Effective Treatment Case of Esophagogastric Varices With a To-and-Fro Flow State Using Convex Ultrasound Endoscopy

Abstract

Esophagogastric varices often involve connection of blood flow between the esophagus and stomach [1]. Endoscopic injection sclerotherapy (EIS) represents a useful treatment for esophagogastric varices [1-4]. However, with advanced portal hypertension, the left gastric vein (LGV) of main blood supply route is considered to have a period during which a to-and-fro state of flow occurs [4, 5]. We usually evaluate this to-and-fro flow state using color Doppler-enhanced EUS before treating continuous esophagogastric varices. To the best of our knowledge, this report is the first of a video case confirming a to-and-fro flow state of LGV during EIS.

This video presents a typical case (Video 1). The patient, a 66-year-old female, had primary biliary cholangitis and esophagogastric varices (Figure 1a,b). Contrast-enhanced CT showed the hemodynamics of esophagogastric varices which fed from LGV through the gastric varices to esophageal varices (Figure 1c). Color Doppler-enhanced EUS shows a to-and-fro flow state of varices (Figure 1d,e). Based on the hemodynamics described, we took care to avoid excessive sclerosant injection during EIS. Specifically, we performed injection only from the esophageal varices to the gastric varices. After the esophageal varices were punctured using a 23G needle (EZ shot3 plus; Olympus Corp.), a sclerosant (ethanolamine oleate, EO) was injected from the esophageal varices to the gastric varices (Figure 2a). After needle removal, pressure was applied to the puncture site with a balloon, which was repositioned near the esophagogastric junction to achieve adequate compression. Given the to-and-fro flow state, temporary occlusion of the outflow route may have facilitated preferential flow of the sclerosant into the LGV (Figure 2b).

In advanced portal hypertension, especially in esophagogastric varices, evaluation of the to-and-fro flow state using color Doppler-enhanced EUS before treatment is important. During EIS in this flow state, sclerosant may preferentially flow toward the portal system; therefore, careful attention is required.

K.N. and A.I. wrote the manuscript. A.I. and K.N. revised the manuscript and are the article guarantors. T.S. supervised the manuscript.

The authors have nothing to report.

The authors declare no conflicts of interest.