The Usefulness of Endoscopic Color Doppler Ultrasonography (ECDUS) for Endoscopic Injection Sclerotherapy (EIS)

Abstract: We studied 12 patients using endoscopic injection sclerotherapy (EIS) guided by endoscopic color Doppler ultrasonography (ECDUS). The ECDUS was performed with a PENTAX FG-32UA (7.5MH2, convex type) and a HlTACHl EUB 565 as a display machine. The EIS needle, as well as changes in intramural blood flow before and after EIS were clearly observed with the ECDUS. When the sclerosant was injected properly into the esophageal varices, the blood flow in the esophageal varices could not be detected with color Doppler flow imaging nor with fast-Fourier transform (FFT) analysis. Therefore EIS was safely performed with an adequate volume of sclerosant having been accurately injected into the varices. Of the disadvantages of this technique, the forceps channel was found to be a bit narrow, and the anterior view was somewhat oblique. Even so, EIS guided by ECDUS is surely a promising method for the treatment of esophageal varices, especially once the technical difficulties are overcome. (Dig Endosc 1994; 6 : 39–44)     

An Evaluation of Endoscopic Color Doppler Ultrasonography in a Gastric Variceal Patient Who Underwent Balloon-Occluded Retrograde Transvenous Obliteration

Abstract: A 64-year-old female was admitted to our hospital with enlarged solitary gastric varices. Cardiofornical varices were seen using an endoscopy. We performed balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices using 5% ethanolamine oleate. We observed the gastric varices before and after B-RTO using endoscopic color Doppler ultrasonography (ECDUS). Prior to B-RTO, the intramural and extramural blood flow coming from gastric varices were detected. The intramural blood flow produced a to and fro color image on ECDUS. The blood flow velocity was 31.2 cm/sec. The amount of blood flow was 2.40 liter/min. Seven days after the B-RTO, high echo lesions were observed in the gastric varices which indicated that the thrombosis and color flow image had also decreased. Twenty one days after B-RTO, the color flow image of the gastric varices had nearly disappeared and had completely disappeared after 3 months. In this case, ECDUS was an extremely useful modality for viewing the therapeutic effects of B-RTO.     

Use of the Ultrasonic Microprobe to Evaluate Gastric Varices –Comparison with Endoscopic Color Doppler Ultrasonography–

Abstract: This study was designed to evaluate the usefulness of the ultrasonic microprobe (UMP), as compared with endoscopic color Doppler ultrasonography (ECDUS), in detecting gastric varices in 18 patients. The gastric varices detected were categorized as follows: 14 F₂ type varices, four F₃ type. Among the 18 cases, four had cardiac varices, nine cardiofornical varices, and five fundic varices. UMP was easily performed visually by using an endoscope with a UM-3R (20MHz) probe, inserted via the biopsy channel, and a display unit (Olympus EU-M20). ECDUS was performed using a PENTAX FG-32UA and a FG-36UX, 7.5MHz, convex type. The display monitor was a HITACHI EUB 565. We were able to clearly delineate the vessel images of gastric varices in all 18 patients using UMP. Although the overall features of the peri-gastric collateral veins could not be discerned with UMP, the color flow images of gastric varices and peri-gastric collateral veins were clearly visualized in all 18 patients using ECDUS. It was thus possible to determine blood flow direction using ECDUS. We found the use of UMP to be advantageous in terms of the ease of operation and the excellent view provided of gastric varices. The fact that, due to limited penetration, UMP inadequately delineates the peri-gastric collateral veins was determined to be a major drawback. Therefore, we recommend ECDUS for evaluating overall hemodynamics. It was, however, technically difficult to scan the fundal region because of the characteristics of the ECDUS instrument. Thus, we conclude that detailed evaluation of gastric varix hemodynamics is most successfully accomplished by using UMP in conjunction with ECDUS.     

Pulsatile Wave Observed by Endoscopic Color Doppler Ultrasonography in Rectal Varices

A 52‐year‐old man with portal hypertension due to Hepatitis C developed anal bleeding, and endoscopic variceal ligation was performed for the internal hemorrhoids. This patient experienced anal bleeding after 1 year, and colonoscopy revealed tortuous rectal varices extending 4 cm from the dentate line. Color flow images of rectal varices and a continuous wave with fast‐Fourier transform analysis were detected via endoscopic color Doppler ultrasonography, and a pulsatile wave was delineated at the anal site of the rectal varices. Endoscopic injection sclerotherapy for rectal varices was performed on this patient, and endoscopic color Doppler ultrasonography revealed the disappearance of variceal blood flow and the decrease of pulsatile wave at anal site of rectal varices.     

Perforating Veins in Recurrent Esophageal Varices after Endoscopic Therapy Visualized by Endoscopic Color Doppler Ultrasonography

This study was designed to evaluate the detection rate and the direction of blood flow of perforating veins using endoscopic color Doppler ultrasonography (EC-DUS) in cases of recurrent esophageal varices after endoscopic therapy with complete eradication. Perforating veins were defined as vessels communicating between esophageal varices and paraesophageal veins. The study involved thirty patients with recurrent esophageal varices who had been followed up for more than one year. Seven of them had high risk intramucosal venous dilatation (IMVD) of the esophagus, and 23 had F₁ (small straight varices) red color (RC) positive varices. Color flow images of perforating veins were obtained in 18 patients (60.0%). The perforating veins were classified into three types according to flow direction. Type 1 had inflow from paraesophageal veins to esophageal varices, Type 2 had outflow type from esophageal varices to paraesophageal veins, and Type 3 was mixed, showing both inflow and outflow. Of the 18 patients in whom color flow images were obtained, 15 (83.3%) cases were Type 1, none were Type 2, and three (16.7%) were Type 3. All the color flow images in the perforating veins were demonstrated as a continuous wave. In conclusion, perforating veins can be detected at a high rate by ECDUS in cases of recurrent esophageal varices after endoscopic therapy with complete eradication. (Dig Endosc 1999; 11: 236–240)     

Assessment of Underlying Blood Vessels in Gastric Ulcers with Bleeding Episode by Endoscopic Color Doppler Ultrasonography

We used endoscopic color Doppler ultrasonography to detect hemorrhagic gastric ulcer, and to determine whether this modality could show blood vessels present deep to ulcers and whether these vessels influenced clinical course. Subjects were 20 patients with hemorrhagic gastric ulcers which had visible vessels on the ulcer base endoscopically. In 11 of 20 patients (group P) color signals indicating blood flow were observed, in which a weak pulsatile wave was detected in five cases. In two operated cases the signals were confirmed as blood vessels histologically. The diameters of these vessels were over 0.35 mm. It was thought that in cases undetectable on endoscopic color Doppler ultrasonography (group N) the diameter of vessels was too narrow or the velocity of blood too slow. There were no differences in the clinical background of group P and group N. However, ulcer bleeding was more severe in group P cases (P<0.05). Many patients in whom blood flow was detected experienced repeated ulcer bleeding as well as ulcer recurrences. Patients with hemorrhagic ulcers and in whom ultrasonic imaging demonstrates blood flow should be managed with great care. (Dig Endosc 1999; 11: 231–235)     

Usefulness of electronic radial endoscopic color Doppler ultrasonography in esophageal varices: comparison with convex type

Background Endoscopic color Doppler ultrasonography (ECDUS) is a method for detecting color flow images in blood vessels. We previously reported on the usefulness of ECDUS (convex-type scanning instruments with forward—oblique viewing) for evaluating the hemodynamics of esophageal varices. In the present study, we report the usefulness of new electronic radial ECDUS in cases of esophageal varices by comparison with convex-type ECDUS. Methods Twenty-six patients with esophageal varices were identified and studied. The underlying pathologies of portal hypertension included liver cirrhosis (15 patients) and cirrhosis associated with hepatocellular carcinoma (11 patients). Endoscopic findings of esophageal varices were as follows: Cb, F3, and Ls varices in four patients; Cb, F2, and Lm varices in 21 patients; and Cb, Lm, and F1 varices in one patient. RC₁ was observed in the esophagus in 14 of the 26 patients. RC₂ was noted in 11 cases, and RC₀ was seen in one patient. ECDUS was performed using a Pentax EG-3630UR (forward view) with a distal tip diameter of 12 mm. The instrument (electronic radial array) has a curved array scanning transducer with variable frequency (5.0, 7.5, 10.0 MHz). A Hitachi EUB 6500,8500 was used for the display, providing 270° images. We monitored the color flow images of esophageal varices, paraesophageal veins, palisade veins, perforating veins, and pulsatile waves using this technique. As a control, 110 patients were examined by convex-type ECDUS. Results (1) Color flow images of esophageal varices and paraesophageal veins were obtained in 26 of the 26 patients, whereas color flow images of perforating veins were obtained in 18 of the 26 patients (69.2%). Color flow images of palisade veins were obtained in 12 of the 26 patients (46.2%). (2) Color flow images of pulsatile waves were obtained in 10 of the 26 patients (38.5%). Color flow images of pulsatile waves were detected in zero (0%) of the 4 F3 varices, in nine (42.9%) of the 21 F2 varices, and in the 1 (100%) case of F1 varices. Also, color flow images of pulsatile waves were detected in seven (50.0%) of the 14 RC₁ varices, in two (18.2%) of the 11 RC₂ varices, and in the 1 (100%) case of RC₀ varices. (3) As a control, 110 patients were examined by convex-type ECDUS. Color flow images of esophageal varices and paraesophageal veins were obtained in 110 of the 110 patients, whereas color flow images of perforating veins were obtained in 74 of 110 (67.3%) with convex-type ECDUS. The detection rate of palisade veins with electronic radial ECDUS (12 of the 26 patients, 46.2%) was significantly higher than with convex-type ECDUS (28 of the 110 patients, 25.5%) (P < 0.05). The detection rate of pulsatile waves with electronic radial ECDUS (10 of the 26 cases, 38.5%) was significantly higher than with convex-type ECDUS (3 of the 110 cases, 2.7%) (P < 0.0001). Conclusions Electronic radial ECDUS provides clear color flow images of blood vessels in esophageal varices with the additional advantages of forward-view optics and extended 270° views. Electronic radial ECDUS was superior to convex-type ECDUS in detecting palisade veins and pulsatile waves.     

Diagnosis of the Depth of Advanced Gastric Cancer Invasion by Endoscopic Ultrasonography

Preoperative endoscopic ultrasonography (EUS) was performed in 272 patients with advanced gastric cancer who underwent gastrectomy between December 1986 and December 1993. We divided the subjects into two groups: group A consisted of patients whose stomachs were filled with water for the EUS examination (water-filling method: 1986.12–1992. 10) and group B of patients in whom EUS was performed with the water-filled balloon compression method (balloon-compression method) in addition to the water-filling method (1992.11–1993. 12). A comparative study of EUS diagnostic efficacy, as regards the depth of invasion, was made between group A and group B. The following results were obtained: 1) In group A, the depth of invasion of mass-forming type carcinoma was accurately diagnosed by EUS in 59.3% of patients with mp cancer, in 28.8% of those with ss cancer, in 78.8% of those with se cancer, and in 83.3% of those with si cancer. The accuracy rate in diagnosing the depth of invasion of wall-thickening type carcinoma was 46.2% in patients with mp cancer, 68.0% in those with ss cancer, 59.1% in those with se cancer, and 66.7% in those with si cancer. 2) In group B, the depth of invasion of mass-forming type carcinoma was accurately diagnosed by EUS in 70.6% of patients with mp cancer, in 68.4% of those with ss cancer, in 92.3% of those with se cancer, and in 100% of those with si cancer. The accuracy rate in diagnosing the depth of invasion of wall-thickening type carcinoma was 75.0% in patients with mp cancer, 72.7% in those with ss cancer, 76.5% in those with se cancer, and 100% in those with si cancer. 3) These results suggest that the diagnostic efficacy of EUS utilizing both the balloon-compression method and the water-filling method is greater, as regards the depth of advanced gastric cancer invasion, than EUS utilizing only the water-filling method.     

Color Doppler-enhanced Endoscopic Ultrasonographic Diagnosis of Upper Gastrointestinal Submucosal Lesions

Abstract: We investigated the usefulness of color Doppler-enhanced endoscopic ultrasonography for the assessment of upper gastrointentinal tract submucosal lesions. The subjects were 61 patients with endoscopically detected lesions : five extraluminal, four solitary varices, 26 leiomyomas, seven leiomyosarcomas, five aberrant pancreata, five cysts, three granular cell tumors, three lipomas, two schwannomas and one fibroma. Lesions were confirmed by surgery, biopsy or angiography, as appropriate. The ultrasonographic appearance of the lesions and their locations within the five-layered structure of the wall are described. For leiomyomatous tumors less than 5 cm including leiomysarcoma, the presence of turbulent, pulsatile flow, as demonstrated on fast Fourier transform analysis, was associated with a sensitivity of 100% (7/7) and a specificity of 77.8% (7/9). We speculate that the flow pattern is related to abnormal vessels in the malignant tumors. Evaluation of the ultrasonographic characteristics of leiomyomatous tumors utilizing the pulsatile wave pattern may allow the diagnosis of leiomyosarcoma. Color Doppler-enhanced endoscopic ultrasonography is potentially useful in the preoperative diagnosis of submucosal lesions involving the upper gastrointestinal tract.     

An Evaluation of the Efficacy of Preoperative Therapy for Thoracic Esophageal Carcinoma Using Endoscopic Ultrasonography

Abstract: We performed endoscopic ultrasonography (EUS) to assess the therapeutic efficacy of thoracic esophageal carcinoma treatment and compared this assessment with that of histology. The subjects were 43 patients who underwent surgical resection following preoperative chemotherapy for advanced thoracic esophageal carcinoma. The region of maximal thickness and the cross-sectional area of the tumor were measured, and the percent reduction was taken to be the degree of reduction. Total assessment of metastatic lymph nodes was made on the basis of the degree of reduction in the major axis and cross-sectional area, and the three elements of morphology, border echo and inner echo. The histological findings were classified into Grades 0 through 3 according to criteria for the management of esophageal carcinoma and compared with the EUS findings. The reduction in tumor thickness was 30% or less in 16 patients, 14 (87.5%) of whom had Grades of 0 to 1. The degree of reduction was greater than 50% in 17 patients, 15 (88.2%) of whom had Grades 2 to 3. The degree of reduction was 60% or greater in eight patients, six (75%) of whom had a Grade of 3. Reduction in the cross-sectional area was less than 50% in 19 patients, 16 (84.2%) of whom had Grades of 0 to 1. Of the 19, all who showed a reduction of 30% or less had Grades of 0 to 1. The reduction in cross-sectional area was greater than 50% in 24 patients, 20 (83.3%) of whom had Grades of 2 to 3. A significant difference was noted in the correlation between reduction in thickness and histological assessment between Grades 0 to 1 and Grade 2 (p<0.01) and between of Grades 2 and 3 (p<0.02). The correlation between reduction in cross-sectional area and histological assessment was similar to that for reduction in thickness. None of the methods produced satisfactory results in relation to assessment of metastatic lymph nodes. Assessment of accuracy by down-staging did not prove useful.     

Five Cases of Recurrent Varices Located in the Middle Esophagus

Recurrent varices located in the middle esophagus are considered to be rare. We could find no scientific reports on this type of recurrent varices. We report herein on five cases diagnosed by endoscopy and endoscopic color Doppler ultrasonography (ECDUS). Endoscopic findings revealed the disappearance of varices in the lower esophagus and F₂ type recurrent varices in the middle esophagus. Color flow images of the left gastric vein and the developed para‐esophageal vein, and the perforating vein of inflow type from para‐esophageal veins to esophageal varices in the middle esophagus were produced using ECDUS. One of the five cases had red color (RC)‐positive recurrent varices located in the middle esophagus and was admitted to our hospital with hematemesis. In such cases, where the recurrent varices show a high‐risk sign, rupture is probable.     

Heat-Probe Coagulation Treatment of Recurrent Intramucosal Venous Dilatation of the Esophagus and Endoscopic Color Doppler Ultrasonographic Follow-up

We treated 14 patients with high risk intramucosal venous dilatation (high risk IMVD) of esophageal varices using heat-probe coagulation. Two of the 14 patients experienced bleeding from the high risk IMVD. We used an Olympus heat-probe unit CD-20Z to stop or prevent variceal bleeding. The 14 patients were treated one to four times (mean: 1.9 times) using a total of 450–2100 joules (mean: 1459 joules). The high risk IMVD disappeared with healing of the heat-probe-induced ulcers. No severe side effects were recorded. Two patients with bleeding from high risk IMVD were successfully treated by the heat-probe technique. In addition, we studied the effects of endoscopic heat-probe coagulation for esophageal varices via endoscopic color Doppler ultrasonography (ECDUS) in six patients. Our ECDUS study was conducted with a PENTAX FG-32UA, 7.5MHz convex type, and a HITACHI EUB 565 display monitor. Following heat-probe treatment, the esophageal walls thickened from 5.1 to 8 mm (mean: 6.3 mm) and a low echoic pattern was visualized by ECDUS. Esophageal intramural blood flow was not observed in any of the six patients. Paraesophageal veins and passageways remained patent in all six patients.     

Quantitation of Duodenogastric Reflux and Antral Motility by Color Doppler Ultrasonography: Study in Healthy Volunteers and Patients with Gastric Ulcer

Fujimura J, Haruma K, Hata J, Yamanaka H, Sumii K, Kajiyama G. Quantitation of duodenogastric reflux and antral motility by color Doppler ultrasonography. Study in healthy volunteers and patients with gastric ulcer. Scand J Gastroenterol 1994;29:897-902.

Background: Our objective was to develop a simple, noninvasive method for evaluating duodenogastric reflux, along with antral motility and gastric emptying of a liquid meal. Methods: Antral motility and gastric emptying were measured by ordinary ultrasonography after a meal of 400 ml consommé. Duodenogastric reflux was evaluated by means of color Doppler. In a preliminary in vitro study we demonstrated that the test meal (consommé) contained oil particles suitable as a marker for color Doppler. We then investigated duodenogastric reflux, antral motility, and gastric emptying of a liquid meal in 43 asymptomatic healthy volunteers and in 24 patients with gastric ulcer. Results: This approach was feasible in 65 (97.0%) of the 67 subjects studied. Duodenogastric reflux was demonstrated in 26 (61.9%) of the 42 healthy volunteers and in 20 (87.0%) of the 23 patients with gastric ulcer. The frequency of the duodenogastric reflux and the reflux index were significantly increased in patients with gastric ulcer as compared with asymptomatic healthy volunteers. Gastric emptying and the motility index of antral contractions were significantly decreased in patients with gastric ulcer as compared with asymptomatic healthy volunteers. Conclusions: Ultrasonography with color Doppler is useful for evaluating abnormalities of gastroduodenal motility and can be used to understand the pathogenesis of such disorders.     

Clinical and endoscopic features of gastric varices secondary to splenic vein occlusion

Aim: This study provides a retrospective evaluation of cases with gastric varices secondary to splenic vein occlusion. Methods: Our study group consisted of 14 patients. The clinical manifestations, diagnostic methods and therapeutic modalities were analyzed retrospectively. Results: Eleven patients had co‐existing pancreatic diseases: seven with chronic pancreatitis, three with cancer of the pancreatic body or tail and one with severe acute pancreatitis. Among the three remaining patients, one had advanced left renal cancer, one had myeloproliferative disease and the third had splenic vein occlusion due to an obscure cause. A diagnosis of gastric varices was made following endoscope gastroduodenoscopy or endoscopic color Doppler ultrasonography (ECDUS), and splenic vein occlusions were diagnosed from enhanced computed tomography in all cases. Specific findings of gastric varices secondary to splenic vein occlusion were based on ECDUS color flow images of gastric variceal flow that clearly depicted round cardiac and fundal regions at the center, with varices expanding to the curvatura ventriculi major of the gastric body. For three cases with gastric variceal bleeding, endoscopic injection sclerotherapy using a mixture of histoacryl and lipiodol (70% histoacryl solution) was performed, after which no further bleeding from gastric varices was detected. Due to a high risk of gastric variceal rupture, splenectomy was performed in two cases and splenic arterial embolization in another two cases. Conclusion: ECDUS color flow images of gastric variceal flow depicted specific findings of gastric varices secondary to splenic vein occlusion. Treatment should take into account the diseases underlying these conditions.     

Morphological and Functional Evaluation of Gastric Ulcer Healing and Recurrence by Endoscopic Ultrasonography

Abstract: The aim of this study was the evaluation of gastric ulcer healing and recurrence, from the viewpoints of morphology and function, by means of endoscopic ultrasonography (EUS). We determined ulcer depth by EUS and quantified ulcer size in EUS images. In addition, we measured the total gastric juice acid content after fasting and the macromolecular glycoprotein weight in antral biopsies. First, we examined 22 patients receiving initial therapy during the active ulcer stage. Fourteen of these patients were reexamined after healing. The ulcer area diminished significantly, as did the total acid content, during the scarring stage. Then, another 22 patients on maintenance therapy were followed for recurrence over a 10 month period. The recurrence rate in UI-IV ulcers was significantly higher than those in UI-II or III ulcers. The ulcer area was greater and the macromolecular glycoprotein content lower in patients experiencing recurrence. In conclusion, morphological and functional factors (ulcer depth and ulcer area; total acid content and macromolecular glycoprotein weight), which could be assessed easily and simultaneously using an EUS fiberscope with a biopsy channel, were useful for evaluating gastric ulcer healing and recurrence.     

Usefulness and Limitations of Endoscopic Ultrasonography in Diagnosis of Adenomyomatosis of the Gallbladder

Abstract: Although endoscopic ultrasonography (EUS) is commonly used to examine lesions in the gallbladder, its ability to accurately diagnose adenomyomatosis (ADM) has not been evaluated. We compared the accuracy of EUS and various other imaging techniques in the diagnosis of ADM. Thirty-one patients undergoing cholecystectomy after elevated lesions were found in the gallbladder by various imaging techniques were studied retrospectively. Based on histopathologic examination, the sensitivity and specificity of EUS were evaluated in ADM. The sensitivity of abdominal ultrasonography, CT and ERCP in ADM were also evaluated. Of the 11 patients diagnosed with ADM by EUS, 9 cases were confirmed histologically (81.8%). Of the 11 patients with histologic diagnosis of ADM, 9 were accurately diagnosed preoperatively by EUS (81.8%). EUS proved more reliable for diagnosis of ADM than the other imaging techniques. Important diagnostic features include preservation of the three-layered structure of the gallbladder, wall-thickening exceeding 3 mm, and 2 or more Rokitansky-Aschoff sinuses occurring within a 1 cm area of the gallbladder.     

The Differential Diagnosis of Malignant Lymphoma and Reactive Lymphoreticular Hyperplasia of the Stomach Using Endoscopic Ultrasonography

Abstract: It is difficult to differentiate between reactive lymphoreticular hyperplasia (RLH) and malignant lymphoma (ML) even with an endoscopic biopsy. We performed endoscopic ultrasonography (EUS) examination on 25 cases histologically diagnosed as being RLH or ML. We classified their EUS findings into three types; protruding, wall-thickening and superficial types, and examined their ultrasonographic findings. Of the four cases classified as being the protruding type (ML 3, RLH 1), disruption of the third layer was seen in the cases of ML, while it was preserved in the case of RLH. All nine cases of the wall-thickening type were ML. Twelve cases were classified as being the superficial type (ML 6, RLH 6). Of the five cases of this type without ulcerative changes, thickening of the second layer of the low echoic homogeneous pattern (“Loss of original mucosal structure: OMS”) was seen in all two cases of ML, while the second layer was dotted with low echoic granular particles and looked grossly heterogeneous (“Granular pattern”) in all three cases of RLH. In the other seven cases the lesion looked like an advanced tumor due to ulcerative changes. From observations of the surrounding nonulcerative area, “Loss of OMS” was seen in three of four cases of ML, while a “Granular pattern” was seen in all three cases of RLH. Six of seven cases with only the “Granular pattern” were RLH, and all 16 cases with only the “Tumorous pattern” were ML. Of the two cases with the “Combined pattern” which had the “Tumorous pattern” in the central area and “Granular pattern” in the peripheral area, one was ML and the other was RLH. EUS is thought to be a useful diagnostic technique which provides us with important information to differentiate between ML and RLH.     

Color Doppler endoscopic ultrasonography in identifying groups at a high-risk of recurrence of esophageal varices after endoscopic treatment

BACKGROUND: Our preliminary study indicated that either a high hepatofugal flow velocity in the left gastric vein (LGV) or an anterior branch dominant pattern seen under color Doppler EUS (CD-EUS) were possible contributing risk factors for variceal recurrence after endoscopic treatment. However, the sample size was too small, and in this study we aimed to validate the results of the preliminary study. METHODS: Sixty-eight patients treated for moderate or large esophageal varices between 2001 and 2004 at a single university hospital were enrolled in this study. CD-EUS was followed by endoscopic variceal ligation and sclerotherapy. RESULTS: Patients were classified into either a high-risk group, which exhibited anterior branch dominance and flow velocity of 12 cm/s or more, or a low-risk group, which included all other patients. Half of the patients in the high-risk group exhibited a recurrence within half a year, whereas it took almost 2 years for half of the patients in the other group to exhibit a recurrence (P=0.0044). Using the Cox proportional hazard model with multivariate analysis, only the features of the high-risk group were significant in triggering recurrence of varices (hazard ratio [HR], 3.00; 95% confidence interval [CI], 1.35-6.65; P<0.001). CONCLUSIONS: These results suggest that patients showing anterior branch dominance and rapid hepatofugal flow velocity in the LGV on CD-EUS examination may have a high risk of an early recurrence of esophageal varices.     

Visualization of palisade veins in esophageal varices by endoscopic color Doppler ultrasonography

Background: Endoscopic color Doppler ultrasonography (ECDUS) is a useful modality for obtaining color flow images of esophageal varices. Levovist is a microbubble echo‐enhancing agent that improves Doppler ultrasound examination. This study is designed to evaluate the usefulness of ECDUS using Levovist in diagnosing palisade veins of esophageal varices. Methods: The study involved 67 patients with esophageal varices using ECDUS. All 67 patients received Levovist intravenously at a concentration of 300 mg/mL. A 7.5‐mL dose of the contrast agent was injected at a slow infusion rate of 1 mL/min. We compared vessel images detected with precontrast with those detected by enhanced ECDUS. Results: Color flow images of palisade veins were obtained in 16 (23.9%) of the 67 patients with precontrast ECDUS. Vessel images of palisade veins were detected in 15 of 61 F2 type varices (24.6%) and in one of six F3 varices (16.7%). The color flows of these vessels showed a continuous wave on fast‐Fourier transform analysis. Sixteen palisade veins had velocities in the 3.3 cm/s?11.6 cm/s range. Color flow images of palisade veins were obtained in 27 (40.3%) of the 67 cases by enhanced ECDUS using Levovist. Palisade veins could be delineated after Levovist contrast in 11 patients who could not be detected on precontrast ECDUS. After Levovist contrast, color flow images detected with precontrast ECDUS were enhanced in all patients. Conclusion: Endoscopic color Doppler ultrasonography with Levovist contrast can improve the diagnostic quality of the palisade veins in esophageal varices.     

Endoscopic Therapy of Early Gastric Cancer —Comparison of Endoscopic Mucosal Coagulation and Resection—

Abstract: The clinical efficacy of various methods of endoscopic treatment was evaluated in 70 patients with early gastric cancer. The treatments included using an Nd- YAG laser on 22 patients (2 IIa cases, 3 IIa + IIc cases and 17 IIc cases), a heater probe on 2 patients (IIc) and endoscopic mucosal resection (EMR) on 46 patients (13 I cases, 15 IIa cases, 2 IIa + IIc cases and 16 IIc cases). Laser irradiation and the heater probe method (endscopic mucosal coagulation; EMC), which cause coagulation and necrosis to lesions using heat energy, were found to be successful for well differentiated adenocarcinoma confined to the mucosa even if the size of the lesions was 20 mm and over. Poorly differentiated adenocarcinoma with lesions 20 mm or smaller reoccurred, and only well differentiated adenocarcinoma with infiltration limited to the mucosa seemed to be treatable endoscopically by EMR. Whether or not total resection was possible was determined with respect to the size and site of lesions in patients treated by EMR. Great therapeutic efficacy was achieved when the lesions were 10 mm or smaller and located in the anterior wall or the greater curvature. Piecemeal resection had to be made in a majority of cases when the lesions measured 10 mm or more or were located in the lesser curvature or the posterior wall. Therefore, endoscopic EMR is recommended if the size of the lesions is 10 mm or less, while EMC must also be considered if the lesions are larger or piecemeal resection is required.