International Session（Symposium）9(JGES・JSGE・JSGS・JSGCS)
Sat. November 7th   9:00 - 11:30   Room 11: Portopia Hotel South Wing Topaz
IS-S9-4_E
 The role of endoscopy on the management of gastroesophageal variceal bleeding
Ming Chih Hou
Department of Medicine, Taipei Veterans General Hospital
Gastroesophageal variceal bleeding (GEVB) is a major consequence of chronic liver disease and is characteristic of high rebleeding rate and mortality. Prognostic improvement has been made due to the progress in pharmacological, radiologic and endoscopic treatment of GEVB. In suspected variceal bleeding, vasoactive drugs and prophylactic antibiotics should be started as soon as possible, before endoscopy.
Endoscopic treatment, endoscopic variceal ligation (EVL) using rubber band is preferred, should be offered to any patient with endoscopy proved EVB. Sclerotherapy may be used if EVL is technically difficult. Vasoactive drugs such as terlipressin and somatostatin analogue should be used in combination with endoscopic treatment and continued for up to 3~5 days. First aid using nano-powder spray followed by urgent elective EVL may decrease rebleeding. Esophageal stenting is more effective than balloon tamponade for refractory EVB. Other novel endoscopic methods eg. argon plasma coagulation, cryotherapy maybe optionally used.
Gastric varices (GV) rarely rupture, however the outcome is worse than rupture
of EV. Up to date, the treatment of GV bleeding (GVB) is still sub-optimal in contrast
to the treatment of EVB. Various specific methods including injection of tissue glue (cyanoacrylate), sclerosants, thrombin and ligation with rubber bands, detachable nylon loop and steel snares, are used to control GVB and prevent rebleeding. Most of the methods, except endoscopic injection of cyanoacrylate (GVO), were far from ideal and lack of evidence. The expertise is required to reduce the embolic complications and instrumental injuries. Whether the better hemostasis can be achieved by double dose vs. single dose, diluted vs. undiluted cyanoacrylate is challenging. Another unsolved issue is whether GV and EV should be treated simultaneously. Recently, EUS-guided GVO using cyanoacrylate and/or coil was reported to be promising.
In summary, the efficacy of specific treatment for GEVB is still sub-optimal. Consecutive innovation of new endoscopic methods and controlled trials are required to further improve the prognosis of GEVB.
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