Date of Graduation

Summer 8-9-2014

Degree Type

Capstone Project

Degree Name

Master of Science in Physician Assistant Studies

First Advisor

Annjanette Sommers

Abstract

Background: Esophageal and gastric varices are a frequent complication of patients with increased portal venous pressure. Gastic varice occurs and bleeds less frequently than esophageal varice in patients with portal hypertension. Bleeding of gastric varices, however, tends to be more severe and is associated with a higher rate of rebleeds and mortality. Currently, the treatment for preventing secondary gastric variceal hemorrhage includes transjuglar intrahepatic portosystemic shunting, band ligation propranolol and isosorbide mononitrate. Cyanoacrylate is the preferred treatment and has been effective in the treatment of actue gastric variceal hemorrhage worldwide but its use is limited in the United States. The use of cyanoacrylate in the preventing secondary gastric varices has not been well studied. It has been well documented that beta-blockers are effective in decreasing the incidence of secondary esophageal varices and is used empirically in prophylaxis of secondary gastric varices, without proof. The purpose of this systematic review is to determine whether the use of cyanoacrylate more effective than beta-blockers in preventing secondary gastric varices?

Methods: An exhaustive search was conducted using Medline-OVID, CINAHL, EBMR Multifile, and Web of Science using the keywords: cyanoacrylate, beta-blocker, gastric varices and portal hypertension. Relevant articles were assessed for quality using GRADE. A search on the NIH clinical trials site reveals there are no trials comparing the efficacy of cyanoacrylate and beta-blockers in preventing secondary gastric varices.

Results: Two studies met the inclusion criteria and were included in this systematic review. A randomized controlled trial included 64 patients with portal hypertension and upper gastrointestinal bleeding who met the inclusion criteria. The study showed a statistically significant reduction in secondary gastric variceal hemorrhage with cyanoacrylate injection compared beta-blocker. A randomized control trial consisting of 41 patients with esophageal or gastric variceal bleeding were included in the study. Results demonstrated that repeat cyanoacrylate injections were associated with more complication compared to beta-blocker with similar rebleeding rates after 6 weeks.

Conclusion: Cyanoacrylate is effective in decreasing the incidence of gastroesphageal varice type II and isolated gastric varice type I rebleeds and mortality compared to beta-blockers. Beta-blockers demonstated a reduction in hepatic venous pressure gradient but there is no evidence that it prevents rebleeds from gastric varices. In addition, mixing cyanoacrylate and lipiodol resulted in more complication than cyanoacrylate alone. A strong recommendation can be made for the use of cyanoacrylate in both acute gastric variceal hemorrhage and secondary prophylaxis of gastric variceal bleed.

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