What is the Aim of Esophageal Variceal Sclerotherapy—Prevention of Rebleeding or Complete Obliteration of Veins?

Abstract

Endoscopic variceal sclerotherapy (EVS) is highly effective in arresting active esophageal variceal bleeding. Subsequent repeated EVS sessions significantly reduce recurrence of bleeding; long-term survival is reported as prolonged or unaltered. In contrast, EVS for preventing first variceal bleeding (prophylactic sclerotherapy) is not recommended, even for high-risk patients, because it enhances mortality by significantly increasing the risk of bleeding in the treated group compared with controls. The risk of variceal rebleeding is maximum within 6 weeks of index bleeding; most patients who survive 6 weeks of variceal bleeding (with or without sclerotherapy) behave like patients who have never bled from varices. Thus, EVS continued beyond 6 weeks, to obliterate the veins completely, is akin to prophylactic sclerotherapy. Significant complications of EVS--its cost, discomfort to patient, and loss of doctor and patient time--should be weighed against doubtful benefit of continuing prolonged EVS beyond 6 weeks, just to completely obliterate esophageal veins. The possibility of better long-term survival with sclerotherapy limited to 6 weeks cannot be excluded, because prophylactic sclerotherapy shortens long-term survival.