What procedure can be done for portal hypertension (PH) via upper gastrointestinal (GI) endoscopy?

Endoscopic Procedures for Portal Hypertension Management

Endoscopic variceal ligation (EVL) is the primary endoscopic procedure for management of portal hypertension via upper GI endoscopy, particularly for esophageal varices, while cyanoacrylate injection is preferred for gastric varices. 1, 2

Esophageal Varices Management

Acute Variceal Bleeding

• First-line endoscopic therapy: Endoscopic variceal ligation (EVL)
  • More effective than sclerotherapy with fewer complications
  • Reduces rebleeding rate and mortality compared to sclerotherapy 1
  • Should be performed within 12 hours of presentation after hemodynamic stabilization 2

Primary Prophylaxis

• For patients with high-risk esophageal varices who cannot take non-selective beta blockers (NSBBs)
• EVL should be repeated every 2-4 weeks until variceal eradication 2
• Follow-up endoscopy every 3-6 months in the first year after eradication

Secondary Prophylaxis

• Schedule follow-up EVL sessions at 1-4 week intervals to eradicate varices 2
• Combine with NSBBs (propranolol or carvedilol) for optimal prevention of rebleeding

Gastric Varices Management

• Gastroesophageal varices type 1 (GOV1): Either EVL or cyanoacrylate injection 2
• Gastroesophageal varices type 2 (GOV2) and isolated gastric varices (IGV1): Endoscopic cyanoacrylate injection is the preferred method 2

Portal Hypertensive Gastropathy

• Endoscopic therapy has limited role
• NSBBs and iron therapy are the mainstay of treatment 1
• TIPSS may be considered for refractory bleeding from portal hypertensive gastropathy 1

Technical Considerations

• Modern multi-band ligators eliminate the need for overtube, making the procedure faster and more tolerable 3
• For EVL, 2-6 bands are typically placed depending on the number and size of varices 4
• Fewer sessions are needed with EVL compared to sclerotherapy to achieve variceal eradication 1

Rescue Therapies for Failed Endoscopic Management

1. Self-expandable metal stents (SEMS) - Temporary measure for uncontrolled bleeding 5
2. Transjugular intrahepatic portosystemic shunt (TIPSS) - For refractory bleeding despite endoscopic and pharmacological therapy 1
   • Pre-emptive TIPSS within 72 hours (ideally within 24 hours) for high-risk patients (Child-Pugh C ≤13 or Child-Pugh B with active bleeding) 2

Pitfalls and Caveats

• In Fontan-associated liver disease, "downhill" varices may be present in the upper esophagus due to elevated superior vena cava pressure, distinct from portal hypertension-related varices 1
• Careful assessment of variceal location (upper vs. lower esophagus) is essential for proper management
• EVL carries risks of transient chest pain, dysphagia, and rarely, esophageal ulceration or stricture
• Sedation risks must be considered, particularly in patients with advanced liver disease or cardiac conditions 1
• Endoscopic therapy should be performed alongside vasoactive medications (terlipressin, octreotide, or somatostatin) and antibiotic prophylaxis in acute bleeding 2

EVL has demonstrated excellent outcomes in both adults and children, with eradication rates of 90% and significant reduction in bleeding risk 4. The procedure is safe and effective regardless of the etiology of portal hypertension.