Intravariceal Sclerotherapy Research Articles

Secure intravariceal sclerotherapy with red dichromatic imaging decreases the recurrence rate of esophageal varices: A propensity score matching analysis.

Red dichromatic imaging (RDI) is next-generation image-enhanced endoscopy technique released in July 2020. We previously reported that RDI can predict esophageal varices (EV) depth and decrease their recurrence rate by accurate intravariceal injections during endoscopic injection sclerotherapy (EIS) using unreleased prototype RDI endoscope. In this study, we analyzed whether RDI improves the overall survival (OS) rate and whether it is more accurate independent predictor of EV recurrence than white light imaging (WLI), using propensity score matching. A total of 179 patients were enrolled. Patients were matched for age, platelet count, liver function, EV size, luminal diameter, and EV depth using propensity score matching, and 78 patients (RDI, 39; WLI, 39) were finally matched. Primary endpoints were OS and recurrence rates. Secondary endpoints were success rate of intravariceal injection, operating time, incidence of adverse events (AEs), and predictors associated with OS and recurrence rates. There was no difference in OS (P=.193), but the cumulative recurrence rate in the RDI group was significantly lower than in the WLI group (P=.002). Success rates of intrainjection, operating time, and incidence of AEs were better in the RDI group (p=0.035, .026, and .0019, respectively). Independent predictors associated with recurrence rate by Cox proportional regression were RDI function and luminal diameter (P<.001 and .017, respectively). RDI did not improve OS but decreased the recurrence rate. Independent predictors of recurrence rate were RDI and luminal diameter, resulting from secure intravariceal injections in EIS.

Role of dual red imaging to guide intravariceal sclerotherapy injection of esophageal varices (with videos)

Dual red imaging (DRI) is a novel image-enhanced endoscopy technique that can increase the visibility and predict the depth of esophageal varices (EVs). The recurrence rate of EVs after endoscopic injection sclerotherapy (EIS) reportedly decreases by intravariceal injection of a sclerosant. We evaluated prospectively whether the EIS success rate was increased by DRI compared with the white-light imaging (WLI) mode. A total of 79 patients with EVs were randomly divided into the DRI (n= 40) and WLI (n= 39) groups. The primary endpoint was the success rate of intravariceal injection on the first EIS puncture. The secondary endpoint was the recurrence rate. A variable puncture needle was used, and the length was adjusted according to the EV visibility change by DRI. In the WLI group, DRI was not used. The success rate of the first puncture was significantly higher in the DRI group than in the WLI group (80.0% vs 46.2%; P= .0018). The cumulative recurrence rate was significantly lower in the DRI group (P= .031). The sum of the depth and luminal diameter of EVs was investigated by EUS. The Pearson correlation coefficient between this value and the needle length was higher in the DRI group than in the WLI group (r= 0.878 vs 0.603). DRI increased the EIS success rate and decreased the recurrence rate. This resulted from the puncture needle adjustment to the appropriate length via EV depth prediction by DRI.

Abstract No. 277: Transportal Intravariceal Sclerotherapy with N-Butyl-2-Cyanoacrylate for Gastric Varices

Abstract No. 277: Transportal Intravariceal Sclerotherapy with N-Butyl-2-Cyanoacrylate for Gastric Varices

Endoscopic sclerotherapy in the treatment of gastric varices.

Of 309 patients with portal hypertension, gastric varices were found in 48 (16 per cent). While the majority (88 per cent) of the patients had gastric varices in association with oesophageal varices, 6 (12 per cent) patients had 'isolated' gastric varices. Gastric varices were seen significantly (P less than 0.01) more often with grade 4 than with grade 3 varices. In 11 (28 per cent) of the 40 patients who completed sclerotherapy for oesophageal varices, gastric varices disappeared concurrently on eradication of oesophageal varices or during the following 6 months. Of the initial five patients with gastric varices who received direct intravariceal injections, four rebled; this technique was therefore replaced by combination (paravariceal + intravariceal) gastric variceal sclerotherapy. Emergency combination sclerotherapy successfully controlled bleeding from gastric varices in six of the eight treated patients. Thirty-two patients entered a programme of elective combination gastric variceal sclerotherapy. Variceal obliteration was achieved in 12 cases (38 per cent) and reduction in size was noted in another 7 patients (22 per cent) after a minimum of four courses. There were 11 (23 per cent) deaths, 8 due to uncontrolled bleeding from gastric varices and 3 due to hepatic coma. The other complications of gastric variceal sclerotherapy were minor and included retrosternal pain, fever and dysphagia. It is concluded that gastric varices often coexist with large oesophageal varices. If they persist for 6 months after eradication of oesophageal varices, a combination of paravariceal and intravariceal sclerotherapy should be attempted for their obliteration.

Transportal Intravariceal Sclerotherapy with N-Butyl-2-Cyanoacrylate for Gastric Varices

Four patients with gastric varices without catheterizable draining veins through a systemic vein were treated with transportal intravariceal sclerotherapy with n-butyl-2-cyanoacrylate (NBCA). In all patients, the gastric varices were successfully obliterated with 2-5 mL of NBCA-lipiodol mixture injected via a microcatheter introduced into the varices with transhepatic or transileocolic portal venous access. No complications related to the procedure were encountered. Follow-up gastroendoscopy showed disappearance (n = 3) or marked decrease (n = 1) of the varices. Neither recurrent gastric varices nor variceal bleeding were observed during the follow-up period (6-46 months). Transportal intravariceal sclerotherapy is useful for obliteration of gastric varices in selected cases.

Esophageal motility changes after endoscopic intravariceal sclerotherapy with absolute alcohol.

Endoscopic sclerotherapy (EST) leads to structural and motility changes in the esophagus; the former are thought to be commoner after EST with absolute alcohol (AA), which is a commonly used sclerosant in India as it is cheap and effective. There are no previous studies on changes in esophageal motility after EST with AA. Accordingly, we studied patients with portal hypertension before (n = 24) and after (n = 22) variceal obliteration by EST with AA using a water perfusion esophageal manometry system. Contraction amplitude in the distal esophagus was reduced in the post-EST group compared with the pre-EST group (63.4 +/- 24.9 vs. 18.2 +/- 14.3 mmHg, p < 0.01). Duration of esophageal contraction in both the proximal and distal esophagus became prolonged in the post-EST compared with the pre-EST group (3.3 +/- 0.8 vs. 5.4 +/- 2.6 and 4.3 +/- 1.1 vs. 6.6 +/- 2.3 s, p < 0.001 for both). Lower esophageal sphincter (LES) pressure was reduced in the post-EST compared with the pre-EST group, although the difference was not significant statistically. Abnormal contraction waveforms were more frequent in the post-EST group. One patient in the post-EST group had persistent dysphagia in the absence of endoscopically documented stricture at the time of manometric study. This study shows frequent occurrence of esophageal dysmotility after EST with AA; however, esophageal dysmotility after EST was infrequently associated with motor dysphagia.

Randomized, prospective study of cyanoacrylate injection, sclerotherapy, or rubber band ligation for endoscopic hemostasis of bleeding canine gastric varices

The purpose of this randomized, nonblinded study was to compare the effectiveness, safety, and technical ease of three different endoscopic techniques for the treatment of bleeding gastric varices in a canine model. Twenty dogs with large, bleeding gastric varices underwent endoscopic hemostasis with rubber band ligation, sclerotherapy, and cyanoacrylate injection. The time and number of attempts required to achieve definitive hemostasis were evaluated for each technique, and each method was assessed for ease of use. Ulceration rates, ulcer size and depth, and stigmata of ulcer hemorrhage were assessed at 1 week. Intravariceal sclerotherapy was the fastest and easiest to perform. Rubber band ligation was intermediate in technical ease, but it caused the largest and deepest ulcers and had the highest rates of stigmata of ulcer hemorrhage and secondary bleeding. Cyanoacrylate injection was the most cumbersome endoscopic method to perform. All three treatments were effective for controlling gastric variceal bleeding. Intravariceal sclerotherapy had the most favorable results overall because of its technical ease, efficacy, and modest complication rates. (Gastrointest Endosc 1995;41:201-5.)

Propranolol versus sclerotherapy in preventing variceal rebleeding: A randomized controlled trial

Background : Sclerotherapy has been widely recommended as initial treatment for prevention of variceal rebleeding. The present study was aimed at comparing the efficacy of endoscopic Sclerotherapy and long-term administration of propranolol in the prevention of rebleeding and long-term survival in patients who had bled from varices. Methods : One hundred sixteen consecutive cirrhotic patients admitted because of variceal bleeding were randomly allocated to either continuous administration of propranolol to reduce the resting heart rate by 25% (58 patients) or weekly intravariceal sclerotherapy sessions using 5% ethanolamide oleate until varices disappeared (58 patients). Results were analyzed on an intention-to-treat basis. Results : Rebleeding occurred in 37 patients of the propranolol group and in 26 patients of the Sclerotherapy group (RR = 1.45; 95% Cl, 1.03–2.03). The actuarial probability of rebleeding was lower in the Sclerotherapy group ( P = 0.02). No differences were found in rebleeding index, hospitalization requirements, survival, and causes of death. Complications were significantly more frequent and severe in the sclerotherapy group. Conclusions : Despite the higher efficacy of sclerotherapy decreasing the probability of rebleeding when compared with propranolol, no beneficial effects were observed on other parameters also reflecting the efficacy of therapy. Moreover, complications of sclerotherapy were more frequent and severe than those of propranolol, which probably shall restrict the use of long-term elective sclerotherapy.

Evaluation of Endosonography in Sclerotherapy of Esophageal Varices

During intravariceal sclerotherapy of esophageal varices with polidocanol in 32 patients with portal hypertension due to liver cirrhosis of various etiologies, endosonographic assessment of both esophageal and gastric intramural vessels was carried out in order to evaluate the usefulness of endosonography in the follow-up of the variceal status. In all cases endosonography demonstrated esophageal and gastric varices; in contrast, only five cases of gastric varices could be demonstrated by endoscopy. Furthermore, different stages of variceal obliteration following sclerotherapy could be demonstrated by means of endosonography, and it was possible to identify incomplete obliteration in about one-third of the patients in whom inadequate sclerotherapy was suspected endoscopically. In addition, the status of gastric varices during sclerotherapy was demonstrated by means of endosonography. Only in cases of adequate sclerotherapy of esophageal varices, as assessed by both endoscopic and endosonographic criteria, were gastric varices plugged. On the basis of these findings endosonography would appear to be a useful technique for the diagnosis and follow-up of esophageal and gastric varices during intravariceal sclerotherapy.

Ulcers After Intravariceal Sclerotherapy

Esophageal variceal ulcers have been held responsible for most postsclerotherapy complaints. To investigate a possible relation between these ulcers and symptoms, we followed for 4 weeks 40 patients with portal hypertension who had received a single course of intravariceal sclerotherapy. All 40 patients were found to have mucosal variceal ulcers on the day after sclerotherapy. One or more symptoms were given by 26 (65%) patients; dysphagia by 53% (mean duration 4.6 +/- 2.2 days), retrosternal pain by 28% (mean duration 3.0 +/- 2.5 days), and fever by 15% (mean duration 2.1 +/- 0.4 days). A gastric variceal ulcer was responsible for bleeding in one (2.2%) patient. We found no correlation between the occurrence and duration of symptoms and the presence of variceal ulcers. While symptoms were transient, ulcers persisted for several days to weeks in most patients. Patients who had received a higher amount of sclerosant developed larger ulcers (greater than 1 cm) with more symptoms and healing was more delayed than in those who had received lesser amounts and developed smaller ulcers (less than 1 cm). In patients with a serum albumin level greater than 3.0 g/dl, ulcers healed more often than in those with a less than 3.0 g/dl albumin (72 versus 18%, p less than 0.05). Development of mucosal ulcers is a natural consequence of intravariceal sclerotherapy and it appears unrelated to symptoms. The chemical nature and the volume of the injected sclerosant are probably responsible for the symptoms after sclerotherapy. Further, postsclerotherapy ulcers heal spontaneously, more often in patients with good nutritional status.

Pulmonary hemodynamic changes after intravariceal sclerotherapy with absolute alcohol

To investigate whether alcohol used as variceal sclerosant has any effect on pulmonary hemodynamics, 14 patients with portal hypertension received intravariceal injections of absolute alcohol. Six additional patients were injected with equivalent volumes of saline and they served as controls. After intravariceal injection of absolute alcohol (8 ml in 12 patients and 12 ml in 2 patients), mean +/- SD pulmonary artery pressure was seen to increase significantly (p less than 0.01) at 1 and 5 min and return to basal level by 15 min. Similar changes in pulmonary arterial pressure were seen after intravariceal injection of saline; the difference in the rise in pulmonary arterial pressure between the two groups was not significant. The pulmonary capillary-wedged pressure and systemic blood pressure did not change significantly after intravariceal injection of alcohol. Absolute alcohol in the amount usually used for sclerotherapy has minimal and transient effects on pulmonary hemodynamics and, in this respect, it appears to be a relatively safe sclerosant.

Prospective controlled trial of elective endoscopic sclerotherapy in comparison with percutaneous transhepatic obliteration of esophageal varices in patients with nonalcoholic cirrhosis

The results of a prospective randomized controlled trial of elective endoscopic intravariceal sclerotherapy carried out over a 36-mo period in comparison with elective percutaneous transhepatic obliteration of varices (PTO, are presented. Sixty-six patients with nonalcoholic cirrhosis were randomized after they had stabilized, usually between 7 and 14 days after variceal bleeding had stopped following medical treatment (balloon tamponade and vasopressin infusion). Thirty-three patients were assigned to the sclerotherapy group and the other 33 patients were assigned to the PTO group. The mean follow-up period was similar in both groups. There was no significant difference in demographic, clinical, and laboratory data between the two groups. Six patients (18%) in the sclerotherapy group and 21 (64%) in the PTO group had at least one episode of gastrointestinal bleeding during the follow-up period (p < 0.005). Three patients in the sclerotherapy group and 1 patient in the PTO group bled from lesions other than varices; therefore the incidence of variceal bleeding was 9% in the former and 61% in the latter (p < 0.005). The cumulative variceal bleeding rate was significantly lower in the sclerotherapy group than the PTO group (p < 0.05). Five patients in the sclerotherapy group died during the follow-up period but none died of recurrent variceal bleeding. Nineteen patients in the PTO group died and 10 of them died of bleeding from varices. The cumulative survival rate was significantly better in the sclerotherapy group (p < 0.05). These results indicate that elective endoscopic intravariceal sclerotherapy is superior to elective PTO in the prevention of recurrent variceal hemorrhage and mortality in nonalcoholic cirrhosis.

Usefulness of manometric assessment of varices in maintenance sclerotherapy: A controlled trial

In a prospective controlled study, 68 patients undergoing maintenance sclerotherapy were randomized to have intravariceal sclerotherapy based on either manometric assessment (n = 35) or visual assessment (controls, n = 33) of varix patency. For manometric assessment, a perfused variceal needle punctured each variceal column and, if low pressures fluctuating with respiration were obtained, the varix was injected. Control patients had patent varices injected based on visual assessment alone. During a mean follow-up of 13 mo (range 4–16 mo), 1 manometrically assessed patient bled once (0.002 bleeds/patient month) and 7 visually assessed patients bled 14 times from varices (0.03 bleeds/patient-month) (p < 0.05). Two and nine episodes of ulceration occurred in manometric and visually assessed patients, respectively, (p < 0.05). Varices were obliterated (i.e., disappeared) in 11 patients undergoing manometric assessment and in 2 patients undergoing visual assessment (p < 0.01). Comparing results of visual and manometric assessment within “manometric” patients showed a consistent 25% error rate in diagnosing patency or thrombosis by visual assessment. Manometric assessment of varices during maintenance sclerotherapy reduces rebleeding and ulceration to very low levels.

Sclerotherapy continues to undergo evaluation

Findings from the first prospective, controlled study of chronic esophageal sclerotherapy from the United States have become available. Jacob Korula, MD, assistant professor of medicine at the University of Southern California (USC) School of Medicine, Los Angeles, reported at the recent meeting of the American Association for the Study of Liver Diseases in Chicago that sclerotherapy appears to decrease bleeding risk and transfusion requirements, and to prolong the bleeding-free interval, but it doesn't appear to increase survival. According to Korula, only one other prospective, fully controlled study of intravariceal sclerotherapy has emerged from the field. That one was done in England ( Lancet 1982;1:124-127). In this country, the treatment has been studied intensely only for the last four to five years. At the time of the meeting, Korula and co-workers at USC's liver unit, Rancho Los Amigos Hospital, Downey, Calif, had treated 120 patients who had portal hypertension: 63 were randomized