Fatal outcome following endoscopic fundal variceal ligation

Abstract

Steigmann et al.1Stiegmann GV Goff JS Michaletz-Onody PA et al.Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding varices.N Engl J Med. 1992; 326: 1527-1532Crossref PubMed Scopus (643) Google Scholar have shown that endoscopic variceal ligation (EVL) is equivalent to endoscopic sclerotherapy (ES) in controlling active bleeding by rupture of esophageal varices and in preventing their recurrence. Moreover, patients treated with EVL had less complications and their survival rate was better than that of patients treated with ES.1Stiegmann GV Goff JS Michaletz-Onody PA et al.Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding varices.N Engl J Med. 1992; 326: 1527-1532Crossref PubMed Scopus (643) Google Scholar Short-term success with ligation of gastric varices using a detachable snare has also been proposed.2Yoshida T Hayashi N Suzumi N et al.Endoscopic ligation of gastric varices using a detachable snare.Endoscopy. 1994; 26: 502-505Crossref PubMed Scopus (65) Google Scholar We report herein a case of gastric variceal ligation with elastic O rings that illustrates the inadequacy of the method for the stomach. A 39-year-old man was admitted for hematemesis January 1, 1994. Upon admission, the patient was jaundiced, his pulse rate was 140 beats min., and he had ascites. Laboratory tests showed the following values: prothrombin time 34%; factor V 29%; hemoglobin 7.2 g/100 ml; bilirubin 210 mcM/L; ASAT 394 (N < 40 IU/L); and ALAT 55 (N < 50 IU/L). Gastroscopy revealed bright red blood that precluded correct examination of the stomach and grade II esophageal varices that were sclerosed by polidocanol. Prednisolone, 40 mg a day, was initiated once the diagnosis of alcoholic hepatitis associated with cirrhosis was established through biopsy. Two further ES sessions of esophageal varices were achieved at 1-week intervals (Jan 13 and 20). Nodular gastric varices were then demonstrated and treatment with propanolol was begun to prevent their rupture. Because predictive factors of rupture were present (nodular character, site, and degree of hepatocellular insufficiency), EVL was done. Six days after ligation, the patient rebled massively and eventually died in spite of an emergency proximal gastrectomy for hemostasis. Histologic examination of the stomach disclosed two acute 8 mm ulcerations at the level of the fundus where the ligations were done and a ruptured varice at the bottom of one of the ulcerations. Gastric varices are observed in 11% to 75% of cirrhotic patients with portal hypertension.3Merican I Burroughs AK. Gastric varices.European Journal of Gastroenterology and Hepatology. 1992; 4: 511-520Google Scholar The incidence of bleeding by rupture of gastric varices ranges from 3% to 30%.3Merican I Burroughs AK. Gastric varices.European Journal of Gastroenterology and Hepatology. 1992; 4: 511-520Google Scholar This risk is superior for varices of the fundus as compared with the cardia4Sarin SK Lahoti D Saxena SP Murthy NS Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients.Hepatology. 1992; 16: 1343-1349Crossref PubMed Scopus (829) Google Scholar and for nodular varices with red spot, located on the greater curvature.5Hashizume M Kitano S Yamaga H Koyanagi N Sugimachi K. Endoscopic classification of gastric varices.Gastrointest Endosc. 1990; 36: 276-280Abstract Full Text PDF PubMed Scopus (143) Google Scholar The necessity of preventive treatment after rupture of gastric varices is no longer questioned. The best endoscopy treatment to prevent rebleeding, however, remains unknown. Bucrylate is considered by certain authors as an efficient treatment of bleeding varices and prevention of rebleeding from fundal varices.3Merican I Burroughs AK. Gastric varices.European Journal of Gastroenterology and Hepatology. 1992; 4: 511-520Google Scholar Ligation is an attractive method of hemostasis and was proposed by Yoshida et al.2Yoshida T Hayashi N Suzumi N et al.Endoscopic ligation of gastric varices using a detachable snare.Endoscopy. 1994; 26: 502-505Crossref PubMed Scopus (65) Google Scholar who described a detachable snare to treat gastric varices. In that study, 10 patients were treated, and all had postligation gastric ulcerations, one of which rebled. As regards our patient, it is possible that ligation failed because the entire varix was not destroyed and rebled when the eschar was discarded. In any event, EVL with O rings appears to be a dangerous technique and should not be used in the treatment of gastric varices because of the high risk of rebleeding.