Pipeline esophageal varices: Insights from clinical cases and models

Abstract

Objectives: While esophageal varices (EVs) are typically treated endoscopically, other options such as interventional radiology or surgical treatment are considered when endoscopic treatment is challenging. Pipeline EVs are difficult to treat endoscopically due to their large diameter, and currently, no specific treatment guidelines have been established.

Methods: We reviewed cases of pipeline EVs treated at our hospital and analyzed previously reported cases to collect evidence for the formulation of treatment guidelines. Additionally, we created EV simple models to evaluate the safety margin of endoscopic variceal ligation for varices.

Results: Our analysis included 14 cases of pipeline EVs (four cases treated at our hospital from 2013 to 2024 and 10 previously reported cases from 1990 to 2024). Endoscopic treatment alone was insufficient in six cases (42.9%), and five cases (35.7%) required interventional radiology or surgical intervention. Using EV simple models with varying diameters, EVL was inadequate for varices with diameters of 20 mm or larger.

Conclusions: There are few reported cases of pipeline EVs, making it difficult to determine a treatment algorithm. In our study using an EV simple model, it was suggested that endoscopic variceal ligation is effective in blocking blood flow for EVs with a diameter of 15 mm or less. It is important that we understand there are EVs, such as pipeline EVs, for which there are limitations to safely occluding blood flow with endoscopic variceal ligation, and it may be necessary to develop treatment strategies that include methods other than endoscopic therapy.

Keywords: endoscopic injection sclerotherapy; endoscopic variceal ligation; esophageal varices; giant esophageal varices; pipeline esophageal varices.

FIGURE 1

A 70‐year‐old man was admitted with complaints of hematemesis. Pipeline esophageal varix (EV) measuring 25 mm in diameter was identified in contrast‐enhanced computed tomography (a–d). In the emergency upper endoscopy (e–i), hemostasis was achieved at the site of the red plug using endoscopic variceal ligation (EVL). On day 8, endoscopic injection sclerotherapy was performed using the ethanolamine oleate method, but the sclerosing agent failed to stagnate within the blood vessels. Absolute ethanol was intermittently injected in 1 mL increments (a total of 3 mL), but the treatment proved ineffective. EVL was performed at the puncture site, completing the procedure. On day 12, the patient experienced hematemesis, prompting another emergency upper endoscopy. The initial EVL site had ulcerated, and active bleeding was observed nearby (j). EVL was difficult due to the proximity to the ulcer. An attempt to place a Sengstaken‐Blakemore tube was made, but the patient's blood pressure dropped during preparation, and he died. (a) Dilated left gastric vein (arrow). (b) Left gastric vein flowing into the gastric cardia (arrow). (c) Left gastric vein continuing into the esophagus without passing through blind vessels (arrow). (d) Dilated EVs (arrow). (e) Pipeline EV visible at the 2 o'clock position. (f) Red plug on the pipeline EV (arrow). (g) Varices in the gastric cardia. (h) EVL performed on the red plug area. (i) Image showing hemostasis after EVL. (j) Upper endoscopy image during rebleeding, with bleeding observed near the ulcer after EVL (arrow).

FIGURE 2

Creation of esophageal varix (EV) simple models. (a) EV model made from polyethylene. (b) Models of EV in various sizes (10, 15, 20, and 25 mm from right to left). (c) Enlarged photograph of a 10 mm diameter EV model. (d) Enlarged photograph of a 15 mm diameter EV model. (e) Enlarged photograph of a 20 mm diameter EV model (f) Enlarged photograph of a 25 mm diameter EV model. (g) EV in Case 4 (maximum diameter, 25 mm). (h) EV model that evaluates the effectiveness of blood flow occlusion by flowing a red liquid resembling blood inside the model. (i) Image of endoscopic variceal ligation in the 15 mm diameter model.

FIGURE 3

Illustrations of unsuccessful cases of ligation and blood flow occlusion. (a) Poor ligation and blood flow occlusion using endoscoic variceal ligation (EVL). The varices diameter is larger than that of the EVL band (O‐ring), leading to inadequate ligation. (b) The EVL band may fall off. (c) EVL does not completely block blood flow with a high risk of rebleeding from the ulcer.