Repeated endoscopic sclerotherapy of oesophageal varices due to non-cirrhotic portal fibrosis using intravariceal polidocanol

Forty patients with variceal bleeding due to non-cirrhotic portal fibrosis have been treated by repeated endoscopic injection sclerotherapy using intravariceal polidocanol (1%). This has decreased re-bleeding as evidenced by a decrease in mean bleeding risk factor (BRF) and transfusion requirement; difference between presclerotherapy and postsclerotherapy parameters were significant ( P < 0.001). Low doses of polidocanol (mean 13.2 ml per session) were effective in the obliteration of varices. The mean sclerotherapy sessions required for obliteration were 8.04 (s.d. = 2.24). Complications were infrequent. Cumulative survival for 4 years was 92.5%. Based on these results endoscopic sclerotherapy is recommended for managing variceal bleeding due to non-cirrhotic portal fibrosis and is a reasonable alternative to surgery.     

Frequency of gastropathy and gastric varices in children with extrahepatic portal venous obstruction treated with sclerotherapy

BACKGROUND: There are limited reports of the effect of endoscopic sclerotherapy (EST) on portal hypertensive gastropathy (PHG) and gastric varices (GV) in children with extrahepatic portal venous obstruction (EHPVO). We have studied the prevalence of PHG and GV in children with EHPVO and assessed the effect of EST on them on long-term follow-up. METHODS: From January 1992 to June 2002, consecutive children presenting with variceal bleeding due to EHPVO were included in this study. All children underwent EST at presentation and at 2-3 week intervals thereafter. During each session of endoscopy, gastric mucosa and fundus of the stomach was screened carefully to detect PHG and GV. Gastric varices were classified as gastroesophageal (GOV) and isolated gastric varices (IGV). RESULTS: In total, 274 cases of EHPVO were managed during the study period. The mean age was 7.4 +/- 3.5 years with a male to female ratio of 2.3:1. Of these 274 cases, 186 completed the EST program (study population), 60 were lost to follow-up, five died and 23 underwent surgery. At presentation (n = 274) 27% cases had PHG (3.6% severe) and 68.6% had GV (GOV 66.8%, IGV 1.8%). Following EST (n = 186) there was a significant (P < 0.001) decrease in GOV (45% from 64%) but an increase in IGV (14% from 1%) and PHG (51.6% from 24.7%).There was also a significant increase in severe PHG (15.6% from 3.2%, P < 0.05). On follow-up (mean follow-up 38 +/- 30 months) 19% children with IGV bled while none with PHG bled. CONCLUSIONS: Portal hypertensive gastropathy and gastric varices are quite common in children with EHPVO. Following EST, there is a chance of developing isolated gastric varices.     

Influence of extravariceal collateral channel pattern on recurrence of esophageal varices after sclerotherapy

We investigated the influence of extravariceal collateral channel pattern on the recurrence of esophageal varices after sclerotherapy. One hundred and fifteen patients with cirrhosis and esophageal varices were studied. They were divided into four groups according to extravariceal collateral pattern on portal venography. Group 1 patients had neither paraesophageal veins nor gastrorenal veins (n-49); group 2 patients had paraesophageal veins only (n=30); group 3 patients had gastrorenal veins only (n=25); and group 4 patients had paraesophageal veins plus gastrorenal veins (n=11). Sclerotherapy was repeated to eradicate esophageal varices and follow-up endoscopic examination were performed. The overall recurrence-free rate at 36 months was 68%. The log-rank test showed the recurrence-free rate to be significantly higher in group 3 (76%) and group 4 patients (89%) than in group 1 patients (51%;P<0.05 andP<0.05, respectively). Although the recurrence-free rate was higher in group 4 than in group 2 patients (59%), this did not reach the level of significance (P=0.10). No significant differences were found between other pairs of groups. These results suggest that gastrorenal veins play an important role in the protection against recurrent esophageal varices after sclerotherapy, while the protective role of paraesophageal veins appears to be small.     

Dysphagia after prophylactic endoscopic injection sclerotherapy for oesophageal varices: not fatal but a distressing complication

BACKGROUND: Although dysphagia resulting from oesophageal strictures induced by endoscopic injection sclerotherapy (EIS) is not a fatal complication, it is often quite distressing for the patients. The aim of the current study was to clarify the relationship between dysphagia resulting from oesophageal stricture following prophylactic EIS and the volume of sclerosant consumed in the EIS series. METHODS: Fifty-two patients with oesophageal varices, who had been treated by prophylactic EIS, were selected as the subjects. RESULTS: Seventeen (32.7%) patients developed dysphagia following prophylactic EIS, and five patients with a severe stricture required bougie dilatation to take meals. The volume of sclerosant used in the initial session of EIS for patients with subsequent dysphagia (24.9 +/- 4.0 mL) was significantly larger than that for patients without dysphagia (18.4 +/- 5.1 mL; P < 0.001). The mean volume of sclerosant consumed per session during the EIS series for patients with dysphagia (16.5 +/- 3.0 mL) was also significantly larger than that for patients without dysphagia (13.1 +/- 3.8 mL; P < 0.01). CONCLUSIONS: The injection of a superfluous amount of sclerosant in prophylactic EIS brings about distressing dysphagia with oesophageal stricture in the patients with oesophageal varices who had no such complaint or symptoms before the therapy.     

食管静脉曲张破裂大出血的急诊硬化治疗

目的 总结食管静脉曲张破裂大出血极危重患者在急诊内镜下行硬化治疗(EIS)的经验。方法 176例食管静脉曲张破裂大出血患者在改良三腔管牵引下，共用5%鱼肝油酸钠食管静脉内注射209次，其中181次为致死性活动性大出血。结果 首次EIS能明确出血部位166例(94．3%)，急诊EIS止血成功201次(96．2％)，其中21例为多次EIS后止血，并发症15例(8．5％)，死亡3例(1．7％)。结论 改良三腔管牵引下行EIS是急诊救治致死性食管静脉曲张大出血的安全、有效、简便方法。     

102例肝硬化合并食管静脉曲张出血二级预防硬化治疗分析

目的 评价硬化治疗预防食管静脉曲张再出血的疗效。方法 回顾性分析我院2010年3月—2012年2月行食管静脉曲张硬化治疗(esophageal varices sclerotherapy,EVS)二级预防的肝硬化合并食管静脉曲张出血患者102例的临床资料。102例共行EVS328例次,其中择期309例次,追加治疗19例次,首次治疗(3.0±0.8)次。对其中88例进行1～20(10.2±2.5)个月随访。结果 随访88例中,食管静脉曲张消失和基本消失率为79.5%,远期再出血率为12.5%。主要并发症为术后发热、食管注射点溃疡或糜烂出血。结论 EVS治疗食管静脉曲张出血,可明显降低再出血率。     

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.     

Endoscopic injection sclerotherapy with n-butyl-2-cyanoacrylate for ruptured duodenal varices

Duodenal varices are a rare site of hemorrhage in patients with portal hypertension, but their rupture is a serious and often fatal event. We report the case of a 77-year-old woman with cirrhosis who presented with melena. She was admitted to our Department because of prolonged shock although she had received a large blood transfusion. Upper gastrointestinal endoscopy revealed nodular varices in the third portion of the duodenum which were considered to be the source of the bleeding. Endoscopic injection sclerotherapy (EIS) with n-butyl-2-cyanoacrylate (Histoacryl; Braun-Melsungen, Germany), an adhesive agent, was performed. We injected 1.5 ml of Histoacryl with Lipiodol (Laboratoire-Guerbet, France) intravariceally and achieved successful hemostasis. This patient's duodenal varices had almost completely resolved 1 month after EIS. We conclude that EIS with Histoacryl is an effective hemostatic measure for ruptured duodenal varices. (Received July 9, 1997, accepted Nov. 28, 1997)     

Prophylactic versus emergency sclerotherapy of large esophageal varices prior to liver transplantation

From January 1985 through July 1987, adult patients accepted for liver transplantation with large esophageal varices were enrolled in a study evaluating the use of prophylactic vs emergency sclerotherapy. Six hundred forty-eight subjects received prophylactic sclerotherapy, and 172 received emergent sclerotherapy. Esophageal stricture formation was increased 12.9-fold (P<0.001), esophageal perforation 6.4-fold (P<0.005), and postsclerotherapy bleeding esophageal ulcers 3.7-fold (P<0.001) in those receiving emergency sclerotherapy as opposed to prophylactic sclerotherapy. These differences were even greater if the number of sclerotherapy sessions rather than the number of patients was used as the denominator for the comparisons. In total, 19.6% of emergency sclerotherapy cases were associated with an untoward outcome of sclerotherapy; only 1.9% of cases receiving prophylactic sclerotherapy experienced an untoward outcome (P <0.001). These data demonstrate that emergency sclerotherapy is associated with a greater prevalence of complications and support earlier studies that show that sclerotherapy prevents variceal bleeding over the short term. The data also suggest that when applied to patients with large varices awaiting orthotopic liver transplantation, it enhances the chance of a patient surviving to be transplanted by preventing a variceal bleed and the spiral of liver failure and death that frequently follows an episode of acute variceal bleeding.     

Long-term follow up of a randomized, controlled trial on prophylactic sclerotherapy of small oesophageal varices in liver cirrhosis

BACKGROUND: In order to evaluate the prophylactic impact of sclerotherapy of small varices in patients with cirrhosis and no endoscopic signs suggesting risk of haemorrhage, a randomized clinical trial was performed. METHODS: Seventy-one hospitalized patients met the inclusion criteria of diagnosis of cirrhosis with no previous bleeding and small varices. Due to exclusion criteria of: gastroduodenal ulcers (n = 5), diverticulosis (n = 1), hepatic insufficiency (n = 10), hepatocellular carcinoma (n = 4), death before randomization (n = 6), age over 70 (n = 1) and denial of consent to participate in the study (n = 1), 43 patients could be randomized, 21 for sclerotherapy and 22 for the control group. Two patients (one in each group) were lost to follow up, and another patient, although not lost, refused sclerotherapy after randomization. Ethanolamine oleate was used as the sclerosing agent. All patients were followed up for a mean time of 60 months, initially every 2 months for the first 2 years and clinical and endoscopic controls were performed each 6-12 months thereafter. RESULTS AND CONCLUSIONS: During the first 2 years clinical assessment showed that there were five bleedings in the sclerotherapy group and none in the control group, but mortality was similar in both groups. Long-term follow up continued to show a higher prevalence of bleeding in the sclerotherapy group but that mortality was not different from the control group.     

Prognostic indicators of successful endoscopic sclerotherapy for prevention of rebleeding from oesophageal varices in cirrhosis: a long-term cohort study

Background. Although band ligation is now recommended for prevention of rebleeding from oesophageal varices in cirrhosis, sclerotherapy is still widely used. Patients submitted to chronic sclerotherapy undergo several endoscopies and experience a large number of serious complications. However, long-term outcome is poorly defined.

Aims. To assess the clinical course and prognostic indicators of patients undergoing chronic sclerotherapy for prevention of variceal rebleeding as a basis for future evaluation of long-term band ligation outcome.

Methods. Prospective cohort study prognostic analysis by the Cox proportional hazards model.

Results. A total of 218 consecutive cirrhotic patients (37 Child class A, 154 B, 27 CJ were enrolled in the study. Varices were obliterated in 139 (64%) patients in a mean of 5 (±2.6) sessions and recurred in 58/139 (41.7%) within one year. A total of 132 (60%) patients experienced 283 rebleeding episodes and 73 (33%) died. Bleeding from oesophageal ulcers was the most serious complication causing 14% of all rebleeding episodes. Significant prognostic indicators of sclerotherapy outcome were: Child-Pugh class for variceal obliteration; gastric varices and platelet count for recurrence of varices; failure to obliterate varices, variceal size and gastric varices for rebleeding; blood urea nitrogen and failure to obliterate varices for death. Presence of gastric varices was the only prognostic indicator for death in the 79 patients not achieving variceal obliteration. A mean of 10 endoscopies and of 6 hospital admissions were needed per each patient with an estimated cost of US$ 7154 per patient during the first two years of therapy.

Conclusions. Sclerotherapy is a very demanding and costly treatment, and is associated with frequent and serious side-effects. The probability of treatment failure is significantly higher in Child C patients with gastric varices. Alternative treatments should be considered for these patients.     

Evaluation of patient outcome following sclerotherapy for esophageal varices

After excluding terminally all patients, we evaluated a total of 718 patients treated with endoscopic injection sclerotherapy. They involved 350 episodes of acute hemorrhage and 368 prophylactic procedures in patients with risky varices. The 1-year cumulative survival rate was significantly lower in the acute hemorrhage group than in the prophylactic group (P<0.05). The difference in survival between the two groups was primarily due to the number of deaths in the first 2 months after sclerotherapy (20.1% vs 0.8%,P<0.0005). Improvements in the sclerotherapy technique significantly reduced the number of deaths from bleeding (9.3% vs 3.4%,P<0.05), but not those from liver failure following variceal hemorrhag. Prophylactic EIS is advantageous in the treatment of esophageal varices, i.e. it may prevent deaths fromliver failure attributed to variceal hemorrhages. The present study shows that preliminary prevention of variceal hemorrhage provides favorable hemostatic efficacy in patients with risky varices.     

Successful endoscopic sclerotherapy for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol

Two patients with liver cirrhosis and portal hyper-tension related to hepatitis infection were admitted to Shanghai Ruijin Hospital due to recurrent melena and hematemesis. Isolated gastric varices were observed in the gastric fundus during the retroflexion of gastroscope. We carried out endoscopic sclerotherapy successfully for bleeding gastric varices with combined cyanoacrylate and aethoxysklerol, which disappeared dramatically several months after two courses of sclerotherapy for each patient. No complication and clinical signs of gastrointestinal re-bleeding were observed during the 6-mo endoscopic follow-up. CT portal angiography （CTPA） has been widely used in the assessment of variceal treatment and improves the results of endoscopic injection therapy.     

肝硬化门静脉高压食管胃静脉曲张内镜下硬化治疗专家共识（2022，长沙）

肝硬化门静脉高压食管胃静脉曲张出血是临床常见危急重症,内镜下硬化治疗在食管胃静脉曲张的治疗中起着重要作用,然而目前国内外尚无其规范化治疗的相关共识。2022年,中华医学会消化内镜学分会食管胃静脉曲张内镜诊断与治疗学组组织全国相关领域权威专家讨论,提出了肝硬化门静脉高压食管胃静脉曲张内镜下硬化治疗专家共识,以期规范该技术在食管胃静脉曲张中的应用。本共识共分为食管胃静脉曲张分型、肝硬化食管胃静脉曲张诊断等12个部分,共17条陈述。     

Role of portal haemodynamic parameters in prediction of oesophageal varices in cirrhotic patients

Background and study aimsScreening all cirrhotic patients by endoscopy for detection of varices is not cost-effective as the number of patients increases by time and half of them still would not have developed varices 10 years after being diagnosed with cirrhosis. Therefore, this study aimed to evaluate hepatic haemodynamic Doppler parameters in predicting the presence of oesophageal varices (OVs) in cirrhotic patients for better selection of those actually needed for screening endoscopy.Patients and methodsEighty-one patients with liver cirrhosis, 32 females and 49 males, with a mean age of 50.7 ± 11.7 years were recruited for the study. They included 61 patients with OVs and 20 patients without varices. The diagnosis of liver cirrhosis was based on clinical history, examination, and investigations. Liver function and kidney function tests and complete blood count (CBC) were performed for all patients. All patients underwent abdominal ultrasound (US), upper endoscopy, and hepatic Doppler US examination.ResultsThe portal vein velocity (PVV) and liver vascular index (LVI) showed statistically significantly lower values in patients with OVs than those without OVs (p value = 0.02 and 0.000, respectively). The congestion index (CI) of the portal vein, the portal hypertension index (PHI), and the splenoportal index (SPI) showed statistically significantly higher values in patients with OVs than those without OVs (p value = 0.006, 0.001, and 0.001, respectively). CI and SPI were the best parameters that could predict the presence of OVs with high sensitivity, specificity, and diagnostic accuracy when cutoff values were set at >0.069 and 3.57, respectively (area under the curve = 0.864 and 0.894, respectively).ConclusionsThe CI of the portal vein and SPI are good predictors for the presence of OVs in cirrhotic patients, and could be used noninvasively to decrease the burden on the upper endoscopy unit by proper selection of those who are candidates for screening endoscopy.     

硬化剂在肝硬化食管静脉曲张破裂出血防治中的优化应用

约50%的肝硬化患者初诊时即存在食管胃静脉曲张,尤以食管静脉曲张(EV)常见,且EV的发生率随肝脏疾病严重程度增加而增高(Child-Pugh A 43%、Child-Pugh B 71%、Child-Pugh C 76%)[1]。<5 mm的EV以每年10%的速度进展为大的EV,小EV的年出血率为5%,而大EV可达15%,EV出血后6周内死亡率高达20%[2-4]。急性EV破裂出血停止后再次出血率和死亡率较高,未进行二级预防的EV患者1~2年内再次出血率高达60%,死亡率高达33%[5]。因此EV破裂出血的防治非常重要,内镜干预在EV破裂出血的防治中起重要作用,包括内镜下静脉曲张套扎术(EVL)、内镜下硬化剂注射治疗(EIS)、自膨式金属支架等[5-6]。本文就EIS在EV破裂出血的防治作用做一述评。     

Variceal band ligation in the management of bleeding oesophageal varices: an overview

Endotherapy is, in many centres, still the cornerstone in the first-line approach of a patient with variceal haemorrhage. Since the introduction of the multiband ligation, devices, active variceal bleeding is controlled as efficiently as with sclerotherapy, and variceal eradication can be obtained much faster with fewer treatment-related complications. This observation is now supported by several randomized trials. Combining sclerotherapy with band ligation has no additional effect and can even increase the number of side-effects. Therefore, multiband ligation can be considered as a first-step treatment for bleeding oesophageal varices.