Bacterial peritonitis after elective endoscopic variceal ligation: a prospective study

OBJECTIVE: Endoscopic variceal ligation is becoming the therapy of choice for esophageal varices, replacing endoscopic variceal sclerotherapy. The latter is associated with a 5-53% incidence of port-procedural bacteremia and a 0.5-3% incidence of peritonitis, whereas the former carries a 3-6% risk of bacteremia. However, the incidence of peritonitis after variceal ligation has not been well studied. This prospective study is designed to investigate the risk of developing bacteremia and bacterial peritonitis after elective endoscopic variceal ligation. METHODS: Sixty-seven patients with esophageal varices and ascites secondary to liver cirrhosis underwent elective endoscopic variceal ligation. Before the procedure, ascitic fluid was drawn under ultrasound guidance and sent for cell counts, Gram stain, and cultures. Two to 4 days afterward, a repeat ascitic fluid sample was sent for the same studies whether or not the patient had symptoms or signs suggestive of infection. Blood cultures were drawn both immediately before and after the endoscopic ligation procedure. RESULTS: Of 67 subjects, 11 developed asymptomatic bacteremia with Gram-positive commensals. However, none of them progressed to peritonitis. Two patients who did not have bacteremia developed mild febrile peritonitis with Escherichia coli and were successfully treated with oral antibiotics. No other infectious complications were noted. CONCLUSIONS: There is a significant risk of asymptomatic bacteremia and bacterial peritonitis after elective variceal ligation. The peritonitis does not seem to be related to the bacteremia, as patients who had bacteremia did not develop peritonitis and vice versa. In addition, the involved organisms were quite different. Unlike the bacteremia, postligation peritonitis may be a consequence of severe liver cirrhosis rather than the procedure itself. The clinical significance of postligation bacteremia is doubtful. With regard to peritonitis, in our opinion the use of prophylactic antibiotics should be reserved for patients with Child's C class cirrhosis, a recent history of variceal bleeding, a past history of bacterial peritonitis, or a comorbid immunosuppressive condition.     

Bacteremia after endoscopic injection of N-butyl-2-cyanoacrylate for gastric variceal bleeding

BACKGROUND: Cyanoacrylate may form a barrier that prevents bacterial invasion when used in tissue. Because cyanoacrylate polymerizes within seconds on contact with aqueous media, it is used worldwide to arrest gastric variceal bleeding. The aim of this study was to determine the frequency of bacteremia after endoscopic cyanoacrylate injection for gastric variceal bleeding. METHODS: Patients with cirrhosis who underwent endoscopic cyanoacrylate injection for gastric variceal bleeding were included. Patients with cirrhosis who underwent upper endoscopy for nonvariceal upper GI bleeding were recruited as controls. Patients with infection before endoscopy were excluded. Blood was cultured in both groups. Injection needles and endoscope accessory channels were cultured in the cyanoacrylate injection group. RESULTS: More patients injected with cyanoacrylate had positive blood cultures in comparison with the control group (15/47 vs. 1/47, p < 0.0001). In the cyanoacrylate injection group, the volume of blood transfused and Child-Pugh score were factors associated with the occurrence of bacteremia. Most episodes of bacteremia were transient, except for 1 patient who died of sepsis. Most of the microorganisms cultured from blood samples were identical to those cultured from injection needles (65%) and accessory channels (90%). CONCLUSIONS: Endoscopic cyanoacrylate injection for gastric varices does not limit the spread of bacteria. The endoscope accessory channel was the major source of bacteria. Most episodes of bacteremia were transient and uneventful.     

Bacteremia after endoscopic band ligation of esophageal varices.

In a 6-month period, 17 consecutive unselected patients undergoing emergency or elective endoscopic variceal band ligation were evaluated prospectively for clinical and bacteriological signs of bacteremia after each treatment session. None had signs of sepsis, fever, or chills; however, in one patient, a coagulase-negative Staphylococcus epidermidis was cultured from peripheral blood at 5 but not 30 min after the procedure. These data indicate that, in contrast to sclerotherapy, endoscopic variceal ligation rarely induces bacteremia.     

High frequency of bacteremia with endoscopic treatment of esophageal varices in advanced cirrhosis.

OBJECTIVES: The fregency of bacteremia after endoscopic variceal band ligation (EVL) is reported to be lower when compared to that after endoscopic variceal sclerotherapy (EVS). However, there are conflicting reports on the infectious sequelae after EVL. AIM: To compare the frequency on bacteremia and infectious sequelae after EVL and EVS in patients with cirrhosis of liver. METHODS: Bacteremia and infectious sequelae were studied in 32 sessions of EVL in 18 cirrhotic patients (Child-Pugh class A-6, B-5, C-7), 30 sessions of EVS in 22 cirrhotic patients (Child-Pugh class A-2, B-5, C-15) and 14 diagnostic upper gastrointestinal endoscopies. Blood cultures were collected before, during and 30 minutes after the procedure. Patients were observed for infectious sequelae during subsequent hospitalization. RESULTS: Before the procedure, bacteremia was present in 7/62 (11%) sessions. Significant bacteremia during and 30 min post-procedure developed in 8/32 (25%) and 12/30 (40%) of EVL and EVS sessions, respectively (p = ns), and in 1/14 (7%) upper gastrointestinal endoscopy sessions. There was more frequent bacteremia with severe liver disease (Child-Pugh class A-0/6, B-1/5. C-7/21; p = 0.09) in the EVL but not in the EVS group (Child-Pugh class A-1/3, B-2/5, C-9/22; p = ns). The incidence was higher with emergency sclerotherapy compared to elective sclerotherapy (6/8 [75%] vs 6/22 [27%]; p <0.01). One patient in the EVS group developed spontaneous bacterial peritonitis. CONCLUSIONS: Bacteremia occurs frequently following EVL and EVS in patients with advanced liver diseases. In the EVS group it is more common after emergency sclerotherapy. This bacteremia is rarely associated with significant infectious sequelae.     

The influence of endoscopic variceal ligation on the portal pressure gradient in cirrhotics

BACKGROUND/AIMS: After variceal eradication by endoscopic ligation, fundal varices and worsening of portal hypertensive gastropathy can occur. The aim of this study is to verify the impact of the eradication of esophageal varices by endoscopic ligation on the portal pressure gradient, worsening of portal hypertensive gastropathy and development of fundal varices. METHODOLOGY: Twenty-two (15M/7F, mean age: 54.5 years) cirrhotics with previous variceal bleeding were submitted to measurement of hepatic venous pressure gradient before and after variceal eradication by endoscopic ligation. RESULTS: The mean hepatic venous pressure gradient in the first measurement was 14.1 mmHg and after eradication, 13.5 mmHg (p = 0.403). After eradication, 12 patients experienced a reduction in portal pressure and 10, an elevation. Three patients developed fundal varices. Their mean gradient before treatment was 22 mmHg and 18.8 mmHg after therapy (p = 0.368). The gastropathy worsened in 9 patients (mean gradient before therapy of 15.2 mmHg; and 16.1 mmHg after treatment) (p = 0.303). The initial pressure gradient of these patients was not different from the other 13 cases (p = 0.463). CONCLUSIONS: The esophageal variceal eradication by endoscopic band ligation does not alter the hepatic venous pressure gradient. There is no significant variation in the portal pressure of patients in whom there was a worsening of portal hypertensive gastropathy or fundal varices development.     

Comparison of endoscopic variceal sclerotherapy with sequential endoscopic band ligation plus low-dose sclerotherapy for secondary prophylaxis of variceal hemorrhage: a prospective randomized study.

BACKGROUND: Endoscopic variceal sclerotherapy and band ligation both have certain limitations such as, respectively, esophageal complications and early recurrence of varices. METHODS: From February 1994 to March 1996, all consecutive patients with portal hypertension due to either cirrhosis or noncirrhotic portal fibrosis and a history of variceal bleeding were included in a prospective study and randomly assigned to receive either endoscopic variceal sclerotherapy alone or endoscopic variceal band ligation plus low-dose endoscopic variceal sclerotherapy. RESULTS: Of 69 patients, 34 were randomly assigned to receive endoscopic variceal sclerotherapy alone; 35 received endoscopic variceal band ligation plus endoscopic variceal sclerotherapy. Complete variceal eradication rates (85% vs. 80%) and the number of endoscopic sessions required for eradication (6.61 +/- 2.94 vs. 7.85 +/- 3.31) were similar in the endoscopic variceal sclerotherapy and endoscopic variceal band ligation plus endoscopic variceal sclerotherapy groups, respectively. The mean volume of sclerosant required in the combined group (54.94 +/- 33.74 mL) was significantly less than that in the endoscopic variceal sclerotherapy group (81.91 +/- 34.80 mL). The complication and recurrent bleeding rates were significantly higher in the endoscopic variceal sclerotherapy group than those in the combined group (20% and 16% vs. 3% and 3%, respectively). CONCLUSIONS: Both endoscopic variceal sclerotherapy and endoscopic variceal band ligation plus endoscopic variceal sclerotherapy were comparable in eradicating varices but the combined technique was associated with significantly lower complication and recurrent bleeding rates.     

Prevention of variceal recurrence, bleeding, and death in cirrhosis patients with hypersplenism, especially those with severe thrombocytopenia

BACKGROUND/AIMS: We investigated the impact of different treatments on the prognosis of cirrhosis patients with esophageal varices and thrombocytopenia. METHODOLOGY: This prospective study enrolled 52 cirrhosis patients with esophageal varices and hypersplenism (platelet count < 50,000/mm3). In 26 patients, endoscopic variceal ligation plus partial splenic embolization were performed, while endoscopic variceal ligation alone was done in 26 patients. Endoscopic variceal ligation was repeated until complete eradication of varices was achieved. Partial splenic embolization was performed using the Seldinger method and embolic material was injected until a 60% to 80% reduction of splenic blood flow was achieved. The primary endpoints during the follow-up period included recurrence of varices, variceal bleeding, and death. RESULTS: Comparison of endoscopic variceal ligation plus partial splenic embolization with endoscopic variceal ligation alone by multivariate analysis showed a relative risk ratio of 0.390 (95% CI [0.178-0.854]; p = 0.024) for new varices, 0.191 (95% CI [0.047-0.780]; p = 0.021) for variceal bleeding, and 0.193 (95% CI [0.053-0.699]; p = 0.012) for death. CONCLUSIONS: These results suggest that endoscopic variceal ligation plus partial splenic embolization can prevent variceal recurrence, bleeding, and death in cirrhosis patients with esophageal varices and thrombocytopenia.     

内镜套扎与普萘洛尔预防肝硬化食管静脉曲张首次出血效能的Meta分析

目的比较内镜下套扎术（EVL）和普萘洛尔预防肝硬化食管静脉曲张首次出血的疗效和安全性。方法计算机检索1999至2012年12月31日PubMed、EBMBASE、万方数据库中关于EVL和普萘洛尔预防肝硬化食管静脉曲张首次出血的随机对照试验,同时追索纳入文献的参考文献。使用RevMan 5.1专业Meta分析软件对治疗后首次出血率,出血病死率,总病死率和不良反应发生率进行Meta分析。结果纳入6个随机对照试验,包括EVL组280例和普萘洛尔组301例患者。文献的Cochrane质量评价均为B级,属于较高质量文献。Meta分析结果显示,EVL在预防肝硬化食管静脉曲张患者的首次出血率、出血病死率、总病死率和不良反应发生率分别为16.4%、4.3%、22.5%和25.0%,与普萘洛尔组的21.6%（P=0.07）、6.3%（P=0.27）、20.9%（P=0.56）和31.9%（P=0.33）相比均无显著性差异;漏斗图存在不对称的现象,提示可能存在发表性偏倚;敏感性分析表明纳入研究具有稳定性。结论EVL与普萘洛尔在预防肝硬化食管静脉曲张破裂的效能无显著性差异。     

A new "sandwich" method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: a randomized trial

BACKGROUND: Variceal ligation is the optimum endoscopic method for treating esophageal variceal bleeding. However, both early and multiple recurrences of esophageal varices frequently follow ligation. The aim of this randomized study was to determine whether a new, combined endoscopic "sandwich" method (i.e., ligation-sclerotherapy-ligation) could achieve better results than ligation alone. METHODS: Ninety-four patients with cirrhosis and acute or recent esophageal variceal bleeding were randomized to undergo either the "sandwich" method or ligation alone (47 patients in each group). RESULTS: The sclerosant was retained in the varices for more than 30 minutes in 7 of 8 patients undergoing the "sandwich" method plus radiographic contrast medium. Active bleeding was controlled with this new method (9/9) as efficiently as ligation (12/12). The rate of recurrent bleeding was similar for both methods. Multivariate analysis showed the necessity for the use of antibiotics (odds ratio 3.95: 95% CI [1.60, 9.76]) to be an independent factor for recurrent bleeding. Two patients in the "sandwich" group developed strictures, but the frequency of other complications did not differ between the 2 groups. Kaplan-Meier analysis showed the cumulative probability of variceal recurrence was lower with the "sandwich" method (p = 0.0391). The survival rate and causes of death were similar in both groups. CONCLUSIONS: The "sandwich" method leads to longer retention of sclerosant in varices. This method is superior to ligation alone in terms of lower variceal recurrence rate and comparable to ligation with respect to hemostasis. However, it is unknown whether the lower recurrence rate of varices will persist long-term.     

Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: preliminary results of a prospective randomized trial

BACKGROUND: Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series. The aim of this study was to determine whether argon plasma coagulation is effective in reducing variceal recurrence after endoscopic variceal ligation. METHODS: Thirty patients with cirrhosis, a history of acute esophageal variceal bleeding, and eradication of varices by endoscopic variceal ligation were randomized to argon plasma coagulation (16 patients) or observation (14 patients). The 2 groups were similar with respect to all background variables including age, Child-Pugh score, presence of gastric varices, and degree of portal hypertensive gastropathy. In the argon plasma coagulation group, the entire esophageal mucosa 4 to 5 cm proximal to the esophagogastric junction was thermocoagulated circumferentially with argon plasma coagulation in 1 to 3 sessions performed at weekly intervals. Endoscopy was performed every 3 months to check for recurrence of varices in both groups. RESULTS: During the course of the study, no serious complication was noted. After argon plasma coagulation, transient fever occurred in 13 patients and 8 complained of dysphagia or retrosternal pain/discomfort. Mean follow-up for all patients was 16 months (range 9-28 months). No recurrence of varices or variceal hemorrhage was observed in the argon plasma coagulation group, whereas varices recurred in 42.8% (6/14) of the patients in the control group (p < 0.04) and bleeding recurred in 7.2% (1/14). CONCLUSIONS: Argon plasma coagulation of the distal esophageal mucosa after eradication of esophageal varices by endoscopic variceal ligation is safe and effective for reducing the rate of variceal recurrence.     

Effects of Endoscopic Variceal Ligation on Oxygen Transport and the Arterial Lactate Levels in Patients With Cirrhosis

Objective: Despite the increased cardiac output and oxygen delivery, an impaired oxygen uptake has been noted in patients with cirrhosis. We recently observed that endoscopic variceal ligation decreased the cardiac output due to a reduction in the cardiac preload. It is thus possible that a variceal ligation decreases the oxygen delivery and thereby negatively influences tissue oxygenation in patients receiving such treatment. We thus investigated the effects of variceal ligation on oxygen delivery, oxygen uptake, and the arterial lactate levels.
Methods: There were 22 patients with compensated cirrhosis and risky esophageal varices (Child's class  A:B = 13:9  ). Twelve patients underwent an endoscopic variceal ligation and 10 patients received gastroscopy as a control. The cardiac function, blood gas status, oxygen delivery, and arterial lactate concentration were also assessed before and after variceal ligation. The oxygen uptake was calculated by the Fick equation.
Results: Following variceal ligation, there was an immediate decrease in the cardiac output and oxygen delivery. The reduction in oxygen delivery was associated with a slight but significant increase in the arterial lactate concentration. The decreased oxygen delivery was also associated with a concomitant decrease in the oxygen uptake. In the control subjects, gastroscopy did not alter the systemic hemodynamics, arterial oxygen status, or arterial lactate levels.
Conclusion: We found a significant decrease in the oxygen delivery in patients undergoing an endoscopic variceal ligation. Such deteriorated tissue oxygenation may be serious especially in patients with a low oxygen transport ability such as in patients with variceal hemorrhage with anemia. However, the clinical significance of these changes remains unclear and further studies are therefore warranted.     

内镜下结扎术联合心得安预防肝硬化食管静脉曲张出血的疗效与安全性研究

目的探讨内镜下结扎术联合心得安预防肝硬化食管静脉曲张出血的近期疗效和安全性。方法将103例肝硬化门脉高压食管静脉曲张患者随机分为3组:结扎 心得安组37例,先进行食管静脉曲张结扎术后,再服用心得安维持治疗;结扎组32例;心得安组34例。定期随访,比较3组的静脉曲张消失率、首次出血率、静脉曲张复发率、并发症和不良反应。结果静脉曲张消失率:结扎 心得安组与结扎组相似(88.2%vs.81.3%,P>0.05),两组均明显高于心得安组的66.7%(P<0.05)。首次出血率在结扎 心得安组为8.9%,明显低于结扎组的15.6%与心得安组的30.0%(P<0.05)。静脉曲张复发率:结扎 心得安组、结扎组与心得安组分别为11.74%、21.9%、33.3%(P<0.05)。达到静脉曲张完全消失所需的平均治疗次数:结扎 心得安组与结扎组分别为1.9±1.0和2.8±0.7(P<0.05)。达到静脉曲张完全消失所需的平均结扎环数:结扎 心得安组与结扎组分别为7.0±3.0和11.0±2.0(P<0.05)。3组均无治疗相关死亡报告,结扎组有3例(9.4%)术后并发出血,结扎 心得安组无一例发生术后出血。结论结扎术联合心得安预防EVB,效果显著,安全性高,有肯定的临床价值。     

Variceal bleeding and portal hypertensive gastropathy

Cirrhosis can be the end stage of any chronic liver disease. At the time of diagnosis of cirrhosis varices are present in about 60% of decompensated and 30% of compensated patients. The risk factors for the first episode of variceal bleeding in cirrhotic patients are the severity of liver dysfunction, large size of varices and the presence of endoscopic red colour signs but only one-third of patients who have variceal haemorrhage have the above risk factors. Recent interest has been directed at identifying haemodynamic factors that may reflect the pathophysiological changes which lead to variceal bleeding, e.g. it has been confirmed that no bleeding occurs if HVPG falls below 12 mmHg and also a hypothesis has been put forward in which bacterial infection is considered a trigger for bleeding. Pharmacological treatment with beta-blockers is safe, effective and is the standard long-term treatment for the prevention of recurrence of variceal bleeding. Combination of beta-blockers with isosorbide-5-mononitrate needs further testing in randomized controlled trials. The use of haemodynamic targets for reduction in HVPG response needs further study, and surrogate markers of pressure response need evaluation. If endoscopic treatment is chosen, variceal ligation is the modality of choice. The combination of simultaneous variceal ligation and sclerotherapy does not offer any benefit. However, the use of additional sclerotherapy for the complete eradication of small varices after variceal ligation needs to be evaluated. The results of current prospective randomized controlled trials comparing variceal ligation with pharmacological treatment are awaited with great interest. Finally, the use of transjugular intrahepatic portosystemic shunt (TIPS) for the secondary prevention of variceal bleeding is not substantiated by current data, as survival is not improved and because of its worse cost-benefit profile compared to other treatments. In contrast, there still is a role for the selective surgical shunts in the modern management of portal hypertension. The ideal patients should be well compensated cirrhotics, who have had troublesome bleeding - either who have failed at least one other modality of therapy (drugs or ligation), have bled from gastric varices despite medical or endoscopic therapy, or live far from suitable medical services. Recently, ligation has been compared to beta-blockers for primary prophylaxis but so far there is no good evidence to recommend banding for primary prophylaxis, if beta-blockers can be given.     

Effects of endoscopic variceal treatment on oesophageal function: a prospective, randomized study

AIM : Endoscopic methods are currently the most widely used techniques for the treatment of bleeding oesophageal varices (BOV). However, a number of complications may limit their usefulness. We conducted a prospective, randomized comparison of variceal ligation versus sclerotherapy in cirrhotics after the control of variceal haemorrhage to study the relative short-term risks of these two procedures with respect to oesophageal motility and gastro-oesophageal reflux. METHODS : Seventy-three patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to treatment with sclerotherapy or ligation until variceal eradication. In 60 of these patients, oesophageal manometry and 24-h intra-oesophageal pH monitoring were performed at inclusion and 1 month after variceal eradication. RESULTS : After variceal eradication with sclerotherapy, peristaltic wave amplitude decreased from 76.2 +/- 14.7 mmHg to 61.6 +/- 17.7 mmHg (P = 0.0001), simultaneous contractions increased from 0% to 37.9% (P = 0.0008), and the percentage of time with pH < 4 increased from 1.60 +/- 0.25 to 4.91 +/- 1.16% in channel 1 (P = 0.0002) and from 1.82 +/- 0.27 to 5.69 +/- 1.37% in channel 2 (P = 0.0006). In contrast, the above parameters were not disturbed with ligation. CONCLUSION : Our data define the advantages of ligation over sclerotherapy with respect to post-treatment oesophageal dysmotility and associated gastro-oesophageal reflux.     

Successful topical application of Ankaferd blood stopper in a patient with life-threatening fundal variceal bleeding despite cyanoacrilate injection

Gastric variceal bleeding is a common problem in patients with cirrhosis and despite early endoscopic and/or pharmacological therapy, variceal bleeding cannot be controlled or recurs early in about 10 to 20% of patients with considerable morbidity and mortality rates. For this reason, effective control of active bleeding varices is of great importance for the prevention of late complications. Although endoscopic band ligation and sclerotherapy are the choice of endoscopic treatment modalities with various grades of success, limited data is available for the use of Ankaferd Blood Stopper (ABS) for the controlling of variceal bleeding due to gastric varices. We herein present a unique case of gastric variceal bleeding despite cyanoacrilate injection, which was successfully controlled with topical ABS application.     

Bacteremia caused by digestive system endoscopy.

AIM: to evaluate bacteremias caused during endoscopic examination of the digestive tract. PATIENTS AND METHODS: prospective study of randomly selected patients who underwent digestive system endoscopic examination. Emergency endoscopic examinations were excluded. RESULTS: a total of 102 patients were analyzed. Of 44 patients who underwent gastroscopy, 11 (25%) subsequently had positive blood culture, and Staphylococcus spp and Streptococcus spp were isolated. Of 30 patients who underwent colonoscopy, 3 (10%) had positive blood cultures, and Staphylococcus spp were isolated. Of 28 patients who underwent endoscopic retrograde cholangiopancreatography, 11 (39.2%) had positive blood cultures, and Escherichia coli, Morganella morganii, Staphylococcus spp and Streptococcus spp were isolated. No deaths, endocarditis or other septic phenomena were attributed to bacteremia. CONCLUSIONS: the incidence of bacteremia ranged from 10% to 39% depending on the type of endoscopy. The microorganisms that were isolated most frequently were Staphylococcus spp and Streptococcus spp. Gram-negative bacilli and enterobacteria were isolated in patients who had undergone endoscopic retrograde cholangiopancreatography.     

药物联合内镜治疗预防肝硬化门静脉高压食管胃静脉曲张再出血的疗效观察

目的观察药物（普奈洛尔）联合内镜（套扎或/和组织胶）治疗预防肝硬化门静脉高压食管胃静脉曲张再出血的疗效。方法将65例肝硬化门静脉高压食管胃静脉曲张出血经内科药物治疗出血停止的患者随机分为2组：治疗组34例,采用普奈洛尔联合内镜治疗（对单纯食管静脉曲张行套扎治疗,对食管胃静脉曲张行套扎治疗＋组织胶治疗）;对照组31例,单用普奈洛尔治疗。随访12个月,观察治疗后患者再出血率、死亡率等。结果随访12个月期间再出血率治疗组20.6%（7/34）,对照组32.3%（10/31）,差异有统计学意义（P〈0.05）;死亡率治疗组8.8%（3/34）,对照组9.7%（3/31）,差异无统计学意义（P〉0.05）。结论药物联合内镜治疗可以有效预防肝硬化门静脉高压食管胃静脉曲张再出血,提高患者生活质量,值得临床推广。     

Endoscopic variceal ligation is a sufficient procedure for the treatment of oesophageal varices in patients with hepatitis C liver cirrhosis: comparison with injection sclerotherapy

AIMS: Endoscopic variceal ligation (EVL) is a recently developed alternative to endoscopic injection sclerotherapy (EIS) for the treatment of oesophageal varices. Endoscopic variceal ligation and EIS were compared in an attempt to clarify the efficacy and safety of EVL for patients with cirrhosis due to hepatitis C. METHODS: Endoscopic variceal ligation was performed in 60 patients and EIS in 30. Varices were eradicated in all patients by EVL and 87% (26 out of 30) by EIS. RESULTS: There was no significant difference between EVL and EIS in relation to the incidence of bleeding and the 5 year survival rate after treatment. There were no severe complications except mild substernal pain after EVL, while pulmonary embolism occurred in one patient receiving EIS. CONCLUSIONS: Endoscopic variceal ligation is a safe and effective technique for eradicating oesophageal varices in patients with hepatitis C cirrhosis.     

Long-term follow-up of patients with liver cirrhosis after endoscopic esophageal varices ligation therapy: comparison with ethanol injection therapy

BACKGROUND/AIMS: Esophageal variceal hemorrhage is the most dreaded complication of liver disease. Prevention or emergency therapy of bleeding is important. METHODOLOGY: A group of 217 patients underwent endoscopic esophageal variceal therapy including endoscopic ethanol injection, endoscopic esophageal variceal ligation, or a combination of the two. RESULTS: Esophageal varices were eradicated by endoscopic esophageal variceal ligation with the least sessions required, and associated complications with endoscopic esophageal variceal ligation therapy were lower than with the other two approaches. However, the cumulative recurrence-free period of esophageal varices was significantly higher after endoscopic ethanol injection than after endoscopic esophageal variceal ligation and in some cases F3 varices were observed post-endoscopic esophageal variceal ligation hemorrhage. A combined endoscopic esophageal variceal ligation and endoscopic ethanol injection therapy had no advantage with respect to cumulative recurrence-free rate, session number, or complication frequency, relative to either therapy alone. CONCLUSIONS: While the combined observations indicate that endoscopic esophageal variceal ligation is safe and simple, we should consider additional therapy to achieve complete mucosal fibrosis of the esophagus after endoscopic esophageal variceal ligation.     

非侵入性检测指标与食管静脉曲张套扎术后2周内再次出血的关系研究

目的研究非侵入性检测指标与食管静脉曲张套扎术后2周内再次出血的关系。方法回顾性分析自2004年1月至2008年6月行食管静脉曲张套扎治疗患者的临床资料．并进行统计学分析。结果出血组与对照组患者的性别、年龄、Child-pugh分级无统计学差异．肝硬化、肝硬化合并肝癌、肝硬化合并肝癌及门静脉栓子病例所占百分比两组无差别。人院时两组患者腹水、肝性脑病、休克的发生率、血红蛋白、血清白蛋白的平均值相比无统计学差异。出血组血清总胆红素（59．51±40．87μmol／L）、门静脉直径（12．00±1．64mm）均高于对照组（分别为40．90±33．78μmol／L、11．37±1．06mm）,但尚无统计学意义。出血组中肝硬化伴门静脉栓子、既往有食管静脉曲张出血史及有糖尿病史的病例数明显高于对照组（P=0．020,P=0．037,P=0．020）。出血组患者血小板计数的平均值（76．43±18．47）明显低于对照组（89．03±21．75）（P=0．019）,而出血组凝血酶原时间的平均值（19．15±3．23s）则明显高于对照组（17．14±2．94S）（P=0．015）。对具有统计学意义的检测指标进行多变量Logistic回归分析,结果表明凝血酶原时间和既往有糖尿病史是食管静脉曲张套扎治疗后2周内再次出血的独立危险因素,OR值分别为0．808（95％CI：0．659—0．977）和0．172（95％CI：0．032—0．927）。结论凝血酶原时间延长和糖尿病史是食管静脉曲张套扎治疗术后2周内再次出血的独立危险因素。