Sclerotherapy Of Esophageal Varices Research Articles

Embolic and septic complications after sclerotherapy of fundic varices with cyanoacrylate

The use of endoscopic injection sclerotherapy to control acute hemorrhage from gastric varices is well established. 1 Sarin SK Govil A Jain AK Guptan RC Issar SK Jain M et al. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. J Hepatol. 1997; 26: 826-832 Abstract Full Text PDF PubMed Scopus (213) Google Scholar Satisfactory hemostasis can be achieved through the intravariceal and paravariceal injection of various agents, including the tissue adhesive N-butyl cyanoacrylate, ethanolamine oleate, polidocanol, ethanol, sodium tetradecyl sulfate, and sodium morrhuate. 2 Jutabha R Jensen DM See J Machicado G Hirabayashi K Randomized, controlled study of various agents for endoscopic injection sclerotherapy of bleeding canine gastric varices. Gastrointest Endosc. 1995; 41: 206-211 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar , 3 Sarin SK Kumar A Sclerosants for variceal sclerotherapy: a critical appraisal. Am J Gastroenterol. 1990; 85: 641-649 PubMed Google Scholar However, use of these agents may lead to several adverse effects. Minor complications, such as fever and pain due to the inflammatory response, usually resolve spontaneously within a few hours and may be ignored. However, the persistence of these signs can be a consequence of a serious complication, such as local necrosis, possibly leading to mediastinitis or peritonitis. 4 Connors AF Complications of endoscopic variceal sclerotherapy. Chest. 1991; 100: 2-3 Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Other major complications of endoscopic injection sclerosis of gastric varices include ulceration and recurrent bleeding. This is a case of additional life-threatening embolic and septic complications that occurred after endoscopic injection therapy for bleeding gastric varices.

Evaluation of Endoscopic Injection Sclerotherapy for Esophageal Varices in Patients Classified as Group A or B by the Child-Pugh's Criteria

Evaluation of Endoscopic Injection Sclerotherapy for Esophageal Varices in Patients Classified as Group A or B by the Child-Pugh's Criteria

Esophagopleural fistula after endoscopic sclerotherapy in a child

Endoscopic sclerotherapy (EST) for variceal hemorrhage is a reasonably safe procedure. Minor complications such as fever, chest pain, dysphagia, pleural effusion, and esophageal ulceration are common. Major complications (e.g., perforation) occur in only 1% to 4% of cases. 1 Schuman BM Beckman JW Tedesco FJ Griffin JW Assad RT. Complications of endoscopic injection sclerotherapy: a review. Am J Gastroenterol. 1987; 82: 823-830 PubMed Google Scholar Esophageal perforation may occur early due to injury produced with the endoscope or may be delayed due to wall necrosis induced by the sclerosant. 1 Schuman BM Beckman JW Tedesco FJ Griffin JW Assad RT. Complications of endoscopic injection sclerotherapy: a review. Am J Gastroenterol. 1987; 82: 823-830 PubMed Google Scholar In the era of fiberoptic endoscopy, perforation due to instrumentation is unusual, but a few cases of delayed perforation have been reported in adults. 2 Bacon BR Camara DS Duffy MC. Severe ulceration and delayed perforation of the esophagus after endoscopic variceal sclerotherapy. Gastrointest Endosc. 1987; 33: 311-315 Abstract Full Text PDF PubMed Scopus (20) Google Scholar , 3 Korula J Pandya K Yamada S. Perforation of esophagus after endoscopic variceal sclerotherapy. Dig Dis Sci. 1989; 34: 324-329 Crossref PubMed Scopus (23) Google Scholar , 4 Shemesh E Bat L. Esophageal perforation after fiberoptic endoscopic injection sclerotherapy for esophageal varices. Arch Surg. 1980; 121: 243-245 Crossref Scopus (23) Google Scholar , 5 Soderlund C Wiechel K-L. Oesophageal perforation after sclerotherapy for variceal haemorrhage. Acta Chir Scand. 1983; 149: 491-495 PubMed Google Scholar

Glue for gastric varices: some sticky issues

Glue for gastric varices: some sticky issues

Natural history of portal hypertensive gastropathy in patients with liver cirrhosis. The New Italian Endoscopic Club for the study and treatment of esophageal varices (NIEC).

The clinical importance of portal hypertensive gastropathy (PHG) as a source of gastrointestinal bleeding in patients with cirrhosis is poorly defined. We investigated the natural history of this condition in a large series of patients. All patients with cirrhosis seen at 7 hospitals during June and July 1992 were followed up with clinical and endoscopic examinations every 6 months for up to 3 years. Gastropathy was classified according to the classification of the New Italian Endoscopic Club. The prevalence of gastropathy was 80% and was correlated with the duration of disease, presence and size of esophagogastric varices, and a previous history of endoscopic variceal sclerotherapy. During 18+/-8 months of follow-up, gastropathy was stable in 29% of patients, deteriorated in 23%, improved in 23%, and fluctuated with time in 25%. The evolution of gastropathy with time was identical in patients with and without previous or current sclerotherapy. Acute bleeding from gastropathy occurred in 8 of 315 patients (2.5%). The bleeding-related mortality rate was 12.5%. Chronic bleeding occurred in 34 patients (10.8%). PHG is common in patients with cirrhosis, and its prevalence parallels the severity of portal hypertension. Gastropathy can progress from mild to severe and vice versa or even disappear completely. Bleeding from this lesion is relatively uncommon and rarely severe. Sclerotherapy of esophageal varices does not seem to influence the natural history of this condition.

The role of endoscopic therapy in the treatment of bleeding varices

The role of endoscopy in bleeding varices is both diagnostic and therapeutic. While sclerotherapy of oesophageal varices remains an established modality, ligation has, in view of its higher safety margin, turned out to be superior in recent years. The excellent initial results of ligation are, however, tainted by a higher recurrence rate in the long term. Since the end-point of treatment is the achievement and maintenance of variceal eradication, the addition of low-dose sclerotherapy following initial eradication by ligation seems to be the optimal method to combine the best of both techniques. In the management of life-threatening bleeding from oesophageal varices and gastric varices, cyanoacrylate remains the only promising non-surgical option. Primary endoscopic prophylaxis is still under evaluation. It is only justified in high-risk patients with large varices bearing red colour signs and in the presence of an intolerance of or contra-indication to propranolol. When indicated, ligation seems to be preferable, and the addition of low-dose sclerotherapy after initial variceal eradication may maintain the benefits accrued in such high-risk patients. The present review examines the available evidence regarding the above issues in the recent literature.

Absolute ethanol and 5% ethanolamine oleate are comparable for sclerotherapy of esophageal varices

Background: Endoscopic sclerotherapy is widely accepted as an effective treatment for the eradication of esophageal varices in patients with portal hypertension and a history of upper gastrointestinal bleeding. The objective of this study was to assess the effectiveness and safety of absolute ethanol as an alternative sclerosing agent to the commonly used 5% ethanolamine oleate. Methods: One hundred fifty-seven patients with portal hypertension and a history of variceal bleeding were randomly assigned to sclerotherapy with absolute ethanol (n = 66) or 5% ethanolamine oleate (n = 91) between January 1992 and July 1994. Once eradication was achieved, these patients were prospectively followed until September 1998. Results: Sclerotherapy with both sclerosants resulted in similar eradication rates (~90%), with comparable numbers of sessions required for eradication (5.4 and 5.9 sessions for absolute ethanol and 5% ethanolamine oleate, respectively). Similar complication and recurrent bleeding rates were observed among both groups. Conclusion: Sclerotherapy with absolute ethanol is as effective as with 5% ethanolamine oleate in preventing further bleeding in patients with portal hypertension. (Gastrointest Endosc 2000;51:573-6.)

Absolute ethanol and 5% ethanolamine oleate are comparable for sclerotherapy of esophageal varices

Absolute ethanol and 5% ethanolamine oleate are comparable for sclerotherapy of esophageal varices

7224 Incidence of stricture formation, ulcer bleeding, perforation and massive hematoma formation from sclerotherapy versus band ligation of esophageal varices.

BACKGROUND: Numerous complications have been reported with use of sclerotherapy (Scl)and with band ligation (BL) of esophageal varices. AIM: The aim was to compare the incidence of complications from esophageal variceal Scl and BL. Specific complications examined included: esophageal stricture formation, post Scl/BL ulcer bleeding, massive esophageal hematoma and esophageal perforation. METHODS: Consecutive EGDs in which Scl or BL were performed for either acute variceal treatment or subsequent obliterative therapy and entered into a computerized endoscopy database over a 7 year period were evaluated. Scl was performed with standard technique. BL was performed primarily with the Wilson-Cook Saeed 6 and/or 10 shooter. The choice to use Scl or BL was per the discretion of the endoscopist. Complications were assessed at scheduled follow up clinic and endoscopy visits, review of quality assurance data tallied on a monthly basis as well as patient records. RESULTS: 285 cases of Scl were performed in 95 patients (95M, mean age 57.1 yrs) compared to 102 cases of BL in 47 patients (94M:1F, mean age 55.8 yrs). For Scl sessions a mean of 5.8 injections were used to deliver a mean of 7.8 ml of sclerosant (range 0.5 ml to 27 ml). During BL 1 to 13 bands were placed (mean 4.7/case). Complications from Scl and BL are shown in Table below on a per patient basis. CONCLUSIONS: The incidence of complications from Scl of varices is much higher than that compared to BL with stricture formation incidence reaching statistical significance. Additional prospective multicenter follow up will be necessary to determine whether the incidence of ulcer bleeding, perforation and hematoma are truely different between BL and Scl. Per Patient Complications from Variceal Sclerotherapy or Band LigationSclerotherapy Band ligation p value Stricture 9.6% 2.1%

3482 Endoscopic removal of impacted sharp foreign body in esophagus.

Background/Aims: Sharp impacted esophageal foreign bodies can be very difficult to manage. When attempting to remove such objects inappropriately, life threatening complications, such as perforation can occur. Therefore, surgical intervention generally affords a safer approach. The aim of this study is to evaluate the safety and efficacy of endoscopic removal of impacted sharp esophageal foreign bodies using dilation method with oral side balloon. Methods: Total of 17 patients(Male 6, Female 11) with impacted sharp esophageal foreign bodies underwent endoscopic extraction. The following technique was successfully performed at our hospital(Figure A,B). Oral side balloon(Top Co. Japan) for esophageal variceal sclerotherapy was attached on the distal part of endoscope. Under local anesthesia, endoscope was inserted near the proximal part of the esophageal foreign body. Then, oral side balloon was gradually dilated. Dilataion of proximal part of esophagus made it possible to release the impacted sharp foreign body from the esophageal wall. Results: The types of foreign bodies were fish bones(10 case), and press-through packages(7 cases). Endoscopic removal was successful in all 17 cases without complications such as perforation. Conclusion: This method using oral side balloon is safe and effective in removing impacted sharp esophageal foreign bodies avoiding surgery and possible perforation.

Endoscopic injection sclerotherapy for esophageal varices in children

Endoscopic injection sclerotherapy for esophageal varices in children

Effect of esophageal variceal sclerotherapy on hemorrhoids, anorectal varices and portal colopathy.

Endoscopic sclerotherapy (EST) results in an increase in the prevalence of portal hypertensive gastropathy (PHG). However, the effects of sclerotherapy on hemorrhoids, anorectal or colonic varices and portal hypertensive colopathy are not known. The aim of this study was to investigate these effects. A total of 39 patients with portal hypertension were studied. Upper gastrointestinal endoscopy and full-length colonoscopy were carried out before the patients underwent EST for esophageal varices, and after obliteration of the varices following sclerotherapy. The obliteration of esophageal varices by EST did not significantly affect the prevalence of hemorrhoids (32 % before and after), anorectal varices (45% before and after) or portal hypertensive colopathy (60.5 % before and 66 % after, P > 0.05). Obliteration of esophageal varices does not affect the prevalence of hemorrhoids, anorectal varices, or portal hypertensive colopathy.

Gastritis and gastropathy of childhood.

Gastritis and gastropathy of childhood.

Incidence and fate of antral varices.

To study the incidence of antral varices (AV) and their fate in patients with portal hypertension so as to formulate a management policy. Prospective cohort study. Single surgical unit specializing in portal hypertension management in a tertiary level centre. Three hundred and seventy-one patients [cirrhosis 170, non-cirrhotic portal fibrosis (NCPF) 53, extrahepatic portal venous obstruction (EHPVO) 148] with history of bleeding from oesophageal varices were inducted in the chronic sclerotherapy programme. Protocol-based endoscopic sclerotherapy and management of bleeding for oesophageal varices. Development or disappearance of AV, bleeding from AV. No patient had AV on index endoscopy. Thirteen (3.5%) patients developed AV, in cirrhosis 2.9%, EHPVO 4.1%, NCPF 3.8% (P = 0.86). AV developed after a mean of 15 months. Oesophageal varices took a longer number of sessions to obliterate in patients with AV (11.1 vs 5.98 sessions, P<0.0001). Only one patient bled, having coexistent oesophageal varices and gastropathy. AV disappeared spontaneously in seven patients, recurring in only one. Of seven persisting AV, none have bled over a mean follow-up of 30 months (SD 23.2). AV are seen in a small proportion of patients, and are distributed equally amongst the aetiologies of portal hypertension. They rarely bleed and may be ignored during sclerotherapy of oesophageal varices.

Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices

Background: Endoscopic band ligation combined with sclerotherapy has been postulated to be superior to ligation alone for the treatment of esophageal variceal bleeding. Methods: A randomized trial of ligation versus combined ligation and sclerotherapy was designed to determine whether combined therapy results in faster eradication of varices compared to ligation alone. Sixty patients were randomized to undergo band ligation or ligation combined with injection of 1 to 2 mL of polidocanol (1%) into each variceal column immediately proximal to the previously placed bands. Therapy was repeated at 1- or 2-week intervals until variceal eradication was achieved. Follow-up endoscopy was performed at 3 months and then at 6-month intervals. Results: The demographic and clinical characteristics of the 31 patients who underwent ligation were similar to those of the 29 who received combined treatment. Sixty percent of the patients had cirrhosis due to viral hepatitis. No significant differences were found between the combined and ligation alone groups in arresting active bleeding [9 of 9 (100%) vs. 6 of 7 (86%)], units of blood transfusion (3 ± 0.8 vs. 2 ± 0.6), number of sessions required to eradicate varices (3.8 ± 0.5 vs. 3.6 ± 0.4), treatment failure [2 (17%) vs. 4 (14%)], esophageal varice recurrence [6 (21.%) vs. 2 (6%)], gastric varices formation [4 (14%) vs. 1 (3%)], stricture [1 (3%) vs. 0 (0%)], recurrent bleeding [5 (17%) vs. 7 (23%)], other complications [10 (34%) vs. 9 (29%)], or death [3 (10%) vs. 7 (23%)] during a follow-up period of up to 36 months. Conclusions: Combined ligation and sclerotherapy does not reduce the number of endoscopic treatment sessions required for variceal eradication and offers no benefit over ligation alone. Because of the lack of benefit, the added procedure time, and the cost, we do not advocate combination therapy, and ligation alone remains the best endoscopic treatment. (Gastrointest Endosc 1999;50:1-6.)

Outcome of cystic fibrosis-associated liver cirrhosis: management of portal hypertension

Background/Aim: Variceal bleeding is the most severe complication in patients with cystic fibrosis-associated liver cirrhosis, who often do not have severe respiratory failure. The advent of liver transplantation has broadened the treatment options. The purpose of this study was to report our experience with the management of portal hypertension. Methods: Clinical and biochemical features, outcome of liver disease and management of portal hypertension were analyzed retrospectively in 44 children with cystic fibrosis-associated liver cirrhosis. Results: The mean age at diagnosis of liver cirrhosis was 9 years. Eighty-six per cent of the children developed esophageal varices, 50% of whom bled early in their second decade. Injection sclerotherapy of esophageal varices did not prevent recurrence of bleeding in five of seven children. Elective surgical portosystemic shunting was successfully performed in nine of 11 patients considered being at high risk of bleeding or with recurrent bleeding episodes but without severe pulmonary failure and liver dysfunction, allowing prolonged post-operative survival up to 15 years. Two of three children who underwent isolated liver transplantation for severe portal hypertension died post-operatively. Conclusions: Management emphasis in cystic fibrosis patients with liver cirrhosis should be on control of bleeding and variceal decompression. These results suggest that surgical portosystemic shunting may be considered to relieve portal hypertension in patients without progressive liver failure and severe lung disease as an alternative to liver transplantation. With this policy, patients may be stabilized for many years until progression of liver or lung diseases indicates liver or lung-liver transplantation.

Hematoma with High Oxygen Partial Pressure Resulting from Injection Sclerotherapy for Esophageal Varices — Report of a Case

Abstract: Endoscopic injection sclerotherapy (EIS) was performed on a 44‐year‐old Japanese male, who had been suffering from risky esophageal varices due to cirrhosis of the liver. Blood gas analysis at the beginning of therapy showed that the partial pressure of oxygen at the variceal (PO2) and arterial blood (PaO2) were 47.2 mmHg and 64.1 mmHg, respectively. Sclerosant with contrast medium was injected into the varices and the left gastric vein was embolized; this was always confirmed by endoscopic varicealography during injection scleorotherapy (EVIS). During the fifth EIS session, there was evidence of pooling of contrast medium with sclerosant and an intramural hematoma had developed, which could not be reduced by puncture. The blood gas analysis showed a drastic increase in PO2 (107.9 mmHg), whereas PaO2 remained mostly unchanged (58.8 mmHg). To our knowledge, this is the first report of blood gas analysis during hematoma and the high PO2 compared with PaO2 indicated that there was a substantial inflow of oxygen‐rich blood, possibly from the pulmonary vein into the varices. This inflow of blood into the varices may have contributed to the formation of the large hematoma in small varices following EIS. (Dig Endosc 1999; 11: 55–61)

Combination Treatment of Endoscopic Ligation and Sclerotherapy for Esophageal Varices

Combination Treatment of Endoscopic Ligation and Sclerotherapy for Esophageal Varices

Two Cases of Rectal Varices Treated by Endoscopic Variceal Ligation

Abstract: Case 1 was a 49‐year‐old asymptomatic, woman with enlarged esophageal varices due to cirrhosis of the liver. Fourteen days after the last session of endoscopic injection sclerotherapy (EIS) for esophageal varices, colonoscopy revealed large tortuous rectal varices extending 4 cm from the dentate line. Endoscopic variceal ligation (EVL) was performed for rectal varices, and bands were placed on the varices at seven sites. There were no complications. Seven days after EVL, colonoscopy revealed ulcers in the rectum, and shrinkage of varices. Case 2 was a 62‐year‐old woman with general fatigue due to cirrhosis of the liver. At 50 years of age, she underwent a transection of the esophagus to remove varices, and splenectomy. At 57 years of age, EIS was per formed for recurrent esophageal varices. Colonoscopy was performed because of anal bleeding, and revealed tortuous rectal varices extending 5 cm from the dentate line. EVL was then performed, and bands were placed on the varices at eight sites, with no complications. Seven days after EVL, colonoscopy indicated ulcers in the rectum and shrinkage of the varices. EVL appears to be a safe and effective therapy for rectal varices. (Dig Endosc 1999; 11: 66–69)

Evaluation of long terms follow up after endoscopic injection sclerotherapy for esophageal varices assessed by the estimation of EVIS and the medical expenditures at the first therapy :

Evaluation of long terms follow up after endoscopic injection sclerotherapy for esophageal varices assessed by the estimation of EVIS and the medical expenditures at the first therapy :