Gastric Varices, El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Massive Upper Gastrointestinal , In this video clip,  you  can observe one of the worst bleeding.of the gastrointestinal track.    It is more difficult to stop bleeding from the gastric varices than from the esophageal varices. The rate of hemostasis by endoscopic management is higher with the Histoacryl than that with the other sclerosing agents such as 5%  ethanolamine oleate. After introducing N-butyl-2-cyanoacrylate (Histoacryl) to the management of bleeding gastric varices, the hemostasis rate improves to almost 100% However, the rebleeding rate is still high if any further additional treatment has not been performed until the gastric varices have been eradicated. There is still a controversy regarding the management for the gastric varices.

Video Endoscopic Sequence 1 of 3.

Massive Upper Gastrointestinal Bleeding.

 In this video clip, you can observe one of the worst
 bleeding of the gastrointestinal track.

 It is more difficult to stop bleeding from the gastric varices
 than from the esophageal varices. The rate of hemostasis
 by endoscopic management is higher with the Histoacryl
 than that with the other sclerosing agents such as 5%
 ethanolamine oleate.

 After introducing N-butyl-2 -cyanoacrylate (Histoacryl) to
 the management of bleeding gastric varices, the hemostasis
 rate improves to almost 100% However, the rebleeding
 rate is still high if any further additional treatment has not
 been performed until the gastric varices have been
 eradicated. There is still a controversy regarding the
 management for the gastric varices.

 For more endoscopic details download the video clips by
 clicking on the endoscopic images, wait to be downloaded
 complete then press Alt and Enter; thus you can observe
 the video in full screen.

 All endoscopic images shown in this Atlas contain
 video clips.

                                   Medline.

Bleeding from gastric varices is a life-threatening complication of portal  hypertension. Fundal and isolated gastric varices are at high risk for variceal  bleeding.  The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate in those who survive.

Video Endoscopic Sequence 2 of 3.

 Bleeding from gastric varices is a life-threatening
 complication of portal  hypertension. Fundal and isolated
 gastric varices are at high risk for variceal bleeding.

 The first episode of variceal bleeding is not only associated
 with a high mortality, but also with a high recurrence rate in
 those who survive.

 Gastrointestinal (GI) hemorrhage from portal hypertension
 is the most ominous form of bleeding. It carries the highest
 mortality, ranging from 30 to 40% and has an equally high
 rate of recurrence.

 Vascular collaterals in the stomach, esophagus, small bowel
 , and colon form as a consequence of portal hypertension,
 and these vessels have a high risk of rupture. The vascular
 congestion can also lead to mucosal bleeding throughout
 the GI tract from portal hypertensive gastropathy,
 enteropathy, and colopathy.

Argon Plasma Coagulation was used as emergency tool.    Gastric varices occur in about 20% of patients with portal hypertension and approxiamately 25% of gastric varices bleed during lifetime. Gastric variceal bleeding has a higher rate of recurrence than esophageal variceal bleeding, and is associated with decreased survival. The cumulative mortality of fundal varices reaches as high as 52% at the end of 1 year.

Video Endoscopic Sequence 3 of 3.

Argon Plasma Coagulation was used as a emergency tool.

 Gastric varices occur in about 20% of patients with portal
 hypertension and approxiamately 25% of gastric varices
 bleed during lifetime. Gastric variceal bleeding has a
 higher rate of recurrence than esophageal variceal
 bleeding, and is associated with decreased survival. The
 cumulative mortality of fundal varices reaches as high as
 52% at the end of 1 year.

This 66 year old female, presented with massive upper gastrointestinal bleeding. Endoscopy revealed spurting from a large varix in the gastric fundus.

Video Endoscopic Sequence 1 of 7.

 This 66 year old female, presented with massive upper
 gastrointestinal bleeding. Endoscopy revealed spurting
 from a large varix in the gastric fundus.

 Endoscopic appearance of actively bleeding gastric varices.
 Esophagogastroduodenoscopy in a cirrhotic patient with
 exsanguinating upper gastrointestinal hemorrhage reveals
 the characteristic endoscopic findings of superficial,
 purplish, serpiginous lesions in the very proximal stomach
 from fundal varices.

 Active bleeding is evidenced by the spurting of blood from
 a varix and the adjacent pooling of bright red blood. In this
 retrofl exed view, the endoscopic shaft is seen adjacent to
 the fundal varices exiting from the gastroesophageal
 junction

 Bleeding from gastric varices is a life-threatening event
 that presents a therapeutic challenge for clinicians.

 

Active pulsatile bleeding from a gastric fundic, varix was seen at endoscopy.  Gastric Varices are much less common cause of variceal hemorrhage than Esophageal ones; but are important to recognize as the source of bleeding because their management is different. When gastric varices are prominent and associated with minimal to absent Esophageal varices, one must consider splecnic vein thrombosis as the etiology of the increased venous pressures. Angiography may verify this diagnosis. These patients are best treated with simple splecnectomy, which adequately decompresses their varices. Such patients have an excellent prognosis because of the lack of underlying liver disease. Splecnic vein thrombosis may occur as a complication of pancreatitis due to contiguous inflammation from the body and tail of the pancreas.  Histoacryl (N-butyl-2-cyanocrylate) has been used in bleeding esophagus gastric and ectopic varices.

Video Endoscopic Sequence 2 of 7.

 Active pulsatile bleeding from a gastric fundic, varix was
 seen at endoscopy.

 Gastric Varices are much less common cause of variceal
 hemorrhage than esophageal ones; but are important to
 recognize as the source of bleeding because their
 management is different. When gastric varices are
 prominent and associated with minimal to absent
 esophageal varices, one must consider splecnic vein
 thrombosis as the etiology of the increased venous
 pressures. Angiography may verify this diagnosis. These
 patients are best treated with simple splecnectomy, which
 adequately decompresses their varices.
 Such patients have an excellent prognosis because of the
 lack of underlying liver disease.
 Splecnic vein thrombosis may occur as a complication of
 pancreatitis due to contiguous inflammation from the body
 and tail of the pancreas. 
 Histoacryl (N-butyl-2-cyanocrylate) has been used in
 bleeding esophagogastric and ectopic varices.

                                           Medline

Continuous flow of blood from the varix. Gastric varices occur in about 20% of patients with portal. Hypertension and approximately 25% of gastric varices bleed during lifetime. Gastric variceal bleeding  especially from isolated gastric varices usually is profuse, has a higher rate of recurrence than Esophageal variceal bleeding , and is associated with decreased survival (cumulative mortality of fundal varices reaching as high as 52% at the end of 1 year). The optimal treatment for gastric variceal bleeding is still controversial, primarily because of the apparent ineffectiveness of conventional antivariceal therapy and the inclusion of patients with gastric varices located at different sites.

Video Endoscopic Sequence 3 of 7.

Continuous flow of blood from the varix.

 Gastric varices occur in about 20% of patients with portal
 hypertension and approximately 25% of gastric varices
 bleed during lifetime. Gastric variceal bleeding especially
 from isolated gastric varices usually is profuse, has a
 higher rate of recurrence than esophageal variceal bleeding
 , and is associated with decreased survival (cumulative
 mortality of fundal varices reaching as high as 52% at the
 end of 1 year). The optimal treatment for gastric variceal
 bleeding is still controversial, primarily because of the
 apparent ineffectiveness of conventional antivariceal
 therapy and the inclusion of patients with gastric varices
 located at different sites.

Hemostasis was achieved using argon plasma coagulator APC. Bleeding from gastric varices is often a serious medical emergency.   Although the incidence of bleeding from gastric varices is relatively low (10–36%), massive bleeding from gastric varices is life-threatening.

Video Endoscopic Sequence 4 of 7.

 Hemostasis was achieved using argon plasma coagulator
 APC.

 Bleeding from gastric varices is often a serious medical
 emergency.

 Although the incidence of bleeding from gastric varices is
 relatively low (10–36%), massive bleeding from gastric
 varices is life-threatening.

 

The video clip displays the APC stopping the hemorrhage.          Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. An adjuvant vasoactive agent is useful for the prevention of early rebleeding.   Follow-up endoscopic treatment is necessary in order to   obliterate residual varices.

Video Endoscopic Sequence 5 of 7.

 The video clip displays the APC stopping the hemorrhage.

 Endoscopic variceal ligation is safer and more efficacious
 than sclerotherapy as initial treatment of bleeding
 esophageal varices, whereas cyanoacrylate injection is the
 endoscopic treatment of choice for gastric varices. An
 adjuvant vasoactive agent is useful for the prevention of
 early rebleeding.

 Follow-up endoscopic treatment is necessary in order to
 obliterate residual varices.

Status post coagulation with APC.   Gastric varices are most commonly located in the cardia in continuity with esophageal varices. Isolated gastric varices are most commonly located in the fundus and can be seen in patients with cirrhosis and portal hypertension, as well as in patients with splenic vein thrombosis (e.g., from pancreatic disease) or portal vein thrombosis. Bleeding from gastric varices is typically high volume in nature and can present with massive hematemesis.

Video Endoscopic Sequence 6 of 7.

Status post coagulation with APC.

 Gastric varices are most commonly located in the cardia in
 continuity with esophageal varices. Isolated gastric varices
 are most commonly located in the fundus and can be seen
 in patients with cirrhosis and portal hypertension, as well as
 in patients with splenic vein thrombosis (e.g., from
 pancreatic disease) or portal vein thrombosis. Bleeding
 from gastric varices is typically high volume in nature and
 can present with massive hematemesis.

Status post APC application seen with magnifying endoscope.  Endoscopic ultrasonography is useful in the prediction of recurrence of varices and facilitates visualization and guidance of further treatment of gastric varices.

Video Endoscopic Sequence 7 of 7.

 Status post APC application seen with magnifying
 endoscope.

 Endoscopic ultrasonography is useful in the prediction of
 recurrence of varices and facilitates visualization and
 guidance of further treatment of gastric varices.

 

 

                                          Medline.

Large Gastric Varices.  This 56 year-old lady with Esophagus-Gastric Varices.  Hemostatic methods that use standard therapy for esophageal varices have not been found effective for gastric varices.

Video Endoscopic Sequence 1 of 25.

Large Gastric Varices.

This 56 year-old lady with Esophagus-Gastric Varices.

 Hemostatic methods that use standard therapy for
 esophageal varices have not been found effective for
 gastric varices.

Development of gastric varices is an important manifestation of portal hypertension. In segmental portal hypertension, gastric varices originate from short gastric and gastroepiploic veins. In generalized portal hypertension, intrinsic veins at cardia participate in the formation of gastric varices. Endoscopy and/or splenoportovenography and a high index of suspicion are required for the diagnosis of gastric varices.

Video Endoscopic Sequence 2 of 25.

 Development of gastric varices is an important
 manifestation of portal hypertension. In segmental portal
 hypertension, gastric varices originate from short gastric
 and gastroepiploic veins. In generalized portal
 hypertension, intrinsic veins at cardia participate in the
 formation of gastric varices. Endoscopy and/or
 splenoportovenography and a high index of suspicion are
 required for the diagnosis of gastric varices.

 

Sarin’s classification of gastric varices.

Video Endoscopic Sequence 3 of 25.

Sarin’s classification of gastric varices

Figure 1

Sarin et al. defined four subtypes of gastric varices (Figure 1). Gastro-oesophageal varices (GOVs) are associated with oesophageal varices along the lesser curve (type 1, GOV1), or along the fundus (type 2, GOV2). Isolated gastric varices (IGVs) are present in isolation in the fundus (IGV1) or at ectopic sites in the stomach or the first part of the duodenum (IGV2). Gastric varices may be primary (at initial presentation) or secondary (appearing after obliteration of oesophageal varices). GOV1, the commonest at 70% of gastric varices, are also known as cardial varices. GOV2 and IGV1, at 21% and 7% of gastric varices, respectively, together referred to as fundal varices. The incidence of bleeding is highest with IGV1 (78%), followed by GOV2 (55%), and much less for GOV1 and IGV2 at 10%. Although the mortality rate with GOV1 is high, endoscopic treatment of GOV1 is likely to be more successful than the other subtypes.

Video Endoscopic Sequence 4 of 25.

 Sarin et al. defined four subtypes of gastric varices
 (Figure1). Gastro-esophageal varices (GOVs) are
 associated with esophageal varices along the lesser curve
 (type 1, GOV1), or along the fundus (type 2, GOV2).

 Isolated gastric varices (IGVs) are present in isolation in
 the fundus (IGV1) or at ectopic sites in the stomach or the
 first part of the duodenum (IGV2). Gastric varices may be
 primary (at initial presentation) or secondary (appearing
 after obliteration of esophageal varices).

 GOV1, the commonest at 70% of gastric varices, are also
 known as cardial varices. GOV2 and IGV1, at 21% and 7%
 of gastric varices, respectively, together referred to as
 fundal varices.

 The incidence of bleeding is highest with IGV1 (78%),
 followed by GOV2 (55%), and much less for GOV1 and
 IGV2 at 10%. Although the mortality rate with GOV1 is
 high, endoscopic treatment of GOV1 is likely to be more
 successful than the other subtypes.

The natural history of bleeding gastric varices differs from that of esophageal varices. Although the risk of bleeding from gastric varices is half that of oesophageal varices, the transfusion requirements and mortality once bleeding has occurred are greater particularly for IGV. It has been reported that patients with large gastric varices have a lower portal pressure than those with oesophageal varices, which may be as a result of the development of gastrorenal porto-systemic shunts, or large size of the varices resulting in increased variceal wall tension.

Video Endoscopic Sequence 5 of 25.

 The natural history of bleeding gastric varices differs from
 that of esophageal varices. Although the risk of bleeding
 from gastric varices is half that of esophageal varices, the
 transfusion requirements and mortality once bleeding has
 occurred are greater particularly for IGV. It has been
 reported that patients with large gastric varices have a
 lower portal pressure than those with esophageal varices,
 which may be as a result of the development of gastrorenal
 porto-systemic shunts, or large size of the varices resulting
 in increased variceal wall tension.

 

8 months after the first endoscopy the patient began with her first hemorrhage presenting several episodes of hematemesis and melena. This emergency endoscopy was carry out in the operation room under general anesthesia with endotracheal tube.     Hematemesis, melena, and hematochezia are symptoms of acute gastrointestinal bleeding. Bleeding that brings the patient to the physician is a potential emergency and must be considered as such until its seriousness can be evaluated. The goals in managing a major acute gastrointestinal hemorrhage are to treat hypovolemia by restoring the blood volume to normal, to make a diagnosis of the bleeding site and its underlying cause.

Video Endoscopic Sequence 6 of 25.

 8 months after the first endoscopy the patient began with
 her first hemorrhage presenting several episodes of
 
hematemesis and melena.

 This emergency endoscopy was carry out in the operation
 room under
general anesthesia with endotracheal tube.

 

Identifying the Source of Bleeding.  Irrigation and suction are helpful in removing old blood and blood clots from the stomach, it is not unusual to have residual clots obscuring the endoscopic view and preventing proper identification of the source of bleeding. A number of interventions have been described to help remove these clots and improve endoscopic visibility.  The irrigating hood is a device designed to be placed at the tip of the endoscope to allow forceful intragastric irrigation while maintaining an adequate intraluminal view of the bleeding site. Its use has been demonstrated to improve the endoscopic view and shorten procedure time.

Video Endoscopic Sequence 7 of 25.

Identifying the Source of Bleeding

 Irrigation and suction are helpful in removing old blood and
 blood clots from the stomach, it is not unusual to have
 residual clots obscuring the endoscopic view and
 preventing proper identification of the source of bleeding.
 A number of interventions have been described to help
 remove these clots and improve endoscopic visibility.

 The irrigating hood is a device designed to be placed at the
 tip of the endoscope to allow forceful intragastric irrigation
 while maintaining an adequate intraluminal view of the
 bleeding site. Its use has been demonstrated to improve
 the endoscopic view and shorten procedure time.

 

 Multiple large gastric varices can be seen in the gastric cardia and fundus. The treatment chosen for this patient was intravariceal injection with cyanoacrylate. After volume resuscitation and blood transfusion, urgent upper endoscopy was performed. The stomach and duodenum were clear of either fresh or old blood. There was an isolated cluster of gastric varices within the fundus, appreciated only on retroflexion. A red, flat spot was noted on one of the suspected varices.

Video Endoscopic Sequence 8 of 25.

 Multiple large gastric varices can be seen in the gastric
 cardia and fundus. The treatment chosen for this patient
 was intravariceal injection with cyanoacrylate.

 After volume resuscitation and blood transfusion, urgent
 upper endoscopy was performed. The stomach and
 duodenum were clear of either fresh or old blood. There
 was an isolated cluster of gastric varices within the fundus,
 appreciated only on retroflexion. A red, flat spot was noted
 on one of the suspected varices.

 

In tis video clips shows the exact site of the bleeding.

Video Endoscopic Sequence 9 of 25.

In this video clips shows the exact site of the bleeding

 Due to the rubbing of the injector with the surface of the
 varix, initiates the exact site of bleed varix was then noted
 to bleed actively.

 3 ml of pure lipoidol was injected into the working channel
 of the endoscope to prevent occlusion of the channel by the
 glue. Endoscopic injection of tissue-adhesive agents has
 been shown to be very effective. Of these, the most
 successful has been N-butyl-cyanoacrylate (Histoacryl)
 Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL
 of Lipiodol.

                                           Medline.

Bleeding from FV. Bleeding was considered to arise from FV if one of the following criteria was present: (1) active bleeding from the FV was seen, (2) a clot or an ulcer was present over the FV, or (3) occurrence of bleeding in the context of distinct large FV in the absence of EV or other causes of upper GI bleeding.

Video Endoscopic Sequence 10 of 25.

 Glue for gastric varices

 A mixture of Histoacryl with with Lipiodol
 (0.8 mL in 0.5 mL) will be injected intra-variceal.

 Bleeding from FV. Bleeding was considered to arise from
 FV if one of the following criteria was present: (1) active
 bleeding from the FV was seen, (2) a clot or an ulcer was
 present over the FV, or (3) occurrence of bleeding in the
 context of distinct large FV in the absence of EV or other
 causes of upper GI bleeding.

                                          Medline.                                                                       

Video Endoscopic Sequence 11 of 25.

Intravariceal injection Histoacryl with with Lipiodol

 After the injection of the mixture, the syringe got stuck
 completely to the Luer Lock injector with the security knob.
 That is why the procedure itself was difficult. The
needle
 had to be drawn out of the bleeding varicose vein without
 having obliterated it first, creating a larger bleeding area.
 Another injector of a different model had to be used. It is
 always advisable to have multiple syringes ready with the
 mixture.

 In order to treat varices of the fundus with this mixture,
 injector probes of metallic Luer Lock must be used, and in
 this way sticking of the syringe is avoided.

Inmediately a new shot of the mixture of Histoacryl with with Lipiodol  was injected with another injector, being successful with this.   general, endoscopic therapy for the treatment of bleeding gastric varices has been less successful than for esophageal varices. Treatment options that have been studied in prospective trials include injection of cyanoacrylate-based tissue adhesives, alcohol, sclerosants, and the use of band ligation. Results from this limited number of small studies have had varying success rates and were uncontrolled, making it difficult to draw definitive conclusions about their efficacy or the superiority of one therapy over another. All techniques appear to be useful, but rebleeding and mortality rates in these studies were high. There are insufficient data to recommend repeat endoscopic procedures to achieve obliteration or secondary prophylaxis of isolated gastric varices.

Video Endoscopic Sequence 12 of 25.

 Inmediately a new shot of the mixture of Histoacryl with
 with Lipiodol
was injected with another injector, being
 successful with this.

 In general, endoscopic therapy for the treatment of
 bleeding gastric varices has been less successful than for
 esophageal varices. Treatment options that have been
 studied in prospective trials include injection of
 cyanoacrylate-based tissue adhesives, alcohol, sclerosants,
 and the use of band ligation. Results from this limited
 number of small studies have had varying success rates
 and were uncontrolled, making it difficult to draw definitive
 conclusions about their efficacy or the superiority of one
 therapy over another. All techniques appear to be useful,
 but rebleeding and mortality rates in these studies were
 high. There are insufficient data to recommend repeat
 endoscopic procedures to achieve obliteration or secondary
 prophylaxis of isolated gastric varices
.

Withdrawing the needle from the varix, washing it with saline solution to avoid be occluded by the glue and thus reuses it.

Video Endoscopic Sequence 13 of 25.

 Withdrawing the needle from the varix, washing it with
 saline solution to avoid be occluded by the glue and thus
 reuses it.

In this video clip, another shot of  the mixture of glue is injected, after retiring the needle a slight bleeding of wall is observed.

Video Endoscopic Sequence 14 of 25.

 In this video clip, another shot of the mixture of glue is
 injected, after retiring the needle a slight bleeding of wall is
 observed.

 

After have applied histoacryl had been a slight bleeding which was handling with argon plasma.

Video Endoscopic Sequence 15 of 25.

 After have applied histoacryl had been a slight bleeding
 which was handling with argon plasma.

 

The catheter of argon plasma is being coagulated the site of this bleed..

Video Endoscopic Sequence 16 of 25.

 The catheter of argon plasma is being coagulated the site
 of this bleed.
.

The hemorrhage has stopped.

Video Endoscopic Sequence 17 of 25.

The hemorrhage has stopped.

The site of the last bleeding, besides of using glue and argon plasma, the hemostasis is reinforced with rubber bands.

Video Endoscopic Sequence 18 of 25.

 The site of the last bleeding, besides of using glue and
 argon plasma, the hemostasis is reinforced with rubber
 bands.

 Endoscopic injection with tissue adhesives such as
 histoacryl can effectively control active bleeding. However,
 gastric varices cannot disappear due to the unsatisfactory
 control of inflammation and fibrous organization caused by
 adhesives. Although endoscopic variceal ligation therapy
 (EVL) has shown its benefit for esophageal varices, it
 cannot achieve a similar success in the management of
 gastric varices.

                                         Medline.

Bleed has stopped completely.  Management for gastric varices usually include vasoactive agents, endoscopic therapy and surgery. Rupture of gastric fundal varices is often lethal because of massive bleeding.

Video Endoscopic Sequence 19 of 25.

Bleed has stopped completely.

 Management for gastric varices usually include vasoactive
 agents, endoscopic therapy and surgery. Rupture of gastric
 fundal varices is often lethal because of massive bleeding.

Hemostasis was achieved. Hematemesis, melena, and hematochezia are symptoms of  acute gastrointestinal bleeding. Bleeding that brings the patient to the physician is a potential emergency and must   be considered as such until its seriousness can be evaluated. The goals in managing a major acute  gastrointestinal hemorrhage are to treat hypovolemia by  restoring the blood volume to normal, to make a diagnosis   of the bleeding site and its underlying cause.

Video Endoscopic Sequence 20 of 25.

Hemostasis was achieved

 Hematemesis, melena, and hematochezia are symptoms
 of acute gastrointestinal bleeding. Bleeding that brings the
 patient to the physician is a potential emergency and must
 be considered as such until its seriousness can be
 evaluated. The goals in managing a major acute
 gastrointestinal hemorrhage are to treat hypovolemia by
 restoring the blood volume to normal, to make a diagnosis
 of the bleeding site and its underlying cause
.

 To avoid bronco aspiration the patient must be with endotracheal tube.   This image as well as the video clips show endotraqueal tube, there are a plenty of fresh blood in the oropharynx, that is the main reason to perform this procedure in the operation room.

Video Endoscopic Sequence 21 of 25.

 To avoid bronco aspiration the patient must be with endotracheal tube.

 This image as well as the video clips show endotraqueal
 tube, there are a plenty of fresh blood in the oropharynx,
 that is the main reason to perform this procedure in the
 operation room. 

 We can see the endotracheal tube that is placed to prevent
 aspiration. Every patient who has hematemesis should have
 an upper endoscopy practiced under general anesthesia,
 with placement of an endotracheal tube. In this example we
 can clearly see the amount of blood in the oropharynx.
 Orotracheal intubation is indicated when there is risk of
 aspiration because of continuous hematemesis.

 The main complications associated with gastrointestinal
 bleeding in patients with hepatic cirrhosis include
 aspiration, hepatic encephalopathy, and renal failure. All of
 the complications mentioned cause rapid deterioration of
 the patient and are an important cause of death.

 The major risk for aspiration occurs during hematemesis
 and upper endoscopy, as well as during esophageal
 tamponade, especially in patients with altered
 consciousness. Prevention of aspiration is obtained by
 orotracheal placement in patients with grade III-IV
 encephalopathy, as well as aspiration of gastric contents
 before the endoscopic procedure by means of a nasogastric
 tube
.

 

The injector should have a Luer-lock metal fitting because, as Histoacryl is caustic to plastic and may crack a plastic hub.

Video Endoscopic Sequence 22 of 25.

 The injector should have a Luer-lock metal fitting because,
 as Histoacryl is caustic to plastic and may crack a plastic
 hub.

Postprocedure chest radiograph. In the thorax x-ray the mixture of histoacril with lipoidol is  observed in the gastric bubble. Obtaining of this form the obliteración of varice that cause the bleed.

Video Endoscopic Sequence 23 of 25.

Post Procedure Chest Radiograph.

 In the thorax x-ray the mixture of histoacril with lipoidol is
 observed in the gastric bubble. Obtaining of this form the
 obliteración of varice that cause the bleed.

What is the role of radiographs in the documentation varix obliteration? Because Lipiodol is radioopaque, varices filled with the cyanoacrylate mixture are well visualized radiographically. However, the ability of radiographs to distinguish intra- and perivariceal injection or document varix obliteration has never been studied. Fluoroscopy is occasionally used to monitor the intravariceal injection of cyanoacrylate.

Video Endoscopic Sequence 24 of 25.

 What is the role of radiographs in the documentation varix
 obliteration? Because Lipiodol is radioopaque, varices
 filled with the cyanoacrylate mixture are well visualized
 radiographically. However, the ability of radiographs to
 distinguish intra- and perivariceal injection or document
 varix obliteration has never been studied. Fluoroscopy is
 occasionally used to monitor the intravariceal injection of
 cyanoacrylate.

 The use of a convex array echoendoscope to provide
 real-time monitoring of cyanoacrylate injection is
 technically possible but its benefit is questionable in
 comparison with endoscopy-guided injection.

The treatment of bleeding gastric varices is one of the final frontiers of flexible endoscopy-a chapter as yet incomplete in our textbooks.

Video Endoscopic Sequence 25 of 25.

 The treatment of bleeding gastric varices is one of the final
 frontiers of flexible endoscopy—a chapter
as yet
 incomplete in our textbooks.

 

Endoscopic ablation with cyanoacrylate glue This 49 year-old female was hospitalized in a social security  hospital in El Salvador, She was discharged from the hospital on day 10, after that visit us for a therapeutical endoscopy. An upper endoscopy was practiced shows gastric varices of the fundus with a small quantity of blood emerging from the varix.

Video Endoscopic Sequence 1 of 18.

Endoscopic Ablation with Cyanoacrylate Glue

 This 49 year-old female was hospitalized in a social security
 hospital in El Salvador,
She was discharged from the
 hospital on day 10, after that visit us for a therapeutical
 endoscopy.

 An upper endoscopy was practiced shows gastric varices of
 the fundus with a small quantity of blood emerging from the
 varix.

Although gastric varices tend to bleed less frequently than esophageal varices, the morbidity and mortality associated with gastric variceal hemorrhage are substantial.

Video Endoscopic Sequence 2 of 18.

 Although gastric varices tend to bleed less frequently than
 esophageal varices, the morbidity and mortality associated
 with gastric variceal hemorrhage are substantial.

 Gastric varices are dilated submucosal veins in the
 stomach, which can be a life-threatening cause of upper
 gastrointestinal hemorrhage. They are most commonly
 found in patients with portal hypertension, or elevated
 pressure in the portal vein system, which may be a
 complication of cirrhosis. Gastric varices may also be
 found in patients with thrombosis of the splenic vein, into
 which the short gastric veins which drain the fundus of the
 stomach flow. The latter may be a complication of acute
 pancreatitis, pancreatic cancer, or other abdominal
 tumours.

In the same day a therapeutic endoscopy a histoacryl injection is programed, under general anesthesia with endotracheal tube is achieved.    Stigmata of recent bleeding.

Video Endoscopic Sequence 3 of 18.

 In the same day a therapeutic endoscopy a histoacryl
 injection is programed, under general anesthesia with
 endotracheal tube is achieved. Stigmata of recent bleeding
 is observed.

 

Gastric varices (GV) occur in 20% of patients with portal hypertension. GV located in the fundus (FV) tend to cause serious bleeding and are reported to be less responsive to endoscopic treatment. The risk of FV bleeding may range from 55% to 78%, with a bleeding-related mortality rate of 45%.

Video Endoscopic Sequence 4 of 18.

 Gastric varices (GV) occur in 20% of patients with portal
 hypertension. GV located in the fundus (FV) tend to cause
 serious bleeding and are reported to be less responsive to
 endoscopic treatment. The risk of FV bleeding may range
 from 55% to 78%, with a bleeding-related mortality rate
 of 45%.

N-butyl-2-cyanoacrylate (Histoacryl) is a watery substance that polymerizes and hardens instantaneously when it comes into contact with blood. This unique property makes it attractive for use in obliterating varices. It is particularly useful in the treatment of fundic varices. Histoacryl is reconstituted with Lipiodol (0.8 mL in 0.5 mL), an oil-based radiopaque contrast agent .      ). the therapeutic channel of the endoscope is first rinsed with 2mL of Lipiodol. The injection needle is then filled with 2mL of Lipiodol. The varix is punctured, and the Histoacryl-Lipiodol mixture is injected. Before retraction of the needle, residual glue is pushed into the varix with a further 2mL of Lipiodol. The needle is then retracted, and the catheter is rinsed with water. It is important at this juncture not to activate suction in the endoscope, and to continue irrigation to avoid contact between the glue and the lenses .

Video Endoscopic Sequence 5 of 18.

 N-butyl-2-cyanoacrylate (Histoacryl) is a watery substance
 that polymerizes and hardens instantaneously when it
 comes into contact with blood. This unique property makes
 it attractive for use in obliterating varices. It is particularly
 useful in the treatment of fundic varices. Histoacryl is
 reconstituted with Lipiodol (0.8 mL in 0.5 mL), an oil-based
 radiopaque contrast agent
). the therapeutic channel of the
 endoscope is first rinsed with 2mL of Lipiodol.
 The injection needle is then filled with 2mL of Lipiodol.
 The varix is punctured, and the Histoacryl-Lipiodol mixture
 is injected. Before retraction of the needle, residual glue is
 pushed into the varix with a further 2mL of Lipiodol. The
 needle is then retracted, and the catheter is rinsed with
 water. It is important at this juncture not to activate suction
 in the endoscope, and to continue irrigation to avoid
 contact between the glue and the lenses. 

 

                                          Medline.

The image and the video clip show the status of histoacryl injection.  When Histoacryl is mixed in a ratio of 0.5 cm3 (volume per tube of Histoacryl) to 0.8 cm' Lipiodol, hardening is delayed by approximately 20 seconds. The two components are drawn up together into a 2 ml syringe and then mixed by inverting the syringe several times. To help prevent Histoacryl from adhering to the catheter wall, several millilitres of Lipiodol are injected into the catheter.

Video Endoscopic Sequence 6 of 18.

The image and the video clip show the status of histoacryl injection.

 When Histoacryl is mixed in a ratio of 0.5 cm3 (volume per
 tube of Histoacryl) to 0.8 cm' Lipiodol, hardening is
 delayed by approximately 20 seconds. The two components
 are drawn up together into a 2 ml syringe and then mixed
 by inverting the syringe several times. To help prevent
 Histoacryl from adhering to the catheter wall, several
 millilitres of Lipiodol are injected into the catheter.

The image and the video clips show the second shot of histoacryl.     Endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding was first reported in 1986. The tissue glue polymerizes on contact with blood, solidifying within the varix instantly, thus obliterating the varix and preventing bleeding. The glue cast will eventually slough off weeks to months later. Because of its excellent efficacy, N-butyl-2-cyanoacrylate is considered to be the optimal therapy for FV bleeding by many clinicians worldwide.

Video Endoscopic Sequence 7 of 18.

The image and the video clips show the second shot of histoacryl.

 Endoscopic injection of N-butyl-2-cyanoacrylate for gastric
 variceal bleeding was first reported in 1986. The tissue
 glue polymerizes on contact with blood, solidifying within
 the varix instantly, thus obliterating the varix and
 preventing bleeding. The glue cast will eventually slough
 off weeks to months later. Because of its excellent
 efficacy, N-butyl-2-cyanoacrylate is considered to be the
 optimal therapy for FV bleeding by many clinicians
 worldwide.

he image and the video clips show the third shot of histoacryl.

Video Endoscopic Sequence 8 of 18.

The image and the video clips show the third shot of histoacryl.

 The dilution ratio increases if Lipiodol is used to flush the
 injector before injection. The rationale for diluting
 Histoacryl with Lipiodol is to delay the otherwise
 instantaneous
polymerization reaction in order to complete
 the injection and remove the needle.

 

Hemostatic methods that use standard therapy for esophageal varices have not been found effective for gastric varices. Due to their large size and extensive distribution, it is difficult if not impossible to eradicate gastric varices with sclerotherapy or band ligation. More importantly, tissue necrosis resulting from these endoscopic interventions can cause significant and sometimes disastrous complications.

Video Endoscopic Sequence 9 of 18.

 Hemostatic methods that use standard therapy for
 esophageal varices have not been found effective for
 gastric varices. Due to their large size and extensive
 distribution, it is difficult if not impossible to eradicate
 gastric varices with sclerotherapy or band ligation. More
 importantly, tissue necrosis resulting from these
 endoscopic interventions can cause significant and
 sometimes disastrous complications.

Conceptually, cyanoacrylate glue provides an ideal endoscopic treatment for gastric varices. Native cyanoacrylate is a liquid with a consistency similar to water and therefore lends itself to intravariceal injection. When added to a physiologic medium such as blood, the cyanoacrylate rapidly polymerizes, forming a hard substance. Thus, after injection into a varix, the cyanoacrylate plugs the lumen. This results not only in rapid hemostasis in cases of active bleeding, but it also prevents the recurrence of bleeding from the treated varix.

Video Endoscopic Sequence 10 of 18.

 Conceptually, cyanoacrylate glue provides an ideal
 endoscopic treatment for gastric varices. Native
 cyanoacrylate is a liquid with a consistency similar to water
 and therefore lends itself to intravariceal injection. When
 added to a physiologic medium such as blood, the
 cyanoacrylate rapidly polymerizes, forming a hard
 substance. Thus, after injection into a varix, the
 cyanoacrylate plugs the lumen. This results not only in
 rapid hemostasis in cases of active bleeding, but it also
 prevents the recurrence of bleeding from the treated varix.

The patient has not had any further episodes of gastrointestinal bleeding in the months since her procedure. Histoacryl is highly effective for the treatment of bleeding gastric varices. The treatment failure-related mortality rate was almost a result of malignancy or underlying liver disease. Serious adverse event may appear although under experienced endoscopist.

Video Endoscopic Sequence 11 of 18.

 The patient has not had any further episodes of
 gastrointestinal bleeding in the months since her procedure.

 Histoacryl is highly effective for the treatment of bleeding
 gastric varices. The treatment failure-related mortality rate
 was almost a result of malignancy or underlying liver
 disease. Serious adverse event may appear although under
 experienced endoscopist.

 

A follow up endoscopy one week later was performed.  Status post injection of histoacryl mixture.

Video Endoscopic Sequence 12 of 18.

Successful obliteration with hardening of variceal bed. A follow up endoscopy one week later was performed.

 It is essential to define the endpoint of treatment, as well
 as have a standardized protocol to achieve the endpoint.
 The goal of cyanoacrylate injection should be the
 obliteration of visible varices. The term “obliteration”
 more accurately describes the desired endpoint than
 “eradication,” because a varix occluded with cyanoacrylate
 may remain visible for many weeks. The completeness of
 obliterationdeserves special emphasis, as cyanoacrylates
 induce mucosal necrosis at the site of injection.

 The amount of Histoacryl required to achieve obliteration
 will vary depending on varix size and extent. In general,
 Histoacryl is injected in aliquots of 0.5 mL (content of 1
 ampoule), which translates to 1 to 2 mL after dilution with
 Lipiodol. Obliteration is tested by palpating the varix with
 the needle retracted. If “soft,” the varix is injected with an
 additional aliquot of Histoacryl.

Under normal circumstances blood from the fundus is drained by the short and posterior gastric veins into the splenic vein. In portal hypertension the direction of flow is reversed and blood drains from the spleen toward the stomach into FV. The majority of FVs drain into the inferior phrenic vein, which then joins with either the left renal vein to form the gastrorenal shunt (GRS) (80%-85%) or with the inferior vena cava just below the diaphragm to form the gastrocaval shunt (10%-15%).

Video Endoscopic Sequence 13 of 18.

 Status post injection of histoacryl mixture.

 Under normal circumstances blood from the fundus is
 drained by the short and posterior gastric veins into the
 splenic vein. In portal hypertension the
direction of flow is
 reversed and blood drains from the spleen toward the
 stomach into FV. The majority of FVs drain into the
 inferior phrenic vein, which then joins with either the left
 renal vein to form the gastrorenal shunt (GRS) (80%-85%)
 or with the inferior vena cava just below the diaphragm to
 form the gastrocaval shunt (10%-15%).

Massive transfusions by nature lead to hemodilution, acidosis, hypothermia and ultimately coagulopathy. To minimize these complications it is recommended to replace plasma constituents and platelets with packed red blood cell infusions. A protocol with a replacement ratio of 5 PRBC, 5 FFP and 2 units of platelets minimizes bleeding, hemodilution and persistent thrombocytopenia.

Video Endoscopic Sequence 14 of 18.

 Massive transfusions by nature lead to hemodilution,
 acidosis, hypothermia and ultimately coagulopathy. To
 minimize these complications it is recommended to replace
 plasma constituents and platelets with packed red blood
 cell infusions. A protocol with a replacement ratio of 5
 PRBC, 5 FFP and 2 units of platelets minimizes bleeding,
 hemodilution and persistent thrombocytopenia.

 

Status post variceal ligation is observed at the cardias.

Video Endoscopic Sequence 15 of 18.

Status post variceal ligation is observed at the cardias.

Fibrin and ulcers of post banding at the esophagus are displayed.

Video Endoscopic Sequence 16 of 18.

Fibrin and ulcers of post banding at the esophagus are displayed

 Follow up Endoscopy ,  After two year and a half it is observed complete obliteration of the varix.

Video Endoscopic Sequence 17 of 18.

 Follow up Endoscopy

After two year and a half it is observed complete obliteration of the varix.

Complete obliteration status, Gastric variceal obliteration was achieved .

Video Endoscopic Sequence 18 of 18.

Complete obliteration status

Gastric variceal obliteration was achieved

Endoscopy of Ulcerated Flat Gastric Varix.  Image of ulcer with visble vassel.  This is the case of 63 year-old male with alcoholic cirrhosis Child-Pugh Score C, with generalized anasarca, mild Encephalopathy, jaundice; endoscopy shows varices of te esophagus and multiple gastric erosions at the gastric fundus display the image and the video clip here presented.

Endoscopy of Ulcerated Flat Gastric Varix

Image of ulcer with visble vassel

 This is the case of 63 year-old male with alcoholic cirrhosis
 Child-Pugh Score C, with generalized anasarca, mild
 encephalopathy, jaundice; endoscopy shows varices of the
 esophagus and multiple gastric erosions at the gastric
 fundus display the image and the video clip here presented.

 

Large Gastric Varices. This 72 year old female with a recurrent episode of  bleeding from gastric varices. Seen on retroflexion are pendulous varices in the gastric cardia and fundus.

Video Endoscopic Sequence 1 of 4.

Large Gastric Varices.

 This 72 year old female with a recurrent episode of
 bleeding from gastric varices. Seen on retroflexion are
 pendulous varices in the gastric cardia and fundus.

 

Ulcerated Gastric Varix. Primary gastric varices are said to be detected in 20% patients with portal hypertensions. The data suggests that gastric varices bleed less frequently (14%-16%) , but once it bleeds it is torrential and severe.

Video Endoscopic Sequence 2 of 4.

Ulcerated Gastric Varix.

 Primary gastric varices are said to be detected in 20%
 patients with portal hypertensions. The data suggests that
 gastric varices bleed less frequently (14%-16%) , but once
 it bleeds it is torrential and severe.

The patient underwent Cyanoacrylate glue injection for her gastric  varices. Variceal obstruction with cyanoacrylate tissue adhesive had been used successfully and most studies have achieved control of bleeding in almost 100% of patients.

Video Endoscopic Sequence 3 of 4.

 The patient underwent Cyanoacrylate glue injection for her
 gastricvarices.

 Variceal obstruction with cyanoacrylate tissue adhesive had been
 used successfully and most studies have achieved control of
 bleeding in almost 100% of patients.

 

This image and the video clip was obtained with magnifying endoscope.  Gastric varices develop in patients with portal hypertension, including liver cirrhosis, idiopathic portal hypertension as well as left sided-local portal hypertension such as splenic vein thrombosis or splenic AV malformation. The inflow vein is the left gastric vein, posterior vein, or short gastric vein, while the outflow vein is the gastro-renal shunt in most of the patients with gastric varices. The form of the gastric varices is classified into three types of venous dilatation; tortuous type, notched type and tumor type according to the shape and size of the varices.

Video Endoscopic Sequence 4 of 4.

 This image and the video clip was obtained with magnifying
 endoscope.

 Gastric varices develop in patients with portal hypertension
 , including liver cirrhosis, idiopathic portal hypertension as
 well as left sided-local portal hypertension such as splenic
 vein thrombosis or splenic AV malformation. The inflow
 vein is the left gastric vein, posterior vein, or short gastric
 vein, while the outflow vein is the gastro-renal shunt in
 most of the patients with gastric varices. The form of the
 gastric varices is classified into three types of venous
 dilatation; tortuous type, notched type and tumor type
 according to the shape and size of the varices.

 

 Fundus Varices.  Fundus varices are observed in the maneuver of retroflexion, and the signs of recent bleeding are also observed. Gastric varices usually accompany esophageal varices, although they may occur alone. They are located in the gastric fundus and are best appreciated endoscopically on  retroflexed view.

 Fundus Varices.

 Fundus varices are observed in the maneuver of
 retroflexion,
and the signs of recent bleeding are also
 observed.

 Gastric varices usually accompany esophageal varices,
 although they may occur alone. They are located in the
 gastric fundus and are best appreciated endoscopically on
 retroflexed view.

Ulcerated Gastric Varix of the fundus that caused severe gastrointestinal hemorrhage. Gastric Varices are much less common cause of variceal hemorrhage than esophageal ones; but are important to recognize as the source of bleeding because their management is different. When gastric varices are prominent and associated with minimal to absent esophageal varices, one must consider splecnic vein thrombosis as the etiology of the increased venous pressures. Angiography may verify this diagnosis. These  patients are best treated with simple splecnectomy, which adequately decompresses their varices. Such patients have an excellent prognosis because of the lack of underlying liver disease. Splecnic vein thrombosis may occur as a complication of pancreatitis due to contiguous inflammation from the body and tail of the pancreas.Histoacryl (N-butyl-2-cyanocrylate) has been used in bleeding esophagogastric and ectopic varices.

Enormous Erosioned Gastric Varix.

 Ulcerated Gastric Varix of the fundus that caused severe
 gastrointestinal hemorrhage.

Varices of the gastric fundus.  More commonly, bleeding gastric varices are associated with large esophageal varices and are due to underlying liver disease.

Varices of the Gastric Fundus.

 More commonly, bleeding gastric varices are associated
 with large esophageal varices and are due to underlying
 liver disease. 

A 90 year-old female with fundus varices recent bleeding  activity is observed.

Fundus Varices.

 A 90 year-old female with fundus varices, recent bleeding
 activity is observed.

 Status Post Histoacryl. Histoacryl was injected intravariceally. Histoacryl injection sclerotherapy is highly effective for the treatment of bleeding gastric varices, with rare complications occurring both acutely and long-term. Therefore, Histoacryl injection sclerotherapy is considered to be the first choice of treatment for bleeding gastric varices, but the rate of recurrent bleeding is so high that further methods or devices still need to be developed in order to prevent gastric variceal rebleeding.

 Status Post Histoacryl.

Histoacryl was injected intravariceally.

 Histoacryl injection sclerotherapy is highly effective for the
 treatment of bleeding gastric varices, with rare
 complications occurring both acutely and long-term.
 Therefore, Histoacryl injection sclerotherapy is considered
 to be the first choice of treatment for bleeding gastric
 varices, but the rate of recurrent bleeding is so high that
 further methods or devices still need to be developed in
 order to prevent gastric variceal rebleeding
.

 Linear varices in the gastric body of a 72 year-old man with abdominal pain and weight loss. There were no varices in the esophagus or gastric cardia. The woman was ultimately found to have pancreatic carcinoma, and was suspected to have splenic vein thrombosis.

Video Endoscopic Sequence 1 of 3.

Linear Gastric Varices.

 Linear varices in the gastric body of a 72 year-old man
 with abdominal pain and weight loss. There were no varices
 in the esophagus or gastric cardia. The woman was
 ultimately found to have pancreatic carcinoma, and was
 suspected to have splenic vein thrombosis.
 

Linear Gastric Varices. Gastric variceal bleeding can be challenging to the clinician.

Video Endoscopic Sequence 2 of 3.

Linear Gastric Varices.

Gastric variceal bleeding can be challenging to the clinician

 

Linear Gastric Varices.

Video Endoscopic Sequence 3 of 3.

Linear Gastric Varices.

Gastroesophagic Varices. This 72 year-old lady, 15 days previous it was hospitalized due to upper gastrointestinal bleeding in another hospital At that time had an upper endoscopy revealing two ulcers one with visible vessel but they do not described varices of the esophagus, she was discharged from the hospital, two weeks after the patient present a severe re-bled and was hospitalized again, referred to our endoscopic unit.

Video Endoscopic Sequence 1 of 7.

Gastroesophagic Varices.

 This 72 year-old lady, 15 days previous it was hospitalized
 due to upper gastrointestinal bleeding in another hospital.
 At that time had an upper endoscopy revealing two ulcers
 one with visible vessel but they do not described varices of
 the esophagus, she was discharged from the hospital, two
 weeks after the patient present a severe re-bled and was
 hospitalized again, referred to our endoscopic unit, her
 hemoglobin was 5.7
g/dl.

Ulcerated Gastric Varix . An ulcer with a large visible vassel is seen, retroflexed image.

Video Endoscopic Sequence 2 of 7.

 Ulcerated Gastric Varix

An ulcer with a large visible vassel is seen, retroflexed image.

Ulcerated Gastric Varix, Due to the large vassel as well as the re-bled we decide any hemostatic maneuver to be used.

Video Endoscopic Sequence 3 of 7.

Ulcerated Gastric Varix

Due to the large vassel as well as the re-bled we decide any
 hemostatic maneuver to be used.

Ulcerated Gastric Varix

Video Endoscopic Sequence 4 of 7.

Ulcerated Gastric Varix.

In this image and video clip you can observe the other ulceration that was coagulated with argon plasma coagulator.

Video Endoscopic Sequence 5 of 7.

 In this image and video clip you can observe the small
 ulceration that was coagulated with argon plasma
 coagulator.

The coagulation with argon plasma is observed.

Video Endoscopic Sequence 6 of 7.

The coagulation with argon plasma is observed.

 

In order to perform therapeutic hemostasis Argon plasma coagulation was used, but it caused an impressive bleeding to stop this hemorrhage a Sengstaken-Blakemore tube had to be placed using the gastric balloon.

Video Endoscopic Sequence 7 of 7.

Gastric Ulcerated Varix

 In order to perform a therapeutic hemostasis Argon
 plasma coagulation was used, but it caused an impressive
 bleeding to stop this hemorrhage a
Sengstaken-Blakemore
 tube had to be placed using the gastric balloon.

 Retrospectively, I would prefer using a rubber band
 ligation combining with h
istoacryl to
obliterate this large
 vessel.

 

This patient of 66 year-old male who has alcoholic hepatic cirrhosis had been hospitalized in a hospital of national insurance in San Salvador due to a massive bleeding of the upper digestive track a Sengstaken-Blakemore tube had been placed, after ten day of hospitalization the hemorrhage. tree shot of histoacryl injection was carry out.

Video Endoscopic Sequence 1 of 7.

Gastroesophagic Varices.

 This patient of 66 year-old male who has alcoholic hepatic
 cirrhosis had been hospitalized in a hospital of national
 insurance in San Salvador due to a massive bleeding of the
 upper digestive track a Sengstaken-Blakemore tube had
 been placed, after ten day of
hospitalization the
 hemorrhage had been continuing, the physicians in that
 hospital wanted to performed a surgical procedure
 explained to the patient the high morbi-mortality, patient
 and his relatives declining that surgery. patient was
 preferred to our unit performing
histoacryl injection in the
 operation room stopping the hemorrhage, tree shot of
 histoacryl injection was carry out.
 

The patient was received from the other hospital with the  Sengstaken-Blakemore tube.

Video Endoscopic Sequence 2 of 7.

The patient was received from the other hospital with the Sengstaken-Blakemore tube.

 The image and the video clip show the status post use
 the
Sengstaken-Blakemore tube, showing the aspect of the
 mucosa that is edematized, the endoscopic
anatomy, is
 deformed in the gastric fundus and the proximal body.

Through the cardia, one ulcerated gastric varix is observed, which was the exact site of the bleeeding.

Video Endoscopic Sequence 3 of 7.

 Through the cardia, one ulcerated gastric varix is observed,
 which was the exact site of the bleeding.

 

The cardias is found ulcerated due to the  Sengstaken-Blakemore tube, patient had two more ulcers one in the middle third and upper third.      Balloon tamponade is used if sclerotherapy and vasoconstrictor therapy fail to control variceal bleeding or are contra-indicated. The usual tube is a Sengstaken- Blakemore which is passed into the stomach. The gastric balloon is inflated; the oesophageal balloon is inflated only if bleeding is not controlled by the gastric balloon. The technique is successful in 90% of cases. Serious complications, with a 5% mortality, include aspiration pneumonia, oesophageal rupture and mucosal ulceration. It is very unpleasant for the patient.

Video Endoscopic Sequence 4 of 7.

 The cardias is found ulcerated due to the
 Sengstaken-Blakemore tube, patient had two more ulcers
 one in the middle third and upper third.

 Balloon tamponade is used if sclerotherapy and
 vasoconstrictor therapy fail to control variceal bleeding or
 are contra-indicated. The usual tube is a Sengstaken-
 Blakemore which is passed into the stomach. The gastric
 balloon is inflated; the esophageal balloon is inflated only
 if bleeding is not controlled by the gastric balloon. The
 technique is successful in 90% of cases. Serious
 complications, with a 5% mortality, include aspiration
 pneumonia, esophageal rupture and mucosal ulceration. It
 is very unpleasant for the patient.

 Note that balloon tamponade is a temporary measure and it
 may cause pressure necrosis after 48-72 hours. Thus
 sclerotherapy or some other means of control should be
 used after 12-24 hours.

In addition to the ablative therapy of the gastric varix, ten  esophageal varices were ligated.

Video Endoscopic Sequence 5 of 7.

 In addition to the ablative therapy of the gastric varix, ten
 esophageal varices were ligated.

The upper esophageal sphincter was found ulcerated due to  Sengstaken-Blakemore tube which found it misplaced.

Video Endoscopic Sequence 6 of 7.

The upper esophageal sphincter was found ulcerated due to
Sengstaken-Blakemore tube which found it misplaced.
 

Status post injection of histoacryl mixture, tree shot of histoacryl injection was carry out.  A follow up endoscopy one month later was performed.

Video Endoscopic Sequence 7 of 7.

Status post injection of histoacryl mixture, tree shot of histoacryl injection was carry out.

A follow up endoscopy one month later was performed.

 65 year old woman referred to our endoscopic unit for evaluation and treatment of an upper GI bleeding. Recent history includes: 4 days previously, Surgical removal of giant ovarian tumor that compressed great abdominal vessels, also 2 previous episodes of upper GI bleeding, with placement of Sengstaken-Blakemore probe on one occasion.

Video Endoscopic Sequence 1 of 22.

Gastric Varices Rosettes formation

 65 year old woman referred to our endoscopic unit for
 evaluation and treatment of an upper GI bleeding. Recent
 history includes: 4 days previously, Surgical removal of
 giant ovarian tumor
that compressed great abdominal
 vessels, also 2 previous episodes of upper GI bleeding,
 with placement of Sengstaken-Blakemore probe on one
 occasion.

Varices were found only in the gastric fundus. No varices were found in the esophagus. No other significant findings were recorded.

Video Endoscopic Sequence 2 of 22.

Gastric Varices Rosettes formation

 The first upper endoscopy was practiced in an outpatient
 setting with signs of recent bleeding. Abundant bloody
 secretions were aspirated, and the patient was admitted to
 the hospital for hemodynamic stabilization and monitoring.

 

Varices were found only in the gastric fundus. No varices were found in the esophagus. No other significant findings were recorded.

Video Endoscopic Sequence 3 of 22.

 Varices were found only in the gastric fundus. No varices
 were found in the esophagus. No other significant findings
 were recorded.

 

Another image of the varices located in the gastric fundus.  Therapeutic endoscopy was practiced in the operating room with placement of an orotracheal tube to prevent bronchoaspiration.

Video Endoscopic Sequence 4 of 22.

 We can observe a small ulceration in one of the varices,
 which could indicate a bleeding spot.

 Therapeutic endoscopy was practiced in the operating
 room with placement of an orotracheal tube to prevent
 bronchoaspiration.

 

Another image of the varices located in the gastric fundus.

Video Endoscopic Sequence 5 of 22.

 Another image of the varices located in the gastric fundus.

 

Due to the gastric washing in order to look for the probable sites of bleeding acute bleeding is reactivated.

Video Endoscopic Sequence 6 of 22.

Due to the gastric washing in order to look for the probable sites of bleeding acute bleeding is reactivated.

Bleeding has been sufficiently severe, we used the therapeutic endoscopy of double channel.

Video Endoscopic Sequence 7 of 22.

 Bleeding has been sufficiently severe, we used the
 therapeutic endoscopy of double channel.

After to have washed and to have aspired abundant blood, the image was partially clarified and seen through the water and in a form of submarine swimming we managed to identify the varix and the probable site of bleeding.

Video Endoscopic Sequence 8 of 22.

 After to have washed and to have aspired abundant blood,
 the image was partially clarified and seen through the
 water and in a form of submarine swimming we managed to
 identify the varix and the probable site of bleeding.

 

Video Endoscopic Sequence 9 of 22.

Next step is that to inject a mixture of histoacryl with with lipiodol (0.8 mL in 0.5 mL) will be injected intra-variceal. 

It is observed when the mixture of the glue emerges through varix.

Video Endoscopic Sequence 10 of 22.

 It is observed when the mixture of the glue emerges through varix.

The glue emerging from the varix.

Video Endoscopic Sequence 11 of 22.

The glue emerging from the varix.

 

TThe glue in the middle of varix which has stopped the bleeding.

Video Endoscopic Sequence 12 of 22.

The glue in the middle of varix which has stopped the bleeding.

 

Another image of varix with its glue.

Video Endoscopic Sequence 13 of 22.

Another image of varix with its glue

 

In the thorax x-ray the mixture of histoacryl with lipoidol is observed in the gastric bubble.

Video Endoscopic Sequence 14 of 22.

In the thorax x-ray the mixture of histoacryl with lipoidol is observed in the gastric bubble

 

Another image of the glue, the lipoidol makes radio-opaque.

Video Endoscopic Sequence 15 of 22.

 Another image of the glue, the lipoidol makes radio-opaque

 

3 weeks after a follow up endoscopy was performed.  Showing the images and video clips of the 16 to 22 sequence, observing the glue (yellow) that emerges from the varix.

Video Endoscopic Sequence 16 of 22.

3 weeks after a follow up endoscopy was performed

 Showing the images and video clips of the 16 to 22 sequence, observing the glue (yellow) that emerges from the varix.

 

STDsXVaricesGastricDulceN17

Video Endoscopic Sequence 17 of 22.

Approach by retroflexión to the varix

 

Retroflexed image observing the varix  with its glue

Video Endoscopic Sequence 18 of 22.

Retroflexed image observing the varix with its glue

Gastric varices have been increasingly recognized as a major cause of gastrointestinal bleeding in patients with portal hypertension. Compared with esophageal variceal bleeding, hemorrhage caused by gastric varices is usually more severe and hemostatic control is reported to be more difficult.

Video Endoscopic Sequence 19 of 22.

 Gastric varices have been increasingly recognized as a
 major cause of gastrointestinal bleeding in patients with
 portal hypertension. Compared with esophageal variceal
 bleeding, hemorrhage caused by gastric varices is usually
 more severe and hemostatic control is reported to be more
 difficult.

STDsXVaricesGastricDulceN20

Video Endoscopic Sequence 20 of 22.

Gastric Varices Rosettes formation

STDsXVaricesGastricDulceN21

Video Endoscopic Sequence 21 of 22.

STDsXVaricesGastricDulceN22

Video Endoscopic Sequence 22 of 22.

GastricVarixDemabond1

Video Endoscopic Sequence 1 of 9.

 Upper gastrointestinal bleeding due to gastric varices

 This is a 58 year-old male with a history of abuse of
 alcoholic beverages, iniciates with severe bleeding with
 hematemesis and melena. Was transferred from
 another hospital to our unit. He was stabilized
 hemodynamically.

 In the the operating room, therapeutic endoscopy was
 performed under oropharyngeal intubation. At the moment
 to enter to the operation room his hemoglobin was 3.5 g /dl.

GastricVarixDemabond2

Video Endoscopic Sequence 2 of 9.

Finding the exact site of bleeding

The possible sites of bleeding were revised, finding esophagogastric varices
 

GastricVarixDemabond3

Video Endoscopic Sequence 3 of 9.

 Gastric varices are seen with ulceration in the gastric fundus.

GastricVarixDemabond4

Video Endoscopic Sequence 4 of 9.

Ulcerated Gastric Varix

 This is the view from the cardias, observing the site of this
 bleeding an ulcerated gastric varix, seen in this picture a
 small plug of fibrin, but had two more discretely hidden.
 

GastricVarixDemabond5

Video Endoscopic Sequence 5 of 9.

An ulcerated varix is barely seen in this retroflexed image (around 10 clockwise).

GastricVarixDemabond6

Video Endoscopic Sequence 6 of 9.

The therapeutic endoscopy is starting, performing hemostasis
 injecting Dermabond. (2-Octyl-cyanoacrylate).
 The technique of injecting this glue must consider an
 average by pass slowly 45 seconds. (different to histoacryl
)


 

GastricVarixDemabond7

Video Endoscopic Sequence 7 of 9.

The glue was injected, and it came out from another hole
The adhesive was detached. Some of the glue stayed inside the varix.

GastricVarixDemabond8

Video Endoscopic Sequence 8 of 9.

Endoscopic image after the injection of glue

GastricVarixDemabond9

Video Endoscopic Sequence 9 of 9.

After satisfactory evolution, the patient was discharged 48 hours later.