The Clinical Role of Endoscopic Ultrasound for Management of Bleeding Esophageal Varices in Liver Cirrhosis

Abstract

Bleeding esophageal varices (BEV) is a serious clinical condition and can potentially be life-threatening. Esophageal varices are caused by abnormal dilated submucosal and collateral veins in the esophagus wall as a result of portal hypertension due to liver cirrhosis. Consequently, it is important to administer appropriate preventive treatment for the disease in order to decrease morbidity and mortality rates. The current gold standard to identify esophageal varices is the use of esophagogastroduodenoscopy (EGD). However, EGD has limitations due to its inability in observing detailed information of varices morphology and esophagogastric hemodynamics. This report shares the potential role of endoscopic ultrasound (EUS) to overcome the limitation of EGD in clinical practices. Two cases of BEV in hepatitis B liver cirrhosis patients were described in the report. In case 1, large esophageal varices were found through EGD, and large paraesophageal varices were found through EUS. In case 2, small esophageal varices were found through EGD, and submucosal varices with a large periesophageal collateral vein and perforating vein in the distal esophagus were found through EUS. Cyanoacrylate injection guided by EUS was performed in both cases, and no rebleeding occurred after the procedure. In these cases, we showed that EUS is proven to be a potential tool in diagnosis and management of BEV in liver cirrhosis. EUS provides more accurate diagnostic aspects to find varices, assess bleeding risk, and predict bleeding recurrence. EUS also provides more beneficial treatment aspects to guide the treatment procedure and to monitor post treatment response.

Keywords: Bleeding esophageal varices; Endoscopic ultrasound; Liver cirrhosis.

Fig. 1

a Large esophageal varices were found under EGD. b Large paraesophageal varices was found under EUS. c Needle insertion guided by EUS. d Paraesophageal varices after CYA injection. e Small esophageal varices were found under EGD. f Large peri-ECV and PV were found under EUS. g Large peri-ECV after CYA injection.