Use of the Curved Linear-Array Echo Endoscope to Identify Gastrorenal Shunts in Patients with Gastric Fundal Varices

We read with interest the article by Kakutani et al. reporting on the value of echo endoscopy for detecting and identifying gastrorenal shunts in patients presenting with gastric fundal varices [1]. The authors note that balloon-occluded retrograde transvenous obliteration has been described as effective in patients with bleeding fundal varices. This treatment modality requires a spontaneously developed gastrorenal shunt as a pathway for the balloon catheter to reach the fundal varices. The authors suggest that the curved linear-array echo endoscope can be used to assess whether a gastrorenal shunt is present, and compared this method with contrast-enhanced computed tomography.

It is surprising that the authors do not mention percutaneous color Doppler ultrasonography. We believe this method is simple to use in experienced hands, and it is also low-cost, highly effective, and does not require general anesthesia. In comparison with contrast-enhanced computed tomography, color Doppler ultrasonography can also be regarded as a reference method for assessing the presence of gastrorenal shunts, in our experience [2]. In addition, the examination can be carried out in the patient’s room or in an intensive-care unit at any time.

We consider that endoscopic ultrasonography should be avoided for this indication in cirrhotic patients, who are usually in poor general condition due to previous bleeding and severe hepatic dysfunction. Increasing the duration of the endoscopy procedure could be dangerous. In our view, color Doppler should be the initial test used to determine the presence of a gastrorenal shunt, and if necessary the examination can be complemented with contrast-enhanced computed tomography. As the authors also state, a study comparing ultrasound with magnetic resonance angiography would be of interest.

References

• 1 Kakutani H, Hino S, Ikeda K. et al . Use of the curved linear-array echo endoscope to identify gastrorenal shunts in patients with gastric fundal varices.  Endoscopy. 2004;  36 710-714
• 2 Pietri H, Bastid C, Lecarme D. et al . Anastomoses porto-sus-hépatiques et reperméabilisation des veines portes intra-hépatiques dans les thromboses spléno-portales. Etude ultrasonographique.  Ann Gastro-Enterol Hepatol. 1988;  24 275-276