A comparison of immediate versus delayed endoscopic injection sclerosis of bleeding esophageal varices

The authors report their experience with immediate endoscopic injection sclerosis at the time of diagnosis of active bleeding esophageal varices compared to delayed sclerotherapy performed after control of variceal bleeding with vasopressin and Sengstaken-Blakemore tamponade. Twenty-eight active index bleeders and 20 active rebleeders were treated by immediate endoscopic injection sclerosis, which could technically be performed on all of the former and in 18 of the rebleeders (96%). Immediate control of active bleeding was achieved in all patients whose varices were injected (100%). Control at 48 hours was 89% for the index bleeding group and 80% for the rebleeding group. In the delayed sclerotherapy group of 19 patients, initial control (79%) and 48-hour control (64%) were significantly less. The rebleeding rate, complications, and death from exsanguination were greater in the delayed group, whereas longevity was similar in both groups. We conclude that immediate sclerotherapy effectively controls acutely bleeding esophageal varices with a lower complication rate than sclerotherapy performed after conventional medical therapy with vasopressin and Sengstaken-Blakemore tube tamponade.     

Endoscopic ligation compared with sclerotherapy for bleeding esophageal varices in children with extrahepatic portal venous obstruction

Endoscopic sclerotherapy is an effective treatment for bleeding esophageal varices, but it is associated with significant complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, has been shown to be superior to sclerotherapy in adult patients with cirrhosis. To determine the efficacy and safety of endoscopic sclerotherapy and ligation, the 2 methods were compared in a randomized control trial in 49 children with extrahepatic portal venous obstruction who had proven bleeding from esophageal varices. Twenty-four patients were treated with sclerotherapy and 25 with band ligation. No significant differences were found between the sclerotherapy and ligation groups in arresting active index bleeding (100% each) and achieving variceal eradication (91.7% vs. 96%, P =.61). Band ligation eradicated varices in fewer endoscopic sessions than did sclerotherapy (3.9 +/- 1.1 vs. 6.1 +/- 1.7, respectively, P <.0001). The rebleeding rate was significantly higher in the sclerotherapy group (25% vs. 4%, P =.049), as was the rate of major complications (25% vs. 4%, P =.049). After eradication, esophageal variceal recurrence was not significantly different in patients treated by ligation than by sclerotherapy (17.4% vs. 10%, P =.67). In conclusion, variceal band ligation in children is a safe and effective technique that achieves variceal eradication more quickly, with a lower rebleeding rate and fewer complications compared with sclerotherapy.     

Propranolol reduces the rebleeding rate during endoscopic sclerotherapy before variceal obliteration.

In patients treated with sclerotherapy, most rebleeding episodes are observed before variceal obliteration. This prospective randomized study aimed to assess if propranolol together with sclerotherapy could reduce the rebleeding rate before variceal obliteration. Seventy-five patients (59 male, 16 female; mean age, 54 +/- 15 years) with cirrhosis (from alcohol abuse in 91%) admitted with upper gastrointestinal bleeding, which was endoscopically proven to originate from ruptured esophageal varices, were included. After initial control of bleeding, the patients were randomized into the following two groups: group 1 treated with sclerotherapy alone (36 patients) and group 2 treated with sclerotherapy plus propranolol (39 patients). They were followed up to variceal obliteration. In group 2, 7 patients rebled as compared with 14 patients treated with sclerotherapy alone (P less than 0.005). When considering only rebleedings from esophageal varices, 4 patients rebled in group 2 vs. 10 in group 1 (P less than 0.10). The total number of rebleeding episodes was lower in group 2 than in group 1 whether considering all causes (8 vs. 17; P less than 0.07) or variceal rebleedings alone (4 vs. 13; P less than 0.01). Mean total blood requirement per patient was lower in group 2 than in group 1 (1.4 +/- 3.4 vs. 2.79 +/- 6.4 units of blood, respectively; P less than 0.01). Mortality was similar in both groups of patients (14% vs. 13% in groups 1 and 2, respectively, NS). It is concluded that patients treated with sclerotherapy should be given propranolol before variceal obliteration.     

Development of large spleno-adreno-renal shunt after endoscopic sclerotherapy

Endoscopic sclerotherapy is now a well-established form of treatment for bleeding esophageal varices. However, it is not known what effect obliteration of varices has on the development of natural portosystemic shunts. We have studied 15 patients bleeding from esophageal varices due to extrahepatic portal venous obstruction with splenoportovenography, before and after endoscopic obliteration of varices. A splenorenal (natural) shunt was defined when the contrast, injected into the spleen, immediately revealed the inferior vena cava. Such shunts were seen in 6 (40%) of 15 patients after the obliteration of esophageal varices and with a mean interval between the two sessions of splenoportovenography of 23.5 mo. In contrast, none of the 13 patients with bleeding due to extrahepatic portal venous obstruction developed splenorenal shunts (p less than 0.05) in the absence of treatment over a mean period of 40.8 mo. After obliteration, reappearance of esophageal varices requiring sclerotherapy was observed only in patients who did not develop shunts (p less than 0.05). In conclusion, natural splenorenal shunts were seen frequently in a group of patients with extrahepatic portal venous obstruction observed for 23.5 mo who also underwent sclerotherapy. It appears that splenorenal shunts result from sclerotherapy, and protect patients from rebleeding and recurrence of varices.     

Improved long-term survival following complete eradication of esophageal varices by sclerotherapy

BACKGROUND/AIMS: Conflicting results have been reported concerning the effect of endoscopic injection sclerotherapy upon the long-term survival of cirrhotic patients with esophageal varix. The recurrence and rebleeding of esophageal varices seems to be an important factor influencing long-term survival. We investigated the long-term survival of patients after complete eradication of esophageal varices. METHODOLOGY: Forty patients treated by endoscopic injection sclerotherapy for acute esophageal variceal bleeding were studied. The recurrence rate of varices and the long-term survival of patients in whom complete eradication of esophageal varices was obtained were compared with those of patients in whom the eradication of varices was incomplete. RESULTS: The frequency of the recurrence/deterioration rate of varices and rebleeding in the complete eradication group was significantly lower than that in the incomplete eradication group (10.7% vs. 100%, 0% vs. 58.3%, respectively, p < 0.01). Accumulated 5-year survival rate of the complete eradication group was significantly higher than that of the incomplete eradication group (68.2% vs. 43.2%, p < 0.05). CONCLUSIONS: Complete eradication of esophageal varices by endoscopic injection sclerotherapy is effective both in preventing variceal re-bleeding and in improving the survival of cirrhotic patients with esophageal varices.     

Improved survival following injection sclerotherapy for esophageal varices: final analysis of a controlled trial

Long-term follow-up (median: 37 months; range: 19 to 68) of the 116 patients (56 sclerotherapy, 60 control group) entered into a controlled trial of endoscopic variceal sclerotherapy has shown a total of 18 deaths in the sclerotherapy group, including five from variceal bleeding compared with 32 deaths in the control group (p less than 0.01), of which 25 were from variceal hemorrhage (p less than 0.001). Survival as assessed by cumulative life analysis was significantly better in those treated by sclerotherapy (p less than 0.001). Both the cumulative proportion of patients rebleeding and the total number of episodes of variceal hemorrhage were also significantly less in the sclerotherapy group (p less than 0.01). Recurrence of varices was observed in 27 of 45 patients in whom variceal obliteration was initially observed at a median of 11 months (range: 2 to 27) later, although in only 12 of these did bleeding recur and was the cause of death in one.     

Endoscopic injection sclerosis in bleeding gastric varices

Ninety-two consecutive, nonrandomized patients with bleeding varices were prospectively studied using sclerotherapy to control and prevent rebleeding. During this study, nine patients with gastric variceal bleeding were identified. A gastric variceal subset is defined and represents a 10% incidence in this series. All patients presented with indexed gastric bleeding varices that subsequently accounted for 34 bleeding sessions. The units of blood per rebleeding episode, hospital days, cost, and outcome were markedly different from the esophageal variceal groups. Initial management of indexed bleeding episodes by sclerotherapy and Sengstaken-Blakemore tubes were comparable; however, the number of rebleeding episodes was much higher. There was poor control of rebleeding with an associated higher rebleeding mortality and complications secondary to repeated sclerotherapy and Sengstaken-Blakemore tube use. In 37% of the patients, rebleeding was the direct result of gastric ulcerations at the endoscopic injection sclerotherapy site. The survival curve of this group was much lower than esophageal variceal bleeders. Endoscopic injection sclerotherapy in patients with bleeding gastric varices offers only temporary control of bleeding, and the high incidence of severe early rebleeding requires consideration of alternative methods for management or modified sclerotherapy techniques.     

Recurrence factors studied by percutaneous transhepatic portography before and after endoscopic sclerotherapy for esophageal varices

High recurrence and rebleeding rates have been reported when endoscopic sclerotherapy has been performed on patients with esophageal varices. We studied the relationship between embolization range and recurrence rate in 26 patients in whom percutaneous transhepatic portography was carried out before and after sclerotherapy. Patients were divided into complete and incomplete embolization groups. The complete embolization group consisted of 16 patients whose esophageal varices had disappeared and in whom embolization of the feeders to the varices had occurred. The incomplete embolization group consisted of 10 patients whose esophageal varices had disappeared, but no embolization had occurred. Recurrence rates within 2 yr after the treatment were compared between complete and incomplete embolization groups. The recurrence rates in the respective groups were 6.7% (1 of 15) and 70.0% (7 of 10), indicating a significant difference between the two groups (p less than 0.05) and indicating that embolization of both esophageal varices and their feeders is essential to lower the recurrence rate after sclerotherapy.     

Percutaneous transhepatic and transileocolic obliteration with absolute ethanol for the treatment of bleeding gastroesophageal varices

Embolization of bleeding gastroesophageal varices with absolute ethanol performed in the recent two years was reported. The treatment was carried out either by means of percutaneous transhepatic or transileocolic obliteration. Obliteration treatment was attempted in 42 cases, among which 20 were transhepatic and 22 transileocolic. 16 of the 20 and 17 of the 22 were effectively obliterated with a total success rate of 78.6%. Two control groups of bleeding varices, one of 45 cases treated with conventional medical methods and the other of 53 cases treated with endoscopic sclerotherapy, were studied to compare the results. The efficacy for control of active bleeding in the obliteration, conventional and sclerotherapy groups were 100%, 84.1%, and 91% respectively, while the rebleeding rate was 27.2%, 31.5% and 23.2% and mortality rate (due to rebleeding) 12.1%, 31.5% and 11.6% respectively. The control of active bleeding, the results in the three groups were more or less similar, but the rebleeding rate was much lower in the obliteration and sclerotherapy groups than in the conventional group. However, sclerotherapy requires longer time and yields more complications than obliteration is a valuable therapeutic measure in controlling variceal bleeding and preventing rebleeding.     

Terlipressin in bleeding esophageal varices: a placebo-controlled, double-blind study

The effect of terlipressin (N-alpha-triglycyl-8-lysine-vasopressin) in bleeding esophageal varices was evaluated in a prospective placebo-controlled study. Fifty bleeding episodes from esophageal varices in 34 patients were randomized. Standard therapy with transfusions, fluid and electrolyte correction, and lactulose was performed in both groups. Balloon tamponade was used in 20 bleeding episodes in the terlipressin group and in 19 bleeding episodes in the control group. In the terlipressin group, hemorrhage was controlled in all bleeding episodes (25/25) whereas in the placebo group, only 20 of 25 bleeding episodes could be stopped within 36 hr (p less than 0.05). Sclerotherapy was performed in five bleeding episodes in the terlipressin group and in seven bleeding episodes in the placebo group. Treatment failures, including patients who required sclerotherapy, occurred in five bleedings in the terlipressin group and in 12 in the control group (p less than 0.05). The hospital mortality rate was 12% (3/25) in the terlipressin group and 32% (8/25) in the control group. Patients in the terlipressin group required fewer transfusions, the balloon needed to be inflated for a shorter time and the duration of bleeding was shorter than in the control group. However, these differences were not significant. These data do not allow conclusions concerning monotherapy with terlipressin, but they indicate that the addition of terlipressin to standard therapy may increase the control rate in acute variceal hemorrhage.     

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。     

食管静脉曲张治疗后复发出血的临床分析

探讨食管静脉曲张硬化治疗后复发出血的规律及有关因素。对２６０例肝硬化食管静脉曲张硬化治疗后患者，追随观察６到７２个月，对反复出血的５５例患者进行临床分析。本组复发出血率为２１．２％，一年内复发出血占６９％，５２例再次接受硬化治疗，急诊止血率为９６．１％。追随期中，死亡８例，其中３例死于出血。存活４７例，生存期１～６年。结论：１．复发出血与肝功能、门静脉主干宽度无明显关系，而与静脉曲张消失和基本消失率低以及其他门体静脉侧支未建立有关。２．复发出血者小中量占多数。３；对复发出血的规律及如何预防复发出血作了简要讨论。     

A prospective randomized trial comparing repeated endoscopic sclerotherapy and propranolol in decompensated (Child class B and C) cirrhotic patients.

A prospective randomized study was conducted to compare the efficacy of long-term endoscopic sclerotherapy vs. propranolol in Child class B and C patients with variceal bleeds within the 30 days before the study. Forty-five and 46 patients were randomized to receive sclerotherapy and propranolol, respectively, after preentry stratification for Child scores. Sclerotherapy was administered with 1% polidocanol at 10-day intervals until obliteration of varices was achieved. Propranolol was administered to achieve a reduction in resting pulse rate of 25%. Rebleeding occurred in 19 patients undergoing sclerotherapy and in 31 receiving propranolol (p less than 0.05). The number of episodes of rebleeding was higher (p less than 0.05) in the propranolol group (n = 64) than in the sclerotherapy group (n = 35). The mean bleeding risk factor, number of hospitalizations for rebleeding and blood transfusion requirement were also significantly higher in the propranolol-treated patients. The median bleed-free period was more than 36 mo in the sclerotherapy group and 2.5 mo in the propranolol group (p less than 0.01). The median survival time was significantly longer in the sclerotherapy group (greater than 36 mo) than in the propranolol group (greater than 24 mo). We conclude that in decompensated cirrhotic patients, long-term endoscopic sclerotherapy is superior to propranolol in preventing rebleeding and improving survival.     

Endoscopic management for bleeding esophageal varices: sclerotherapy versus sclerotherapy plus band ligation versus band ligation alone. One year experience at a main hospital in Saudi Arabia.

BACKGROUND/AIMS: This study was done retrospectively to compare the outcome of sclerotherapy alone, band ligation alone and band ligation alternating with sclerotherapy in treatment of esophageal varices. METHODOLOGY: During 1 year 30 patients were admitted with variceal bleeding. They received either injection sclerotherapy (8 patients) or band ligation (11 patients), and 11 patients had a combination of both either during first bleed or during follow-up therapy, which is more than 2 sessions in each group. RESULTS: The success rate for stopping first bleeding was 100% in the band ligation and sclerotherapy alone group. The rebleeding rate was 27% in the combination group, 9% in the band ligation group, and none had rebleeding in the sclerotherapy group during follow-up. Eradication of varices was observed in 33% of patients after a second set of sclerotherapy and band ligation. CONCLUSIONS: Our study showed no significant difference between sclerotherapy versus band ligation in stopping initial bleeding or eradication of varices during the follow-up period, but there was a difference in re-bleeding rates among the three groups.     

Endoscopic injection sclerotherapy for esophageal varices in cirrhotic patients without hepatocellular carcinoma: a comparison of longterm survival between prophylactic therapy and emergency therapy

BACKGROUND: This study aimed to determine whether prophylactic endoscopic injection sclerotherapy prolonged survival in patients with esophageal varices complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy. METHODS: The subjects included 160 patients suffering from esophageal varices complicated by liver cirrhosis without hepatocellular carcinoma. Sixty-eight patients underwent emergency therapy for bleeding varices and the remaining 92 patients underwent prophylactic sclerotherapy. All subjects continued to receive therapy until the varices disappeared. RESULTS: Five-year survival was significantly better in the prophylactic group compared with the emergency group. During the 5-year observation period, 20 of the 68 patients in the emergency group experienced rebleeding and 5 patients died as a result of rebleeding. These rates were significantly higher than those in the prophylactic group (1 of 9 patients with bleeding died among the 92 prophylactic sclerotherapy patients). Multivariate analysis showed that prophylactic therapy and Child's C hepatic function were significant factors for 5-year survival. CONCLUSIONS: Prophylactic sclerotherapy for esophageal varices might be more effective in prolonging longterm survival of patients complicated by liver cirrhosis in the absence of hepatocellular carcinoma, compared with emergency sclerotherapy.     

Demonstration of two distinct subsets of gastric varices

Over a seven-year period, assessment of gastric varices was made on 225 patients receiving endoscopic sclerotherapy for variceal hemorrhage. Of 170 patients with complete data, gastric varices were observed in 26 (15.3%). Importantly, two distinct subsets of gastric varices were identified: varices distal to the gastroesophageal junction without extension into the fundus, termed "junctional varices," occurred in 11.2%, and varices that were confined only to the fundus, termed "fundal varices," occurred less frequently in 4.1%. Although rebleeding was increased in both subsets of gastric varices, junctional varices were more amenable to sclerotherapy. Patients with fundal varices (N = 7) had a significantly higher rebleeding rate, increased complications with sclerotherapy, and significantly decreased survival (P less than 0.005) when compared to patients with esophageal varices alone (N = 87) who were followed for more than three months. Cumulative survival was not significantly different (P less than 0.08) in patients with junctional varices (N = 19) when compared with patients with esophageal varices alone. We conclude that not all patients with gastric varices have a poor result with sclerotherapy. Recognition of these subsets may improve treatment strategies in patients with gastric varices.     

Variceal sclerosis in schistosomotic patients: a 5-year follow-up study

To assess the therapeutic possibilities of injection sclerosis in schistosomotic portal hypertension, a 5-year prospective study was conducted in northeast Brazil, where this parasitosis is endemic. Fifty patients undergoing endoscopy for upper gastrointestinal hemorrhage from rupture of esophageal varices from July through December 1981 were chosen for the study. The 32 consenting patients were submitted to injection sclerotherapy paravariceally, using ethanolamine oleate; the 18 refusing to participate were assigned to the control group. The incidence of rebleeding was 28.1% in the former and 44.5% in the latter, a difference which was not statistically significant (Fisher's test, p = 0.375). Mortality from rupture of esophageal varices was 3.1% in the sclerotherapy group and 27.7% in the control group, a statistically significant difference (Fischer's test, p = 0.017). Since sclerotherapy markedly improved the long-term survival rate of the patients, this procedure is advocated for the treatment of esophageal varices in cases of portal hypertension due to schistosomiasis.     

Prophylactic sclerotherapy of high-risk esophageal varices: results of a multicentric prospective controlled trial

In this prospective, multicenter trial, 140 cirrhotic patients with no previous upper gastrointestinal bleeding and with esophageal varices endoscopically judged to be at high risk of hemorrhage were randomized to receive either sclerotherapy or conservative treatment for the prevention of first variceal bleeding. The end-points of the study were bleeding and death. Life table curves showed that prophylactic sclerotherapy significantly diminished the incidence of variceal hemorrhage (p less than 0.001) and overall mortality (p less than 0.01). Two-year cumulative bleeding rate was 18% in the sclerosis group (95% confidence interval = 10 and 31) and 57% (95% confidence interval = 40 and 72) in the control group. Two-year cumulative mortality rate was 30% (95% confidence interval = 19 and 45) in the sclerotherapy group and 56% (95% confidence interval = 39 and 72) in the controls. One patient died after hemorrhage from an ulcer secondary to sclerotherapy. Analysis by the Cox model of the factors potentially confounding or interacting with the effect of sclerotherapy suggested that sclerotherapy was more efficient in preventing first bleeding in patients with decompensated disease (Child B and C) than in those in good condition (Child A). However, the 2-year cumulative bleeding rate of untreated Child A patients was only 19%, showing how in this group the endoscopic findings were unreliable in selecting high-risk varices and explaining why after a 2-year follow-up prophylactic sclerosis did not show any benefit in such patients. We conclude that sclerotherapy can decrease the incidence of first variceal bleeding and death for a period of 2 years in cirrhotic patients with high-risk varices.     

Preventive therapy of first gastrointestinal bleeding in patients with cirrhosis: results of a controlled trial comparing propranolol, endoscopic sclerotherapy and placebo

Propranolol and endoscopic sclerosis of esophageal varices are the two approaches currently used in prophylaxis of the first gastrointestinal hemorrhage in the cirrhotic patient. One hundred twenty-six cirrhotic patients with esophageal varices and no histories of bleeding were included in the trial regardless of the gravity of the cirrhosis or the size of the esophageal varices. Patients with hepatocarcinomas or other cancers, clearly impossible follow-up, previous treatment for portal hypertension or contraindication to beta-blockers were excluded. After randomization, 43 patients received propranolol twice daily at a dose reducing the heart rate by 25%; 42 patients were treated with intravariceal and extravariceal injections of Polidocanol; 41 control patients received vitamin K orally as placebo. The patients were seen at 3-mo intervals for 2 yr. On entry to the trial the three groups were comparable in terms of clinical and biological parameters, including size of esophageal varices (grade I = 51, grade II = 54, grade III = 17), Child-Pugh classification (A = 29, B = 61, C = 32) and the origin of cirrhosis (alcoholic in 79% of cases). Twenty-four patients bled (two bled in the propranolol group, nine bled in the endoscopic sclerosis of esophageal varices group and 13 bled in the placebo group). Actuarial estimates (Kaplan-Meier) of the time of onset of first bleeding showed that the differences were significant between propranolol and placebo (p less than 0.004) and between propranolol and sclerotherapy (p less than 0.03) but not between sclerotherapy and placebo.(ABSTRACT TRUNCATED AT 250 WORDS)     

Octreotide for esophageal variceal bleeding treated with endoscopic sclerotherapy: a randomized, placebo-controlled trial

BACKGROUND/AIMS: Endoscopic sclerotherapy is considered a first line therapy to stop bleeding from esophageal varices, but acute variceal bleeding is still associated with high risk of rebleeding and death. We compared the use of octreotide with endoscopic sclerotherapy versus sclerotherapy alone to control acute variceal bleeding and prevent rebleeding in patients with cirrhosis. METHODOLOGY: In a prospective controlled trial, 68 patients with cirrhosis and acute variceal bleeding who underwent emergency sclerotherapy were randomly assigned to receive a continuous infusion of octreotide or placebo for two days. The primary outcome measure was 7-day mortality. RESULTS: After seven days the overall mortality was 19.1%, and the proportion of patients who died in octreotide group (8 of 40, or 20%) was similar to the placebo group (5 of 28, or 17.85%; p = 0.74). Rebleeding occurred in 20.6% (14 of 68 patients), being 20% (8 of 40) in the octreotide group vs. 21.4% (6 of 28) in the placebo group (p = 0.88). The mean number of units of blood transfused after sclerotherapy was 2.05 units in the octreotide group vs. 2.08 units in the placebo group (p = 0.96). Thirty patients needed intensive care support (20 of 40 in the octreotide group vs. 10 of 28 in the placebo group; p = 0.24). The differences remained without statistical significance even after adjustment for hepatic function and endoscopic bleeding stigmata by a linear regression model analysis test. CONCLUSIONS: In patients with cirrhosis, octreotide intravenous per 48h associated with sclerotherapy is not superior to sclerotherapy alone in terms of 7-day mortality, frequency of rebleeding, number of units of packet red blood cell transfusion and length of stay in intensive care setting.