Combination Of Sclerotherapy Research Articles

THE ROLE OF LIVER TRANSPLANTATION IN THE MANAGEMENT OF PORTAL HYPERTENSION

Liver transplantation is the treatment of choice for end stage liver disease and not a treatment specifically for portal hypertension. A patient with complications of portal hypertension must be evaluated for the presence, etiology, and severity of liver disease to determine the most appropriate therapy. In a Child's Class A patient, who would not be a liver transplant candidate for two to three years, surgical shunts may be indicated. Shunt surgery, however, does not address the underlying liver disease. Liver transplantation is reserved for the patient with complications of cirrhosis (such as ascites, encephalopathy, malnutrition, intractable pruritus, and variceal hemorrhage) for whom no other form of therapy exists.

Copper bromide laser treatment of facial telangiectasia: results of patients treated over five years.

Various yellow light lasers have been used over the past decade in an attempt to eradicate facial telangiectasia. Based on their power output, spot size, and pulsing characteristics, these lasers belong to one of two categories that exist at either end of a spectrum--high power, short pulse, and large spot size, or low power, long exposure, and small spot size. The copper bromide laser clearly belongs in the latter group, but with higher available power than most other lasers in this group, it exists further along the spectrum toward the region in which the laser parameters might be considered closer to theoretical ideals for treating certain cutaneous vascular pathologies. The objective of this study was to ascertain the role and efficacy of the copper bromide laser on treatment of a variety of facial telangiectasia. A total of 570 patients with facial telangiectasia of different diameters and on different regions of the face were treated with the copper bromide laser one or more times and followed up over 5 years. More than 75% clearance was achieved in 70% patients, 50-75% clearance in 17.4% patients, and < 50% clearance in 12.6% patients. Poor results were correlated with anatomical location on the nasal alae and nasal tip and also with vessel size. Very small (< 100 microns) and very large (> 300 microns) vessels did not respond as well as vessels in the 100-300-micron diameter group. Very large vessels responded better to a combination of sclerotherapy and laser treatment. There were no reported long-term adverse effects. The copper bromide laser is a safe and effective modality for the treatment of the majority of facial telangiectasia. It is less suited to treating very small vessel lesions such as diffuse erythema, and conversely very large vessels as well as those of the nasal alae. These latter two groups respond better and more permanently to combined sclerotherapy and laser treatment.

Venous malformation of the pediatric airway

Objective: To evaluate the management of venous malformations of the pediatric airway, including diagnostic criteria and response to sclerotherapy and laser photocoagulation. Design: Case series analysis of eight patients diagnosed with venous malformations of the upper airway. Setting: Academic, tertiary care, children's hospital. Patients: Eight patients (3 female, 5 male) with congenital venous malformations of the upper airway. Intervention: Each patient underwent an individualized treatment regimen of sclerotherapy, laser photocoagulation and/or surgery. Results: The combination of sclerotherapy and laser photocoagulation appears to cause gradual regression of the malformation. Five of the eight patients will require further therapy; two patients remain tracheotomy dependent. Conclusions: Extensive venous malformations of the pediatric airway require staged therapy, with a combination of sclerotherapy and photocoagulation. Long-term follow-up is essential because of the natural history of these lesions.

Propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing endoscopic sclerotherapy. A randomized controlled trial

The purpose of this study was to investigate the possible value of continuous administration of propranolol in the prevention of recurrent upper gastrointestinal bleeding in patients with cirrhosis undergoing chronic endoscopic sclerotherapy. Among 239 patients admitted for acute variceal bleeding, 85 with cirrhosis were randomized to receive sclerotherapy either alone (40) or in combination with propranolol (45). Sclerotherapy was carried out with an intravariceal injection of 5% ethanolamine oleate through a fiberoptic endoscope. The procedure was performed every week, until the esophageal varices at the gastroesophageal junction were too small for any further injections. Varices were reinjected if they recurred. Propranolol was given orally twice a day until heart rate was reduced by 25% in the resting position. The mean follow-up period was 23.2 and 24.2 months for sclerotherapy and the sclerotherapy plus propranolol groups, respectively. During this period a significant (P = 0.001) reduction in the recurrence of esophageal varices was observed in patients treated with the combination of sclerotherapy plus propranolol compared with those treated with sclerotherapy alone. However, the time of rebleeding from any source or from esophageal varices did not differ significantly between the two groups. In the sclerotherapy group 21 patients rebled (35 bleeding episodes) compared with 14 (22 episodes) in the combination therapy group. Patients in the sclerotherapy group were more prone to bleed from gastric varices and congestive gastropathy than patients treated with the combination of sclerotherapy plus propranolol (P = 0.012). Twenty-five patients in the endoscopic sclerotherapy group developed complications attributed to sclerotherapy compared with 23 patients in the sclerotherapy plus propranolol group. Complications directly attributable to propranolol were observed in 11 patients. Three of these patients stopped taking the drug due to heart failure (1) and flapping tremor (2). Eight patients (17.8%) died in the latter group while the corresponding figure in the sclerotherapy group was nine (22.5%). It is concluded that the continuous administration of propranolol may reduce incidences of recurrent upper gastrointestinal hemorrhage from gastric sources in patients with cirrhosis undergoing chronic sclerotherapy.

12 - Prevention of Recurrent Variceal Bleeding: Non-surgical Procedures

Patients with cirrhosis, who have survived an episode of variceal bleeding, often have far-advanced liver disease and therefore, on average, a severely restricted life expectancy. Still, the prognosis for the individual patient varies greatly depending on the presence or absence of large varices and the Child classification. Centres evaluating treatment of variceal bleeding often attract different patient populations. Comparison of the outcome of the complete series of patients is usually meaningless since results reflect the composition of the patient population rather than the applied therapy. The natural history of patients with variceal bleeding should be defined by Child category, allowing more precise definition of the therapeutic aims and subsequently assessment of the results. Persistent lowering of the portal pressure by pharmacological modulation of the portal haemodynamic system is now feasible due to the availability of long-acting oral medication. Propranolol is still the leading drug and, in one centre, its use in predominantly Child A patients was associated with a marked reduction in recurrent gastrointestinal bleeding and subsequently mortality rate. These results could not be reproduced in another centre. Both the restricted indication as well as the uncertain efficacy limit the current use of propranolol, but further pharmacological developments are bound to appear. Endoscopic sclerotherapy has become the treatment of choice in the prevention of recurrent variceal haemorrhage. The proponents of paravasal injection report excellent efficacy in combination with a low incidence of side-effects, whereas mainly theoretical reasons are advanced by users of intravariceal injections. Still, variceal haemorrhage remains an important clinical problem in the period between the start of sclerotherapy and the eradication of varices. Combination of sclerotherapy with portal antihypertensive medication might become the treatment of choice until eradication of varices has been achieved; thereafter either continued medication or repeated endoscopy will maintain an avariceal state and effective prevention of recurrent variceal bleeding.