Benefit of prophylactic endoscopic sclerotherapy of esophageal varices

Background: The therapeutic schedule in bleeding esophageal varices is today established: emergency endoscopy with sclerotherapy or ligation combined with somatostatin and decreasing portal pressure drug followed by repetitive sclerotherapy or ligation. But the approach to varices that do not bleed is not clear. Methods: The authors submit the results of a 6-year sclerotherapeutic program. Since January 1989 they have treated 421 patients with varices and have together performed 4,115 endoscopic sclerotherapeutic procedures. Among the 421 patients 95 were treated during acute bleeding and 254 were treated after first bleeding; in 72 patients prophylactic sclerotherapy (PSG) was performed. Results: The procedure was indicated, when grade III or IV varices or high-risk signs and/or hepatic venous pressure gradient (HVPG) > 15 in grade II varices were observed. Prophylactic therapy (not-treated group—NTG) refused next 31 selected patients. The mean follow-up time was 32 months in the PS group and 28 months in NTG (n.s.). Fifteen PSG patients died (21%), while the mortality among the NTG patients (13 = 42% patients) was significantly higher (P < 0.02). Conclusions: We recommend prophylactic sclerotherapy with 1% polidocanol in patients with advanced varices in liver cirrhosis of varied etiology. We emphasize the need to perform these procedures in a department with adequate experience, where at least 100–200 sclerotherapies per year are performed. Received: 31 July 1995/Accepted: 28 December 1995     

Portal hypertension management

Summary Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric evascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic portosystemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.     

Ostomy closure for recurrent stomal hemorrhage: an indication for prophylactic sclerotherapy in biliary atresia

Two patients with failed drainage procedures for biliary atresia are presented in whom major hemorrhage from esophageal varices followed shortly after ostomy closure for recurrent stomal bleeding. Before ostomy closure is contemplated in these patients, evaluation for esophageal varices and their prophylactic obliteration with sclerotherapy is recommended.     

内镜治疗食管胃静脉曲张的效果分析

目的探讨内镜下套扎、硬化剂、组织粘合剂治疗食管胃静脉曲张的临床疗效。方法选择有食管、胃静脉曲张破裂出血史的患者107例,进行胃镜检查,依据LDRf分型结果选择内镜下套扎、硬化剂或者组织粘合剂治疗食管胃静脉曲张并随访。结果进行内镜下套扎治疗52例,硬化剂治疗18例,组织粘合剂治疗8例,硬化剂加组织粘合剂治疗15例,未进行内镜下治疗14例。结论内镜下治疗食管胃底静脉曲张破裂出血操作简单、疗效可靠、止血率高、静脉曲张消失快、并发症少,是治疗食管胃底静脉曲张破裂出血的有效方法。LDRf内镜下分型简单明了、规范、统一,对于食管胃静脉曲张的内镜下治疗有指导意义。     

秋田注气及附加气囊结扎器治疗食管静脉曲张

目的：探讨秋田注气及附加气囊MD－48720结扎器治疗食管静脉曲张的安全性和操作特点。方法：53例肝硬化食管静脉曲张破裂出血病人分成两组,A组28例行秋田注气结扎治疗,B组25例行乙氧硬化醇注射治疗,对比研究两者治疗特点及并发症等。结果：A组消退曲张静脉方面优于B组（P＜0．01）,急性出血可经气囊填压及硬化剂即时治疗。结论：秋田注气及附加气囊MD－48720结扎器结扎食管曲张静脉在安全性、消退曲张静脉及并发症处理方面均优于乙氧硬化醇治疗。     

Bacteremia after injection of esophageal varices

Summary Elective sclerotherapy for esophageal varices produces bacteremia in 4% to 53% of patients. The clinical importance of this phenomenon is uncertain. This study was undertaken to re-assess the incidence and clinical relevance of post-sclerotherapy bacteremia. Blood cultures were taken prior to and at 5 min and 4 h after endoscopy in 50 patients for whom sclerotherapy was planned. In the 41 patients in whom varices were injected, positive cultures were obtained 5 min after sclerotherapy in only 4 patients (10%) and all but 1 patient had other possible causes of bacteremia. After 4 h, all blood cultures were sterile. No infective complications were identified. Bacteremia appears to be an infrequent and transient event after elective sclerotherapy. Only patients with prosthetic heart valves or endocardial abnormalities require antibiotic prophylaxis.     

A transparent over-tube for endoscopic injection sclerotherapy and results in patients with esophageal varices

This report describes our data regarding repeated injection sclerotherapy using a newly designed over-tube. We treated 17 consecutive patients with esophageal varices, (3 acute, 6 elective and 8 prophylactic). An intravariceal injection of 5 per cent ethanolamine oleate was administered, using a newly designed transparent over-tube containing a second lumen for a flexible injection needle. This over-tube provides an easier, safer, shorter-in-time method of sclerosing esophageal varices. One of the 17 patients died as a result of liver failure associated with advanced cirrhosis and a concomitant hepatoma. Eradication of esophageal varices was attained in the remaining 16 patients, after an average of 5.0 injections over an average period of 5.8 weeks (range: 3-7 injections during 3-11 weeks). No complications, such as esophageal perforation or aspiration pneumonia were encountered. Recurrent variceal bleeding has not occurred during the 9 months follow-up.     

Sonographic evaluation of the portal venous system after elective endoscopic sclerotherapy of esophageal varices

Summary In order to evaluate possible changes in the portal venous system after endoscopic sclerosis of esophageal varices, 25 cirrhotic patients underwent abdominal ultrasonography before the first session of sclerotherapy and after eradication of esophageal varices had been achieved. The caliber of the portal, splenic, and superior mesenteric veins was measured sonographically in each case. Sonographic results were compared statistically before and after sclerotherapy. Neither evidence of significant variations in the caliber of the portal veins nor thrombotic obliteration was seen. These results support the view that sclerotherapy has no significant negative side effects on the portal venous system.     

Endoscopic resection of carcinoma in situ of the esophagus accompanied by esophageal varices

Summary A case of carcinoma in situ of the esophagus accompanied by esophageal varices was treated by endoscopic mucosal resection using a transparent tube (EMRT) following eradication of the varices via injection sclerotherapy (EIS). Intravariceal injection sclerotherapy was performed for esophageal varices, and after eradication of the varices had been achieved, half of the circumferential esophageal mucosal resection of the cancer lesion was carried out. No serious complication such as perforation or mass bleeding was observed. Cancer-involved mucosa was completely resected and all specimens contributed well to accurate histopathological study, being diagnosed as intraepithelial squamous-cell carcinoma. The artificial ulcer recovered completely, showing no stenotic changes. Our conclusion from this experience is that EIS + EMRT is a valuable and minimally invasive treatment for patients exhibiting this disease, providing an accurate histopathological diagnosis.     

A transparent over-tube for endoscopic injection sclerotherapy and results in patients with esophageal varices

This report describes our data regarding repeated injection sclerotherapy using a newly designed over-tube. We treated 17 consecutive patients with esophageal varices, (3 acute, 6 elective and 8 prophylactic). An intravariceal injection of 5 per cent ethanolamine oleate was administered, using a newly designed transparent over-tube containing a second lumen for a flexible injection needle. This over-tube provides an easier, safer, shorter-in-time method of sclerosing esophageal varices. One of the 17 patients died as a result of liver failure associated with advanced cirrhosis and a concomitant hepatoma. Eradication of esophageal varices was attained in the remaining 16 patients, after an average of 5.0 injections over an average period of 5.8 weeks (range: 3–7 injections during 3–11 weeks). No complications, such as esophageal perforation or aspiration pneumonia were encountered. Recurrent variceal bleeding has not occurred during the 9 months follow-up.     

Long-term effects of repeated injection sclerotherapy on esophageal motility and mucosa

Background: Endoscopic sclerotherapy (ST), widely used as treatment of bleeding esophageal varices, might cause motility disturbances of the esophagus as well as mucosal damage. We performed this study to evaluate the long-term effects of repeated sclerotherapy on esophageal motility and mucosa. Methods: Ten patients with liver cirrhosis and bleeding esophageal varices treated with repeated ST were evaluated after the last ST, median 52 months, by esophageal manometry and gastroscopy where forceps biopsies were taken. Results: We found a significant difference in the distal esophageal sphincter intraabdominal length. The distal esophageal sphincter pressure was somewhat lower in the ST group although the difference did not reach statistical significance. There was infiltration of neutrophil leukocytes in biopsies from four patients and normal findings in the rest. Conclusions: Long-term follow-up evaluation showed statistically longer distal esophageal intraabdominal length in the ST group. No mucosal alterations were found at the histopathological investigation. Received: 22 April 1996/Accepted: 20 August 1996     

Esophageal function after injection sclerotherapy: pathogenesis of esophageal stricture

Injection sclerotherapy effectively controls hemorrhage from esophageal varices. Treatment must be repeated at intervals to obliterate varices. Long-term sequelae of such treatment are unknown but may include stricture formation. To assess the impact of repeated sclerotherapy on esophageal function, this prospective study measured lower esophageal sphincter pressure, reflux, and motility in patients before and after treatment. Injection sclerotherapy had no effect on lower esophageal sphincter pressure. Reflux was common before treatment and became even more prevalent after treatment, with reflux occurring in 60 percent of postsclerotherapy patients. Striking disturbances in esophageal motility were observed after treatment. Injection sclerotherapy induces a chemical esophagitis that impairs esophageal motility. Delayed acid clearance in the presence of reflux results in superimposed acid esophagitis. Esophageal strictures may thus be produced. We advise a standard antireflux medical regimen in our sclerotherapy patients.     

Endoscopic noninvasive manometry of esophageal varices: Prognostic significance

Our study attempts to establish a relation between the pressure in the esophageal varices and the clinical outcome in 18 patients in whom sclerotherapy for bleeding esophageal varices was performed. The measured pressure was compared to the endoscopic findings. Before sclerotherapy, a noninvasive manometric measurement was performed on the varices using a spheric membrane manometer fixed at the tip of an endoscope. Twelve of our 18 patients suffered repeated hemorrhage which led to death in five. We discovered a relation between the measured pressure and the outcome. Beside this, we measured the highest pressures in the largest varices. The relation that seems to exist between the pressure in the esophageal varices, the endoscopic findings, and the severity of the portal hypertension may provide new opportunities for research in this field.     

Esophageal motility: effects of injection sclerotherapy

The purpose of this project was to evaluate the acute and chronic effects of sclerotherapy on esophageal motility and function. We studied motility in eight patients before and after injection sclerotherapy of esophageal varices. We injected the varices with 5% sodium morrhuate twice during the first week and then at 1, 2, 3, and 6 months. Lower esophageal sphincter pressure, contraction wave amplitude, and duration were not altered by sclerotherapy. However, the length of the high-pressure zone increased significantly from 3.6 +/- 0.3 cm to 4.2 +/- 0.2 cm during the first 3 days after initial treatment, and sclerotherapy caused considerable distortion of peristaltic wave form. Also, esophageal peristaltic velocity decreased in three patients who complained of dysphagia and subsequently developed esophageal stricture. The strictures have responded well to dilatation, and in two patients velocity has even returned toward the baseline value. Reflux esophagitis has not been a problem. Esophageal motility is altered by sclerotherapy of esophageal varices. Stricture formation seems to be reversible after sclerotherapy is stopped or discontinued.     

Management of Variceal Hemorrhage in Children with Extrahepatic Portal Venous Obstruction-Shunt Surgery Versus Endoscopic Sclerotherapy

Extrahepatic portal venous obstruction (EHPVO) is a common cause of portal hypertention in children. Esophageal variceal hemorrhage is a major cause of morbidity and mortality in these patients. For many decades, portal systemic shunts were considered as the most effective treatment of variceal hemorrhage. Endoscopic injection sclerotherapy (EIS) was first introduced for emergency management of bleeding varices and subsequently as definitive treatment to prevent recurrent hemorrhage. The purpose of the study was to compare the safety and efficacy of shunt surgery and endoscopic sclerotherapy for patients with proven esophageal variceal bleeding due to EHPVO. The study was a prospective randomized study of 61 children with bleeding esophageal varices due to EHPVO carried out jointly by the department of General Surgery and Gastroenterology at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, between March 2001 and September 2003. Thirty patients received surgery and other 31 patients received EIS. Overall incidence of rebleeding was 22.6% in sclerotherapy group and 3.3% in shunt surgery group. Treatment failure occurred in 19.4% patients in sclerotherapy group and 6.7% in shunt surgery group. The rebleeding rate of sclerotherapy is significantly higher than that of shunt surgery. However, the therapy failure rate of sclerotherapy is not significantly different from that of shunt surgery.     

Evaluation of propranolol for prevention of recurrent bleeding from esophageal varices between sclerotherapy sessions

Forty-one patients admitted with first episode of bleeding from esophageal varices were enrolled in a trial of the efficacy of oral propranolol to prevent rebleeding during the course of endoscopic sclerotherapy until obliteration. Single-blind randomization to sclerotherapy alone or with propranolol was used. At monthly endoscopy the varices were injected with 1% Aethoxysclerol until obliteration. If bleeding recurred, additional sclerotherapy was given. There was no intergroup difference in time to eradication of varices (8.1 vs. 7.7 months). The cumulative number of bleedings from varices and from distal esophageal ulcerations was identical in the two study groups. Five patients in the control group but only one in the propranolol group died of bleeding in the study period, a difference of only borderline significance (chi 2 = 4.08, df = 1). There were no specific side effects of propranolol. Thus propranolol did not significantly reduce the frequency of rebleeding until variceal obliteration, but could have had some influence on the gravity of rebleeding.     

Prophylactic Sclerotherapy: Yes or No!

Controlled trials of endoscopic sclerotherapy for the prevention of the first variceal hemorrhage have given controversial results. We continued a previously reported study and randomly assigned 141 patients with esophageal varics and no prior gastrointestinal bleeding to either prophylactic sclerotherapy (n=70) or no treatment (n=71). Sclerotherapy was performed until complete eradication of the varices was achieved; recurrent varics were treated with repeat sclerotherapy. The groups were well balanced in terms of demographic and clinical characteristics. Patients in both groups who bled from varices received sclerotherapy whenever possible.During a median follow-up of 56 months, variceal bleeding occurred in 7% in sclerotherapy patients and 44% on control patients (p < 0.01). In the sclerotherapy group 59% died, and in the control group 51% (n.s.). In both groups, the mortality rate increased with the severity of liver function impairment. Sclerotherapy was not found to improve survival in patients, irrespective of the etiology of cirrhosis (alcoholic or nonalcoholic) or variceal size (low-grade or high-grade). We conclude that sclerotherapy is a suitable method to reduce the occurrence of the first variceal hemorrhage, but it does not appear to have an effect on survival.     

Prophylactic sclerotherapy in children with esophageal varices: long-term results of a controlled prospective randomized trial

BACKGROUND/PURPOSE: Experience using endoscopic prophylactic sclerotherapy (PS) is restricted to adult patients and has led to conflicting results. There has not been a randomized, controlled study on the use of PS in children. The purpose of this study is to evaluate prospectively the value of PS to prevent the first hemorrhage from esophageal varices in children with portal hypertension and to assess the effect of PS on survival rate. METHODS: In a controlled, prospective, computer-based randomized trial, the effectiveness of PS was analyzed in 100 consecutive children allocated to a group receiving sclerotherapy (n = 50) or to a control group (n = 50) subjected only to regular clinical and endoscopic examinations. Clinical characteristics in both groups were similar. The minimum follow-up period was at least 18 months after the cessation of the sessions of sclerotherapy. RESULTS: After a median follow-up of 4.5 years, PS eliminated the esophageal varices in 47 of 50 (94%) patients but only 38 (76%) of them do not present upper digestive hemorrhage. Before complete obliteration of the varices, upper gastrointestinal bleeding occurred in 12 patients (24%). Six children (12%) had gastric varices, 3 of 6 of whom (50%) bled. Congestive hypertensive gastropathy was observed to occur in 8 (16%) patients, 4 of 8 of which (50%) had hemorrhagic episodes. Two patients bled from undetermined cause. In the control group, only 29 (58%) children remained free from esophageal variceal bleeding and 26 (52%) from any upper gastrointestinal bleeding (P<.05). During the follow-up period, the development of gastric varices was observed in 5 (10%) patients (P>.05) and of congestive hypertensive gastropathy in only 3 (6%) patients (P<.05), but none of them bled. PS does not improve survival rate. CONCLUSIONS: In children with cirrhotic and noncirrhotic portal hypertension, PS reduces the overall incidence of bleeding from esophageal varices that were eradicated in 94% of cases. The source of bleeding has been different in each group, being predominantly from esophageal varices in the control group and from the stomach in the prophylaxis group. When applied with appropriate technique, PS is a safe procedure with a low incidence of minor complications. PS does not change the incidence of gastric varices but increases the development of congestive hypertensive gastropathy. PS increases the risk of bleeding from the naturally formed gastric varices and from congestive hypertensive gastropathy. PS does not affect survival rate.     

A prospective evaluation of injection sclerotherapy in the treatment of acute bleeding from esophageal varices.

In a 25 month study of massive upper-gastrointestinal hemorrhage, 64 patients were shown to have esophageal varices on emergency endoscopy. Twenty-four patients were actively bleeding from varices and were treated with a Sengstaken tube, and in 22 this was followed by emergency injection sclerotherapy using a rigid esophagoscope and general anesthesia. These 22 patients were followed prospectively and had 51 episodes of endoscopically proven active bleeding from esophageal varices which required Sengstaken tube control of hemorrhage during 36 separate admissions. This group included our total experience of injection sclerotherapy in acute variceal bleeding. The majority (14 of 22 patients) had alcoholic cirrhosis. Definitive control of variceal bleeding during the period of hospitalization was achieved in 33 hospital admissions (92%), usually with a single injection (27 hospital admissions: 75%). The results were satisfactory in 26 hospital admissions (72%). There were nine deaths (41% overall patient mortality rate), but no patient died primarily of variceal bleeding, and exsanguinating variceal bleeding was no longer a problem. The mortality rate per injection was 18%, and the mortality rate per hospital admission was 25%. Injection sclerotherapy is proposed as the emergency treatment of choice for patients with proven bleeding esophageal varices who do not stop bleeding on initial conservative treatment.     

A prospective randomized controlled trial of sclerotherapy vs ligation in the prophylactic treatment of high-risk esophageal varices

Background: Endoscopic ligation (EVL) and endoscopic sclerotherapy (EIS) are both effective in the treatment of bleeding esophageal varices, but the efficacy of the two techniques in the prophylaxis of first variceal bleeding has not been investigated. The aim of this study was to investigate the frequency of first variceal bleeding, the recurrence of varices, and survival after treatment with the two techniques, as compared to a nontreated control group. Methods: A total of 157 patients with liver cirrhosis and advanced esophageal varices with no previous history of upper gastrointestinal bleeding were randomly assigned to either an EIS group (n= 55), an EVL group (n= 52), or a nontreated control group (n= 50). After the eradication of esophageal varices in the EIS and in EVL groups and in all control patients, the endoscopic examination was performed at 3-month intervals. Results: There were no significant differences between EIS and EVL in the eradication rate of esophageal varices (85% in the EIS group versus 81% in the EVL group). The mean number of sessions required to obtain eradication was lower in the EVL group than in the EIS group (4.8 ± 1.8 versus 6.2 ± 2.0; p= 0.0003), but the recurrence of esophageal varices was higher in the EVL group (31% versus 11%; p= 0.01). Total mortality was significantly lower in the EIS patients than in the controls (20% versus 38%; p= 0.04). It was also lower, but not significantly, in the EVL patients than in the controls (23% versus 38%; p= 0.10). A significant decrease in variceal bleeding was observed both in sclerotherapy cases (20%) and controls (54%; p= 0.0005) and in ligation cases and controls (29%; p= 0.01). No significant difference in bleeding episodes was observed between the sclerotherapy and ligation cases (p= 0.29). No serious complications were observed either in the EIS or EVL groups. Conclusions: EIS and EVL are similarly effective in the prevention of first variceal bleeding. The choice between EIS and EVL depends on the skill of the endoscopic unit. For highly experienced surgeons facing no complications, sclerotherapy seems to be preferable; for all others, it is technically easier to perform ligation. Received: 29 June 1998/Accepted: 18 September 1998