This ASG video tip is sponsored by Braintree, maker of the newly approved Souffle and Soutab. All right, so when you do the one stop shop that we just heard about, you're looking for liver stiffness. Instead of doing fibro scans, we're able to do it via EUS. You could do portal pressure measurements, which we heard about, biopsies, but you could also screen and treat for varices. You heard the bleeding talk earlier on, but this is sort of how we do it via EUS. And we're not limited as endoscenographers by ascites or obesity. So it's definitely a hot topic. There's been a rise in publications in the last few years, and you can see sort of in the last three years, there's been a whole host of publications. So as was noted, Ken Chang really developed this field, and he was one of the first to what we call the pillow sign of the liver. So instead of just looking at the liver and moving on to looking at the pancreas and elsewhere, you can look at the liver and see how stiff it is. And based on that, we started looking at the liver stiffness measurement, initially measured through transient elastography, which is the fibro scan, but we can do it through EUS. So EUS initially had the shear wave, the strain elastography SE, which was back in 2003. And more recently, we started doing it with shear wave elastography. And the way it measures, it measures absolute values with 2D measurements by sort of the amount of pressure that the transducer does. In an early study, what it did show is that there is really good measurements in patients with cirrhosis in both the right and the left lobe of the liver with upwards of 96%. And in a study that was just presented yesterday at DDW by Marvin's group, they looked at 54 patients with NASH and NAFLD. And what is important here is that shear wave was the best predictor out of all the non-invasive measurements, including fibro scan in this group, sort of suggesting that maybe as endosynographers, or if you want to do that one-stop shop, it's patients with NASH and obesity that we want to really target. So now we shift from diagnostics to therapeutics. So when you do an EUS or an EGD, you see someone with varices. How do we treat them? We know we can treat them with banding, with endoscopic techniques, IR, and via EUS. Gastric varices can be present in portal hypertensive patients in anywhere between 17 to 20% of patients, in cirrhotic and up to 20% of patients, but they can happen without portal hypertension. I want to draw your attention to guidelines that were published last year by the AGA, where you really look at your local expertise before embarking on anything else. So if you're able to do it, great, but you should combine expertise with your IR group as well. So management, as with anything bleeding, it's the ABC intubation, blood products, etc. But for EUS, you really need to know the difference in gastric varices between GOV1s, 2s, and whether they're connected to the esophageal varices. And so when we look, and what we're going to talk about is the cyanoacrylate and glue injections, and that's what we can do via EUS. This is a video from Marvin back in 2018. You can see here the actual advantages of EUS. So you can see the varices, and then you can stick the varices with a 19-gauge needle, and then advance coils, which are the same coils that IR use for embolization. And then you can do color Doppler flow at the time of the injection or the embolization to confirm that you have obliterated the varices. You can do this via fluoroscopy, or sometimes you do it at the bedside when you're in the ICU. And then you can follow it with an injection of gelatin slurry or glue, depending on what you have available. And this was a study back from Kenman Moller's group with 152 patients. What you can see here is that the technical success is upwards of 99%. They injected an average of 1.4 coils, followed by glue. The follow-up time at three months showed complete obliteration of the varices, which is great, and it's a really good way of treating these patients that would have traditionally gone to IR. So the follow-up is either at one month to do repeat treatments, at four months to ensure complete eradication. And if you re-bleed or they continue re-bleeding, you should consider doing cross-sectional imaging to ensure that there's nothing else going on. So what do you do? Do you do just cyanoacrylate? Do you do just coils, or do you do a combination? This was a meta-analysis published out three years ago with 11 studies, and essentially what it did show is that the combination group, which is the cyanoacrylate coil, is better than one alone. You can see here that the technical success is higher in the groups, and also the rate of success is higher, the rate of adverse events are lower, and the rate of re-intervention are also lower. So in summary for the acute gastric varices treatment is that although they're uncommon, you can do management via EUS. You don't need to call your IR colleagues, except if you need to, but you can do combination therapy. But you need to ensure that you have good expertise and good backup in your local hospital.

endoscopic ultrasound

liver stiffness

gastric varices

shear wave elastography

combination therapy