Has sclerotherapy altered the management of patients with variceal bleeding?

Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices

OBJECTIVE

This study tested the validity of the hypothesis that eradication of esophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding varices in a high-risk cohort of alcoholic patients with cirrhosis.

SUMMARY BACKGROUND DATA

Although banding of esophageal varices is now regarded as the most effective method of endoscopic intervention, injection sclerotherapy is still widely used to control acute esophageal variceal bleeding as well as to eradicate varices to prevent recurrent bleeding. This large single-center prospective study provides data on the natural history of alcoholic cirrhotic patients with bleeding varices who underwent injection sclerotherapy.

METHODS

Between 1984 and 2001, 287 alcoholic cirrhotic patients (225 men, 62 women; mean age, 51.9 years; range, 24-87 years; Child-Pugh grades A, 39; B, 116; C, 132) underwent a total of 2565 upper gastrointestinal endoscopic sessions, which included 353 emergency and 1015 elective variceal injection treatments. Variceal rebleeding, eradication, recurrence, and survival were recorded.

RESULTS

Before eradication of varices was achieved, 104 (36.2%) of the 287 patients had a total of 170 further bleeding episodes after the first endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 147 (80.7%) of 182 patients who survived more than 3 months, varices were eradicated after a mean of 5 injection sessions and remained eradicated in 69 patients (mean follow-up, 34.6 months; range, 1-174 months). Varices recurred in 78 patients and rebled in 45 of these patients. Median follow-up was 32.3 months (mean, 42.1 months; range, 3-198.9 months). Cumulative overall survival by life-table analysis was 67%, 42%, and 26% at 1, 3, and 5 years, respectively. A total of 201 (70%) patients died during follow-up. Liver failure was the most common cause of death.

CONCLUSION

Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Despite control of variceal bleeding, survival at 5 years was only 26% because of death due to liver failure in most patients.

Endoscopic injection sclerotherapy in the management of 2105 patients with esophageal varices

BACKGROUND

The objective of this study is to examine the overall clinical results of endoscopic injection sclerotherapy (EIS) for patients with esophageal varices in our institution.

METHODS

From January 1982 to May 2001, 2105 patients with esophageal varices were treated with EIS, which included prophylactic injections for patients with risky varices according to our criteria. Follow-up endoscopy was performed every 3 months, and recurrent varices were treated with additional EIS.

RESULTS

Acute variceal bleeding was controlled in 468 of 473 patients (98.9%). Esophageal varices were completely eradicated in 1757 of 2105 patients (83.5%) with 3.8 +/- 1.6 sessions of EIS. The cumulative recurrence rates were 32.2% at 5 years, 36.5% at 10 years, and 37.8% at 15 years. The cumulative nonbleeding rates were 92.3% at 5 years, 90.1% at 10 years, and 89.5% at 15 years. The survival rate of acute bleeders was significantly lower than for both elective and prophylactic cases (P <.05). The overall cumulative survival rate was 28.2% at 10 years.

CONCLUSIONS

EIS is the first choice of treatment for esophageal variceal bleeding, and rebleeding was shown to be well controlled in a long-term follow-up with endoscopy and additional EIS. The lower survival rate observed in acute bleeders may therefore justify the use of prophylactic EIS.

Dysphagia after prophylactic endoscopic injection sclerotherapy for oesophageal varices: not fatal but a distressing complication

BACKGROUND

Although dysphagia resulting from oesophageal strictures induced by endoscopic injection sclerotherapy (EIS) is not a fatal complication, it is often quite distressing for the patients. The aim of the current study was to clarify the relationship between dysphagia resulting from oesophageal stricture following prophylactic EIS and the volume of sclerosant consumed in the EIS series.

METHODS

Fifty-two patients with oesophageal varices, who had been treated by prophylactic EIS, were selected as the subjects.

RESULTS

Seventeen (32.7%) patients developed dysphagia following prophylactic EIS, and five patients with a severe stricture required bougie dilatation to take meals. The volume of sclerosant used in the initial session of EIS for patients with subsequent dysphagia (24.9 +/- 4.0 mL) was significantly larger than that for patients without dysphagia (18.4 +/- 5.1 mL; P < 0.001). The mean volume of sclerosant consumed per session during the EIS series for patients with dysphagia (16.5 +/- 3.0 mL) was also significantly larger than that for patients without dysphagia (13.1 +/- 3.8 mL; P < 0.01).

CONCLUSIONS

The injection of a superfluous amount of sclerosant in prophylactic EIS brings about distressing dysphagia with oesophageal stricture in the patients with oesophageal varices who had no such complaint or symptoms before the therapy.

Effect of previous sclerotherapy on the outcome of gastro-oesophageal devascularization and oesophageal transection in bleeding oesophageal varices

This retrospective analysis studied the effect of sclerotherapy on subsequent oesophageal transection in the management of patients with bleeding oesophageal varices and compared the result with that in those who did not receive sclerotherapy as the primary treatment. Fifty patients were treated by gastro-oesophageal devascularization and oesophageal transection for bleeding oesophageal varices over a 4-year period. Twenty-six patients did not receive sclerotherapy (group 1) and 24 received between one and four sessions of sclerotherapy (group 2) before surgery. Oedema and thickness of the lower end of the oesophagus and some adhesions were noted during surgery in patients who had had previous sclerotherapy; however, stapled oesophageal transection and anastomosis could be performed in all these patients. There was no oesophageal leak in any patient, although there was a higher rate of chest complications (nine versus six patients) in group 2. Six patients (12 per cent) died (three in each group) during the postoperative period; three had Child grade C disease. It is concluded that the decision to operate to control bleeding varices should be made early. One or two sessions of sclerotherapy before surgery does not increase intraoperative difficulty or the postoperative leak rate following oesophageal transection. The outcome of surgery is directly related to the state of liver reserve (Child grade).

Endoscopic injection sclerotherapy for esophageal varices in the elderly

A group of 1127 patients who underwent sclerotherapy for esophageal varices were compared for outcome in terms of age: over and under age 70 years. Esophageal varices were completely eradicated in 81 of 110 patients > 70 years (73.6%) and in 791 of 1017 patients < 70 years (77.8%). Gastrointestinal bleeding after sclerotherapy occurred in 9 patients > 70 years (8.2%) and in 84 of those < 70 years (8.3%). Complications occurred in 16 patients > 70 years (14.5%) and in 141 < 70 years (13.9%). Liver failure and hepatoma accounted for more than 80% of the causes of death in both groups (80.3% versus 83.8%). The 5-year cumulative survival rates in patients with bleeding esophageal varices (bleeders) without hepatoma were 21.8% in those > 70 years and 58.7% in those < 70 years (p < 0.01), the relative survivals being 25.3% versus 66.6%. Patients without hepatoma and treated by prophylactic sclerotherapy accounted for 66.2% of patients > 70 years and 61.7% of those < 70 years, the relative survivals being 75.9% versus 71.9%. As analyzed by the Cox proportional-hazards model, age > 70 years was a prognostic factor in the bleeders (p < 0.01) but not in the nonbleeders. We recommend that elderly patients with esophageal varices be given prophylactic sclerotherapy, as the outcome for these patients is poor once bleeding has occurred.

Oral isosorbide-5-mononitrate reduces the rebleeding rate during the course of injection sclerotherapy for esophageal varices

A double-blind, multicenter trial was carried out to assess the effectiveness of isosorbide-5-mononitrate in preventing recurrent variceal hemorrhage during the course of endoscopic sclerotherapy. Seventy-six patients with their first bleeding episode from esophageal varices were randomly allocated, after initial control of hemorrhage, to groups receiving either 50 mg/day oral isosorbide-5-mononitrate retard (37 patients) or an identical placebo (39 patients) until variceal eradication. Sclerotherapy was performed at weekly intervals, and varices were intra- and para-variceally injected with 1% polidocanol until eradication. If rebleeding occurred, additional sclerotherapy was performed. Four (10.8%) patients rebled in the isosorbide group, compared with 15 (38.4%) in the placebo group (p = 0.01). The total number of rebleeding episodes was also significantly lower in the isosorbide group (5 versus 19, p = 0.043), whereas comparison between major versus minor rebleedings was not significant. The median transfusion requirement per bleeding episode was not significantly different in the two groups, although the cumulative number of blood units transfused was over threefold greater (22 versus 70) in the placebo group. Two (5.4%) deaths occurred among isosorbide-treated patients and nine (17.9%) among placebo patients (NS). The number of sclerotherapy sessions and the time required to obtain variceal eradication were also comparable in the two groups. Finally, the nitrovasodilator was well tolerated, requiring withdrawal for severe headache in only one patient. In conclusion, isosorbide-5-mononitrate reduces the rebleeding rate and the number of rebleeding episodes before variceal eradication in patients treated with sclerotherapy.

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.

Development of pleural effusion after sclerotherapy with absolute alcohol

Pleural effusion developed in 6 of 31 patients undergoing esophageal variceal sclerotherapy using absolute alcohol. The effusions were small, appeared within 48 hours of sclerotherapy, and disappeared without treatment within 7 days in all six patients. Prevalence of chest pain was significantly greater when pleural effusions developed than when pleural effusions did not develop (83% of patients versus 19%, respectively, p < 0.05). The persistence of chest pain was also significantly greater when pleural effusions developed than when they did not develop (80% of patients versus 19%, respectively, p < 0.05). We conclude that pleural effusion occurs frequently after esophageal variceal sclerotherapy with alcohol and is commonly associated with chest pain.

Management of gastric varices

Gastric varices (GV) are a common (20%) accompaniment of portal hypertension; they are more often seen in those patients who bleed than in those who do not (27% versus 4%, p < 0.01). They can develop in both segmental and generalized portal hypertension. Depending on their location and relation with oesophageal varices, GVs can be classified as gastrooesophageal varices (GOV) and isolated gastric varices (IGV); each of these can be further subdivided as follows: GOV1 (extension of oesophageal varices along lesser curve) and GOV2 (extension of oesophageal varices towards fundus); and IGV1 (varices in the fundus) and IGV2 (isolated varices anywhere in the stomach). The common presentation of GVs is variceal bleeding and encephalopathy. In comparison with oesophageal varices, GVs bleed significantly less often (64% versus 25%, p < 0.01) but more severely (2.9 +/- 0.3 versus 4.8 +/- 0.6 transfusion units, p < 0.01). Patients with GOV2 and IGV1 bleed more often than patients with other types of GVs. Sclerotherapy for oesophageal varices can significantly influence the natural history of GVs. GOV1, or lesser curve varices, disappear in the majority of cases (59%) after obliteration of oesophageal varices. In those with persisting GOV1, the incidence of bleeding and mortality is high and these patients require gastric variceal sclerotherapy (GVS). During oesophageal variceal sclerotherapy, bleeding can occasionally be induced from GVs. After obliteration of oesophageal varices, recurrence as GVs (secondary GVs) can occur in about 9% of patients. Emergency GVS is quite effective in controlling acute bleeding from GVs, more so than balloon tamponade. Potent sclerosants like tetradecyl sulphate and alcohol and a glue, bucrylate, have been quite effective. Elective GVS can achieve obliteration of GVs in nearly 70% of patients. Rebleeding and ulceration are common complications of GVS; probably related to incomplete obliteration and mucosal injury respectively. Splenectomy is quite effective in treating GVs due to segmental protal hypertension. For GV bleeding due to generalized portal hypertension, a shunt operation is often effective. TIPS procedure appear to be a very promising therapy for GV bleeding. Liver transplantation may be a superior alternative to sclerotherapy and shunt surgery for gastric varices.

Selective shunt in the management of variceal bleeding in the era of liver transplantation

This study reports the Emory experience with 147 distal splenorenal shunts (DSRS) and 110 orthotopic liver transplants (OLT) between January 1987 and December 1991. The purpose was to clarify which patients with variceal bleeding should be treated by DSRS versus OLT. Distal splenorenal shunts were selected for patients with adequate or good liver function. Orthotopic liver transplant was offered to patients with end-stage liver disease who fulfilled other selection criteria. The DSRS group comprised 71 Child's A, 70 Child's B, and 6 Child's C patients. The mean galactose elimination capacity for all DSRS patients was 330 +/- 98 mg/minute, which was significantly (p less than 0.01) above the galactose elimination capacity of 237 +/- 82 mg/minute in the OLT group. Survival analysis for the DSRS group showed 91% 1-year and 77% 3-year survival, which was better than the 74% 1-year and 60% 3-year survivals in the OLT group. Variceal bleeding as a major component of end-stage disease leading to OLT had significantly (p less than 0.05) poorer survival (50%) at 1 year compared with patients without variceal bleeding (80%). Hepatic function was maintained after DSRS, as measured by serum albumin and prothrombin time, but galactose elimination capacity decreased significantly (p less than 0.05) to 298 +/- 97 mg/minute. Quality of life, measured by a self-assessment questionnaire, was not significantly different in the DSRS and OLT groups. Hospital charges were significantly higher for OLT (median, $113,733) compared with DSRS ($32,674). These data support a role for selective shunt in the management of patients with variceal bleeding who require surgery and have good hepatic function. Transplantation should be reserved for patients with end-stage liver disease. A thorough evaluation, including tests of liver function, help in selection of the most appropriate therapeutic approach.

Endoscopic injection sclerotherapy for 1,000 patients with esophageal varices: a nine-year prospective study

We report here the results of endoscopic injection sclerotherapy performed in 1,000 consecutively treated Japanese patients with esophageal varices. This prospective study covered the period from 1982 to 1990. Variceal bleeding was controlled in 215 (97.7%) of 220 patients. Esophageal varices were completely eradicated in 778 patients (77.8%); the mean number of sessions was 4.2. In only 3 of the 778 patients did esophageal varices of the same size recur. Small, dilated, venous vessels that required additional sclerotherapy in follow-up endoscopy at 3-mo intervals appeared in 171 (22.2%) of 778 patients. The cumulative nonbleeding rate at 5 yr was 94.5% in patients in whom the varices had been eradicated. Deaths caused by upper gastrointestinal bleeding accounted for 2.6% of cases, whereas the rates of liver failure and hepatoma were 4.6% and 47.3%, respectively. The 5-yr cumulative survival rate was 54.1% in patients without concomitant hepatoma; it was 12.0% in patients with hepatomas. Multivariate analysis showed that hepatoma, Child classification, indication (acute, elective or prophylactic) and eradication were independent factors that significantly influenced survival time. This study clearly shows that close follow-up with endoscopy and complete eradication lead to significant reduction in bleeding from esophageal varices and reduction of mortality related to this bleeding.

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.

The Emory perspective of the distal splenorenal shunt in 1990

The distal splenorenal shunt (DSRS) has been extensively studied at Emory University over the past 18 years to define its role in the management of variceal bleeding. DSRS has been applied broadly in many different patient groups and has been evaluated in prospective randomized trials; thus, a considerable amount of data has accrued on the metabolic and hemodynamic consequences of selective variceal decompression. Its current role is defined as primary therapy for variceal bleeding in patients with portal vein thrombosis and good-risk patients with nonalcoholic cirrhosis. As a therapy for patients whose bleeding is not controlled by sclerotherapy, it should be used as the shunt procedure of choice, but patient evaluation must focus on the choice between DSRS and liver transplantation.