Gastroenterology Commons^™

Sex And Race And/Or Ethnicity Differences In Patients Undergoing Radiofrequency Ablation For Barrett's Esophagus: Results From The U.S. Rfa Registry., Sarina Pasricha, Nan Li, William J. Bulsiewicz, Richard I. Rothstein, Anthony Infantolino, Atilla Ertan, Daniel S. Camara, Evan S. Dellon, George Triadafilopoulos, Charles J. Lightdale, Ryan D. Madanick, William D. Lyday, Raman V. Muthusamy, Bergein F. Overholt, Nicholas J. Shaheen

Department of Medicine Faculty Papers

BACKGROUND: Little is known about differences in Barrett's esophagus (BE) characteristics by sex and race and/or ethnicity or these differences in response to radiofrequency ablation (RFA).

OBJECTIVE: We compared disease-specific characteristics, treatment efficacy, and safety outcomes by sex and race and/or ethnicity in patients treated with RFA for BE.

DESIGN: The U.S. RFA patient registry is a multicenter collaboration reporting processes and outcomes of care for patients treated with RFA for BE.

PATIENTS: Patients enrolled with BE.

INTERVENTIONS: RFA.

MAIN OUTCOME MEASUREMENTS: We assessed safety (stricture, bleeding, perforation, hospitalization), efficacy (complete eradication of intestinal metaplasia [CEIM]), complete eradication of dysplasia, …

Accuracy Of Melena Identification On Physical Exam In Post Graduate Training – Implications Of Level Of Training, Medical Specialty, Rectal Exam Concordance And Appropriateness Of Therapy, Richard M. Wu, Md, Mph, Eugene Han, Md, Andrew Dargan, Md, Cecilia Kelly, Md, Mitchell Conn, Md, Mba

Division of Gastroenterology and Hepatology Faculty Papers

Introduction

Melena is commonly misidentified by young resident physicians.

The magnitude of this inaccurate physical exam has not been quantified.

Precise identification of melena may have important diagnostic and therapeutic implications.

Granular Cell Tumor Of The Common Hepatic Duct As An Unusual Cause Of Jaundice In A Hepatitis C Patient: Looking Beyond The Tip Of The Iceberg!, Tripti R. Chopade, Mbbs, Colin L. Smith, Md, Warren R. Maley, Md, Ali A. Siddiqui, Md, David A. Sass, Md

Division of Gastroenterology and Hepatology Faculty Papers

Introduction

Granular cell tumors (GCTs) are rare, benign mesenchymal tumors of Schwann cell origin. Since they were originally described by Abrikossoff in 1926,most GCTs have been described in the dermis, oral area, or subcutaneous tissue of the chest and arms. Only 5%-9% of reported cases have involved the gastrointestinal tract and fewer than 1% of cases have occurred in the biliary tract.Tumors involving the bile duct are difficult to distinguish radiographically from more common etiologies of biliary stricturing, and a tissue diagnosis is difficult to obtain endoscopically. Diagnosis and treatment is most often made via surgical resection.

Clinical Vignette: A Case Of Successful Surgical Decortication For Empyema With Trapped Lung, In A Patient With Decompensated Cirrhosis, Tripti R. Chopade, Md, She-Yan Wong, Md, David A. Sass, Md, Scott W. Cowan, Md, Jesse M. Civan, Md

Division of Gastroenterology and Hepatology Faculty Papers

Introduction

Hepatic hydrothorax (HH) is a difficult-to-control complication of cirrhosis. Chest tube (CT) drainage is an option for management of HH, but is associated with a high rate of secondary infection and other complications.

Listing Practices For Morbidly Obese Patients At Liver Transplant Centers In The United States, Dina Halegoua-De Marzio, Md, She-Yan Wong, Md, Jonathan M. Fenkel, Md, Cataldo Doria, Md, Phd, David A. Sass, Md

Division of Gastroenterology and Hepatology Faculty Papers

Introduction

• Obesity affects more than one third of Americans.
• Morbid obesity (body mass index (BMI) >35 kg/m2) has been associated with multiple co-morbidities and perioperative complications.
• The effect of morbid obesity on liver transplant outcomes has yielded mixed results.

Treatment Of Duodenal Variceal Hemorrhage With Endoscopic Band Ligation, Tripti R. Chopade, Md, Jesse M. Civan, Md, Jonathan M. Fenkel, Md, Ali A. Siddiqui, Md, Ashish R. Gandhe, Md, Dina L. Halegoua-De Marzio, Md

Division of Gastroenterology and Hepatology Faculty Papers

Introduction

• Duodenal varices (DV) are a rare but potentially serious complication of portal hypertension and carry a high risk of massive gastrointestinal bleeding.

• This is a report of successful treatment of a massive DV hemorrhage with endoscopic band ligation.

Enteral Nutrition Support For A Sarcopenia In End-Stage Liver Disease, Dina Halegoua-De Marzio, Md, She-Yan Wong, Md, Flavius Guglielmo, Md, Jonathan M. Fenkel, Md

Division of Gastroenterology and Hepatology Faculty Papers

Introduction

• Weight loss with muscle wasting, also known as sarcopenia, commonly occurs in patients with end-stage liver disease (ESLD).
• A robust association between sarcopenia and mortality in cirrhotic and post-liver transplant patients has been reported.
• This is a report of a patient with severe sarcopenia and ESLD who was provided enteral nutrition using a Dobhoff tube (DHT) pre-liver transplant resulting in successful bridging to transplant.

Randomised Clinical Trial: Polyethylene Glycol 3350 With Sports Drink Vs. Polyethylene Glycol With Electrolyte Solution As Purgatives For Colonoscopy--The Incidence Of Hyponatraemia., Rebecca Matro, Constantine Daskalakis, Dan Negoianu, Leo Katz, Cassandra Henry, Michael Share, David Kastenberg

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND: Polyethylene glycol 3350 plus sports drink (PEG-SD) is a hypo-osmotic purgative commonly used for colonoscopy, though little safety data are available.

AIM: To evaluate the effect of PEG-SD on serum sodium (Na) and other electrolytes compared with PEG-electrolyte solution (PEG-ELS).

METHODS: We performed a single center, prospective, randomised, investigator-blind comparison of PEG-ELS to PEG-SD in out-patients undergoing colonoscopy. Laboratories were obtained at baseline and immediately before and after colonoscopy. The primary endpoint was development of hyponatraemia (Na/L) the day of colonoscopy. Changes in electrolyte levels were computed as the difference between the lowest value on the day of colonoscopy …

Then And Now: The Progress In Hepatitis B Treatment Over The Past 20 Years., Dina Halegoua-De Marzio, Hie-Won Hann

Department of Medicine Faculty Papers

The ultimate goals of treating chronic hepatitis B (CHB) is prevention of hepatocellular carcinoma (HCC) and hepatic decompensation. Since the advent of effective antiviral drugs that appeared during the past two decades, considerable advances have been made not only in controlling hepatitis B virus (HBV) infection, but also in preventing and reducing the incidence of liver cirrhosis and HCC. Furthermore, several recent studies have suggested the possibility of reducing the incidence of recurrent or new HCC in patients even after they have developed HCC. Currently, six medications are available for HBV treatment including, interferon and five nucleoside/nucleotide analogues. In this …

Efficacy And Safety Of Infliximab In Older Inflammatory Bowel Disease Patients, Christina Cress Lindenmeyer, Md, Stephanie M. Moleski, Md, Maureen P. Whitsett, Med., Patricia L. Kozuch, Md

Division of Gastroenterology and Hepatology Faculty Papers

Background:

The limited data regarding treatment of inflammatory bowel disease (IBD) with anti-tumor necrosis factor antibodies in older patients suggest equal efficacy but higher morbidity and mortality compared to younger patients. This retrospective case control study aims to clarify the efficacy and safety of infliximab (IFX) in older IBD patients.

Occupational Exposure To Hepatitis C Virus: Early T-Cell Responses In The Absence Of Seroconversion In A Longitudinal Cohort Study., Theo Heller, Jens Martin Werner, Fareed Rahman, Eishiro Mizukoshi, Yuji Sobao, Ann Marie Gordon, Arlene Sheets, Averell H. Sherker, Ellen Kessler, Kathleen S. Bean, Steven K. Herrine, M'Lou Stevens, James Schmitt, Barbara Rehermann

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND: T-cell responses have been described in seronegative patients who test negative for hepatitis C virus (HCV) RNA despite frequent HCV exposure. However, the cross-sectional design of those studies did not clarify whether T cells were indeed induced by low-level HCV exposure without seroconversion or whether they resulted from regular acute infection with subsequent antibody loss.

METHODS: Over a 10-year period, our longitudinal study recruited 72 healthcare workers with documented HCV exposure. We studied viremia and antibody and T-cell responses longitudinally for 6 months.

RESULTS: All healthcare workers remained negative for HCV RNA and antibodies. However, 48% developed proliferative T-cell …

A Multicenter, Prospective, Randomized Comparison Of A Novel Signal Transmission Capsule Endoscope To An Existing Capsule Endoscope., Eric H Choi, Klaus Mergener, Carol Semrad, Laurel Fisher, David R Cave, Milan Dodig, Carol Burke, Jonathan A Leighton, David Kastenberg, Peter Simpson, James Sul, Kanishka Bhattacharya, Roger Charles, Lauren Gerson, Luke Weber, Glenn Eisen, Warren Reidel, John J Vargo, Jamile Wakim-Fleming, Simon K Lo

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND: MiroCam, a capsule endoscope, uses a novel transmission technology, electric-field propagation, which uses the human body as a conduction medium for data transmission.

OBJECTIVE: To compare the ability of the MiroCam (MC) and PillCam (PC) to identify sources of obscure GI bleeding (OGIB).

DESIGN: Prospective, multicenter, comparative study.

SETTING: Six academic hospitals.

PATIENTS: A total of 105 patients with OGIB.

INTERVENTION: Patients ingested both the MC and PC capsules sequentially in a randomized fashion.

MAIN OUTCOME MEASUREMENTS: Concordance of rates in identifying a source of OGIB, operational times, and rates of complete small-bowel examination.

RESULTS: Data analysis resulted in …

Prediction Of Advanced Fibrosis In Nonalcoholic Fatty Liver Disease: An Enhanced Model Of Bard Score., Tae Hoon Lee, Seung Hye Han, Ju Dong Yang, Donghee Kim, Monjur Ahmed

Department of Medicine Faculty Papers

UNLABELLED: BACKGROUNDAIMS: The BARD score is a model to detect advanced liver fibrosis in nonalcoholic fatty liver disease (NAFLD) patients. The aims of this study were to identify additional factors and then to build an enhanced version of the BARD score.

METHODS: One hundred seven patients with biopsy-proven NAFLD were enrolled retrospectively. Logistic regressions were performed to identify independent risk factors for advanced liver fibrosis (stage 3 or 4). An enhanced model of the BARD score (BARDI score) was built and evaluated with a receiver operating characteristic (ROC) curve.

RESULTS: In multivariate analysis, age (odds ratio [OR], 0.89; p=0.04), aspartate …

Smooth Muscle Fascicular Reorientation Is Required For Esophageal Morphogenesis And Dependent On Cdo., Anthony I Romer, Jagmohan Singh, Satish Rattan, Robert S Krauss

Department of Medicine Faculty Papers

Postnatal maturation of esophageal musculature involves proximal-to-distal replacement of smooth muscle with skeletal muscle by elusive mechanisms. We report that this process is impaired in mice lacking the cell surface receptor Cdo and identify the underlying developmental mechanism. A myogenic transition zone containing proliferative skeletal muscle precursor cells migrated in a proximal-distal direction, leaving differentiated myofibers in its wake. Distal to the transition zone, smooth muscle fascicles underwent a morphogenetic process whereby they changed their orientation relative to each other and to the lumen. Consequently, a path was cleared for the transition zone, and smooth muscle ultimately occupied only the …

A Multicenter, Prospective Study Of A New Fully Covered Expandable Metal Biliary Stent For The Palliative Treatment Of Malignant Bile Duct Obstruction., Bret T Petersen, Michel Kahaleh, Richard A Kozarek, David E. Loren, Kapil Gupta, Thomas E. Kowalski, Martin Freeman, Yang K Chen, Malcolm S Branch, Steven Edmundowicz, Michael Gluck, Kenneth Binmoeller, Todd H Baron, Raj J Shah, Timothy Kinney, William Ross, Paul Jowell, David Carr-Locke

Division of Gastroenterology and Hepatology Faculty Papers

Background and Study Aims. Endoscopic placement of self-expanding metal stents (SEMSs) is indicated for palliation of inoperable malignant biliary obstruction. A fully covered biliary SEMS (WallFlex Biliary RX Boston Scientific, Natick, USA) was assessed for palliation of extrahepatic malignant biliary obstruction. Patients and Methods. 58 patients were included in this prospective, multicenter series conducted under an FDA-approved IDE. Main outcome measurements included (1) absence of stent occlusion within six months or until death, whichever occurred first and (2) technical success, need for reintervention, bilirubin levels, stent patency, time to stent occlusion, and adverse events. Results. Technical success was achieved in …

The Association Between Acrochorda (Skin Tags), Metabolic Syndrome, And Adenomatous Polyps, Brendan O'Hare, Md, Anastasia Shnitser, Md, Jason Korenblit, Md, Mba, Ali Siddiqui, Md

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND

Acrochorda (skin tags) are benign skin tumors that form primarily at skin creases, generally on the neck, armpit, and groin areas. There have been a small number of published studies in 1980s in patients who were found to have increased number of skin tags and colonic polyps, with a direct correlation described between the two. In addition, metabolic syndrome has been linked to adenomatous polyps, but a link between skin tags and metabolic syndrome has not been established.

Limited Sampling Estimates Of Epigallocatechin Gallate Exposures In Cirrhotic And Noncirrhotic Patients With Hepatitis C After Single Oral Doses Of Green Tea Extract., Dina Halegoua-De Marzio, Walter K. Kraft, Constantine Daskalakis, Xie Ying, Roy L Hawke, Victor J. Navarro

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND: Epigallocatechin-3-gallate (EGCG) has antiangiogenic, antioxidant, and antifibrotic properties that may have therapeutic potential for the treatment of cirrhosis induced by hepatitis C virus (HCV). However, cirrhosis might affect EGCG disposition and augment its reported dose-dependent hepatotoxic potential.

OBJECTIVE: The safety, tolerability, and disposition of a single oral dose of EGCG in cirrhotic patients with HCV were examined in an exploratory fashion.

METHODS: Eleven patients with hepatitis C and detectable viremia were enrolled. Four had Child-Pugh (CP) class A cirrhosis, 4 had Child-Pugh class B cirrhosis, and 3 were noncirrhotic. After a single oral dose of green tea extract 400 …

Development Of A Competency-Based Transplant Hepatology Fellowship, Steven K. Herrine, Andrew P. Keaveny, Ayman Abdel-Latif Koteish, Richard K. Sterling, John R. Lake

Division of Gastroenterology and Hepatology Faculty Papers

Presented at 63rd annual meeting AASLD, The Liver Meeting, Boston MA, November 9-13, 2012.

Purpose: The Accreditation Council for Graduate Medical Education (ACGME) next accreditation system (NAS) provides incentive for medical educators to understand and implement competency-based medical education (CBME) training and assessment in their programs. Noting decreasing enrollees for the American Board of Internal Medicine (ABIM) Transplant Hepatology (TH) exam, workforce concerns in TH, and questionnaire data from Gastroenterology (GI) fellows and Program Directors (PDs), we developed an ABIM-approved one-year competency-based TH pilot program.

Effects Of Scleroderma Antibodies And Pooled Human Immunoglobulin On Anal Sphincter And Colonic Smooth Muscle Function., Jagmohan Singh, Sidney Cohen, Vaibhav Mehendiratta, Fabian A. Mendoza, Sergio A. Jimenez, Anthony J. Dimarino, Satish Rattan

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND & AIMS: Patients with systemic sclerosis (SSc) have impairments in gastrointestinal smooth muscle function. The disorder has been associated with circulating antibodies to cholinergic muscarinic the type-3 receptor (M(3)-R). We investigated whether it is possible to neutralize these antibodies with pooled human IgGs (pooledhIgG).

METHODS: We studied the effects of IgGs purified from patients with SSc (SScIgGs) on cholinergic nerve stimulation in rat colon tissues. We also examined the effects of SScIgGs on M(3)-R activation by bethanechol (BeCh), M(3)-R occupancy, and receptor binding using immunofluorescence, immunoblot, and enzyme-linked immunosorbent analyses of human internal anal sphincter (IAS) smooth muscle cells, …

Melena With Fever, Monica Patel, Jennifer Wilhelm

The Medicine Forum

The patient is a 62 year old Indian male with a past medical history significant for myasthenia gravis, hypertension, and diabetes mellitus, who presented to an outside hospital with fever, fecal incontinence, and melena. Work up at that hospital was remarkable for elevated liver function tests, heme-positive brown stool and a CT of the abdomen showing a thick ascending colon suggesting possible mass. The patient had an episode of desaturation and fever to 105 degrees Fahrenheit prior to transfer to Thomas Jefferson University Hospital for further evaluation. Upon arrival, the patient was in respiratory distress with oxygen saturation of 70% …

Nevirapine Hepatotoxicity: Case Report And Discussion, Matt Baichi

The Medicine Forum

Nevirapine (viramune) is a nonnucleoside reverse transcriptase inhibitor commonly used in combination with other antiretroviral medicines in the treatment of HIV/AIDS. The safety profile of nevirapine, as determined by review of prospective clinical trials, reports rash with an incidence of 16% as the most common side effect. Clinical hepatitis is reported to occur with an incidence of 1%. A review of the literature shows many case reports of nevirapine-induced hepatotoxicity in patients receiving both treatment and prophylaxis for HIV. The purpose of this case report is to stress the importance of early recognition and withdrawal of the offending drug.

A Case Of Chronic Intestinal Pseudo-Obstruction, Matt Baichi

The Medicine Forum

Scleroderma is a systemic disease characterized by the deposition of excessive collagen and other matrix elements in the skin as well as in multiple internal organs. Scleroderma can be classified into diffuse cutaneous disease and limited cutaneous disease. Limited cutaneous disease is characterized by skin involvement limited to the hands, face, feet, and forearms; it includes the CREST variant (calcinosis, raynauds, esophageal dysmotility, sclerodactyly, and telangiectasia). Diffuse cutaneous disease is characterized by skin involvement as well as early and diffuse visceral involvement. Clinically significant gastrointestinal involvement occurs in approximately 50% of all patients with scleroderma. The esophagus is the most …

Sleep Disturbances And Hypnotic Medication Use In Relation To Risk Of Barrett’S Esophagus And Esophageal Adenocarcinoma, Anastasia Shnitser, Md, Abhik Roy, Md, Sidney Cohen, Md, Anthony J. Dimarino, Md

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND

The incidence of esophageal adenocarcinoma (EA) has increased more rapidly than any other cancer (with the exception of malignant melanoma) in the United States over the past 30 years. Gastroesophageal reflux disease (GERD) is the strongest risk factor for the development of Barrett’s esophagus, which in turn leads to the rise of most EA’s. In a large portion of persons with sleep disorders, perhaps as high as 30%, GERD is a major causal or contributing factor. It has been proposed that the use of hypnotics for the treatment of sleep disorders may exacerbate the damaging effects of refluxate on …

Predictive Value Of Alpha-Fetoprotein In The Long-Term Risk Of Developing Hepatocellular Carcinoma In Patients With Hepatitis B Virus Infection--Results From A Clinic-Based Longitudinal Cohort., Hie-Won Hann, Xiaoying Fu, Ronald E. Myers, Richard Hann, Shaogui Wan, Su Hee Kim, Natalie Au, Jinliang Xing, Hushan Yang

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND: Although serum level of alpha-fetoprotein (AFP) has long been used to complement imaging tests in the screening and diagnosis of hepatocellular carcinoma (HCC), whether it can be used as a predictive marker of long-term risk for developing HCC in patients with hepatitis B virus (HBV) has not been extensively evaluated and thus remains controversial.

METHODS: We retrospectively conducted a clinic-based longitudinal cohort study including 617 Korean American patients with HBV who had been followed for up to 22 years (median follow-up time, 6.2 years) to evaluate the association between baseline serum AFP level and the long-term risk of HCC. …

Development Of Myogenic Ias Reconstructs From Human Internal Anal Sphincter (Ias) Smooth Muscle Cells (Smcs) With Functional And Molecular Properties Similar To Intact Human Ias, Jagmohan Singh, Satish Rattan

Division of Gastroenterology and Hepatology Faculty Papers

Poster presented at: Digestive Disease Week (DDW) International meeting in San Diego, California.

Background and Aims:

Rectoanal incontinence is associated with defective Internal Anal Sphincter (IAS). Current therapies are not satisfactory, raising a potential for the replacement of the dysfunctional IAS with the reconstructs. Present studies were performed to develop human IAS smooth muscle reconstructs with functional and molecular attributes similar to the intact human IAS Smooth muscle (SM).

Rhoa/Rock Pathway Is The Major Molecular Determinant Of Basal Tone In Intact Human Internal Anal Sphincter, Satish Rattan, Jagmohan Singh

Division of Gastroenterology and Hepatology Faculty Papers

Poster presented at: Digestive Disease Week (DDW) International meeting in San Diego, California.

Background and Aims

Knowledge of molecular control mechanisms underlying the basal tone in the intact human IAS is critical for the pathophysiology and rational therapy for debilitating rectoanal motility disorders.

Effect Of Pooled Human Intravenous Globulin (Ivig) On The Reversal Of Cholinergic Inhibition Of Smooth Muscle By Immunoglobulins (Iggs) From Patients With Scleroderma (Ssc), Jagmohan Singh, Vaibhav Mehendiratta, Sergio A. Jimenez, Sidney Cohen, Anthony J. Dimarino, Satish Rattan

Division of Gastroenterology and Hepatology Faculty Papers

Poster presented at: Digestive Disease Week (DDW) International meeting in San Diego, California.

Backgrounds and Aims:

The gastrointestinal (GI) tract is the most common internal organ system affected in SSc. We and others have shown before that the SSc immunoglobulins (IgGs) cause selective blockade of muscarinic type-3 cholinergic (M3-R) in the GI tract. Presently, there is no effective treatment for SSc although numerous cytotoxic and immunomodulatory agents have been employed with limited success and are marred with serious side effects. Present studies investigated the reversibility of SScIgGs-caused M3-R blockade by the pooled Intravenous immunoglobulins (IVIG).

The Use Of Infliximab In Older Inflammatory Bowel Disease Patients, Stephanie M. Moleski, Christina C. Lindenmeyer, Patricia L. Kozuch

Department of Medicine Faculty Papers

Limited data suggest anti-tumor necrosis factor (TNF) antibodies have equal efficacy but higher morbidity and mortality in older compared to younger inflammatory bowel disease (IBD) patients(1).

Relative Telomere Length: A Novel Non-Invasive Biomarker For The Risk Of Non-Cirrhotic Hepatocellular Carcinoma In Patients With Chronic Hepatitis B Infection., Xiaoying Fu, Shaogui Wan, Hie-Won Hann, Md, Ronald E Myers, Phd, Richard S Hann, Jennifer Au, Bicui Chen, Jinliang Xing, Hushan Yang

Division of Gastroenterology and Hepatology Faculty Papers

BACKGROUND AND AIMS: Telomere length has emerged as a promising risk predictor of various cancers including hepatocellular carcinoma (HCC). However, the majority of studies in this area measured telomere length in hepatocytes and one in lymphocytes with conflicting results. Moreover, no studies have been reported on using circulating DNA telomere length as a non-invasive HCC biomarker.

METHODS: We conducted a nested case-control study to determine the relative telomere length (RTL) in serum DNA from 140 hepatitis B virus (HBV)-related HCC cases and 280 frequency-matched cancer-free HBV controls.

RESULTS: Cases had a significantly longer RTL (median, 0.31; range, 0.02-2.31) than controls …

Balloon-Occluded Retrograde Transvenous Obliteration For The Treatment Of Gastric Varices., Alia S Dadabhai, Jonathan M Fenkel, Daniel B Brown, Loren Laine

Division of Gastroenterology and Hepatology Faculty Papers

Clinical Perspectives in Hepatology aims to engage two experts with opinions supporting differing perspectives on the management of a case. Typically, the case represents an area of debate or evolving practice in clinical hepatology.

The patient presented below gives us the opportunity to discuss balloon-occluded retrograde transvenous obliteration (BRTO) for treatment of gastric varices. Although described since the mid-1990s and accepted as effective therapy, particularly in Japan, BRTO is used sporadically in the United States and Europe. In fact, it is not mentioned in the U.S. (AASLD) or European (EASL/Baveno V) guidelines. Hopefully, increased awareness of and expertise in this …