Gastroesophageal Reflux after Endoscopic Injection Sclerotherapy

The effect of sclerotherapy of esophageal varices on the gastroesophageal reflux was studied. Gastroesophageal reflux was monitored by a 24-h pH-monitoring catheter introduced into the distal esophagus. The results of pH monitoring of 16 patients who underwent sclerotherapy were compared with those of 21 patients with untreated varices. Seven of the 16 treated patients showed high occurrence rates of gastroesophageal reflux comparable to those observed in cases with severe reflux esophagitis. In the untreated group, only one patient showed pathological reflux (there was a significant difference between treated and untreated groups; p less than 0.01). When the level of reflux was compared with factors that might influence sclerotherapy-induced gastroesophageal reflux, there was a positive correlation between the magnitude of reflux and amount of sclerosant injected paravariceally in the submucosal tissue (p less than 0.05). The results indicate that the paravariceal injection of sclerosant for the treatment of esophageal varix may cause pathological gastroesophageal reflux after sclerotherapy is completed.     

Central Nervous System Infection after Endoscopic Injection Sclerotherapy

Central nervous system (CNS) infection is a rare complication of endoscopic injection sclerotherapy (EIS) for esophageal varices. We report two patients, one of whom developed a solitary brain abscess, and the other, acute meningitis, after EIS. They presented with high fever initially, and then with changes in mental status. In the case of the solitary brain abscess, the CSF revealed evidence of infection, and CT scan disclosed a brain abscess in the left temporo-parieto-occipital region. This patient received EIS six times and developed the CNS complication 4 wk after the last EIS. There was no growth in either the CSF or the abscess cultures in this case. The other patient with acute meningitis, which developed on the second day after the second session of EIS, had a positive CSF culture of Klebsiella pneumoniae. Both of these patients died despite antibiotic treatment, and craniotomy with drainage in the patient with a brain abscess.     

Pyogenic Meningitis and Cerebral Abscesses after Endoscopic Injection Sclerotherapy

Infectious complications of endoscopic injection sclerotherapy (EIS) are rare. We report here a case in which pyogenic meningitis and multiple cerebral abscesses developed after a session of EIS. The patient was successfully treated with a combination of parenteral antibiotics and repeated bedside pus aspirations. Prophylactic antibiotics may be considered in such situations for subsequent sessions of EIS.     

Squamous Cell Carcinoma after Endoscopic Injection Sclerotherapy for Esophageal Varices

We report two cases of squamous cell carcinoma of the esophagus following endoscopic injection sclerotherapy for esophageal varices. The interval between sclerotherapy and the development of carcinoma was 24 months in case 1 and 21 months in case 2. The sclerosant was 5% sodium morrhuate in case 1 (total dose, 10 ml) and 5% ethanolamine oleate in case 2 (45.5 ml). Although no recurrent variceal bleeding occurred after sclerotherapy, we could not perform any curative surgical treatment for esophageal cancer because of the advanced stage of the cancer and the severity of the accompanying liver dysfunction. It is difficult to determine the relationship between sclerotherapy and carcinoma; however, long-term surveillance is essential to avoid overlooking a neoplasm in the esophagus after endoscopic injection sclerotherapy.     

Simple Endoscopic Injection Sclerotherapy of Oesophageal Varices

Abstract: Simple endoscopic injection sclerotherapy of oesophageal varices . O. D. Harris, J. D. Dickey and P. M. Stephenson, Aust. N.Z. J. Med., 1982, 12, pp. 131–135.
A routine upper gastrointestinal fiberoscope (Olympus GIFK) was used for endoscopic sclerotherapy of varices in 38 patients sedated with I.V. diazepam. It was effective in preventing rebleeding in 30 patients, and greatly reducing the size and number of varices in 31 of the patients. This endoscope needs no additional cuff or sheath for this therapy. It is easier to use and safer than the rigid oesophago–scope. Sodium tetradecyl sulphate is as effective as ethanolamine oleate as a sclerosant and causes no chest pain. Four patients developed a fibrotic lower oesophageal stricture. One patient developed an intramural haematoma that was followed by bacteraemia and death.     

Sequential Esophageal Motility Studies after Endoscopic Injection Sclerotherapy: A Prospective Investigation

To assess prospectively the effects of endoscopic intravariceal sclerosis (EIS) on esophageal function, we performed esophageal manometry on 13 cirrhotic patients before EIS, 24 h after the second session and 4 wk after the fourth session. EIS had no impact on lower esophageal sphincter pressure. However, a significant decrease in the amplitude of peristaltic waves was observed immediately post-EIS in the lower two-thirds of the esophagus. There was no modification of duration or velocity of progression of peristaltic waves. A four-fold increase in simultaneous contractions was observed early after EIS. These changes were reversible, as assessed by late esophageal testing after EIS. No correlations were demonstrated between esophageal motor parameters and doses of sclerosant. We conclude that sclerosant injection into the esophageal wall acutely impairs esophageal motility, but motor function is partially restored 4 wk after completion of EIS, suggesting that dysmotility is reversible.     

Complications of Endoscopic Injection Sclerotherapy: A Review

As endoscopic injection sclerotherapy becomes more widely applied to the treatment of bleeding esophageal varices, an increasing number of complications are being reported. Dysphagia, chest pain, and fever are usually transient and incosequential but may herald more serious life-threatening sequelae. Mortality commonly results from the major complications of recurrent bleeding, perforation, sepsis, and respiratory disorders. We carried out a review of sclerotherapy complications to understand their basis and to determine what measures can be taken to prevent or manage them.     

Endoscopic Injection Sclerotherapy for the Treatment of Recurrent Esophageal Varices after Esophageal Transection

Background: We examined the hemodynamic changes associated with recurrent esophageal varices after esophageal transection (ET) and evaluated the effectiveness of endoscopic injection sclerotherapy (EIS) as the treatment for these varices. Methods: Nineteen patients with recurrent esophageal varices after ET were treated by EIS. Endoscopic varicealography during injection sclerotherapy, following oral blockage of flow by a balloon, identified three patterns: (i) type 1: common type, continuous filling by the feeder vessel of the varix; (ii) type 2: retrograde‐disappearing type, confirmed hepatofugal flow; and (iii) type 3: immediate washout type, immediate washout of contrast medium. Results: Angiography revealed that the hepatofugal feeder vessel was the right gastric vein in all cases. Fourteen patients (73.7%) were classified as type 1, 4 patients (21.1%) as type 2, and 1 patient (5.3%) as type 3. Fewer treatment sessions were required in type 1 than in type 2 (P < 0.005). Recurrent varices were completely eradicated in all patients except the patient with type 3 disease. Cumulative re‐recurrence rates at 5 and 10 years were similar for types 1 and 2 (28.6 and 71.4%vs 25 and 25%, respectively). The cumulative survival rates after EIS at 5 and 10 years were also similar for types 1 and 2 (77.1 and 66.1%vs 66.7 and 66.7%). Conclusion: Endoscopic injection sclerotherapy is an effective treatment for recurrent esophageal varices after ET, except in type 3 disease. Our classification based on endoscopic varicealography during injection sclerotherapy provides knowledge of blood flow within the varices that helps to inform the treatment strategy.     

Successful Endoscopic Injection Sclerotherapy of a Bleeding Duodenal Varix

Bleeding from duodenal varices is an unusual event. We report the case of a 50-yr-old man with portal hypertension due to alcoholic cirrhosis who presented with upper gastrointestinal bleeding and encephalopathy. Emergent endoscopy revealed an actively bleeding duodenal varix. The bleeding was treated successfully with injection sclerotherapy. Only four cases of injection sclerotherapy of bleeding duodenal varices have been reported previously. We review and compare reported cases of sclerotherapy of duodenal varices and also review the other therapeutic options. Endoscopic injection sclerotherapy of bleeding duodenal varices appears to be a useful first-line therapy.     

Prospective Randomized Study on the Effect of Ranitidine against Injection Ulcer after Endoscopic Injection Sclerotherapy for Esophageal Varices

Thirty-five consecutive patients undergoing endoscopic injection sclerotherapy for esophageal varices were randomly allocated to either ranitidine-administered group (18 patients) or ranitidine-nonadministered group (17 patients), in an attempt to evaluate the efficacy of ranitidine for prevention and healing of postinjection ulcer with a prospective randomized trial. Two of seventeen patients in the nonadministered group dropped out of this trial because of development of gastric ulcer, so 18 patients in the first group were evaluated and compared with the 15 remaining patients in the second group. Sclerotherapy was performed with 5% ethanolamine oleate and 0.6% polydocanol; the mean number of injection courses and the mean amount of sclerosant were the same in both groups. Moreover, there was no significant difference between the two groups in either the occurrence rate or the size of injection ulcer 1 wk after the last session. However, the persistence rate of ulcer 1 month after last injection in the ranitidine-administered group was significantly lower than that in the ranitidine-nonadministered group (6.3% vs. 38.5%, p less than 0.05). Our study demonstrated that ranitidine administration will help to hasten healing of postinjection ulcer, although it was not effective for prevention of injection ulcer.     

Bilateral Perinephric Abscesses: A Complication of Endoscopic Injection Sclerotherapy

Ten years after right hepatic lobectomy for primary hepatocellular cancer, a 45-yr-old black woman presented with bleeding esophageal varices. After five endoscopic injection sclerotherapy procedures using sodium morrhuate, she developed fever and elevated white blood count. Reendoscopy, chest x-ray, and upper gastrointestinal contrast x-rays showed no local complication. Urine analysis was normal, but CT scans, renal sonograms, and white blood cell radionuclide scan demonstrated bilateral perinephric abscesses. Percutaneous abscess drainage grew Streptococcus pneumoniae, normally found in the nasopharyngeal flora, which was probably a result of hematogenous spread. The perinephric abscesses were successfully treated with percutaneous drainage and antibiotics. Renal infection should be considered as a possible locus of distant blood-borne infection in patients who develop fever after endoscopic injection sclerotherapy.     

Analysis of Patients with Esophageal Varices Surviving More Than Three Years after Endoscopic Injection Sclerotherapy

Of the 205 patients treated by endoscopic injection sclerotherapy in the past 8 years and 4 months, 70 patients (34.1%) have survived more than 3 years. There were more Child's class A patients (p < 0.05) and fewer Child's C patients (p < 0.01) in this group as compared to 51 patients who died within 3 years. In addition, complications due to hepatoma were significantly lower (p < 0.01) in this group. The long-term cumulative survival rates of those who had already survived over 3 years were 82% at the 5-year and 78% at the 7-year follow-up. There was no significant difference among 3 groups classified by severity of liver damage or timing of the therapy. Rebleeding was noted in 13 patients (18.3%) and the cumulative bleeding rates were 9% at the 1-year, 14% at the 3-year, 18% at the 5-year and 21% at the 7-year follow-up. In 12 of these patients hemostasis was obtained by the second sclerotherapy. There was no significant difference in the long-term prognosis between patients who experienced repeat bleeding, and those who did not. Endoscopic findings in patients with rebleeding were characteristic in that the red color sign remained pronounced despite the fact that the varices had shrunk from F₂ or larger to F₁ in 6 patients. Bleeding occurred from the gastric varices in 4 patients. One of them died due to gastric bleeding, but 3 were operated on after sclerotherapy. For improving prognosis, it is important to carefully observe the clinical course and to perform additional aggressive treatments for complete obliteration of varices.     

Survival after Endoscopic Sclerotherapy for Esophageal Varices in Cirrhotics

Objectives: Gastroesophageal bleeding from varices is the most life-threatening complication in liver cirrhosis with portal hypertension. Since its first application, endoscopic sclerotherapy seems to be the most widely applicable procedure to stop the bleeding and to prevent recurrences. The aim of this study was to ascertain the role of some factors as predictors of survival in different groups of cirrhotic patients. Methods: At the time of their first hemorrhage from esophageal varices, 184 patients with portal hypertension from cirrhosis were treated by endoscopic sclerotherapy using a combined intraparavariceal procedure and Polidocanol 1% as sclerosing agent. Results: The follow-up range was 1–106 months (mean, 28.2 months), and 84 patients were still alive (45.7%), 97 had died (52.7%), and three had withdrawn (1.6%) at the end of the period. The major cause of death was bleeding, and 35 patients died in the first 6 wk after sclerotherapy. Using Cox proportional hazard models, Child's grading was the most important prognostic factor of both short-term (first 6 wk) and medium/long-term survival (after the first 6 wk up to 5 years). Complete eradication of varices, too, was associated with both short- and long-term survival, whereas age, sex, etiology of cirrhosis, and the presence of esophageal stenosis as a side effect of sclerotherapy were not. The type of sclerotherapy (elective vs emergent) was associated with survival, but it was not independent from Child's grade, because only patients in Child C treated electively showed a better prognosis than those treated in emergency. Conclusions: We can conclude that patients with severe liver disease (Class C) have poor prognosis, and complete eradication represents an aim because it seems to be protective against the risk of dying.     

The Influence of Endoscopic Injection Sclerotherapy on Organs Surrounding the Esophagus

Abstract: Endoscopic injection sclerotherapy (EIS) is widely accepted as a means of treating esophageal varices. However, various complications of EIS have been reported. To investigate the cause of chest complications after EIS, chest CT and bronchofiberscopy (BF) were carried out in patients undergoing EIS. A contrast medium was added to the sclerosant in a 1: 4 ratio, and a chest CT examination was performed 30 minutes after the EIS procedure. BF was performed before and after EIS. CT findings were classified into four types, i. e., Type I : ring-enhanced esophageal wall, Type II : ring-enhanced paraesophageal wall, Type III : locally enhanced esophageal wall, and Type IV : beltlikeenhanced parietal pleura. The CT findings depended on the frequency of EIS rather than the total volume of sclerosant. After injection into the Paravariceal wall, the sclerosant unexpectedly moved beyond the local injection site during the first or second EIS procedures. During the third or subsequent procedures the sclerosant tended to abide locally in the esophageal wall. Before EIS, bronchial venous dilatation, present mainly in the left main bronchus, was noted and its degree was correlated with the form and location of the esophageal varices. Bronchial venous dilatation decreased in three patients after EIS. The change in venous dilatation seemed to reflect alterations in the esophageal variceal blood flow. After EIS bronchial ulceration was found in the main bronchus in 3 patients. This phenomenon was attributed to both the direct effects of the sclerosant and the physical effects of the endoscopic examination itself_: Minor complications such as pleural effusion, chest pain, and fever were not associated with either CT or BF findings. Patients undergoing EIS should be carefully monitored to facilitate the early detection and management of potential chest complications.     

Endoscopic Sclerotherapy during Pregnancy

Pregnancy in patients with portal hypertension is an uncommon occurrence. Hence, there are no clear guidelines for management of variceal bleed during pregnancy. Moreover, the outcome of variceal sclerotherapy, particularly its effect on conception, as well as its safety and efficacy when used during pregnancy, is not known. We have treated four patients of portal hypertension during pregnancy with sclerotherapy. Two of them presented to us before conception, were put on sclerotherapy for variceal bleed, and conceived while on sclerotherapy schedule. Two other patients were started on sclerotherapy during pregnancy when they presented with variceal bleed. Sclerotherapy with absolute alcohol was effective in control of variceal bleed as well as obliteration of varices in pregnant patients. There was no untoward effect on mother or fetus. The mean number of sessions and volume of alcohol required for variceal obliteration were 6.5 and 42.0 ml, respectively. Variceal sclerotherapy does not interfere with conception and successful pregnancy, and is safe as well as effective during pregnancy.     

Long-Term Risk Factors for Bleeding after First Course of Endoscopic Injection Sclerotherapy: A Univariate and Multivariate Analysis

The purpose of this study was to define the risk factors linked to the rupture of esophageal varices following endoscopic injection sclerotherapy. A total of 197 patients with esophageal varices who had been treated by endoscopic injection sclerotherapy between 1985 and 1991 were observed for post-therapeutic bleeding from esophageal varices. Among 197 patients, 96 had esophageal varices and concomitant hepatocellular carcinoma. Analysis by the multivariate Cox's proportional hazard model disclosed that incomplete eradication of esophageal varices, the presence of hepatocellular carcinoma, and Child-Pugh classes were statistically significant predictors for rupture of esophageal varices after sclerotherapy. We conclude that complete eradication of esophageal varices is essential for sustained effectiveness of endoscopic injection sclerotherapy. The presence of hepatocellular carcinoma and a lack of hepatic functional reserve, as indicated by Child's classification, are also major determinants of post-therapeutic bleeding.     

Esophageal Acid-Clearance and Motility after Endoscopic Sclerotherapy of Esophageal Varices

To investigate the possible mechanisms which may lead to esophageal strictures after endoscopic variceal sclerotherapy, we performed esophageal motility and acid-clearance studies before and after 24 sclerotherapy sessions in 10 patients. Comparing studies before and after sclerotherapy, we found: a 93% mean increase in the number of swallows required to clear a standard amount of administered acid 24 h after sclerotherapy. Acid clearance returned to baseline within 1 wk of sclerotherapy; minimal changes in esophageal motility, none of which was significant except for swallow-induced simultaneous contractions in the distal esophagus which were a prominent feature in manometric recordings within 24 h of sclerotherapy; no increase in acid reflux from the stomach. We conclude that acid clearance from the distal esophagus is markedly delayed for at least 24 h by sclerotherapy but that this defect in acid clearance is transient, lasting no more than 1 wk. The importance of this observation remains to be demonstrated, but it is consistent with the concept that acid-induced injury contributes to the formation of post-sclerotherapy strictures.