A 59-year-old man presented with a massive attack of hematemesis (HB= 7), was
admitted to our hospital. The patient was shocked, so resuscitation was done in
the form of IV fluids, blood transfusion, Sandostatin, and proton pump
inhibitor infusions. After resuscitation, upper esophagogastroduodenoscopy was
done. The scope revealed large esophageal varices with gastric extension into
the fundal region. There is a characteristic white
nipple sign ( arrow in the video)on
the gastric extension (GOV type II, according to Sarin classification).
What
is the line of treatment in the setting of limited options of treatment
(available interventions are sclerotherapy and band ligation)?
My line
of treatment is the injection of gastroesophageal varix and ligation of the
esophageal varices.
The question here
is where to inject gastroesophageal varix, i.e., injection towards the
esophageal side (cardiac) or to the fundal side?
The two options are
possible.
Gastroesophageal
varices type II had dual venous drainage via both the gastrophrenic and
gastroesophageal venous systems
The
anteromedial (cardiac) part of the varix is supplied by the left gastric vein
and drains via the esophageal varices into the gastroesophageal venous system.
The posterior (fundal) part of the varix is supplied by the posterior gastric
vein or short gastric vein and drains via the gastrophrenic venous system.
In this
video, injection of the gastroesophageal varix was done with four ampoules of
amacryl+ Lipiodol through the fundal side of gastroesophageal varix
aiming at occluding of the gastrophrenic venous system (posterior gastric vein
and short gastric veins).
Band
ligation of the esophageal varices was done, aiming at occluding of the cardiac
portion of gastroesophageal varix.
After the endoscopy, the patient
admitted to the ICU and continued medical treatment and discharged from the
hospital after five days.
3weeks after discharge from the hospital, the patient underwent follow-up upper digestive endoscopy and his medical condition was good. another band ligation was done for the esophageal varices.
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