The current treatment for nonalcoholic steatohepatitis (NASH) remains limited to weight loss via lifestyle modification. While bariatric surgery can be considered in otherwise eligible patients who suffer from obesity with concomitant NASH, less than 2% of eligible individuals undergo the surgery. This case represents the convergence of endobariatrics and endohepatology. Specifically, in this video, we demonstrate the use of endoscopic gastric plication (EGP) to treat obesity and NASH in a patient with cirrhosis, as well as the application of endoscopic ultrasound (EUS)-guided portal pressure gradient (PPG) measurement to monitor the severity of portal hypertension.
Our patient was a 68-year-old woman with class III obesity and compensated NASH cirrhosis. She underwent an attempted Roux-en-Y gastric bypass, which was aborted due to cirrhosis. An EUS-guided PPG measurement was performed, which revealed a baseline PPG of 11.5 mmHg. This suggested that she had clinically significant portal hypertension. Subsequently, she underwent a successful EGP procedure to reduce the gastric volume. At 9 months, she experienced clinically significant weight loss as well as a reduction in PPG resulting in resolution of clinically significant portal hypertension. In this video, a step-by-step approach to EUS-guided PPG measurement and EGP is demonstrated as well as their schematic illustrations.
Given the rising incidence of NASH as well as rapid advancement in the field of endobariatrics and endohepatology, endoscopists are in a unique position to work collaboratively with hepatologists to offer a broad spectrum of NASH management ranging from diagnosing to treating and monitoring the response to therapy.
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