Endoscopic Variceal Sclerosis Research Articles

The prognosis of liver cirrhotic patients with acute esophageal variceal bleeding: a Cox regression analysis

Objective To evaluate the risk factors for prognosis in liver cirrhotic patients with acute esophageal variceal bleeding (EVB). Methods Retrospective analysis was carried out in patients with liver cirrhosis,who were admitted to the hospital for EVB between January 2000 and December 2006 . All patients were follow-up to August 31st, 2009. The death of the patients was identified as the end of the study. The vital signs and results of laboratory tests were recorded when patients were admitted to the hospital. Child-Pugh score/grade, model for end stage liver disease (MELD) score and Rockall score were calculated. Results Ninty-five cases (66 males and 29 females) were enrolled in the study. Among them, 60 cases died and 35 cases survived for (42. 61±33.21) months (ranged from 2 days to 114 months). Univariate Cox regression analysis showed that age, male, Child-Pugh score/grade, MELD score, Rockall score, white blood cell counts and active hepatitis B were risk factors for death in liver cirrhotic patients with EVB (P＜0.05), while high level of hemoglobin and high hematocrit, endoscopic variceal sclerosis therapy or surgical treatment were protective factors (P＜0.05). Multivariate Cox regression analysis revealed that Child-Pugh grade (RR= 4. 997,95%CI:2. 787～8. 960, P＜0.01),Rockall score (RR= 1. 284,95%CI:1. 062～1. 553,P=0. 010), high counts of white blood cells (RR= 1. 072,95%CI: 1. 001 ～ 1. 148, P= 0. 046) were risk factors for prognosis of liver cirrhotic patients with EVB. Conclusion It is demonstrated that Child-Pugh grade,Rockall score and high counts of white blood cells are risk factors for prognosis of liver cirrhotic patients with EVB. Key words: Esophageal and gastric varices; Liver cirrhosis; Gastrointestinal hemorrhage; Prognosis; Regression analysis

Surgical management of acute variceal hemorrhage.

The advent of more effective nonoperative therapies, mainly endoscopic variceal sclerosis, has decreased the need for emergency surgery for control of acute variceal hemorrhage. In centers where it is available, nonoperative portal decompression by transjugular intrahepatic portosystemic shunting (TIPS) is likely to have a further impact. When acute or chronic sclerotherapy fails or when bleeding is secondary to gastric varices or portal hypertensive gastropathy, emergency surgery may be life-saving and should be done promptly before worsening hepatic functional decompensation develops. Child's class C liver disease is not a contraindication to emergency surgery; many patients who fail nonoperative attempts at control of bleeding are of this risk status. The most commonly utilized emergency procedures are portacaval and interposition mesocaval shunts, both of which are effective, and esophageal transection, which is associated with a higher incidence of late rebleeding. An emergency distal splenorenal shunt is appropriate for selected patients who are not actively bleeding at the time of surgery. TIPS is the preferred alternative for acute or chronic endoscopic sclerotherapy failures who are candidates for liver transplantation within the succeeding 6 to 12 months.

Three years experience with endoscopic variceal ligation for treatment of bleeding varices.

Endoscopic variceal ligation (EVL) was developed as an alternative to endoscopic variceal sclerosis (ES) because of the high complication rate seen with ES. The new technique involves placement of small elastic bands around the variceal channels in the distal esophagus. The first 146 consecutive patients treated with EVL during the period from August, 1986 to July, 1989 are reported. Portal hypertension was caused by alcoholic liver disease in 93 of these patients. The average age of the patients was 53 years and 66% were males. All of the patients had recently bled from esophageal varices. At the time of treatment, 23% of the patients were actively bleeding. They were all treated acutely with EVL and had repeated treatments with the long-term goal of variceal eradication. The overall survival was 73%. Varices were eradicated or reduced to grade one in 78% of the 125 patients who were followed for more than 30 days. Variceal eradication required a mean of 5.5 sessions. Recurrent bleeding occurred in 44% of the total patient population. There were no major complications from EVL. It is concluded from this non-randomized experience that EVL is an effective treatment for bleeding esophageal varices and that it appears to be as effective as sclerotherapy with fewer complications.

Endoscopic Variceal Ligation for Treatment of Bleeding Varices

Endoscopic variceal ligation (EVL) was developed as an alternative to endoscopic variceal sclerosis (ES) because of the latter's high complication rate. The new technique involves placement of small elastic bands around the variceal channels in the distal esophagus. Initial open trials with EVL showed that it was safe and effective therapy for bleeding esophageal varices. EVL can be used emergently to control actively hemorrhaging varices and electively to eradicate varices with repeated sessions. When compareJ directly with results obtained with ES retrospectively and prospectively, EVL is equal or superior in preventing rebleeding while causing many fewer complications. Combining the two techniques may be even more effective than either alone at eradicating varices. Combination therapy has achieved eradication of varices in an average of three sessions, which is one to three fewer sessions than generally reported to achieve eradication with EVL or ES alone. Combination therapy has also been used to control bleeding gastric varices effectively. EVL, alone or with low dose ES, seems to be the safest and most effective endoscopic means for controlling bleeding from esophageal or gastric varices. EVL needs to be evaluated for prophylactic treatment of esophageal varices since its low morbidity profile may make it more suitable than ES for prophylactic treatment.

Endoscopic variceal sclerosis does not increase the risk of portal venous thrombosis

In this study the risk of thrombosis in the portal venous system was assessed in patients with chronic variceal bleeding undergoing sclerotherapy. Twenty-two patients with cirrhosis were prospectively studied with angiography before initiation of sclerotherapy and at mean (±SD) 26 ± 17-month (range, 8–63 months) follow-up. Sclerotherapy consisted of flexible endoscopy, intravariceal and paravariceal, using sodium morrhuate (1.5%–2%) and sodium tetradecyl sulfate (0.5%–1.5%), to obliteration. The mean number of sessions was 6.5 ± 2.2 (range, 3–11), with a mean total amount of sclerosant of 62 ± 25 mL (range, 25–112 mL). No patient developed splenic or portal vein thrombosis as shown by arteriography. The flow patterns of portal perfusion, vessel size, and coronary vein visualization showed no significant change. Only one patient had spontaneous reversal of portal flow. Splenic vein histology, examined in five patients in whom sclerotherapy failed and who required shunt surgery, was not significantly different from that in eight patients who had no prior sclerotherapy. It is concluded that under the conditions of the current study, chronic sclerotherapy did not increase the risk of thrombosis in the portal venous system and did not significantly alter the histology of the portal hypertensive splenic vein.

Selective Variceal Decompression: Current Status

Since its introduction into clinical practice in 1967, selective variceal decompression by means of a distal splenorenal shunt (DSRS) has become one of the more commonly performed portal-systemic shunting procedures in the treatment of variceal hemorrhage throughout the world. In addition to selective decompression of gastroesophageal varices, the DSRS provides the advantages of preservation of portal perfusion of the liver and maintenance of intestinal venous hypertension. Many large, uncontrolled series and the majority of controlled randomized studies have demonstrated a lower incidence of encephalopathy after the DSRS than after nonselective shunt procedures. A secondary advantage of the DSRS is that the hepatic hilum is avoided, thus making subsequent liver transplantation a less formidable procedure. None of the studies have shown an advantage to this shunt with respect to longterm survival in patients with alcoholic cirrhosis. However, some of the large, uncontrolled series have shown that survival is significantly improved in patients with non-alcoholic cirrhosis compared to nonselective shunt procedures in the same population. Controlled trials comparing the DSRS to endoscopic sclerotherapy have shown that chronic endoscopic variceal sclerosis is an appropriate initial therapy for most patients as long as shunt surgery is readily available if sclerotherapy fails.

Endoscopic Variceal Sclerosis Compared with Distal Splenorenal Shunt To Prevent Recurrent Variceal Bleeding in Cirrhosis

To define the roles of endoscopic variceal sclerosis and distal splenorenal shunt in the prevention of recurrent variceal bleeding in patients with cirrhosis. A prospective, randomized clinical trial with crossover for those failing therapy. The median follow-up was 61 months. A private, tertiary-referral university hospital. Seventy-two patients fulfilling inclusion criteria were drawn from a total of 420 patients treated during a 4.5-year interval. Endoscopic variceal sclerosis or distal splenorenal shunt. Survival was significantly (P = 0.02) improved in patients randomly assigned to receive sclerotherapy: 13 of these 37 (35%) patients failed sclerotherapy and required surgical rescue. A survival advantage (P = 0.01) was seen in patients with alcoholic cirrhosis who had this combined therapy; however, in patients with nonalcoholic cirrhosis, survival for those receiving sclerotherapy and surgical rescue was not significantly (P = 0.36) different from that of patients receiving distal splenorenal shunt. Control of variceal bleeding was significantly (P less than 0.001) better in the distal splenorenal shunt group (34 of 35 [97%] compared with 15 of 37 [41%] in the sclerotherapy group). Using death, uncontrolled rebleeding, or shunt thrombosis as the endpoints resulted in no significant difference between treatment groups. Hepatocyte function and portal perfusion were significantly better maintained in patients with alcoholic cirrhosis who were managed by sclerotherapy rather than shunt (P = 0.01 and P = 0.001, respectively). Endoscopic sclerotherapy with surgical rescue for uncontrolled bleeding is the optimum therapy for patients with alcoholic cirrhosis and variceal bleeding. Survival is similar in nonalcoholic patients treated with either distal splenorenal shunt or endoscopic sclerotherapy, but shunting provides better control of variceal bleeding.

Endoscopic sclerotherapy with portal-systemic shunt rescue

This paper reports the preliminary results of a prospective randomized trial comparing endoscopic variceal sclerosis and distal splenorenal shunt (DSRS) in the management of patients with cirrhosis and variceal bleeding. Seventy-one patients have been entered; 36 have received sclerosis and 35 DSRS. Randomization of the study population was stratified on Child's A/B (56%) and Child's C (44%). Sixty-one per cent had alcoholic and 39% nonalcoholic cirrhosis. No patients have been lost to follow-up, which currently stands at a median of 26 months. Rebleeding occurred significantly (p < 0.05) more frequently in patients in the sclerosis group (19 of 36: 53%) compared to DSRS (1 of 35: 3%), but only 11 of 36 (31%) were not controlled by further sclerosis and failed that therapy. Patients in whom sclerosis failed underwent surgery. Survival was significantly (p < 0.01) improved in the sclerosis group (+ surgery in 31%), with an 84% 2-year survival compared to a 59% 2-year survival in the DSRS group. Portal perfusion was significantly (p < 0.05) better maintained in the sclerosis (95%) compared to the DSRS (53%) group. Galactose elimination capacity improved significantly (p < 0.05) in 21 patients successfully managed by sclerosis at 1 year and was significantly (p < 0.01) better maintained in the sclerosis compared to DSRS group. The authors conclude that endoscopic sclerosis: (1) has a higher rebleeding rate than DSRS, with one third of patients failing therapy from rebleeding; (2) allows significant improvement in liver function when successful; and (3) gives significantly improved survival in the management of variceal bleeding when backed up by surgical therapy for patients with uncontrolled rebleeding. The authors report the results of a randomized comparison of emergency portacaval anastomosis (PCA) (32 patients) with endoscopic sclerotherapy (EST) (32 patients). Short-term survival was similar in the two groups, respectively (44% vs. 50%). The amount of blood transfusions required and the length of the hospital admissions were significantly less in the EST group (p < 0.001). Recurrences of variceal hemorrhage, the number of transfusions required to treat them and the duration of hospital readmissions were all greater in the EST group (p < 0.001). Almost half of the EST patients who were discharged from the hospital alive subsequently rebled and required surgical treatment. The authors conclude that EST is as effective as PCA in the acute treatment of bleeding, but that when EST fails, PCA may be effective management.

Endoscopic variceal sclerosis: a one-year experience

Our first year's experience with endoscopic variceal sclerosis (EVS) performed with a cuffed balloon fiberoptic endoscope is presented. Seventy-five patients have been treated with EVS without requiring the use of general anesthesia. All but one patient had endoscopically documented variceal hemorrhage and underwent EVS while bleeding or shortly thereafter. Ninety-two per cent of the patients were discharged from the hospital after initial treatment with the current overall survival rate being 89.3%. Complications resulting in a prolonged hospitalization were infrequent, but two deaths occurred in which EVS complications may have been a contributing factor. Based on these results, EVS is recommended for managing variceal hemorrhage and is a reasonable alternative for shunt surgery in the management of variceal bleeding.