Hideo Shishido

Role of para‐esophageal collateral veins in patients with portal hypertension based on the results of endoscopic ultrasonography and liver scintigraphy analysis

Background and Aims: Para‐esophageal collateral veins (para‐ECV) are observed by endoscopic ultrasonography (EUS) in patients with portal hypertension. However, the role of para‐ECV in the portal venous system is not clear. To verify the role of para‐ECV in the portal venous system, we investigated the relationship between the development of para‐ECV as determined by EUS, and the portal blood flow ratio (PBFR) as determined by liver scintigraphy using 99mTc‐phytate.

Collateral vessels around the esophageal wall in patients with portal hypertension: comparison of EUS imaging and microscopic findings at autopsy.

BACKGROUND In patients with portal hypertension, EUS reveals the presence of collateral vessels within and outside the esophageal wall such as esophageal varices, periesophageal collateral veins (peri-ECVs), paraesophageal collateral veins (para-ECVs), and perforating veins. This study retrospectively compared radial EUS images of these collateral vessels with histopathologic findings. METHODS Four patients with esophageal varices treated by endoscopic injection sclerotherapy were studied. EUS was performed to evaluate the effects of endoscopic injection sclerotherapy. After endoscopic injection sclerotherapy, the segment of the esophagus from the esophagogastric junction to a point 5 cm proximal to junction was imaged with a 20-MHz radial scanning catheter US probe. Esophageal collateral veins outside the esophageal wall were identified as peri-ECVs (veins lateral to muscularis propria or within adventitia) and para-ECVs (veins lateral and separate from muscularis propria) along with perforating veins (veins connecting extramural collateral veins to submucosal varices). At autopsy, the esophagus with surrounding tissue was removed and cross-sectioned at 1-cm intervals from the esophagogastric junction to a point 5 cm proximal to the junction. Radial EUS images were correlated with histopathologic findings. RESULTS Radial EUS after endoscopic injection sclerotherapy demonstrated peri-ECVs and perforating veins in all cases and para-ECVs in 3 cases. Based on histopathologic findings, veins associated with the esophageal wall were divided into 3 groups: those adjacent to the muscularis propria, veins separated from the wall without contact with the muscularis propria, and veins perforating the muscularis propria. All 3 groups of veins were observed in all cases. These 3 types of veins identified by histopathologic examination corresponded, respectively, to the peri-ECVs, para-ECVs, and perforating veins observed by EUS. CONCLUSION Collateral esophageal veins demonstrated by radial EUS in patients with portal hypertension correspond to collateral veins identified histopathologically. In patients with portal hypertension, EUS is useful for assessment of vascular anatomy around the esophageal wall.

Analysis of prognostic factors in patients with gastric varices after endoscopic treatment.

Background:  The prognostic factors, including gastric variceal bleeding itself, in patients with gastric varices (GV) after endoscopic treatment remain unclear. The aim of this study was to analyze prognostic factors in patients with GV after endoscopic treatment as well as to evaluate safety and efficacy of our endoscopic treatment.

4527 The role of para-esophageal collateral veins in patients with portal hypertension: eus and liver scintigraphy analysis.

Background: In patients with portal hypertension, many collaterals develop around the esophageal wall. Endoscopic ultrasonography (EUS) can reveal the para-esophageal collateral veins (para-ECVs) around the esophageal wall (Gastrointestinal Endosc 1999;50). Liver scintigraphy using 99mTc-phytate enables quantitative grading of the ratio of portal venous to total hepatic blood flow. Collaterals that have developed around the esophageal wall are thought to cause a reduction in the portal blood flow ratio (PBFR). To verify the role of para-ECVs on portal venous blood flow, we investigated the relationship between the development of para- ECVs and the PBRF by EUS and liver scintigraphy. Patients and Method: Twenty patients who did not associate with fundal gastric varices were studied before and after endoscopic injection screlotherapy (EIS). To quantify the degree of development of blood vessels outside the esophageal wall, the cross-sectional area of each para-ECVs observed by EUS was calculated, and the sum total of the areas was used as an index of development of para-ECVs. Portal blood flow was calculated by liver scintigraphy using 99mTc-phytate. Results: The correlation between PBRF and the total cross sectional area of the para-ECVs before and after treatment was examined. Before EIS, the PBRF was 53.42±12.34 % (mean±SD), and the total crosssectional area of the para-ECVs was 34.15±22.39 mm2 (mean±SD). The correlation between the PBRF and the total cross sectional area of para- ECVs before EIS was not significant. On the other hand, the PBFR was 53.42±12.34 % (mean±SD) and the total cross-sectional area of the para- ECVs was 34.15±22.39 mm2 (mean±SD) after EIS. After treatment, the correlation between these two parameters was significant (r=0.70, p

4537 Collaterals around the esophageal wall; comparison of endoscopic ultrasound imaging and microscopic findings on autopsy.

Background: In a previous study, we demonstrated the collaterals around the esophageal wall observed by endoscopic ultrasound (EUS) in patients with portal hypertension can be divided into two groups, peri-esophageal collateral veins (peri-ECVs) and para-esophageal collateral veins (para- ECVs), and that the peri-ECVs and the perforating veins play an important role in the development of esophageal varices (Gastrointestinal Endosc 1999;50). Aim: To compare EUS imaging with microscopic findings in the peri- and para-ECVs and the perforating veins. Patients and Methods: Four patients with esophageal varices treated by endoscopic injection sclerotherapy were studied. After the therapy, the esophago-gastric junction (EGJ) to the upper 5 cm was scanned by EUS. In autopsy, the esophagus with surrounding tissue was removed, and 1 cm cross sections of the EGJ to the upper 5 cm were cut. EUS imaging and microscopic findings were compared. Results: EUS showed that peri-ECVs were developed in all cases and that para-ECVs were developed in 3 cases. Perforating veins were visualized in all cases. On the basis of microscopic findings in autopsy, the collaterals around the esophageal wall were divided into two groups: collaterals adjacent to the muscularis externa of the esophagus, and collaterals distal to the esophageal wall without contact with the muscularis externa. These collaterals were observed in all cases and were considered to correspond to the peri- and para-ECVs observed by EUS. Veins connecting vessels in the submucosal layer and veins around the esophageal wall were observed in all cases. These veins were considered to correspond to the perforating veins observed by EUS. Conclusion: The veins corresponding to peri-ECVs, para-ECVs and perforating veins observed by EUS were identified in autopsy. EUS has shown to be useful for an understanding of vascular structure around the esophageal wall.