Modern management of oesophageal varices

Haemorrhage from oesophageal varices is a life threatening emergency with a mortality rate in the order of 30%-50%. In the last three decades there have been many advances in the treatment and prevention of variceal bleeding. Over recent years the introduction of new pharmaceutical agents that reduce portal pressure, endoscopic variceal ligation, transjugular intrahepatic portosystemic shunt, and the availability of liver transplantation have further increased the therapeutic options available to the physician treating this disorder. This article reviews the literature regarding therapies available in the treatment of haemorrhage from oesophageal varices and provides guidelines to aid the physicians in clinical decision making.     

Bleeding oesophageal varices associated with anabolic steroid use in an athlete

A 30 year old bodybuilder who had been taking anabolic steroids for 18 months presented with bleeding oesophageal varices. Serious liver disease secondary to anabolic steroids including peliosis hepatis, nodular hyperplasia and malignant change is well recognized. We report what is, to our knowledge, the first case of bleeding oesophageal varices associated with the use of anabolic steroids.     

Endoscopic sclerotherapy of bleeding oesophageal varices in Jamaica

The results of oesophageal sclerotherapy (OS) in 18 patients with recurrent bleeding varices are compared with 15 patients treated medically. The total transfusion requirement pre-sclerotherapy was 112 units of blood (mean 6/patient) which decreased to 46 units (mean 2.5) after sclerotherapy treatment was started (p = 0.005). In the medically treated group, total transfusion was 74 units (mean 5 units/patient). One hundred and forty-three injection sclerotherapy sessions were given, and all but one patient had significant reduction or eradication of varices. Three patients died of recurrent bleeding (17%) and one other required surgery. In the medically treated group, 3 patients died of bleeding (20%). Complications of sclerotherapy included mild bleeding (39%), chest pain (28%) and oesophageal ulcer (5.5%). OS reduces transfusion requirements in patients with recurrent variceal bleeding.     

Banding of oesophageal varices using locally improvised materials

Bleeding from oesophageal varices is the commonest cause of significant upper gastrointestinal bleeding in Sri Lanka. Endoscopic band ligation is an effective method in the management of varices. But the cost of banding equipment is high, unaffordable for a majority of our patients. We have devised a cheap method to carry out banding of varices. Banding of varices using this technique was carried out in 235 patients. In the patients who were followed up, there was a reduction in the size of varices across all grades of varices. No complications due to banding were noted, and only 10 patients developed re-bleeding. Since the initial experience on efficacy and safety of this technique is encouraging, we believe that its widespread adoption in Sri Lanka would be cost effective and life-saving.     

Arterial vasoconstrictor therapy for bleeding oesophageal varices.

Upper gastrointestinal bleeding in patients with hepatic cirrhosis carries considerable mortality. Difficulties are encountered both in determining the source of bleeding and in controlling blood loss. The techniques of selective visceral angiography not only supply diagnostic information, but can be used to administer selective intra-arterial vasoconstrictor therapy to control blood loss. We report our experience with 28 patients in whom angiography was performed with particular reference to six patients treated with selective vasoconstrictor therapy. Although the precise role of the technique is not yet established, early experience is most promising. We believe it will play an important role in a difficult group of patients in the future and may well supplant present methods of controlling bleeding.     

Acute respiratory insufficiency after endoscopy for bleeding oesophageal varices

Two patients with alcoholic liver disease and gross ascites underwent endoscopic injection and compression by Sengstaken tube of oesophageal varices under general anaesthesia. Postoperatively both patients developed acute respiratory failure, which resolved after air had been aspirated from the stomach via the Sengstaken tube. All air should be aspirated at the end of the procedure in patients with ascites who undergo endoscopy, and respiration should be carefully supervised postoperatively.     

Management of bleeding oesophageal varices: an eight-year prospective study

Ninety-one patients (56 men) were admitted with bleeding oesophageal varices on 132 occasions from 1972 to 1980 to the haematemesis and melaena unit of Prince Henry's Hospital, Melbourne. For 73 patients, alcoholic liver disease was the cause of portal hypertension. The management protocol for varices included early endoscopy, medical-surgical liaison, balloon tamponade for continued bleeding and strict criteria for surgery. The endoscopic diagnosis rate was 92%. There were 24 deaths (26%) during the initial admission to hospital and a further 12 patients (13%) died within one year. The mean transfusion requirement was 9.7 units per admission. Balloon tamponade was necessary on 103 occasions and failed to control bleeding on six of them. The results suggest that mortality from bleeding oesophageal varices can be reduced by a protocol which includes early endoscopy, intensive care, balloon tamponade, close medical-surgical liaison and portacaval shunt for recurrent bleeding in "good' risk patients.     

Bleeding oesophageal varices and hepatic dysfunction in adult polycystic kidney disease

A patient with adult polycystic liver and kidney disease presented with haematemesis and melaena and was found to have raised serum creatinine, aspartate transaminase, and alkaline phosphatase values; hypoalbuminaemia; and a prolonged prothrombin ratio. She also had oesophageal varices. With haemodialysis her aspartate transaminase activity fell to normal but she remained hypoalbuminaemic with a prolonged prothrombin ratio. She died after three weeks. Although hepatic cysts do occur in adult polycystic kidney disease, they have been thought not to cause major liver disease. The hepatic cysts in this patient, however, did appear to be associated with portal hypertension and impaired hepatocellular function.     

Successful outcome of gestation in a young woman with severe oesophageal varices throughout the pregnancy

During normal pregnancy there is an increase in the maternal blood volume leading to portal hypertension with some changes in liver functions. However, in an apparently healthy woman without known liver cirrhosis or other advanced liver disease, severe oesophageal varices with along with repeated variceal bleeding during pregnancy is rare. In this paper we described a case of severe oesophageal variceal bleeding in a young woman without having any pre-existing liver pathology. Due to repeated pregnancy with short intervel bleeding the patient developed severe anaemia. Packed cell transfusion was done repeatedly and oesophageal variceal ligation (EVL) was done three times. In spite of these measures variceal bleeding continued and patient's condition was deteriorating progressively; so caesarean section was at 33rd week of gestation and a preterm but healthy baby was delivered. The puerperium was uneventful with no haematemesis and there was gradual improvement of the condition. A brief review of the literature on pregnancy with oesophageal varices is also presented.     

非侵入性检查预测食道静脉曲张的临床研究

目的：探讨一个较理想的非侵入性检查预测肝硬化食道静脉曲张的方法。方法：将181例肝硬化住院病人的胃镜检查结果，分为食道静脉曲张（oesophageal varices，OV）组和无食道静脉曲张（non-oesophageal，varices，NOV）组，通过B超测脾脏、抽肘静脉血查血小板计数等进行分析。结果：血小板计数（PC）脾厚度（ST）的分界值为〈1888时，95％正确性（Confidence index）为0．939，是一个理想的非侵入性检查预测肝硬化食道静脉曲张存在最佳的指标。结论：应用血小板计数（PC）脾厚度（ST）比值来预测食道静脉曲张的方法，具有操作技术简便，患者依从性、顺从性好，易于推广。     

评价在乡村初级医疗机构中注意缺陷多动症的诊治情况：美国儿科学会指导方针落实的可行性

目的：美国儿科学会（AAP）颁布关于注意缺陷多动症（ADHD）的指导方针，并为儿科医师能够有效地学习并应用该指导方针而设计一项病案记录。本研究目的即为调查在乡村儿科医疗的ADHD评价中，该病案记录的执行情况。方法：对来自两所初级儿科机构的医疗工作人员（医师、护士等）进行关于应用ADHD-评价病案记录的培训。分别收集应用病案记录前1～2年中101例患者的医疗记录以及随后2～3年中的86例患者的医疗记录，从而评价AAP指导方针的依从性。另外，对34％的医护人员填写的表格进行重审，对其正确性进行评分。结果：在AAP方针和评价性病案记录推广之前，没有任何一所初级医疗机构坚持收集ADHD评价所必需的综合性资料。