Veterans Affairs Cooperative Variceal Sclerotherapy Group. Prophylactic sclerotherapy for esophageal varices in men with alcoholic liver disease. A randomized, single-blind, multicenter clinical trial

Prevention of first variceal bleed: an appraisal of current therapies

Primary prophylaxis of esophageal variceal hemorrhage (EVH) is an important issue in the management of patients with portal hypertension. Given the high rates of initial variceal hemorrhage and mortality in patients who have not experienced bleeding from varices, there is an urgent need for some form of primary prophylaxis in all patients with large esophageal varices. The aim of this article is to review the various therapies that have been clinically assessed in randomized controlled trials for their efficacy in prevention of initial EVH. Beta-blockers have been found to be useful in primary prophylaxis of EVH, and the consensus at present is that they should be offered to all patients with portal hypertension who are at high risk for EVH. Nitrates and other newer agents are under evaluation. Surgery is not recommended for primary prophylaxis of EVH. Endoscopic sclerotherapy has not been shown unequivocally to be efficacious, and may even be deleterious, possibly related to an unacceptably high complication rate in this clinical setting. However, it may merit further clinical evaluation in light of recent reports of benefit in certain subgroups of patients with portal hypertension. On the other hand, endoscopic variceal ligation, which has an inherently low complication rate and brings about rapid obliteration of varices, may be a better option for primary prophylaxis of EVH. In the future, preprimary prophylaxis, an attractive concept, may be considered. This would involve intervention with pharmacologic agents even before the development of portal hypertension or esophageal varices.

Laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices with hypersplenism

BACKGROUND

The combination of sclerotherapy with surgical salvage for sclerotherapy-resistant esophagogastric varices has recently received much attention, however, the longterm results after such an operation have yet to be reported. This is a preliminary report of a laparoscopic adaptation of a previously described surgical procedure for the treatment of refractory esophagogastric varices.

STUDY DESIGN

Laparoscopic gastric devascularization and splenectomy (Hassab's operation) was successfully performed to treat recurrent sclerotherapy-resistant giant esophageal varices (n=4) and recurrent rebleeding gastric varices (n=6). The patients included 8 men and 2 women who ranged in age from 35 to 67 years (average, 54.2 years). The procedure and clinical results were evaluated from various viewpoints.

RESULTS

The duration of the operation ranged from 200 to 400 minutes (mean+/-standard deviation; 287.5+/-66.0 minutes) and blood loss from 10 to 1,500 mL (average, 515.5+/-507.9 mL). The weight of the spleen ranged from 500 to 850 g (average 608.0+/-126.6 g). Conversion to minimal open operation with a gasless lifting method was done in 1 patient because of uncontrolled bleeding from the splenic vein. There were no other major complications either intraoperatively or postoperatively. All patients had hypersplenism; preoperative platelet counts ranged from 1.6 to 6.8 x 10(4)/microL (average, 4.5+/-2.7 x 10(4) microL) and the postoperative count was from 5.9 to 36.0 x 10(4)/microL (average, 21.7+/-11.5 x 10(4) microL). Postoperative endoscopy revealed that varices disappeared, and no patient had recurrence of the varices after operation during the mean followup period of 12.8+/-4.1 months (average, 8 to 20 months).

CONCLUSIONS

The combination of laparoscopic gastric devascularization and splenectomy for sclerotherapy-resistant esophagogastric varices is considered a feasible and relatively safe surgical method for patients with hypersplenism.

Endoscopic sclerotherapy with fibrin glue as compared with polidocanol to prevent early esophageal variceal rebleeding

BACKGROUND/AIMS

Endoscopic sclerotherapy is of proven benefit for patients after esophageal variceal bleeding, but is associated with substantial local and systemic complications. Since fibrin glue is a promising agent for endoscopic sclerotherapy of esophageal varices, we compared its safety and efficacy in patients after esophageal variceal bleeding.

PATIENTS AND METHODS

In a randomized, controlled trial, 36 patients with an acute episode of variceal bleeding were endoscopically treated with either polidocanol (18 patients) or fibrin glue (18 patients) by intravariceal injections within 12 h of admission. Tissue compatibility, incidence of various complications, episodes of rebleeding and overall survival rates were investigated.

RESULTS

Rebleeding, especially from enrollment to day 28, was less common in the fibrin group (p=0.046), and all patients treated with fibrin glue survived for more than 28 days, whereas five patients treated with polidocanol died within this period. The incidence of sclerotherapy-induced ulcers was significantly lower in the fibrin group than in the polidocanol group (p=0.001), and major complications such as perforation or ulcer bleeding were observed only in the polidocanol group. There were no complications in any group due to activation of systemic coagulation, fibrinolysis or clinically relevant pulmonary embolization.

CONCLUSIONS

We conclude that fibrin glue is an efficient and safe agent for endoscopic sclerotherapy of bleeding esophageal varices, especially in the immediate posthemorrhagic period.

Sclerotherapy versus banding in the treatment of variceal bleeding

Endoscopic sclerotherapy has been the mainstay in the management of esophageal variceal bleeding to control acute bleeding and decrease recurrent bleeding. Endoscopic variceal ligation is a new technique that is equally effective in the control of acute bleeding but achieves obliteration of varices in fewer treatment sessions with presumably less cost, results in a lower rebleeding rate, has fewer complications, and is associated with reduced mortality. Combination therapy with both endoscopic variceal ligation and endoscopic sclerotherapy appears to have no clear advantage over variceal ligation alone. On the basis of the results of a number of trials comparing sclerotherapy with band ligation, endoscopic variceal ligation has evolved to be the preferred first line modality for the endoscopic treatment of variceal bleeding.

Natural history of portal hypertension

A rise in pressure in the portal vein is a frequent occurrence in patients with cirrhosis. One common manifestation affecting at least 50% of cirrhosis patients is the development of gastroesophageal varices and portal hypertensive gastropathy. Bleeding from gastric or esophageal varices will occur in approximately 1/4 of cirrhotic patients with an associated high mortality. Large esophageal varices that have red color signs and isolated gastric varices in the fundus of the stomach are most likely to hemorrhage. The greatest risk of bleeding is during the first year following the index endoscopy. Once varices have bled they are almost certain to rebleed in the absence of therapy. Similarly, severe portal hypertensive gastropathy is likely to cause chronic blood loss. Knowledge of the natural history of gastroesophageal varices allows for the development of effective treatment strategies.

Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence

BACKGROUND/AIMS

Endoscopic variceal ligation and endoscopic sclerotherapy are both recommended for the prevention of variceal rebleeding. To compare their efficacy, their influence on gastric varices and the development of portal gastropathy, 95 patients with variceal bleeding were studied.

METHODS

The patients were randomized to receive weekly endoscopic sclerotherapy using alcohol (n=48) or endoscopic variceal ligation (n=47). The endoscopic sclerotherapy and endoscopic variceal ligation groups were comparable in etiology, severity of liver disease and grade of varices.

RESULTS

In the arrest of acute bleed, endoscopic sclerotherapy and endoscopic variceal ligation were comparable (86% vs. 80%, p=ns). Endoscopic variceal ligation as compared to endoscopic sclerotherapy, obliterated esophageal varices in fewer sessions (4.1+/-1.2 vs. 5.2+/-1.8, p<0.01) and a shorter time (4.4+/-1.3 vs. 6.9+/-3.4 wk, p<0.01). Three (6.4%) patients bled after endoscopic variceal ligation and 10 (20.8%) after endoscopic sclerotherapy (p<0.05). The actuarial percentage of variceal recurrence during a follow-up of 8.5+/-4.4 months, was higher after endoscopic variceal ligation than endoscopic sclerotherapy (28.7% vs 7.5%, p<0.05). Esophageal stricture formation after endoscopic sclerotherapy occurred in five (10.4%) patients, but in none after endoscopic variceal ligation. Significantly more patients developed gastropathy after endoscopic sclerotherapy than ligation (20.5% vs. 2.3%; p=0.02). Endoscopic sclerotherapy (52%) and endoscopic variceal ligation (59%) were equally effective in obliterating the lesser curve gastric varices. Six patients died: three in each group.

CONCLUSIONS

(i) Endoscopic sclerotherapy and endoscopic variceal ligation were equally effective in controlling acute bleed; (ii) endoscopic ligation achieved variceal obliteration faster and in fewer treatment sessions; (iii) endoscopic variceal ligation had a significantly lower rate of development of portal gastropathy and rebleeding, (iv) while both techniques influenced gastric varices equally, there was significantly higher esophageal variceal recurrence after endoscopic variceal ligation than sclerotherapy.

Clinical trial of prophylactic endoscopic variceal ligation for esophageal varices

Endoscopic variceal ligation is an effective therapy for variceal bleeding, and use of the method has recently been increasing. We evaluated the clinical usefulness of prophylactic endoscopic variceal ligation. Twenty-two patients with enlarged, tortuous varices and "red color signs" were selected. These patients were treated with ligation therapy alone and the varices were eradicated, i.e., reduced to small, straight varices without red color signs. Ligation therapy was withdrawn if the general condition of the patient worsened or if the varices could not be removed by suction. Follow-up endoscopy was performed every 4 months, and another ligation was performed if there were recurrent varices or variceal bleeding. The total reduction rate was 86.4%, and eradication required two sessions of therapy and 30 days of hospitalization on average. Complications included esophageal injury in 1 patient and treatment-induced bleeding in 1 patient; both complications were easily controlled. No variceal bleeding occurred after the eradication. There was no mortality due to gastrointestinal bleeding during the median follow-up period of 346 days. Prophylactic endoscopic variceal ligation made it possible to prevent fatal variceal bleeding with a minimum risk of complications, suggesting that this could be an alternative method for the prevention of first-time variceal bleeding.

Management of upper gastrointestinal bleeding in the patient with chronic liver disease

This article reviews the management of severe upper gastrointestinal bleeding in the patient with chronic liver diseases. The initial assessment, diagnostic work-up, and treatment options for variceal and nonvariceal bleeding are discussed. The role of diagnostic and therapeutic endoscopy for esophagogastric varices is reviewed with special emphasis on new endoscopic techniques including variceal band ligation and cyanoacrylate injection. Various pharmacologic, surgical, and radiologic treatment options for variceal bleeding also are discussed. In addition, nonvariceal causes of severe upper gastrointestinal bleeding are reviewed including peptic ulcer diseases, Mallory-Weiss tear, portal hypertensive gastropathy, and gastric antral vascular ectasia.

Eleven-year survey of safety and efficacy of endoscopic injection sclerotherapy using 2% sodium tetradecyl sulfate and contrast medium

We conducted a retrospective 11-year survey to evaluate the post-treatment course in 285 patients with esophagogastric varices following administration of endoscopic injection sclerotherapy as an emergency, elective, or prophylactic procedure using freshly prepared 2% sodium tetradecyl sulfate not containing benzyl alcohol. These agents were injected into the varices and the supplying veins under fluoroscopic observation, usually in a single treatment. In all patients the variceal size was greatly reduced following one treatment. The amount of sclerosant necessary to fill the varices and the supplying veins varied widely among the patients. Acute variceal bleeding was controlled in 80 (96.4%) of the 83 patients, and the risk of rebleeding during the first month was 0.0548 in the emergency procedures. The serious complication of perforation was observed in one patient. The cause of death was established in the 122 patients who died and included esophageal variceal bleeding in eight (6.6%) and gastric variceal bleeding in one (0.8%). The overall 50% survival period was 5 years and 4 months. Multivariate analysis disclosed that the factors with the greatest negative effect on survival were poor hepatic status and the presence of hepatocellular carcinoma. The method of preparation and the procedure itself may be considered safe and effective in the treatment of esophagogastric varices.

Endoscopic injection sclerotherapy for esophageal varices associated with concomitant portal venous thrombus of hepatocellular carcinoma

Between 1983 and 1994, we treated 51 patients with esophageal varices and portal trunk and main branch invasion of hepatocellular carcinoma, using endoscopic injection sclerotherapy. Variceal bleeding was controlled in 28 of 29 patients (96.6%), esophageal varices were completely eradicated in 28 (54.9%), and only 2 of 28 (7.1%) bled from small, dilated, venous vessels after eradication. The cumulative nonbleeding rate at 3 years was 87.5%. Death caused by hepatocellular carcinoma accounted for 89.4% of the patients, whereas the rate of bleeding from esophageal varices was 4.3%. Variables significantly associated with the duration of survival were Okuda's clinical stage, alpha-fetoprotein, eradication of esophageal varices by sclerotherapy, and treatment of hepatocellular carcinoma, as determined in a univariate analysis. Multivariate analysis showed that eradication of esophageal varices by sclerotherapy, Okuda's clinical stage, and age were independent factors which significantly influenced survival time. We propose that complete eradication of esophageal varices and close follow-up using endoscopy may lead to a reduction in bleeding from esophageal varices, and hence may reduce mortality rates related to this bleeding.

Hepatic disorders. Features and appropriate management

The spectrum of liver disease is extremely wide, with many of the underlying disorders having acute and chronic presentations. Most of the underlying pathogenetic mechanisms are accounted for by autoimmune disease, viral infection and toxic insult. The management strategy of any liver disease is a combination of treating the symptoms and complications that arise, as well as drug therapies relevant to the specific underlying diagnosis. Encephalopathy, ascites, spontaneous bacterial peritonitis, variceal bleeding and pruritus are the main complications at which drug therapy is directed, although in some cases it represents only 1 aspect of the overall management. Drug therapy per se is largely ineffective in acute liver failure with the possible exception of acetylcysteine, but many drugs are used in the management of the constituent components of this complex medical emergency. Treatments for specific liver conditions are expanding, especially in the areas of autoimmune and viral disease. The increasing availability and success of liver transplantation has tended to change the emphasis of management, and it is often not appropriate to exhaust the treatment options before referring the patient for transplantation. A comprehensive review of all liver disease is beyond the scope of this article, but hopefully the important principles of management and commonly occurring clinical decisions are discussed.

Systemic treatment with recombinant human epidermal growth factor accelerates healing of sclerotherapy-induced esophageal ulcers and prevents esophageal stricture formations in pigs

Human epidermal growth factor (EGF), a small polypeptide (6 kDa) with mitogenic properties, has been implicated in the protection of gastrointestinal mucosal integrity. The efficacy of EGF in the prevention and healing of sclerotherapy-induced esophageal lesions was investigated in 24 minipigs with surgically induced portal hypertension. In addition, the effect of EGF on intragastric acidity and pharmacokinetics was investigated as possible means to explain its protective mechanism of action. The animals underwent three weekly sessions of sclerotherapy with polidocanol 2% and were concomitantly and for an additional three weeks treated with either placebo or EGF administered paravenously in the esophagus and/or subcutaneously. The subcutaneous treatment with EGF significantly (P < 0.05) reduced esophageal stricture and scar formations associated with sclerotherapy. Gastric pH values were significantly (P < 0.01) elevated only in animals receiving subcutaneous injections of EGF. Furthermore, the subcutaneous administration of EGF was associated with unexpected prolonged plasma concentration of the peptide. These results suggest a possible clinical value of EGF as an adjunctive treatment with the sclerotherapy.

Prophylactic treatment of patients with esophageal varices: is it ever indicated?

The prognosis of patients who bleed from esophageal varices is dismal. Prophylactic treatment of the varix or the elevated portal venous pressure offers a possibility of improving the outlook for these patients. However, as only approximately one-third of patients with varices bleed during their lifetime, correct identification of high-risk patients is vital before embarking on prophylaxis. At present, neither European or Japanese selection criteria are perfect in this respect. The documented incidence of initial variceal bleeding varies between 27% and 48%, and most bleeding episodes occur within the first year after varices are diagnosed. Data from six randomized controlled trials comparing prophylactic beta-blockers with placebo demonstrated a decreased incidence of bleeding in propranolol-treated patients, which in large measure may depend on patient compliance and did not significantly affect survival in all but one study. Early randomized studies of prophylactic sclerotherapy have shown significant reductions in both the incidence of bleeding and mortality, but this promise has not been sustained by subsequent trials, and indeed sclerotherapy was detrimental in two studies. The impressive results in highly selected patients treated in Japan by prophylactic surgery are unlikely to be repeated in a Western setting, involving patient populations that consist predominantly of alcoholic cirrhotics. At present prophylaxis with beta-blockade seems to offer the best therapeutic option, but the future may lie in the development of new interventional techniques such as transjugular intrahepatic portosystemic stent shunting (TIPS) or variceal banding, and ultimately with hepatic transplantation.

Relation between liver pathology and prognosis in patients with portal hypertension

The most common causes of variceal bleeding are cirrhosis, schistosomiasis, and extrahepatic portal venous obstruction. The prognosis for an individual patient depends on the severity of the bleeding episode and the underlying liver function. Liver function is determined to a large extent by the underlying liver pathology. Patients with noncirrhotic portal hypertension or cirrhosis with good liver function have good short- and long-term prognoses. In patients with established cirrhosis, the presence of alcoholic hepatitis, hepatocellular carcinoma, or portal venous thrombosis may adversely affect prognosis. In addition to affecting prognosis, the underlying pathology may also influence choice of treatment. This point is particularly true for treatments such as shunt surgery, liver transplantation, or transjugular intrahepatic shunts.

Recombinant human epidermal growth factor prevents sclerotherapy-induced esophageal ulcer and stricture formations in pigs

Human epidermal growth factor (EGF), a naturally occurring protein, has been implicated in the protection of gastrointestinal mucosal integrity. The efficacy of EGF in the prevention of sclerotherapy-induced esophageal lesions was investigated in 18 minipigs with surgically induced portal hypertension. The animals underwent five weekly sessions of sclerotherapy with polidocanol 2% and were concomitantly treated with either placebo or EGF administered either paravenously or subcutaneously. EGF significantly (P < 0.05) reduced esophageal ulcerations, stricture formations, and mucosal histological damage associated with sclerotherapy. The drug was well-tolerated with no overt toxicity. These results suggest a potentially important clinical value of EGF as an adjunctive treatment with the sclerotherapy.

Pathophysiology and prognosis of oesophageal varices

The fundamental initiating factor in portal hypertension is an increase in resistance to portal venous flow. Portal venous pressure rises as a consequence, and collateral channels open to decompress the portal venous system. A number of secondary haemodynamic phenomena occur in animals and humans with portal hypertension. Systemic vascular resistance and mean arterial blood pressure fall and both cardiac output and splanchnic blood flow increase. Current theories suggest that increased vascular production of nitric oxide may have a principal role in the pathogenesis of these secondary haemodynamic changes. The most common causes of variceal bleeding are cirrhosis, schistosomiasis and extrahepatic portal venous obstruction. Varices develop in 90% of cirrhotic patients if follow-up is long enough. Bleeding from varices occurs in approximately 30% of patients followed up for 2-4 years, with mortality rates of 25% to 50% in those who bled. Prognosis is better in conditions where liver function is preserved, e.g. portal venous obstruction, schistosomiasis, etc.

Portal hypertension management

Injection sclerotherapy is the mainstay of treatment for acute variceal bleeding and for long-term management after a variceal bleed. In those few patients in whom sclerotherapy fails to control acute bleeding, either a surgical shunt or a simple esophageal transection is recommended. A surgical shunt or a more extensive esophagogastric devascularization and transection operation is advocated for the failures of long-term sclerotherapy management. The role of pharmacological agents in acute variceal bleed management remains in question, and the use of propranolol in long-term management, either as an alternative to sclerotherapy or in combination with sclerotherapy, is controversial. The definitive roles of the newly described variceal banding and transjugular intrahepatic porto-systemic shunts (TIPS) procedures have yet to be established. All patients presenting with end-stage liver disease and esophageal variceal bleeding should be evaluated for a liver transplant, although few will qualify. A possible future transplant should be kept in mind when emergency treatment is planned. Any form of prophylactic therapy for patients with esophageal varices that have not yet bled will remain unjustified until those patients at high risk of a first variceal bleed can be identified. The gastric mucosal lesion, portal hypertensive gastropathy, has been underdiagnosed in the past. Although bleeding does occur, it is seldom a major clinical problem. When necessary, bleeding can be controlled by propranolol or a surgical shunt.

Children and cancer. A perspective from the Cancer Therapy Evaluation Program, National Cancer Institute

The Cancer Therapy Evaluation Program, National Cancer Institute (CTEP, NCI) strongly supports the role of controlled clinical trials in improving the care of children with cancer, and particularly the central role that the pediatric Cooperative Groups play in this process. Trends that threaten the ability to perform these trials include the increasingly limited financial resources available for clinical investigations and the sentiment within some circles that controlled clinical trials may be inappropriate for ethical reasons. The inherent risks of accepting a new therapy without rigorous comparison to existing therapy strongly support the need for randomized trials with adequate accrual to answer important therapeutic questions in a timely and reliable fashion. Retrospective analysis of multiple clinical trials is one method for identifying compelling hypotheses to be tested prospectively. Using this method, we have demonstrated the association between doxorubicin dose intensity and positive response and outcome for patients with Ewing sarcoma and osteosarcoma, thereby providing direction for the selection of important therapeutic questions to be addressed in future clinical trials for these malignancies.

Portal hypertension and bleeding esophageal varices

Bleeding from esophageal varices exacts a high mortality and extraordinary societal costs. Prophylaxis--medication, sclerotherapy, or shunt surgery to prevent an initial bleeding episode--is ineffective. In patients who have bled from varices, endoscopic injection sclerotherapy can control acute bleeding in more than 90% of patients. Because recurrent bleeding frequently occurs and survival without definitive therapy is dismal, selection of a permanently effective treatment is mandatory once variceal bleeding has been controlled. Long-term injection sclerotherapy can be performed in compliant patients; it is relatively safe but is associated with a 30-50% rebleeding rate. Beta-blockers significantly reduce portal pressure and recurrent bleeding but have not been shown to diminish mortality from BEV. Portal decompressive surgery permanently halts bleeding in more than 90% of patients; the risk of operative mortality is high in decompensated cirrhotics, and long-term complications of encephalopathy and accelerated liver failure may limit indications for shunt surgery to good-risk cirrhotics who are not liver transplant candidates. Devascularization procedures have a low operative mortality and encephalopathy rate but unacceptably high rates of recurrent bleeding. Liver transplantation is curative therapy for bleeding esophageal varices and the associated underlying hepatic dysfunction; cost and availability of donor organs generally limit its use in this setting to variceal bleeders with end-stage liver disease not associated with active alcoholism.

Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices

BACKGROUND

Endoscopic sclerotherapy is an accepted treatment for bleeding esophageal varices, but it is associated with substantial local and systemic complications. Endoscopic ligation, a new form of endoscopic treatment for bleeding varices, may be safer. We compared the effectiveness and safety of the two techniques.

METHODS

In this randomized trial we compared endoscopic sclerotherapy and endoscopic ligation in 129 patients with cirrhosis who had proved bleeding from esophageal varices. Sixty-five patients were treated with sclerotherapy, and 64 with ligation. Initial treatment for acute bleeding was followed by elective retreatment to eradicate varices. The patients were followed for a mean of 10 months, during which we determined the incidence of complications and recurrences of bleeding, the number of treatments needed to eradicate varices, and survival.

RESULTS

Active bleeding at the first treatment was controlled by sclerotherapy in 10 of 13 patients (77 percent) and by ligation in 12 of 14 patients (86 percent). Slightly more sclerotherapy-treated patients had recurrent hemorrhage during the study (48 percent vs. 36 percent for the ligation-treated patients, P = 0.072). The eradication of varices required a lower mean (+/- SD) number of treatments with ligation (4 +/- 2 vs. 5 +/- 2, P = 0.056) than with sclerotherapy. The mortality rate was significantly higher in the sclerotherapy group (45 percent vs. 28 percent, P = 0.041), as was the rate of complications (22 percent vs. 2 percent, P less than 0.001). The complications of sclerotherapy were predominantly esophageal strictures, pneumonias, and other infections.

CONCLUSIONS

Patients with cirrhosis who have bleeding esophageal varices have fewer treatment-related complications and better survival rates when they are treated by esophageal ligation than when they are treated by sclerotherapy.

Sclerotherapy vs. esophageal transection vs. distal splenorenal shunt for the clinical management of esophageal varices in patients with child class A and B liver function: a prospective randomized trial

Ninety-six patients with good liver function (Child class A or B) and esophageal varices were randomly assigned to one of three groups given different treatments: endoscopic injection sclerotherapy (n = 32), esophageal transection (n = 32) or distal splenorenal shunt (n = 32). Five patients (5.2%) had to be excluded from this study because severe chronic pancreatitis made separation of the distal splenic vein from the pancreatic bed difficult. Esophageal transection was performed for these patients. No deaths occurred during the 30 days of treatment. The 5-yr cumulative bleeding rates were 0%, 5.9% and 12.9% in the endoscopic injection sclerotherapy, esophageal transection and distal splenorenal shunt groups, respectively (no statistical significance). In no case in the three groups did death occur because of variceal bleeding. Sixteen patients died, mainly because of underlying liver disease; four were in the endoscopic injection sclerotherapy group, five were in the esophageal transection group and seven were in the distal splenorenal shunt group. No statistically significant difference in survival rate among the three groups was found. These results show that endoscopic injection sclerotherapy is a satisfactory alternative to esophageal transection or distal splenorenal shunt for the clinical management of patients with esophageal varices.

Issues in gastrointestinal endoscopy: oesophageal varices: inject, band, medicate, or operate

Injection sclerotherapy is the most widely used definitive treatment of acute variceal bleeding and is increasingly performed at the time of the first emergency endoscopy. Direct endoscopic ligation of varices by banding is a new technique under evaluation for both acute bleeding varices and long-term management. Repeated injection sclerotherapy is one of the major options for long-term management after variceal bleeding. More major surgical procedures are usually reserved for the failures of sclerotherapy in the management of acute variceal bleeding, whereas portosystemic shunts, particularly the distal splenorenal shunt, or an extensive devascularization and transection operation are commonly used alternative forms of therapy in long-term management. All patients with variceal bleeding should be assessed for liver transplantation, although only a few will ultimately receive a liver transplant. Medication with propranolol is widely recommended in long-term management, but its use in this context remains controversial. The most controversial area of management is prophylactic treatment before variceal bleeding. Major surgical procedures and injection sclerotherapy are not justified at present because it is difficult to identify those patients with a high likelihood of a first variceal bleed. Although medical therapy with propranolol has proved the most successful therapy to date, a case is made for treating most patients conservatively until their first variceal bleed occurs or until better predictive indices for patients at high risk of a first bleed are identified.

Long term management of oesophageal varices

Effective control of variceal rebleeding (secondary prophylaxis) or prevention of the initial bleeding (primary prophylaxis) are the main objectives of the treatment of portal hypertension. Endoscopic sclerotherapy is the treatment of choice for secondary prophylaxis, since it significantly decreases rebleeding and, to some extent, mortality. A combination of propranolol and sclerotherapy may be of benefit by decreasing postsclerotherapy rebleeding. Endoscopic variceal band ligation and transjugular intrahepatic shunt are emerging as useful alternative techniques. Devascularisation and preferably selective shunts should be reserved for use as salvage of sclerotherapy failures. Liver transplantation, if feasible, could become the ultimate therapy by controlling variceal bleeding and improving hepatic function. Pharmacotherapy, while not very successful for secondary prophylaxis, has shown promise for primary prophylaxis of variceal bleeding. Nonselective beta-blockers significantly decrease the rebleeding rates but are associated with only marginal survival benefits. beta-Blockers alone cannot decrease the hepatic venous pressure gradient adequately (to less than 12mm Hg). Combination with nitrates and other drugs may prove beneficial and requires clinical evaluation. Endoscopic sclerotherapy and surgery have little role in primary prevention of variceal bleeding in patients with cirrhosis but need evaluation in noncirrhotic patients.

Prophylaxis of first hemorrhage from esophageal varices by sclerotherapy, propranolol or both in cirrhotic patients: a randomized multicenter trial. The PROVA Study Group

The objective of this randomized multicenter trial was to assess the prophylactic effect on the incidence and severity of the first variceal hemorrhage of endoscopic sclerotherapy, propranolol and the combination of the two compared with none of these treatments in patients with cirrhosis and esophageal varices. Among 819 cirrhotic patients who never had experienced variceal bleeding, esophagoscopy revealed varices in 379, of whom 286 were enrolled in the trial; 73 were allocated to sclerotherapy (paravenous polidocanol [10 mg/ml] every 1 to 2 wk until eradication), 68 to propranolol (slow-release preparation in one daily dose adjusted to provide about 25% heart rate reduction), 73 to both treatments and 72 to neither of the two treatments. The patients were observed for up to 42 mo, with an average of 15 mo. After variceal bleeding, patients in all groups received sclerotherapy only. The incidences of variceal bleeding (n = 50) were almost identical in the four groups. The relative risk (with 95% confidence limits) with sclerotherapy was 1.06 (0.61 to 1.84), and the relative risk with propranolol was 0.92 (0.53 to 1.60). The mortality rate after variceal bleeding (n = 29) did not differ significantly either. The mortality rate without variceal bleeding (n = 46) was 2.75 (1.45 to 5.22) times higher in the sclerotherapy groups than in the nonsclerotherapy groups (p = 0.002), whereas propranolol showed no effect, the relative risk being 1.17 (0.66 to 2.10). The total mortality rate showed no significant difference between the sclerotherapy, propranolol and control groups, but the combined therapy group had a significantly increased mortality rate.(ABSTRACT TRUNCATED AT 250 WORDS)