleeding ): Korean J Gastrointest Endosc 1996;16(4):551-560. Published online November 30, 1995

Abstract PDF: Endoscopic esophageal variceal ligation(EVL) was first introduced by Stiegmann and colleagues in 1986, and it has since grown to he became an extremely popular modality throughout the world as well as Korea. Endoseopic variceal ligation(EVL), which consists of mechanical ligation and thrombosis of varices using elastic O-rings, has been recently developed as a non-operative alternative to endapic injection sclerotherapy(EIS). EVL is minimally operator-dependent and is also associated with fewer local and systemic complications than sclerotherapy. However, the conventional device has only one O ring, and thus the inner cylinder has to be exchanged after each ligation, So, it is a time-consurning procedure that requires the use of an overtube which has somtimes caused tearing of the esophageal mucosa. To save time and control variceal bleeding, multi-band ligation(MBL) was developed. These ligators have five or six O rings, and serial ligation is now possible without exchanging the cylinder or withdrawing the endoscope. (Korean J Gastrointest Endosc 16: 551~ 560, 1996) (continue...)

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원저 : 식도 위장관 ; 식도정맥류 환자에서 식도운동과 산청소능 ( Original Articles : Esophagus , Stomach & Intestine ; Esophageal Motility and Acid Clearance in Patients with Esophageal Varices ): Korean J Gastrointest Endosc 1996;16(1):8-14. Published online November 30, 1995

Abstract PDF: The presense of the esophageal varices might have a partial machanical obstruction and cushion effect on esophageal lumen due to blood within the varices. It may affect on the motility and acid clearance in the esophagus. The aim of this study was to evaluate the acid clearance and the esophageal motility according to the degree of the varices in patients with esophageal varices. We have performed esophageal manometry and acid clearance test in 41 patients with esophageal varices. Esophageal motility disorder was abserved in 29.4% of patients with esophageal varices. The number of swallowing for acid clearance was significantly increased in patients with esophageal varices than control group(23.5 +- 14.1 Vs 6.1 +- 1.6, p=0.004). However, there was no significant corelation with form, location, and redcolor sign of the varices. In conclusion, patients with esophageal varices accompanied esophageal motility disorders and delayed acid clearance. This results might be a useful referance data for changes in esophageal motility before and after treatment of esophageal varices.(Kor J Gaetrointest Endosc 16: 8~14, 1996)

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원저 : 식도정맥류에 대한 내시경적 결찰요법의 장기 추적관찰 ( Original Articles : Longterm Follow-up after Endoscopic Variceal Ligation for Esophageal Varices ): Korean J Gastrointest Endosc 1995;15(3):427-736. Published online November 30, 1994

Abstract PDF: Endoscopic variceal ligation is an accepted new form of safe treatment for esophageal varices. But, there are a few reports of long-term effect of EVL. We analysed 60 patients to evaluate long-term effect of EVL for esophageal varices. The eradication rate was 96.5%, the mean session for eradication of varices 3.0, the number of bands per person 21.5 and the number of bands per session 7.2, Child-Pugh classes(A: B: C) of patients were improved in 25, not changed in 30, deteriorated in 2 cases by EVL(34:19:4 at postEVL vs 20:19:21 at baseline, p<0.01). No serious treatment-related complication resulted from 167 EVL sessions. The patients were followed for a mean of 10.5 months, during which recurrence rate of varices was 14.5%, rebleeding rate 16.4%, and mortality rate 12,7%. The period from last session to recurrence was 4-19 months(mean 9.6). No late complication of EVL was documented. In conclusion, EVL is a safe and effective for hemostasis and eradication of esophageal varices. Thus it can improve liver function and reduce bleeding-related mortality in patients with liver cirrhosis. But the regular periodic examination for recurrence after an eradication of varices should be required.

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원저 : 식도 정맥류 출혈에 대한 내시경적 결찰요법의 치료효과 ( Original Articles : Efficacy of Endoscopic Variceal Ligation on Bleeding Esophageal Varices ): Korean J Gastrointest Endosc 1995;15(1):6-11. Published online November 30, 1994

Abstract PDF: Endoscopic injection sclerotheraphy(EIS) was an effective method for treatment of bleeding esophageal varices. However, it might be associated with some undesirable complications. Endoscopic variceal ligation(EVL) is a recently developed method for control of active variceal bleeding and eradicating esophageal varices with similar efficacy and minimal risk of complications compare to EIS. We performed EVL in 40 patients who had recently bled from esophageal varices. Total 198 variceal ligations were performed during 64 separate EVL session. Control rate of acute bleeding was 90%(36 of 40patients) and 4 patients died after EVL because of failure of bleeding control. Rebleeding following initiation of EVL occured in 5 patients-three patients were successfully controlled by EVL, one patient was controlled but eradication was impossible and one patient died. Varices were eradicated or reduced to grade I in 31(86.1% ) of 36 survivors by 1-9 ligation(mean 5.0) in l-4 EVL sessions(mean 1.6). After EVL, there were mild complications-mild substernal discomfort in 4 patients, mild dysphagia in 2 patients and fever in 2 patients. These results suggest that EVL is a safe and effective method for treatment of bleeding and eradication of esophageal varices with less complication.

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원저 : 식도정맥류 출혈에 대한 내시경적 정맥류 결찰요법의 임상적 고찰 ( Original Articles : Endoscopic Variceal Ligation for Treatment of Esophageal Varices ): Korean J Gastrointest Endosc 1994;14(3):325-330. Published online November 30, 1993

Abstract PDF: Endoscopic injection sclerotherapy(EIS) has been widely used in treating and eradicating acutely bleeding esophageal varies, but may be associated with some undesirable local and systemic complications. Endoscopic variceal ligation(EVL), which consists of mechanicai ligation and thrombosis of varices using elastic o-band, has been recently developed as a non operative alternative to EIS. We performed EVL in 65 patients who had bled from esophageal varices between November 1991 and September 1993. Total 274 sessions were performed and 774 o-bands were used. Six patients were actively bleeding and all of them were successfully controlled by emergency EVL. During the follow-up period, five patients who had combined hepatoma died. Varices were eradicated or reduced grade I in 43(71.6%) of the 60 survivals by 8-36 ligations(mean 15.6 ligation) in 2-13 EVL sessions(mean 5.6 sessions). During follow up period, five patients had recurred from grade 0 to grade 2 or 3 in 106-260 days(mean 182.6 days), and then eradicated by repeated EVL. During or after EVL, there were no complications, except mild substernal distress and mild dysphagia in 17 and 7 patients respectively. These results showed that EVL is a safe and effective method for eradication of bleeding esophageal varices.

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원저 : 간경변증 환자에서 급성 식도정맥류 출혈의 내시경적 정맥류 결찰요법후 추적 관찰 성적 ( Original Articles : Follow-up Results after Endoscopic Variceal Ligation for Treatment of Acute Bleeding Esophageal Varices in Liver Cirrhosis ): Korean J Gastrointest Endosc 1994;14(2):151-160. Published online November 30, 1993

Abstract PDF: Endoscopic injection sclerotherapy(EIS) is currently the most widely practiced method for treating and eradicating bleeding esophageal varices in repeated sessions, but may be associated with some undesirable local and systemic complications. (continue...)

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