Endoscopic Variceal Sclerotherapy Research Articles

Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations.

Executive Summary: Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations.

Endoscopic submucosal dissection with red dichromatic imaging for esophageal squamous cell carcinoma after endoscopic variceal sclerotherapy.

Endoscopic submucosal dissection with red dichromatic imaging for esophageal squamous cell carcinoma after endoscopic variceal sclerotherapy.

CYANOACRYLATE GLUE FOR GASTROESOPHAGEAL VARICES: A SINGLE CENTRE EXPERIENCE FROM NORTH INDIA.

In natural history of cirrhosis, variceal bleeding is one of the earliest decompensations to happen, and, if adequately managed, survival is improved. Gastric varices have challenges in management due to their location, size and propensity to bleed. The N-butyl 2-cyanoacrylate (NBC) glue application has emerged as definitive therapy in bleeding gastric varices. Here we present our experience with use of NBC in management of gastric and difficult cases of esophageal varices. A total of 75 patients underwent NBC glue application for varices which included 69 patients with gastric varices and six patients with esophageal varices. All the procedures were done with flexible endoscope and sclerotherapy needle after due precautionary measures. Hemostasis was varices in all patients after endotherapy. The average quantity of glue used was 2.75±0.95 mL. Complete obliteration with single session of NBC application was achieved in 55 patients. Re-bleeding occurred in five patients within 5 days of index event. 20 patients had in-hospital mortality but none was related to gastrointestinal bleeding. 6-week all-cause mortality was 26 (35%). Glue therapy with NBC is a life saving therapy in patients with bleeding gastric varices and esophageal varices not amenable to endoscopic variceal ligation or sclerotherapy.

EARLY PREDICTION OF ESOPHAGEAL VARICES ON THE BASIS OF ASPARTATE AMINO-TRANSFERASE (AST) TO PLATELET RATIO INDEX (APRI) AND TRANSIENT ELASTOGRAPHY IN PATIENTS OF CIRRHOSIS OF LIVER

Objectives: To study the etiological prole in liver cirrhosis patients & to predict development of esophageal varices at the earliest with the help of Aspartate Amino-Transferase (AST) to Platelet ratio index (APRI) and Transient Elastography in these patients. The study wasMethods: conducted on 100 patients with chronic liver disease from June 2019 to June 2021. Informed consent was taken from the patients and detailed history, physical examination, laboratory investigations were carried out & UGI endoscopies were performed. APRI scores & Transient Elastography (broscan) liver stiffness measurement (LSM) values were then correlated with 'presence or absence' of esophageal varices (EVs) and with the 'grading' of varices. Among the 100 patients with liver cirrhosis, the overall prevalence of liver cirrhosis was higher in malesResults: (67.0%) than females (33.0%). The main cause of liver cirrhosis was alcoholic liver disease (39.0%) followed by chronic hepatitis B infection (15.0%). Different APRI cut-offs of 1.9, 1.4, 0.9 were taken & correlated with 'presence or absence' of EVs & with the 'grading' of EVs, but none shows satisfactory negative predictive value (NPV), proving that there is no satisfactory cut-off value of APRI to be used as a predictor of esophageal varices. However, as the APRI score is increasing, the grading of varices found on UGI endoscopy is increasing (r = 0.605, p<0.001). LSM cut-off values of 24KPa, 19KPa & 14KPa were taken & we observed NPV of 75.0% for predicting esophageal varices at LSM cutoff of 14 KPa. Also, as the LSM score is increasing, the grading of varices found on UGI endoscopy is increasing (r = 0.842, p<0.001). APRIConclusion: scores correlate poorly with the 'presence or absence' of esophageal varices but it correlate signicantly with the 'grading' of varices. Transient elastogram liver stiffness values correlate signicantly with the 'presence or absence' of esophageal varices & also with the 'grading' of varices. Liver stiffness value of ≥14.0 KPa can be used as a guide for early prediction of esophageal varices & endoscopy should be done in these patients to prevent fatal GI bleed from esophageal varices by medical management to decrease portal pressure or by early endotherapy in the form of endoscopic variceal ligation (EVL) or sclerotherapy.

Therapeutic effect of endoscopic variceal ligation plus sclerotherapy for esophageal varices with liver cirrhosis: a randomized controlled trial

Objective To investigate the safety and efficacy of endoscopic varices ligation (EVL) plus endoscopic varices sclerotherapy (EVS) for esophageal varices hemorrhage in patients with liver cirrhosis. Methods Fifty-two liver cirrhosis patients with esophageal varices bleeding were randomly divided into EVL group (n=24) and EVLS group (n=28) according to random numbers generated by computer after first EVL. The EVL group continued undergoing EVL, and the EVLS group was treated by EVS. The interval of treatment was 2 weeks till varices disappeared. All patients were followed up for 18 months with endoscopy and endoscopic ultrasonography (EUS). The efficacy, changes of esophageal varices and perforating veins, varices recurrence and rebleeding were observed. Results There was no significant difference of complete cure rate between EVLS group and EVL group[67.9% (19/28) VS 62.5% (15/24), P>0.05]. The mean session of treatment (2.68±1.0 VS 1.83±0.7, P 0.05], and the varices recurrence rate was higher in EVL group than that in EVLS group[77.3% (17/22) VS 44.0% (11/25), P<0.05]. Child-Pugh class B patients in EVL group had a higher varices recurrence rate compared to that in EVLS group[75.0% (9/12) VS 31.5% (5/16), P<0.05]. Endoscopic recurrences occurred in patients with non-occlusive perforating veins. Conclusion EVL plus EVS sequential procedure is safe and effective for treatment of esophageal varices hemorrhage, especially for Child-Pugh class B patients. Perforating veins may play a key role in the development of esophageal varices and recurrence after endoscopic therapy. EUS findings can direct the endoscopic therapy and predict the variceal recurrence. Key words: Esophageal varices; Endoscopic rubber banding for esophageal varices; Sclerotherapy for esophageal varices; Endoscopic ultrasonography

Portal hypertension in children

Abstract Portal hypertension (PH) is an important complication of chronic liver disease. It can also be caused by a wide range of extrahepatic pathologies in children, and is often clinically silent. Acute variceal haemorrhage (VH) is the most serious consequence of portal hypertension associated with significant morbidity and mortality. Management of PH in children consists of medical, endoscopic and surgical approaches which are mainly focused on acute treatment as well as reducing the risk of variceal haemorrhage. Current treatment strategies for children with PH are mostly based on extrapolation of data from adult studies and expert opinion and consensus. A structured protocol, consisting of surveillance endoscopy with primary and secondary prophylactic therapy by endoscopic variceal ligation or sclerotherapy, is increasingly becoming the standard of care. This article discusses the causes and current treatment options for PH in childhood.

Therapeutic options for bleeding oesophageal varices: cyanoacrylate and balloon-occluded retrograde obliteration (BRTO)

A 56-year-old male with cirrhosis presented with acute bleeding from cardiofundal gastroesophageal varices (GOV) and was treated with endoscopic cyanoacrylate glue. Glue therapy achieved stabilisation of the patient in the...

Sevoflurane may be more beneficial than propofol in patients receiving endoscopic variceal ligation and endoscopic variceal sclerotherapy: A randomized, double-blind study.

The aim of the present study was to evaluate the safety and efficacy of various general anesthesia regimens during endoscopic variceal ligation (EVL) and endoscopic variceal sclerotherapy (EVS). A total of 123 patients with American Society of Anesthesiologists physical status III and IV, aged 40-70 years, undergoing general anesthesia for EVL and EVS were randomly divided into two groups: Sevoflurane anesthesia (group S; n=60) and propofol anesthesia (group P; n=60). Vital signs, particularly heart rate (HR) and mean arterial pressure (MAP), were monitored. The designated time points were as follows: 5 min before induction (T0), and 1, 5, 10, 15, 20, 25 and 30 min after intubation (T1, T2, T3, T4, T5, T6 and T7, respectively). Time intervals were recorded, including recovery time and extubation time. Following surgery, the observer recorded the Ramsay sedation scale (RSS) score and the visual analogue scale (VAS) score. Adverse reactions were noted. Results demonstrated that there were significant differences in MAP between the two groups at T2, T3, T5, T6 and T7 (P<0.05). There was a significant difference in HR between the two groups at T2, T3 and T4 (P<0.05). Recovery time and extubation time in group P were significantly longer than those in group S (P<0.05; 18.38±2.25 min vs. 14.57±1.04 min and 21.70±2.70 min vs. 15.83±0.88 min, respectively). The rate of ephedrine injected was 58.3% (35/60 patients) in group P vs. 28.3% (17/60 patients) in group S (P<0.05). There was a significant difference in the RSS score between the two groups 5 min after extubation (P<0.05). VRS scores demonstrated that anesthetists and patients were significantly more satisfied with the procedure in group S than in group P (P<0.01). In conclusion, the superiority and special clinical value of inhalational anesthesia has been demonstrated during EVL and EVS attributed to stable hemodynamics and high quality of anesthesia recovery in the present study.

Reasons and risk factors for irregular-interval endoscopic variceal sclerotherapy in patients with esophageal variceal bleeding.

Endoscopic variceal sclerotherapy (EVS) is usually carried out at weekly intervals in patients with esophageal variceal bleeding (EVB). However, some patients receive sclerotherapy at irregular intervals. In this study we aimed to elucidate the reasons and risk factors for irregular-interval sclerotherapy in patients with EVB, and to evaluate the safety and efficacy of interrupted irregular intervals in these patients. Medical records of patients who were admitted to the Chinese PLA General Hospital from December 2013 to June 2015 for EVS were retrospectively analyzed. EVS sessions were scheduled to be repeated at regular weekly intervals. However, some of these patients received at least one treatment session at irregular intervals (mainly <7 days). This irregular-interval group was further divided into those whose treatment was rescheduled for emergency and elective reasons. Irregular treatment intervals were mainly caused by early rebleeding, initial emergency treatment, and holidays. However, there were no differences in the rates of complication and variceal eradication between patients treated at weekly and irregular intervals. Multivariate logistic regression analysis identified ascites (P = 0.0009), variceal erosion (P = 0.0003), and maximum injected volume of sclerosing agent per session (P = 0.0008) to be associated with emergency irregular-interval treatment. Only age differed between the elective irregular-treatment and weekly treatment groups. Early rebleeding, initial emergency treatment, and treatment over holidays may necessitate irregular sclerotherapy intervals in patients with EVB. Moreover, ascites, variceal erosion, and maximum injected volume of sclerosing agent per session are risk factors for emergency sclerotherapy, whereas elective adjustments to treatment schedules as a result of holidays do not affect the outcomes of patients undergoing EVS for EVB.

Different Factors Correlated to Early Rebleeding in Cirrhotic Patients Treated by Variceal Band ligation versus Endoscopic Sclerotherapy

Background and study aim : Endoscopic treatment has become the principal first-line intervention in patients with bleeding oesophegeal varices, both during the acute event and for long-term therapy to prevent recurrent bleeding. Several clinical considerations affect the prognosis in individual patients including the severity portal hypertension, the location of the bleeding varices, residual hepatic function, the presence of associated systemic disease, and others. Early rebleeding has been shown to be a strong predictor of mortality and recurrent variceal bleeding substantially increases the risk of complications which further contribute to mortality. This study aimed to evaluate early rebleeding after different methods of endoscopic intervention and investigate the different parameters of the patient that can be correlated to it. Patients and methods: Hundred and four cirrhotic patients with first attack of variceal bleeding were included in this study. They were randomly allocated to two groups, group I: 52 patients who were managed by endoscopic variceal sclerotherapy and group II: 52 patients who were managed by endoscopic variceal band ligation to control their attack. The patients were followed up for six weeks and all their clinical, laboratory, endoscopic parameters were monitored. The rate of mortality and early rebleeding was measured and correlated to these different patients' parameters Results: There was no significant difference between the two groups as regards rate of early rebleeding (15.4% in group I vs 9.6% in group II P= 0.374). The rate of early rebleeding was significantly correlated to Child's score (r=+0.136 P=0.014), PT (r=+0.35 P<0.001), INR(r=+0.419 P<0.001), grade of OV (r=+0.233 P=0.001), risky signs (r=+0.179 P=0.001), units of blood received (r=+0.387 P<0.001), amount of ethanolamine oleate (r=+0.329 P=0.017) and number of rubber bands used (r= +0.245 P=0.039). Mortality rates showed also no significant difference during the six weeks of follow up ,(19.2% in group I vs 21% in group II P= 0.647), as well as mortality rates in rebleeding cases (37.5% in group I vs 40% in group II P=0.925). Conclusion: The factors that are strongly correlated to rate of early rebleeding after endoscopic management of OV are severely decompensated liver disease, larger OV size and presence of risky signs, use of more blood units during resuscitation, use of large amount of ethanolamine oleate during sclerotherapy and use of more rubber band during banding. Sclerotherapy and band ligation are comparable to each other in most outcomes especially early rebleeding and mortality.

Primary prophylaxis of variceal bleeding in children and the role of MesoRex Bypass: Summary of the Baveno VI Pediatric Satellite Symposium.

Approaches to the management of portal hypertension and variceal hemorrhage in pediatrics remain controversial, in large part because they are not well informed by rigorous clinical studies. Fundamental biological and clinical differences preclude automatic application of approaches used for adults to children. On April 11-12, 2015, experts in the field convened at the first Baveno Pediatric Satellite Meeting to discuss and explore current available evidence regarding indications for MesoRex bypass (MRB) in extrahepatic portal vein obstruction and the role of primary prophylaxis of variceal hemorrhage in children. Consensus was reached regarding MRB. The vast majority of children with extrahepatic portal vein obstruction will experience complications that can be prevented by successful MRB surgery. Therefore, children with extrahepatic portal vein obstruction should be offered MRB for primary and secondary prophylaxis of variceal bleeding and other complications, if appropriate surgical expertise is available, if preoperative and intraoperative evaluation demonstrates favorable anatomy, and if appropriate multidisciplinary care is available for postoperative evaluation and management of shunt thrombosis or stenosis. In contrast, consensus was not achieved regarding primary prophylaxis of varices. Although variceal hemorrhage is a concerning complication of portal hypertension in children, the first bleed appears to be only rarely fatal and the associated morbidity has not been well characterized. There are few pediatric data to indicate the efficacy and safety of pharmacologic or endoscopic therapies as primary prophylaxis or that prevention of a sentinel variceal bleed will ultimately improve survival; therefore, no recommendation for primary prophylaxis with endoscopic variceal ligation, sclerotherapy, or nonspecific beta-blockade in children was proposed.

Low risk of bacteremia after endoscopic variceal therapy for esophageal varices: a systematic review and meta-analysis.

Background and study aims: Endoscopic variceal ligation (EVL) and endoscopic variceal sclerotherapy (EVS) are the main therapeutic procedures for the emergency treatment and secondary prophylaxis of esophageal varices in cirrhotics. Post-endoscopic bacteremia has been reported after EVS and EVL, but data on the frequency of bacteremia are conflicting. This study aims to provide incidences of bacteremia after EVS and EVL in different settings through meta-analysis. Methods: Only prospective or randomized studies were included in this meta-analysis. Binomial distribution was used to compute variance for each study. Random effects models were used as the final model for estimating the effect size and 95 % confidence interval. Adjusted effects were obtained using meta-regression analysis. Results: Nineteen prospective studies involving 1001 procedures in 587 patients were included in the meta-analysis on the risk of bacteremia after EVS or EVL in cirrhotics with esophageal varices. The frequency of bacteremia after endoscopic variceal therapy was 13 %. The frequency of bacteremia after EVS (17 %) was higher than after EVL (6 %) with no statistically significant difference (P = 0.106). The frequency of bacteremia after elective EVS (14 %) was significantly less than after emergency EVS (22 %) (P < 0.001). The frequency of bacteremia after elective EVL (7.6 %) was not significantly different from after emergency EVL (3.2 %) (P = 0.850). Conclusions: The incidence of bacteremia is low in patients with cirrhosis and varices after esophageal variceal therapy. These results are consistent with our current guidelines that antibiotic prophylaxis before endoscopic variceal therapy is only necessary for bleeding patients.

Gastroesophageal varices (bleeding) and splenomegaly: the initial manifestations of some pancreatic body and tail carcinoma.

Gastroesophageal varices (bleeding) and splenomegaly: the initial manifestations of some pancreatic body and tail carcinoma.

The Effect of Rabeprazole on Injection Sclerotherapy Complications after First Attack Bleeding Esophageal Varices

Background and study aim : Endoscopic variceal sclerotherapy (EVS) effectively controls bleeding esophageal varices (OV), however it has some adverse effects including sclerosant ulcers, chest pain, dysphagia and odynophagia. Gastric acid plays a central role in mediating and aggravating these complications. Proton pump inhibitors (PPI) are the most potent pharmacologic agents for inhibition of gastric acid secretion. Therefore, these agents are the logical candidates to combat the effects that gastric acid plays in post EVS complications. However, some authors still believe that there is no strong evidence to support their use. This study was designed to evaluate the effects of the use of PPI (rabeprazole) for 8 weeks after endoscopic sclerotherapy for first attack variceal bleeding on the prevention and treatment of complications after EVS. Moreover, we aim to assess the presence of any adverse effects for the use of this drug for this period in this specific patients group. Patients and methods: One hundred patients with first attack variceal bleeding were included in the study. They were allocated randomly into a test group which received 20mg rabeprazole once daily oral dose following endoscopic sclerotherapy starting 6 hours after injection sclerotherapy and continued for 2 months and a control group which did not receive rabeprazole after sclerotherapy. For both groups, endoscopic, laboratory and clinical data were monitored every two weeks for a period 2 months. Results: The test group had significantly lower frequency of all post sclerotherapy adverse symptoms, (dysphagia, odynophagia, heart burn, retrosternal and epigastric pain as well as dyspepsia) as well as lower overall rate of re-bleeding (14% vs 46% in the control group). There were no significant differences in the hematological parameters or endoscopic findings between test and control groups. Moreover, the use of the drug for two months was not associated with any significant infectious or non infectious complications including fever, hepatic encephalopathy, SBP, diarrhea and chest infection. Conclusion: Rabeprazole use decreases post-sclerotherapy symptoms and decrease the rate of rebleeding after sclerotherapy without any increasing the complications related to acid supression.

MELD-Na

There is no study verifying the predictive value of model for end-stage liver disease and sodium (MELD-Na) for rebleeding and its associated mortality in cirrhotic patients after cessation of acute esophageal variceal hemorrhage (AVH) by endoscopic therapy. This study aimed to determine the predictive value of MELD-Na by comparing with MELD or Child-Turcotte-Pugh (CTP) scores. Consecutive adult cirrhotic patients after cessation of AVH by endoscopic therapy (endoscopic variceal ligation or sclerotherapy injections) within 48 hours of admission admitted from 2003 to 2012 were analyzed. The clinical characteristics and laboratory data at admission were documented, based on which MELD-Na, MELD, and CTP scores were calculated. Among 429 patients who had complete control of AVH, 97 patients (22.6%) suffered esophageal variceal rebleeding within 3 months and 206 patients (48.0%) within 1 year. Fifty-three patients (12.4%) died within 3 months and 98 patients (22.8%) within 1 year from rebleeding. The area under receiver operator characteristics curve of the MELD-Na score for predicting rebleeding and its associated mortality was significantly higher than that of the MELD and the CTP score (rebleeding: 0.83 vs. 0.77 vs. 0.69 for 3 months and 0.85 vs. 0.80 vs. 0.65 for 1 year, P<0.05; mortality: 0.81 vs. 0.75 vs. 0.66 for 3 months and 0.82 vs. 0.78 vs. 0.68 for 1 year, P<0.05). The MELD-Na score is clinically useful in predicting 3-month and 1-year rebleeding and its associated mortality in cirrhotic patients after cessation of AVH by endoscopic therapy.

EVS vs TIPS shunt for gastric variceal bleeding in patients with cirrhosis: A meta-analysis.

To evaluate the clinical effects of transjugular intrahepatic portosystemic shunt (TIPS) vs endoscopic variceal sclerotherapy (EVS) in the management of gastric variceal (GV) bleeding in terms of variceal rebleeding, hepatic encephalopathy (HE), and survival by meta-analysis. Medline, Embase, and CNKI were searched. Studies compared TIPS with EVS in treating GV bleeding were identified and included according to our predefined inclusion criteria. Data were extracted independently by two of our authors. Studies with prospective randomized design were considered to be of high quality. Hazard ratios (HRs) or odd ratios (ORs) were calculated using a fixed-effects model when there was no inter-trial heterogeneity. Oppositely, a random-effects model was employed. Three studies with 220 patients who had at least one episode of GV bleeding were included in the present meta-analysis. The proportions of patients with viral cirrhosis and alcoholic cirrhosis were 39% (range 0%-78%) and 36% (range 12% to 41%), respectively. The pooled incidence of variceal rebleeding in the TIPS group was significantly lower than that in the EVS group (HR = 0.3, 0.35, 95%CI: 0.17-0.71, P = 0.004). However, the risk of the development of any degree of HE was significantly increased in the TIPS group (OR = 15.97, 95%CI: 3.61-70.68). The pooled HR of survival was 1.26 (95%CI: 0.76-2.09, P = 0.36). No inter-trial heterogeneity was observed among these analyses. The improved effect of TIPS in the prevention of GV rebleeding is associated with an increased risk of HE. There is no survival difference between the TIPS and EVS groups. Further studies are needed to evaluate the survival benefit of TIPS in cirrhotic patients with GV bleeding.

Evaluation of Portal Hypertensive Enteropathy by Scoring with Capsule Endoscopy: Is Transient Elastography of Clinical Impact?

There is limited data about the mucosal lesions of portal hypertensive enteropathy (PHE) detected by capsule endoscopy, and there is no scoring system to evaluate their severity. Our aim is to create a reliable scoring system for PHE, and to explore the possible usefulness of using transient elastograhy (TE) in that field. We compared the medical records of 31 patients with liver cirrhosis and portal hypertension with 29 control patients. We found that the mucosal lesions compatible with PHE were significantly more common in cirrhotic patients than in control patients (67.7% vs 6.9%, p<0.001). Cirrhotic patients with high TE score (p = 0.018), high Child-Pugh grade, large esophageal varices (EV), portal hypertensive gastropathy, and history of endoscopic variceal injection sclerotherapy or ligation (EIS/EVL) were significantly associated with PHE. Using our scoring system, we found that patients with higher TE score (p = 0.004), high Child-Pugh score (p = 0.011), larger EV (p = 0.006), and prior EIS/EVL (p = 0.006) were significantly associated with higher PHE score. We concluded that using our scoring system might be helpful in grading PHE severity, and TE might be a new non-invasive method for detecting the presence and severity of PHE in cirrhotic patients.

Intramural esophageal hematoma after elective injection sclerotherapy

Although endoscopic esophageal variceal sclerotherapy has been largely supplanted by variceal band ligation, it is still performed routinely in many institutions, especially in developing countries. Intramural esophageal hematoma has been described as a rare complication of sclerotherapy. Risk factors have not been completely established. To demonstrate the incidence of post-sclerotherapy intramural esophageal hematoma in our hospital and discuss the possible factors involved. This is a retrospective observational study made at the 'Hospital Universitário Clementino Fraga Filho', Rio de Janeiro, RJ, Brazil, reviewing the medical records of all esophageal variceal sclerotherapy procedures performed from April 2000 to November 2005. The evaluation of the clinical, laboratorial and endoscopic features in our patients and those reported in the literature was also done. Review of literature was performed through MEDLINE search. A total of 1,433 esophageal variceal sclerotherapy procedures were performed in 397 patients, with an intramural esophageal hematoma incidence of 4 cases (0.28%). Three of our patients developed additional complications, and one death was a direct consequence of a rupture of the hematoma. Nineteen well described cases were reported in the literature. Intramural esophageal hematoma occurred mostly after the forth esophageal variceal sclerotherapy session. Coagulation disturbances were present in the majority of cases. Intramural esophageal hematoma is a rare complication of esophageal variceal sclerotherapy and its incidence in our institution was similar to those observed in the literature. Our study suggests that this complication occurs as a result of a fragile esophageal mucosa after previous esophageal variceal sclerotherapy sessions. Impaired coagulation, although not essential, could contribute to hematoma formation and extension through esophageal submucosa.

Extrahepatic portal venous obstruction: Is the knife irrelevant?

A study on long term outcomes following variceal eradication in patients with extrahepatic portal venous obstruction (EHPVO) was clearly needed. In this issue of the Journal, Thomas et al. present the results of long-term follow up of a cohort of patients treated with endoscopic variceal sclerotherapy (EST). Of the 223 patients treated between 1985 and 1994, they had follow up data available for 198 patients. On a retrospective analysis of these data, 34 (17.2%) patients had rebleeding after initial variceal eradication, 39 (19.7%) had reappearance of esophageal varices and 19 (9.5%) had de novo appearance of fundal varices. The mean duration from the time of eradication of varices to rebleeding was 5.4 (range 1 to 16) years. Based on these results, the authors suggest that endoscopic variceal eradication is an effective treatment modality for bleeding esophageal varices in patients with EHPVO. This study, though retrospective, is quite thorough. 1 It clarifies several questions, while throwing up some new ones. First, the authors base their premise on a cohort of patients in whom they had achieved successful initial hemostasis and long term variceal eradication. A large majority (87%) of their patients presented with active variceal bleeding. However, we remain unsure of the outcome in patients in whom initial EST failed to achieve hemostasis. In 10%–15% of patients, endoscopic treatment may not achieve initial control of bleeding. 2,3 This subset of patients is important since their exclusion may mislead us into believing that EST is successful in all patients with variceal bleeding due to EHPVO. Secondly, 12 patients were lost to follow up from the initial cohort of 223 patients; did these patients die or undergo some other form of treatment elsewhere? No doubt the long term results are important, but without these initial data, establishing the overall efficacy of EST in this group of patients would be incomplete. In the broader clinical perspective, the treatment options available for patients with EHPVO must include surgery. Evidence in the Western literature indicates that if shunt surgery has a role in treatment of portal hypertension, it is in patients with non-cirrhotic portal hypertension, and especially those with EHPVO. 4,5 From India too, excellent long term results of proximal lieno-renal shunt (PLRS) have been reported in such patients. Of 160 children who underwent PLRS with splenectomy at our institution, the overall mortality was 1.9% (elective: 1/140 [0.7%]; emergency 2/20 [10%]), rebleeding rate was 11% and actuarial survival at 15 years by life-table analysis was 95%. 6,7 None of these patients developed encephalopathy. The procedure cured hypersplenism in all the patients who had this. Only one patient developed meningococcal meningitis, which recovered following treatment. Similarly, a study from Chandigarh that included 104 patients with non-cirrhotic portal hypertension who had undergone side-to-side lieno-renal shunt showed a shunt patency rate of 87%, a rebleeding rate of 10%, and no occurrence of encephalopathy after a mean follow up of 54 months. 8 Thus, surgery is a one-time treatment procedure with durable, long term efficacy in preventing variceal rebleeding. Long term studies (15–40 years) from the West have repeatedly shown that shunt surgery with or without splenectomy (proximal lieno-renal, side-to-side splenorenal, distal splenorenal or mesocaval) for EHPVO in children and adults, is associated with shunt patency rates between 90% and 95%, rebleeding rates of 5%–10%, no encephalopathy and 15-year actual survival rates of 95%. 5,9–11 These studies have found portosystemic shunts to be consistently effective for bleeding esophagogastric varices due to EHPVO.

Cyanoacrylate glue injection for acutely bleeding oesophageal varices: Is it ready for prime time?

Gastroesophageal varices are present in approximately 50% of patients with cirrhosis and bleeding from these is the most common lethal complication of cirrhosis [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. Cirrhotic patients without varices can develop them at a rate of 8% per year, and the ones with small varices can develop large varices at a similar rate [ 2 Groszmann R.J. Garcia-Tsao G. Bosch J. et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005; 353: 2254-2261 Crossref PubMed Scopus (712) Google Scholar , 3 Merli M. Nicolini G. Angeloni S. et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol. 2003; 38: 266-272 Abstract Full Text Full Text PDF PubMed Scopus (377) Google Scholar ]. Among these, variceal hemorrhage occurs at a yearly rate of 5–15%, with most important risk factors for bleeding being the size of varices, decompensated cirrhosis (Child B/C) and the endoscopic presence of red wale marks [ 1 Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar , 4 The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988; 319: 983-989 Crossref PubMed Scopus (1060) Google Scholar ]. The current guidelines by the American Association for the Study of Liver Diseases (AASLD) recommend combination of pharmacological therapy (somatostatin or its analogues octreotide and vapreotide; terlipressin) and endoscopic therapy (endoscopic variceal ligation or sclerotherapy) to control active variceal bleeding [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. These recommendations, based on the results of two randomized trials, demonstrate the superiority of combined therapy versus endoscopic variceal ligation alone. Although these advances in the management of bleeding oesophageal varices over the last two decades have led to significant reduction in mortality, mortality rates are still at least 20% at 6 weeks [ [5] Bendtsen F. Krag A. Møller S. Treatment of acute variceal bleeding. Dig Liver Dis. 2008; 40: 328-336 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar ]. The major cause of this mortality is the initial failure to control bleeding or the early rebleeding within the first week of admission [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. Most of these high risk patients are the ones with very high (>20 mmHg) hepatic venous pressure gradient. If no treatment is administered, late rebleeding occurs in approximately 60% of untreated patients, mostly within 1–2 years of the index haemorrhage [ [1] Garcia-Tsao G. Sanyal A.J. Grace N.D. Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007; 46: 922-938 Crossref PubMed Scopus (1333) Google Scholar ]. Hence, can we perform a better therapy which is easy to use, has less rebleeding rates and more importantly decreases mortality compared to the current recommended management?