by Bushra Ibnauf, as part of the SAMA's Visiting Faculty Program in SMSB on June 27th 2011.

1. Variceal Bleeding “ The Bad & the Ugly” Bushra Ibnauf Sulieman, MD MS Consultant, Gastroenterology & Hepatology Department of Medicine King Faisal Specialist Hospital & Research Center - Jeddah

4. Portal Blood Flow

6. Causes of Portal Hypertension

8. Garcia-Tsao, Current Management of the Complications of Cirrhosis And Portal Hypertension. Gastroenterology Feb 2001;120:726-748

10. Esophageal Varices

12. Natural History of Esophageal Varices Treated Untreated

19. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995;123:280-7 Lo GH, Lai KH, Cheng JS, Hwu JH, Chang CF, Chen SM, et al. A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices. Hepatology 1995;22:466-71. S. Kitano, D. Baatar. Endoscopic treatment for esophageal varices: Will there be a place for sclerotherapy during the forthcoming era of ligation?. GI Endoscopy August 2000 Volume 52 • Number 2 EVL vs EIS in the control of acute variceal bleeding Study/year Steigmann et al. 1992 Laine et al. 1993 Gimson et al. 1993 Lo et al 1997 Hou et al 1995 Sarin et al. 1997 Treatment EIS EVL EIS EVL EIS EVL EIS EVL EIS EVL EIS EVL No. of patients 13 14 9 9 23 21 26 36 16 20 7 5 Success rate (%) 77 86 89 89 92 91 76 97 88 100 86 80 Control period* (hr) 8 NA 12 72 24 NA

21. ) D. A. Corley, J. P. Cello, W. Adkisson, W. -F. Ko, K. Kerlikowske, Octreotide for acute esophageal variceal bleeding: A meta-analysis Gastroenterology March 2001 • Volume 120 • Number 4 Octreotide Outcome Alternative therapy RR (95% CI) NNT (95% CI) c P value for homogeneity No. of trials (total patients) Total mortality (at end of follow-up) Any therapy 0.89 (0.69–1.14) N/A 0.3 11 (948) Vasopressin/terlipressin 0.8 (0.54–1.19) N/A 0.88 4 (236) Placebo/no therapy b 0.81 (0.48–1.35) N/A 0.6 4 (424) Sclerotherapy 1.1 (0.73–1.66) N/A 0.02 2 (248) Sustained control of bleeding (during fo-up) Any therapy 0.63 (0.51–0.77) 8 (5–16) 0.2 13 (1077) Vaso/terli 0.58 (0.42–0.81) 6 (3–13) 0.97 5 (279) Placebo/no therapy b 0.46 (0.32–0.67) 6 (4–9) 0.4 5 (510) Sclerotherapy c 0.94 (0.55–1.62) N/A 0.6 2 (248) Any complications Any therapy 0.77 (0.6–1.00) N/A <0.001 11 (948) Vaso/terl 0.52 (0.33–0.82) 6 (2– 0.13 4 (236) Placebo/no therapy b 1.06 (0.72–1.55) N/A 1 4 (424) Sclerotherapy 0.91 (0.5–1.65) N/A <0.001 2 (248)

29. Classification Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992;16:1343-1349.

30. Gastric Varices

31. Genealized PHT A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices . Barbara M. Ryan,Reinhold W. Stockbrugger, J. Mark Ryan. Gastroenterology April 2004 • Volume 126 •No 4

33. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices . Barbara M. Ryan,Reinhold W. Stockbrugger, J. Mark Ryan. Gastroenterology April 2004 • Volume 126 •No 4 Treatment modality/gastric variceal type Primary hemostasis (%) Secondary rebleeding (%) Variceal eradication (%) Endoscopic variceal sclerotherapy GOV1 90–100 5.5 95 GOV2/IGV1 40–60 20–90 40–70 Endoscopic variceal obturation 90–100 23–50 50–100 Endoscopic variceal ligation 45–100 0–50 45–100 TIPS 90–100 10–30 — B-RTO 100 0–10 85–100 Balloon-occluded endoscopic injection sclerotherapy — 0 75–90

41. A pathophysiologic, gastroenterologic, and radiologic approach to the management of gastric varices . Barbara M. Ryan,Reinhold W. Stockbrugger, J. Mark Ryan. Gastroenterology April 2004 • Volume 126 •No 4

42. Balloon-occluded retrograde transvenous obliteration

43. Balloon-occluded endoscopic injection sclerotherapy Matsumoto A, Hamamoto N, Kayazawa M. Balloon endoscopic sclerotherapy, a novel treatment for high-risk gastric fundal varices: a pilot study. Gastroenterology 1999;117:515-516.