Michele Bettinelli RN CCRN Lahey Health and Medical Center

Michele Bettinelli RN CCRN Lahey Health and Medical Center

Differentiate the types of varices Identify glue preparations utilized when treating gastric varices Review the process of glue administration Explain possible complications and discuss appropriate treatment Present alternative treatments and the dilemma with determining standard of care

Associated with cirrhosis Alcoholic Chronic Hepatitis C Portal Vein Thrombosis Biliary Atresia Sarcoidosis Miliary Tuberculosis Constrictive Pericarditis

Increased portal pressure Structural resistance to blood flow Formation of porto-systemic collaterals

Changes in mucosa related to portal hypertension Friable Increased risk of hemorrhage

Varices and variceal hemorrhage are complications of cirrhosis that are directly related to portal hypertension AND Variceal hemorrhage can be lethal

Child Pugh Score Bilirubin Albumin INR Ascites Encephalopathy Model for Endstage Liver Disease Score (MELD) Bilirubin Creatnine INR

Group A B C Bilirubin Below 2.0 2.0-3.0 >3.0 Albumin >3.5 2.8-3.5 <2.8 Ascites None Slight Moderate Encephalopathy None Minimal Grade 1-2 Grade 3-4 INR <1.7 1.7-2.3 >2.3

Calculation which predicts liver transplant survivability Score is between 6 and 40

Varices are present in approximately 50% of individuals with cirrhosis Presence of varices correlates with severity of liver disease Usually asymptomatic but there is an increased risk of rupture EGD to diagnose and evaluate risk of bleeding Variceal hemorrhage occurs yearly between 5-15%

Gastric varices are less prevalent than esophageal varices Present in 5-33% of all individuals with portal hypertension Size of varices is directly correlated with risk of hemorrhage Incidence of bleeding associated with gastric varices is approximately 25% within two years of diagnosis

Approximately 30% mortality rate during initial hospitalization 20% mortality rate within the first 6 weeks of hemorrhage 60% mortality rate within first year following hemorrhage

70% incidence of re-bleeding following initial hemorrhage Development of varices occurs at a rate of 8% for 2 years then increases to 30%

Common misconception that all varices despite location can be treated identically

Nonselective beta blocker medication Variceal band ligation Sclerotherapy Balloon Tamponade TIPS

Bleeding from gastric varices is rare compared to bleeding from esophageal varices however it is more difficult to treat and usually more severe

EGD Assess severity of bleeding Identify the source and determine the location of the bleeding Bleeding varices Presence of stigmata Presence of varices Determine best management of bleeding

Helps to determine management Sarin Classification is most common Based on anatomical location Hashizume Classification Based on endoscopic features

GOV 1 70% GOV 2 / IGV 1 Nearly 30% Bleed the most frequently IGV 2 Very rare

Few randomized controlled clinical trials exist with limited guidelines GOV 1 Located along the lesser curvature and treated as esophageal varices GOV 2/IGV1 Management Approaches Endoscopic Radiologic Surgical

Determined by location of varices GOV 1 Consider band ligation GOV2/IGV1 Sclerotherapy not effective Glue obliteration Thrombin Balloon Tamponade Esophageal Stents TIPS Coil embolization BRTO Surgical shunting Caldwell S. Gastroenterology 2012

AASLD guidelines EGD within 12 hours of hemodynamic stabilization Diagnosis Challenging Consider EUS Bhat YM et al. Gastrointestinal Endoscopy 2015 Endoscopic Treatment Closure with Cyanoacrylate (glue)

Cyanoacrylate Liquid that polymerizes into a solid substance with blood contact Soehendra N et al. Endoscopy 1986 Current evidence demonstrates that the use of Cyanoacrylate controls gastric variceal bleeding in 87%-93% of cases Garcia-Tsao G et al. Hepatology 2007 Tan PC et al.hepatology 2006 Lo GH et al. Hepatology 2001

Histocryl N-butyl-2-cyanoacrylate Rapid polymerization Diluted with Lipiodol Administered with sterile water prime and flush Dermabond 2-octyl-cyanoacrylate Slower polymerization Injected without dilution over 45-60 seconds Administered with Normal saline prime and flush Rengstorff D et al Gastrointestinal Endoscopy 2004

Patient +/- Airway intubation Routine endoscopy preparation Eye protection Glue Personal protective equipment Time consuming Endoscope Tip coated in oil Instrument channel flushed with oil

Therapeutic Gastroscope 23 gauge sclerotherapy needles Cyanoacrylate Lipiodol Oil Sterile water / Normal saline Filtered needles 1 cc syringes 3 cc syringes

Type and location of varices evaluated by complete EGD End of endoscope is coated with oil Working channel of endoscope is flushed with oil/lipiodol

Histocryl Syringes prepared with 0.5ml of lipiodol and 1ml of Histocryl Additional syringes with 3cc of lipiodol used to prime and flush needle Syringes with sterile water used to flush needle Dermabond Syringes prepared with 1cc of Dermabond Additional syringes with saline used to prime and flush needle

Histocryl Needle is primed with 1cc lipiodol Varix is identified and needle is inserted lipiodol Histocryl mixture is administered Needle is flushed with lipiodol or sterile water Needle is withdrawn into stomach and flushed with additional sterile water Varix is probed with blunt end of needle catheter to assess effectiveness of glue Dermabond Needle is primed with 1cc of saline Varix is identified and needle is primed with 1cc of Dermabond in stomach Needle is inserted into varix and Dermabond is administered with 1cc saline over 45-60 seconds Needle with withdrawn into stomach and flushed with additional saline Varix is probed with blunt end of needle catheter to assess effectiveness of glue

Embolization of glue Pulmonary Splenic Portal Vein Cerebral Inability to obliterate varix Sepsis Recurrent bleeding due to ulcer formation Fever Chest pain Abdominal pain Adherence of needle in varixdamage to endoscope due to glue adherence

Balloon Tamponade Temporary measure TIPS Procedure Transjugular intrahepatic portosystemic shunt Fibrin Sealant/Thrombin EUS guided Coiling and Cyanoacrylate injection BRTO Balloon-occluded retrograde transvenous obliteration Surgical Shunt

Steps in a TIPS procedure: A portal hypertension has caused the coronary vein (arrow) and the umbilical vein(arrowhead) to dilate and flow in reverse. This leads to varices in the esophagus and stomach, which can bleed B a needle has been introduced (via the jugular vein) and is passing from the hepatic vein into the portal vein C the tract is dilated with a balloon D after placement of a stent, portal pressure is normalized and the coronary and umbilical veins no longer fill

Cyanoacrylate has been successfully used to treat gastric varices since 1987 Cyanoacrylate is not approved to treat gastric variceal bleeding by the FDA Controlled randomized studies are necessary to validate the effectiveness of Cyanoacrylate

AASLD Practice Guidelines for Gastroesophageal Varices Baveno VI Consensus Conference June 2015 Bhat YM et al. Gastrointestinal Endoscopy 2015 Blinder HJ et al. Gastroenterology 2001 Caldwell S. Gastroenterology 2012 Dale C. Gastroenterology Nursing 2016 Kapoor A et al. Gastrointestinal Endoscopy Clinics of North America 2015 Rengstorff, DS & Binmoeller KF. Gastrointestinal Endoscopy 2004 Weilert F & Binmoeller KF. Gastroenterology Clinics of North America