Treatment Of Esophageal Varices Research Articles

Therapeutic results of endoscopic variceal ligation for acute bleeding of oesophageal and gastric varices

Endoscopic variceal ligation (EVL) using 'O' rings is widely accepted as a treatment of oesophageal varices that is at least as effective as endoscopic injection sclerotherapy but which produces fewer complications. Endoscopic variceal ligation using detachable snares has attracted attention as a safe and easy method of endoscopic treatment for gastric varices. Nineteen patients with acute bleeding from oesophageal or gastric varices were treated in the present study. Of these, 14 patients were treated with EVL using 'O' rings and five patients were treated with EVL using detachable snares and the treatment results were evaluated. Haemostasis was achieved in all patients. No serious complications of the procedures were observed. However, recurrences and rebleeding were observed in some patients during the maximum follow-up period of 24 months. Endoscopic variceal ligation using 'O' rings and detachable snares is useful for achieving haemostasis in cases of acute bleeding from oesophageal or gastric varices. However, additional endoscopic sclerotherapy may be needed to eliminate the variceal feeding vessels to further improve the long-term prognosis of these patients.

The treatment of oesophageal varices: a debate and a discussion.

At the Biennial Meeting of the International Association for the Study of the Liver, in Cape Town, South Africa, 20-24 February 1996, the treatment of oesophageal varices was selected as a subject for the discussion of controversies in portal hypertension. This review gives a summary of that discussion. Dr Didier LeBrec gave a broad overview of the medical management of oesophageal varices by presenting a list of 52 pharmacological agents that reduce portal venous pressure and presented the advantages and disadvantages of each. He emphasized that recent randomized clinical trials (RCT) have demonstrated that propranolol delays and decreases the occurrence of haemorrhage from varices in patients who have not previously suffered such complications. He also reported that isosorbidemononitrate is equally effective and further enhances the effect of propranolol. He also reported that the effects of propranolol plus endoscopic sclerotherapy (EST) were more effective than EST alone in preventing haemorrhage, but not in improving survival. Finally he noted that propranolol in high dosage did not prevent the development of large varices in cirrhotic patients with small or undetectable varices. Dr John Terblanche compared the efficacy of EST and endoscopic ligation of varices (ELV) and reported that all four RCTs found ELV to be superior. He discussed portacaval anastomosis (PCA) and concluded that only emergency PCA as reported by Orloff, is thought to be truly beneficial, and suggested that EST, plus ELV may be the treatment of choice. Dr Harold O. Conn, who served as the moderator of this session summarized the presentations and pointed out that liver transplantation is the most effective form of therapy of all, albeit extremely complex and expensive. He discussed transjugular intrahepatic portosystemic shunts (TIPS), the newest form of therapy, and emphasized its virtues (immediate reduction of portal venous pressure) and its limitations (frequent portosystemic encephalopathy and frequent spontaneous stenoses). He presented a brief discussion of the prevention of the development of the varices themselves, currently termed "pre-primary prophylaxis', a hope for the future. He ended with "Predictions' which if proven correct will give a preview of portal hypertension in the 21st century.

Comparison between long term non-recurrent group and recurrent group after the treatment for esophageal varices by endoscopic injection sclerotherapy

Comparison between long term non-recurrent group and recurrent group after the treatment for esophageal varices by endoscopic injection sclerotherapy

食道静脈瘤治療後に大量下血を起こした大腸癌手術後の肝硬変の1例

食道静脈瘤治療後に大量下血を起こした大腸癌手術後の肝硬変の1例

Evaluation of patient outcome following sclerotherapy for esophageal varices.

After excluding terminally all patients, we evaluated a total of 718 patients treated with endoscopic injection sclerotherapy. They involved 350 episodes of acute hemorrhage and 368 prophylactic procedures in patients with risky varices. The 1-year cumulative survival rate was significantly lower in the acute hemorrhage group than in the prophylactic group (P < 0.05). The difference in survival between the two groups was primarily due to the number of deaths in the first 2 months after sclerotherapy (20.1% vs 0.8%, P < 0.0005). Improvements in the sclerotherapy technique significantly reduced the number of deaths from bleeding (9.3% vs 3.4%, P < 0.05), but not those from liver failure following variceal hemorrhage. Prophylactic EIS is advantageous in the treatment of esophageal varices, i.e. it may prevent deaths from liver failure attributed to variceal hemorrhages. The present study shows that preliminary prevention of variceal hemorrhage provides favorable hemostatic efficacy in patients with risky varices.

Emerging role of endoscopic variceal band ligation in the treatment of esophageal varices.

Bleeding from esophageal varices is the most catastrophic complication of portal hypertension. The associated high morbidity and mortality have necessitated the development of safe and efficacious therapeutic modalities. In recent years, endoscopic band ligation of esophageal varices has proved to be a useful tool in the control of acute variceal bleeding and the prevention of recurrent bleeding. This endoscopic technique is faster than sclerotherapy in obliterating esophageal varices, and is associated with significantly lower local esophageal complications. In the forthcoming years, endoscopic band ligation is expected to gain wider popularity as a definitive therapy for bleeding varices.

内視鏡的食道静脈瘤治療専用クリップの開発

内視鏡的食道静脈瘤治療専用クリップの開発

Suction sclerotherapy for the treatment of esophageal varices: a report of a preliminary feasibility study.

We report a new treatment modality for esophageal varices, suction sclerotherapy, which was designed to lift away mucosa and submucosa during treatment to prevent deep injection and resultant esophageal ulcerations. In order to compare the posttreatment complications of suction sclerotherapy against freehand sclerotherapy, we randomized 4 mongrel dogs to receive ten injections of 0.5-ml aliquots of absolute alcohol into the esophagus by either the suction or freehand sclerotherapy technique. The animals were humanely sacrificed after 48 h and examined. A total of five large, deep, confluent ulcers, free perforation, and lung abscess were seen in the animals randomized to freehand sclerotherapy. In contrast, a total of 14 shallow, discrete, erythematous lesions were found in the suction sclerotherapy group; none of these lesions extended deeper than the submucosa. We conclude that suction sclerotherapy produced local complications limited to the submucosa which were less severe as compared with freehand sclerotherapy.

The treatment of esophageal varices with simultaneous combination method of endoscopic sclerotherapy and endoscopic ligation

The treatment of esophageal varices with simultaneous combination method of endoscopic sclerotherapy and endoscopic ligation

Suction sclerotherapy for the treatment of esophageal varices: A prospective pilot study

Suction sclerotherapy for the treatment of esophageal varices: A prospective pilot study

Continuous Endoscopic Variceal Ligation with a Three‐shooter

Abstract:Endoscopic variceal ligation with an elastic O band has been performed in the treatment of esophageal varices. Generally, after ligating the varix during the treatment the endoscope is removed and the O band is changed each time until the desired result is achieved. However, it is thought that a shorter time to change the O band would make endoscopic variceal ligation more convenient. Therefore, we designed continuous endoscopic variceal ligation with three elastic O bands. To release three bands continuously, a self recoiling spring is attached at the endoscopic side between the inner and outer cylinders. After releasing one band by pulling the wire, the inner cylinder is returned to its original position by recoiling the spring and the next O band is automatically set up. Continuous endoscopic variceal ligation was performed for one case of esophageal varices due to hepatocellular carcinoma with liver cirrhosis. This technique enabled the ligation of three varices concomitantly, thus eliminating the necessity of repeated extraction and insertion of the endoscope every time the varix was ligated. The operation time was considerably shortened. The case reported did not develop any complications. Hence, it was thought that our technique of a three‐shooter is easier to perform and more convenient for the patient.

Treatment of esophageal varices.

Treatment of esophageal varices.

LONG-TERM RESULTS AFTER THE MANAGEMENTS FOR ESOPHAGEAL VARICES IN CHILDREN

In a 26-year period from 1965 to 1991, treatments for esophageal varices have been performed in 26 children. Its long-term clinical results were discussed in this paper. Causes of esophageal varices were congenital extrahepatic portal obstruction (EHPO) in 16, idiopathic portal hypertension in 4, liver cirrhosis or fibrosis in 3, chronic hepatitis in 1, and metabolic liver disease in 2 patients. The total number of treatments came to 45 times. Operative procedures included transabdominal esophageal or gastric transection with paraeso-phageal devascularization on 16, splenectomy on 10, shunt surgery on 15, and endoscopic injection sclerotherapy on 3 patients. Longterm results after treatments of esophageal varices, shunt surgery groups had lower rehemorrhagic rates than others. It may be a fear that hepatic impairment can occur in a longterm follow up after shunt surgery, but no severe impairment has been seen even 10 to 29 years the operation. We recommend that selective shunt surgery might be the procedure of choice for rehemorrhagic esophageal varices in children as well as adults.

Approaches to the endoscopic treatment of esophageal varices.

Endoscopic therapy is commonly employed for both initial and subsequent definitive treatment of variceal bleeding. Sclerotherapy performed with a flexible endoscope is currently the most widespread technique. Available data suggests that such treatment does not improve outcome in the acute treatment of variceal bleeding (first 30 days) but appears superior to conventional medical management in the long term. Sclerotherapy does not appear better or worse than pharmacological therapy or surgical therapy when these treatments are compared in the elective setting. Although effective, endoscopic sclerotherapy is recognized to be associated with many major and minor treatment-related complications and a significant incidence of recurrent hemorrhage. In response to these shortcomings newer forms of endoscopic therapy such as polymer injection and endoscopic ligation have been developed. Polymer injection appears well suited for patients with active bleeding and for those with gastric varices but does not have advantages for chronic treatment aimed at variceal eradication. Endoscopic ligation appears at least as effective as conventional sclerotherapy for control of acute bleeding and prevention of rebleeding and is associated with few treatment induced complications. While endoscopic therapy will likely continue as the most commonly employed treatment for patients with hemorrhage from esophageal varices, newer methods with wider margins of safety and efficacy seem destined to supplement or replace conventional endoscopic sclerotherapy.

The treatment of esophageal varices.

The etiology, the geographic variation in pathology, and the level of hepatic reserve all affect the prognosis in patients with bleeding from esophageal varices. Acute variceal bleeding requires emergency treatment. The options include pharmacological therapy, balloon tube tamponade, and urgent sclerotherapy used singly or in combination. Immediate sclerotherapy at the time of the initial diagnostic endoscopy is the preferred treatment. Those in whom sclerotherapy fails should be subjected to more major surgery. Patients presenting after a variceal bleed has been controlled should be considered for definitive long-term treatment. The main options are repeated sclerotherapy, a portosystemic shunt, or a devascularization and transection operation. All patients should be evaluated for liver transplantation prior to therapy. Repeated sclerotherapy is widely recommended, with many groups reserving major surgery as a salvage procedure if sclerotherapy fails. Pharmacological therapy remains under review. Prophylactic treatment prior to a variceal bleed should probably be restricted to controlled trials.

Somatostatin in acute bleeding oesophageal varices. Pharmacology and rationale for use.

Somatostatin was originally isolated from the hypothalamus, but has subsequently been found throughout the whole gastrointestinal tract. It exerts an inhibitory effect upon numerous functions of the body, and, therefore, increasing attention has been focused on its potential as a therapeutic agent with cytoprotective properties and a potent inhibitory action on a wide variety of functions in endocrine diseases, cancer and gastrointestinal haemorrhage, including bleeding from oesophageal varices. As somatostatin has a very short plasma half-life and requires administration by continuous infusion to maintain therapeutic levels, stable long-acting analogues have been developed. The analogue octreotide has been shown to have a plasma half-life of 113 minutes and to produce a profound selective inhibition of growth hormone. Hepatic excretion of octreotide has been estimated to be between 30 and 40% in healthy volunteers; no data are available in cirrhotic patients. A review of published data assessing systemic and hepatic haemodynamics in animals and humans over varying dosage regimens of somatostatin and octreotide reveals that cardiac output, arterial pressure and peripheral resistance are modified more in animals than in humans. Hepatic haemodynamics are significantly altered in animals as well as in humans in most of the studies. Circumstantial evidence is provided indicating that the mechanisms of action of somatostatin and octreotide in the therapy of bleeding oesophageal varices are mainly mediated by a splanchnic vasoconstrictive effect. Furthermore, gastric acid suppression and potential enhancement of platelet aggregation may contribute to the beneficial outcome after treatment of oesophageal varices with somatostatin.

Treatment of esophageal varices.

Treatment of esophageal varices.

Role of Endoscopic Ultrasonography in the Treatment of Esophageal Varices

Role of Endoscopic Ultrasonography in the Treatment of Esophageal Varices

Endoscopic sclerotherapy in the treatment of esophageal varices — Bangladesh experience

Endoscopic sclerotherapy in the treatment of esophageal varices — Bangladesh experience

Effects of Sclerosing Agents on the Local Blood Flow of the Mesenteric Vein in Rabbits

Abstract: To investigate the pathophysiology of scleroembolization as a treatment for esophageal varices, studies were made of the effects of the intravenous administration of Aethoxysklerol (AS), Ethanolamine Oleate (EO), ethanol and thrombin on the local blood flow of the mesenteric vein, the systemic hemodynamics and thrombus formation in blood vessels in rabbits.The dosages and concentrations of Aethoxysklerol used were from 0.5 to 2 ml and from 0.5% to 2%, respectively. This was done to ascertain the possible relationships of these variances of Aethoxysklerol on the local blood flow in vessels with a low‐flow and a high‐flow.99% ethanol, 50 U thrombin and 5% Ethanolamine Oleate were also administered into low‐flow and high‐flow vessels in doses of 0.5 ml and 1 ml, respectively.The increase in AS concentration from 0.5% to 2% caused no remarkable changes in the degree of blood flow inhibition in vessels with either a low‐or a high‐flow, but the time required for inhibition was 45–50 min in vessels with a high flow, which was longer than the 25 min necessary in vessels with a low‐flow. The increase in AS dosage from 0.5 to 2 ml was negligible for enhancing the inhibitory effect of the drug upon the blood flow, but the blood flow inhibition was significantly increased in the low‐flow vessels compared with the high‐flow vessels even when the AS was administered in the same volume and concentrations.The AS‐induced changes on the systemic blood pressure were minimal even with high dosages and high concentrations.99% ethanol and thrombin were less effective in blood flow inhibition in both the low‐and the high‐flow vessels. 5% Ethanolamine Oleate when administered in a volume of either 0.5 ml or 1 ml significantly inhibited the flow in the low‐flow vessels as compared to the flow in the high‐flow vessles.On the other hand, when AS was administered with thrombin, the inhibitory effects were accelerated to 88±26% in the low flow vessels and 44±16% in the high‐flow vessels as compared with administration of AS alone in both the low‐flow and the high‐flow vessels, respectively.We concluded that the embolizing effect of AS alone is rather weak, although it is a relatively safe drug. We consider it wise to combine it with thrombin.