Role of endoscopic ultrasound in the field of hepatology: Recent advances and future trends

Table 8 Steps of endoscopic ultrasound guided coil and glue placement for gastric varices obliteration

Pre-procedure requirements

(1) All procedures are done under the cover of pre/peri-procedural antibiotics; (2) Patient is usually fasted for 4-6 h before the procedure; and (3) Adequate resuscitation of the patient, in case of active bleeding is ensured, prior to the procedure

Technical aspects

(1) The echoendoscope is usually positioned either in the distal esophagus or the gastric fundus; (2) Water is filled intra-luminally in the fundus. This enables a good acoustic coupling for better visualization of the gastric varices. Adequate examination of the fundus, the intramural varices and the feeder vessels is carried out; (3) The approach can be trans-esophageal or transgastric, wherein the trans-esophageal route is given preference; (4) EUS-guided coil and glue embolization is usually performed using a 22 G/19 G (gauge) FNA needle. The size of the coil is determined by the short axis of the diameter of the varix; (5) After puncture of the varix, blood is aspirated to confirm the location. This is followed by flushing of the needle with saline; (6) The coils are then deployed into the varix using the stylet as a pusher. Once the coils are deployed, flushing of the needle is done with normal saline; (7) After coil deployment, 1-2 mL of cyanoacrylate glue is injected over 30-45 s followed by rapid flushing with saline; and (8) Once, the varix is obliterated, visualized by absence of flow on color Doppler, the sheath of the needle is advanced beyond the endoscope tip for 2-3 cm before withdrawing the scope. This avoids contact of glue with the endoscope tip. The sample aspirated is sent for routine cytological assessment as well as for any additional tests that might be needed

Post procedure

(1) The patients are kept under observation for 12 h; (2) Repeat EUS can be done after 2 d to look for residual varices; and (3) Follow-up EUS can be performed at 1- and 3-mo intervals

EUS: Endoscopic ultrasound; FNA: Fine needle aspiration; G: Gauge.