Injection sclerotherapy in the emergency and elective treatment of oesophageal varices.

Injection sclerotherapy with careful attention to initial diagnosis and technique is an effective way of stopping oesophageal variceal bleeding. It can also be used electively at 3-monthly intervals to obliterate varices after they have once bled. It is relatively safe and simple, but patients must be follwed up and reassessed at least every 6 months, when new varices may be injected if they occur. It is particularly suitable when the experience and facilities for emergency portacaval shunts are not available.     

Perivenous sclerotherapy of oesophageal varices

Sclerotherapy of oesophageal varices is aimed to arrest bleeding from oesophageal varices. One hundred and seven endoscopic sclerotherapy procedures were performed on forty four patients over a period of twenty nine months. A solution of 1% aethoxysclerol, 25% dextrose or botropase diluted in 25% dextrose were used. Perivenous injection is preferred to intravenous injection. Control of bleeding was achieved in thirty five of the thirty-nine patients who had bleeding oesophageal varices. In these thirty-five patients bleeding did not recur during the period of follow-up varying from two to twenty-nine months. Five patients with oesophageal varices underwent sclerotherapy as a prophylactic measure. The procedure has low mortality and morbidity. It is recommended as the procedure of choice for an acute bleeding episode.     

Early and late complications of endoscopic oesophageal varices sclerotherapy

We report the complications of perendoscopic sclerotherapy observed during treatment of oesophageal varices in 104 patients and 409 sclerotherapy sessions. Complications were related to each individual session and to the aim of the treatment (therapeutic or prophylactic). Major complications occurred in 17.3% of the patients treated: 13 cases of severe bleeding and 5 of oesophageal stricture. Conservative therapy stopped haemorrhage in all but 4 patients, who died of uncontrolled bleeding (3.8%). Three oesophageal strictures recovered spontaneously, while the remaining two required endoscopic dilations. Minor complications occurred after 102/409 sessions (24.9%). Epigastric and/or retrosternal pain developed after 17.6% of the sessions, oesophageal ulcerations after 12.5%, fever after 11.7% and transient dysphagia after 3.7%. Bleeding was observed only in Child's category C patients who underwent therapeutic treatment. The risk of bleeding remained unchanged until complete eradication of varices was achieved. The incidence of minor complications did not correlate with the progression or the aim of the treatment.     

Combined sclerotherapy and operation for the treatment of bleeding oesophageal varices.

OBJECTIVE--To identify prognostic factors in a consecutive series of patients with bleeding oesophageal varices and develop an optimum regimen of treatment. DESIGN--Retrospective review. SETTING--I Department of Surgery, University Hospital, Vienna, Austria. PATIENTS--301 consecutive patients with bleeding oesophageal varices. OUTCOME MEASURES--Median survival and survival at one year after sclerotherapy alone (n = 213), or sclerotherapy with portosystemic shunt (n = 54), Hassab's devascularisation (n = 29), or liver transplantation (n = 5). RESULTS--Prognosis was dependent on the severity of liver damage at the start of treatment. Median survival for Child's class A was 47 months, for Child's class B 54 months, and for Child's class C 2 months. The overall one year survival for patients in Child's class C was 33%, for sclerotherapy alone 28%, and for sclerotherapy and portosystemic shunt 42%, Hassab's devascularisation 50%, and liver transplantation 80%. CONCLUSION--Despite the small number of patients who underwent liver transplantation and their poor initial prognosis (Child's class C, n = 4; class B, n = 1) our results suggest that liver transplantation should be considered for the treatment of patients with end stage cirrhosis and bleeding varices.     

Devascularization following endoscopic sclerotherapy of oesophageal varices: dangers and difficulties

Twenty-three patients underwent devascularization operations for acute variceal bleeding. All had received endoscopic sclerotherapy, either long-term or just before surgery. The oesophagus and peri-oesophageal tissues showed either oedematous or fibrotic reaction depending on the number and duration of sessions of sclerotherapy. These changes in the oesophagus and surrounding tissues were responsible for intraoperative oesophageal perforation and postoperative anastomotic leaks. To obviate these problems, stapling of the anterior and posterior walls of the stomach was tried and found to be safer than stapled transection of the oesophagus. During follow-up, varices reappeared in over 75 per cent of patients and were managed by further sclerotherapy. Patients who did not receive sclerotherapy had a higher incidence of rebleeding.     

Eradication of oesophageal varices recurring after portal non-decompressive surgery by injection sclerotherapy

The results of injection sclerotherapy for oesophageal varices which recurred after portal non-decompressive surgery were analysed retrospectively to evaluate its efficacy. We treated 60 consecutive patients with portal hypertension; 19 were treated on an emergency basis, seven electively and 34 on a prophylactic basis. All acute bleeding was controlled with one session of sclerotherapy using a transparent overtube. After eradication by sclerotherapy, no bleeding episodes occurred and there was no recurrence of the varices, except in three uncompliant patients, during a mean follow-up period of 33.1 months. Bleeding from a gastric ulcer and gastritis occurred in one patient each. Oesophageal stenosis occurred in nine (15 per cent) patients and gastric varices developed in two (3 per cent) patients. Twelve patients died, five from liver failure and six with hepatoma, but there was no bleeding from the gastrointestinal tract. The overall 4-year survival rate was 80 per cent. We recommend the use of sclerotherapy as the primary treatment for recurrent oesophageal varices.     

Bleeding oesophageal varices.

At the Royal Prince Alfred Hospital, most patients with bleeding varices have been poor-risk alcoholics. A high proportion were receiving a State pension. The early mortality due to bleeding varices was 53%. This figure comprised a 60% mortality following conservative management and 40% after urgent shunt. All patients having urgent operations which were not portal decompression died. No patient who had an elective shunt died. In a mean follow-up period of 15.4 months, a further 14% of survivors died. No form of conservative management appeared to have much effect on the natural history of the bleeding. A blood replacement of more than five litres indicated that spontaneous cessation of haemorrhage was unlikely. Shunt operations usually controlled haemorrhage, but hepatorenal failure was common after the urgent shunts. The cost of operation was greater than that of conservative management, but in neither case was it considered excessive.     

The use of sclerotherapy for the management of oesophageal varices in portal hypertension

Summary Although sclerotherapy is currently the most widely used treatment for the management of both acute variceal bleeding and the long-term management of patients with varices, its definitive role in the treatment of these patients has yet to be finally proven. Sclerotherapy appears to be the most effective treatment for the majority of patients with acute variceal bleeding. Failures require either a shunt or a transection and/or devascularisation procedure. Current evidence favours simple staple gun transection or a shunt (either a portacaval shunt or a side-to-side narrow diameter polytetrafluoroethylene graft between the portal vein and vena cava). In long-term management of patients after a variceal bleed the currently favoured treatment is repeated sclerotherapy. However, failures should be identified early. We define failures as patients who present with varices that are either difficult to eradicate by sclerotherapy or who have repeated life-threatening variceal bleeds during the course of repeated injection sclerotherapy. Such patients should have either a portal-to-systemic shunt or a transection and devascularisation operation. Further controlled trials are required to define the specific indications for the individual forms of therapy. Prophylactic treatment for varices that have not yet bled is unjustified at present. Based on a presentation to the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Assessment of injection sclerotherapy in the management of 152 children with oesophageal varices

A total of 152 consecutive children with oesophageal varices have been endoscopically reviewed since 1979. In all, 108 of these children presented with variceal bleeding which was managed by injection sclerotherapy. Variceal obliteration was achieved in 33 (92 per cent) children with extrahepatic portal hypertension and 54 (75 per cent) with intrahepatic portal hypertension. Prophylactic injection sclerotherapy was used to obliterate large varices in 11 children with no history of haemorrhage. Bleeding episodes occurred in 38 (39 per cent) children before variceal obliteration was complete. However, the mortality rate from variceal bleeding was only 1 per cent. Complications were oesophageal ulceration (29 per cent) and stricture (16 per cent) which both resolved with conservative management. During a mean follow-up period of 2.9 years after sclerotherapy, recurrent oesophageal or gastric varices developed in 12 (12 per cent) cases, with rebleeding in 9 (9 per cent), but all responded successfully to a second course of treatment. These results are superior to contemporary surgical management and injection sclerotherapy should therefore currently be the primary treatment of choice for bleeding oesophageal varices in children.     

Injection sclerotherapy of oesophageal varices with the free-hand technique: experience in Hong Kong

A prospective study of the efficacy of injection sclerotherapy with the free-hand technique for acute bleeding oesophageal varices was conducted, to evaluate its use in the control of acute variceal bleeding and to assess long-term sclerotherapy as the definitive treatment. Between July 1981 and January 1985, a total of 108 patients (96 men, 12 women with mean age of 54.4 years) had intravariceal injection of 5 per cent ethanolamine oleate. The majority had non-alcoholic cirrhosis and alcoholism accounted for only 18.5 per cent. There were 22 Child's A, 42 Child's B and 44 Child's C patients. During the 411 sessions of injection, major complications occurred in 12 patients (11.1 per cent) with 3 deaths. Of the 145 episodes of acute variceal bleeding 91.7 per cent were successfully controlled. In episodes which required more than one injection to control the bleeding, there was a high mortality of 75 per cent. Over the three and a half year period, 33 out of the 93 patients on long-term sclerotherapy had re-bled (35.5 per cent). Varices were obliterated in 27 patients with a mean of 5.4 injections. From our experience, the procedure is safe and effective. However, its status as a definitive treatment when compared with conventional surgical treatment requires further controlled evaluation.     

Injection sclerotherapy for esophageal varices.

Thirty-five consecutive patients with bleeding esophageal varices were treated by repeated endoscopic injection sclerotherapy. During each session the varices were injected with 14 +/- 4.2 ml (mean +/- SD) of 5% ethanolamine oleate submucosally or intravariceally. The varices were obliterated in 31 (89%) patients. On average 3.3 +/- 2.4 sclerotherapy sessions were required for eradication of the varices. Mild fever was noticed almost in every patient after sclerotherapy. Mediastinitis was a complication in one (2.8%) patient. Esophageal stricture ensued in two (5.7%) patients which did not require treatment. The cumulative survival rates at 1, 2, 3, 4 and 5 years were 83%; 65%; 52%; 52% and 47% respectively. The corresponding 95% confidence intervals were (0.7, 0.96); (0.48, 0.8); (0.34, 0.7); (0.3, 0.74) and (0.22, 0.7). Sclerotherapy is an effective and safe method to treat bleeding esophageal varices.     

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.     

Mechanism of the haemostatic effect of ethanolamine oleate in the injection sclerotherapy for oesophageal varices

Changes in coagulation and fibrinolysis were investigated in 20 patients with oesophageal varices, who underwent endoscopic injection sclerotherapy (EIS) with 5 per cent ethanolamine oleate (EO), by means of serial determination of plasma fibrinopeptide A (FPA) and fibrinopeptide B beta 15-42 (B beta 15-42). One hour after the completion of EIS, the value of FPA was significantly increased to 38.1 +/- 11.1 ng/ml (mean +/- s.e.m.) from a pre-EIS value of 7.1 +/- 1.4 ng/ml (P less than 0.01) and it gradually returned to normal range by 48 h after EIS. A very similar change was observed in the value of B beta 15-42 (P less than 0.01). These observations indicated that EIS provokes transient activation of coagulation and fibrinolysis. In vitro studies, however, revealed that EO inhibits fibrin clot formation because of the Ca2+-chelating ability of its constituent ethanolamine, although oleate or benzyl alcohol exhibited procoagulant activity in FPA formation in vitro. Nevertheless, an external application of EO or oleate over decapsulized kidney of rat resulted in a significant accumulation of 125I-labelled fibrin(ogen). From these results it was suggested that intravascular injection of EO, which exerts an inhibitory effect on coagulation in vitro, activates the local coagulation system. The activation may be accelerated by an acute inflammatory process provoked by oleate, which is supported by such clinical manifestations as mild fever, retrosternal pain leukocytosis and an increase in plasma fibrinogen level which was observed in all during the period.     

Chylothorax as a complication of oesophageal sclerotherapy.

Chylothorax is an unusual complication of sclerotherapy for oesophageal varices. A patient is described in whom a massive chylous effusion followed sclerotherapy with repeated injections of 1.5% sodium tetradecyl sulphate. The thoracic duct traverses the posterior mediastinum in close proximity to the oesophagus, and may be disrupted by injections at mid oesophageal level.     

Endoscopic sclerotherapy of esophageal varices

Magnetic tape recordings of endoscopic images relating to pathologies with it is extremely important to follow morphological changes after treatment offer unquestionable advantages especially in the field of sclerosing endoscopic therapy for esophageal varices. This study--which was carried out using a 3/4 inch U-Matic videotape lasting 10 minutes--confirm the above statement. The criteria of selection for sclerosing techniques are illustrated according to the authors' personal evaluations made on the basis of experience accumulated during more than 10 years' activity; the results of modulated treatment are compared as both emergency and elective treatment, used as the single therapy or following deconnection or portosystemic derivation operations. The choices are confirmed by the number of successful outcomes, with only minimal and almost always easily controlled complications. This has led to the method's inclusion in clinical practice as yet another means of controlling hemorrhages due to portal hypertension, in addition to permitting a marked increase in the percentage of success following deconnecting and derivative operations performed in patients in better conditions of clinical compensation.     

Excision of oesophageal varices

Treatment of bleeding oesophageal varices by total excision of the stomach and oesophagus up to the aortic arch is suggested when a shunt is impossible or contra-indicated. The technique is described and six cases are presented.     

Endoscopic sclerotherapy v. conservative management of bleeding oesophageal varices. A 5-year prospective controlled trial of emergency and long-term treatment

A comparative trial was made of conservative therapy (balloon tamponade and/or vasopression infusion) alone (control group) or with addition of acute and serial endoscopic injection sclerotherapy (ST group). The 107 unselected patients, mainly with alcoholic cirrhosis, were randomly allocated to these groups, which were comparable as regards Child's grading and clinical and laboratory findings. For emergency ST a fibreoptic endoscope and Williams sheath were used. In initial control of index bleed and hospital mortality the two groups did not differ significantly. The median follow-up was 15 and 28 months (minimum 1 year). Supplementary ST (mainly out-patient) gave variceal eradication in 34 of 41 patients, with most failures in persistent alcoholics. A calculated risk factor for rebleeds was 3.6 times higher in the controls than in the ST group. Mortality rate showed no intergroup difference. The cause of death mainly was variceal bleeding in the controls, but not in the ST group. Major complications of treatment occurred in c. 15% of all patients.