Effects of repeated injection sclerotherapy on acid gastroesophageal reflux

Influence of endoscopic variceal ligation on oesophageal motility

BACKGROUND

To determine the change of oesophageal manometry in patients with oesophageal varices before and after oesophageal variceal ligation (EVL).

METHODS

Forty-five patients who had liver cirrhosis and oesophageal varices with high risk of bleeding were managed by EVL. Oesophageal manometry was performed just prior to the ligation and 4-6 weeks after obliteration of varices. Another 45 age- and sex-matched patients without hepatic, oesophageal or systemic disease served as the control group.

RESULTS

At 5 cm above the lower oesophageal sphincter (LES), the amplitude of the contractive wave was significantly lower in patients before EVL (56.9 +/- 31.8 vs 80.1 +/- 30.1, P< 1.05) and returned to the level of control subjects after EVL (76.5 +/- 37.0 vs 80.1 +/- 30.1, P> 0.05). At 10 cm above LES, the amplitude of the contractive wave was significantly lower in patients before and after EVL than the control group (54.3 +/- 29.2 vs 68.1 +/- 29.5, 54.2 +/- 26.0 vs 68.1 +/- 29.5, respectively, P< 0.05). The percentage of tertiary waves was significantly higher in patients before and after EVL than in the control group (31.4 +/- 36.6 vs 5.8 +/- 15.1, 26.9 +/- 32.9 vs 5.8 +/- 15.1, respectively, P< 0.05). However, no significant swallowing disturbance was noted in patients after EVL. There was significantly greater LES length in patients before EVL (4.0 +/- 0.9 vs 3.4 +/- 0.7, P<0.05) but there was no significant difference in the LES length after EVL as compared with the control group. Eighty-six per cent (39/45) of patients developed paraoesophageal varices and 31% (14/45) developed new varices 6 months after variceal obliteration. However, there was no significant difference in manometry at the time of variceal obliteration between patients with variceal recurrence and those without.

CONCLUSIONS

The presence of varices affected oesophageal motility. However, such abnormality had little clinical significance. Endoscopic variceal ligation normalized oesophageal motility and may not induce abnormal oesophageal motility. The manometric change can not be used to predict the recurrence of varices in cirrhotic patients after variceal obliteration.

Effects of endoscopic variceal ligation in lower esophageal motor function: a prospective study

OBJECTIVES

Endoscopic variceal ligation (EVL), a recently developed method for controlling active variceal bleeding and eradicating esophageal varices, has similar efficacy to endoscopic injection sclerotherapy (EIS) and is known to have a minimal risk of complications and fewer complications in the lower esophagus. However, since the site of EVL is chiefly done in the lower esophagus, we prospectively evaluated to investigate the effect of EVL on the lower esophageal motor function.

METHODS

We evaluated the severity of esophageal varix with the endoscopy and the lower esophageal manometry in 27 patients who had no history of interventional therapy, for varices before EVL, 3 weeks and 6 months after the last EVL session.

RESULTS

The EVL caused considerable diminution in the size of esophageal varix by a mean 8.2 (range 3-21) ligations in mean 1.7 (range 1-3) sessions. In most of the cases, the varices reappeared and enlarged when the procedure of EVL was stopped. There were two different types of changes (intermediate and late) in the lower esophageal motility. The intermediate post-EVL effects were the increase of peristaltic contraction amplitude and duration in the lower esophageal body after EVL. The late post-EVL effects were the prolongation of lower esophageal sphinctor (LES) relaxation duration and speedier peristaltic velocity in the lower esophageal body.

CONCLUSIONS

We conclude from these findings that the intermediate post-EVL effect may be transient and the increase of peristaltic wave was due to diminution of esophageal varix.

Role of omeprazole in prevention and treatment of postendoscopic variceal sclerotherapy esophageal complications. Double-blind randomized study

Endoscopic variceal sclerotherapy-related esophageal complications are quite common. The potential efficacy of omeprazole in the prevention and treatment of postsclerotherapy esophageal complications was evaluated in 47 patients with portal hypertension in randomized, placebo-controlled study. Twenty-one patients in the omeprazole group and 23 patients in the placebo group completed the study. The two treatment groups were similar in regards to the etiology of portal hypertension, Child's class, and clinical characteristics. Esophageal ulcers developed in 16 patients in the omeprazole group (2.43 ulcers/patient) and 18 patients in the placebo group (2.39 ulcers/patient). Most of the ulcers (> 90%) healed within 14 days in each group. Esophageal strictures requiring dilatation developed in two and one patient in the omeprazole and placebo groups, respectively. There was no statistically significant difference in regards to the complication rate between the two groups. We conclude that omeprazole is not effective for the prevention or treatment of postsclerotherapy esophageal complications.

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.

Prophylactic versus emergency sclerotherapy of large esophageal varices prior to liver transplantation

From January 1985 through July 1987, adult patients accepted for liver transplantation with large esophageal varices were enrolled in a study evaluating the use of prophylactic vs emergency sclerotherapy. Six hundred forty-eight subjects received prophylactic sclerotherapy, and 172 received emergent sclerotherapy. Esophageal stricture formation was increased 12.9-fold (P < 0.001), esophageal perforation 6.4-fold (P < 0.005), and postsclerotherapy bleeding esophageal ulcers 3.7-fold (P < 0.001) in those receiving emergency sclerotherapy as opposed to prophylactic sclerotherapy. These differences were even greater if the number of sclerotherapy sessions rather than the number of patients was used as the denominator for the comparisons. In total, 19.6% of emergency sclerotherapy cases were associated with an untoward outcome of sclerotherapy; only 1.9% of cases receiving prophylactic sclerotherapy experienced an untoward outcome (P < 0.001). These data demonstrate that emergency sclerotherapy is associated with a greater prevalence of complications and support earlier studies that show that sclerotherapy prevents variceal bleeding over the short term. The data also suggest that when applied to patients with large varices awaiting orthotopic liver transplantation, it enhances the chance of a patient surviving to be transplanted by preventing a variceal bleed and the spiral of liver failure and death that frequently follows an episode of acute variceal bleeding.

Variceal injection sclerotherapy

With the development and widespread use of flexible endoscopes, injection sclerotherapy of oesophageal varices has advanced beyond the early stages. Although slightly different techniques and different sclerosants are used, the results are not strikingly different. The cumulative rate of adverse effects is in the range of 20 to 40%, with a procedure-related mortality of around 1 to 2%. Sclerotherapy is the best available treatment for haemostasis of acute oesophageal variceal bleeding. However, as a long-term therapy it is less effective in the prevention of recurrent gastrointestinal bleeding events, since obliteration of all varices often takes several months. Furthermore, extra-oesophageal bleeding is not amenable to sclerotherapy. Thus, if repeated injections fail to prevent recurrent bleeding, other options such as shunt surgery, transection, chronic medical portal decompression with beta-blockers or even liver transplantation should be considered according to the needs of the individual patient. Prophylaxis of first variceal haemorrhage was beneficial in selected patients with a high bleeding risk. It cannot, however, be generally recommended at present.

Omeprazole in the management of intractable esophageal ulceration following injection sclerotherapy

Transient esophageal ulceration is a common finding after sclerotherapy of varices. A small proportion of these ulcers become chronic and resistant to conventional therapy. Such chronic ulcers have been associated with pain, stricture formation, and recurrent hemorrhage. The use of omeprazole, a proton pump inhibitor, was examined in the current study in the treatment of 10 patients (6 women, 4 men; age range, 27-86 years) with cirrhosis (PBC, 4; sclerosing cholangitis, 2; chronic active liver disease, 2; alcohol, 1; and cryptogenic, 1) who developed an esophageal ulcer after a mean of 13 (range, 8-21) sessions of sclerotherapy. The ulcers had been present for 3-54 months despite prolonged treatment with high-dose H2-receptor antagonists and sucralfate. In each case one or more complications had occurred: severe pain in 3, stricture formation in 4, and recurrent hemorrhage in 7 cases. After an 8-week course of omeprazole, 40 mg daily, endoscopy confirmed complete healing of the ulceration in all 10 cases with symptom resolution. In 2 cases the ulcer recurred, with associated bleeding within 6 weeks of discontinuing the treatment in 1 patient. Both cases responded to repeat therapy. These results confirm the efficacy of omeprazole for postsclerotherapy ulceration and imply that acid-pepsin has a role in perpetuating such ulcers.

Prevention of stricture formation after endoscopic sclerotherapy of esophageal varices

In order to evaluate the effectiveness of an intensive acid protection regimen in preventing sclerotherapy-associated esophageal strictures, 62 patients undergoing sclerotherapy were randomized to receive either acid protection (antacids, cimetidine, and sucralfate) or no acid protection. Of 31 patients (38.7%) in the no acid protection group, 12 developed a symptomatic stricture during the course of sclerotherapy compared with 3 patients (9.7%) in the group assigned to acid protection (p less than 0.01). Our study demonstrates that a vigorous acid protection regimen will help prevent symptomatic esophageal strictures associated with variceal sclerotherapy.

Long-term endoscopic injection sclerotherapy of bleeding esophageal varices. A prospective analysis of results by endoscopy, manometry and 24-h pH-monitoring

From 1 January 1986 to 1 January 1988, 91 consecutive patients who had undergone repeated paravariceal endoscopic injection sclerotherapy (PEIS) for bleeding esophageal varices over a period of up to 10 years were followed up prospectively by endoscopy, manometry and 24-h pH monitoring. In 39% nonfatal complications occurred after two phases of PEIS. The number of complications tended to decrease with increasing phases and was only 12% after five or more phases of PEIS. Endoscopy is undoubtedly the most important method in the follow-up of these patients. Early and long-term complications are mostly diagnosed by direct view and thus can be managed or sometimes even prevented in the follow-up. No significant motility disorders were found. Only 12 patients showed significant gastroesophageal reflux. No correlation was found between the severity of reflux and the number of phases of PEIS. No correlation between clinical symptoms and changes in the manometric and pH metric results could be found. The effects and side effects of PEIS can be closely monitored by manometry and pH monitoring and therapy can be tailored accordingly. Our results suggest that PEIS is a superb method with a low complication rate, both short- and long-term. It has proven to be an effective long-term treatment of bleeding esophageal varices.

Manometric and pH consequences of esophageal endosclerosis in children

Twenty-seven manometric and 22 18-hour pH monitoring studies were done in 17 consecutive patients undergoing esophageal endosclerosis. Prior to endosclerosis, esophageal manometry was normal in eight of nine patients. Peristaltic dysfunction was observed in all 13 postendosclerosis patients and consisted of (1) decreased mean peristaltic amplitude pressures. Pressures were 61.4 and 74.7 mmHg at 0 to 2 cm and 3 to 4 cm above the lower esophageal sphincter (LES), respectively, prior to treatment. After endosclerosis, values fell to 30.2 and 43.3 mmHg; (2) a drop in mean resting LES pressure from 22.3 mmHg before endosclerosis to 17.1 mmHg afterward and (3) an increase in the rate of peristaltic propagation failure from 12% to 26% after endosclerosis. Esophageal pH monitoring demonstrated gastroesophageal reflux (GER) in three of seven patients before endosclerosis and in five of 11 patients afterward. Because of the major incidence of GER before endosclerosis, the procedure could not be causally incriminated. However, GER was roughly correlated with the severity of the manometric dysfunction. There was no correlation of GER or manometric abnormality with the number of endosclerosis treatment nor the interval between endosclerosis and pH and manometric studies. The remote sequelae of the abnormalities are conjectural.

Long-term survivors after variceal haemorrhage. Follow-up of a controlled study of endoscopic sclerotherapy versus conservative management

In a prospective controlled trial of conservative therapy (vasopressin/balloon tamponade (control group] versus endoscopic sclerotherapy (ST) for the acute bleeding and at rebleeding, 107 cirrhotic patients with major variceal haemorrhage were studied from 1979 to 1983. The prospective follow-up study is now presented of the 51 patients surviving for more than 1 year. The present ST group (30 patients) was followed for a median of 5 years (range, 1-7.5 years), and the controls for 4 years (3-5.5 years). Variceal eradication was obtained in 22 ST patients in the 1st year after a median of 6 months and 5 ST sessions, and in 7 ST patients after 21 months and 9 ST sessions. The delay was due to alcoholic abuse. Eleven ST patients and 11 controls (NS) rebled on 30 and 45 occasions during a total follow-up time of 1364 and 696 months and 0.0220 and 0.0647 bleeds per patient-month, respectively (p = 0.098). Eight ST patients experienced 12 variceal bleeds, 11 controls had 39 haemorrhages with variceal aetiology, 0.0088 and 0.0560 bleeds per patient-month (p = 0.016), respectively. Five ST patients had recurrent varices on nine occasions with five episodes of bleeding a median of 13 months after completion of the initial serial ST. Reelimination was achieved with a median of three ST sessions during 3 months, but three patients had a second variceal recurrence 14-24 months later, successfully treated with one ST session in two of them. There was no difference in survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal collagen content and mechanical strength after endoscopic sclerotherapy of esophageal varices. An experimental study in rabbits

Twenty-five rabbits with esophageal varices were randomized to no treatment (n = 10) or endoscopic paravenous sclerotherapy of the varices (n = 15). Five other rabbits served as sham-operated controls. When they were killed, the mechanical strength and collagen content of the esophagus were determined at proximal, middle, and distal levels. The esophagus was examined histologically at proximal and distal levels. Animals treated by sclerotherapy showed histologic edema and inflammation of the esophageal wall after 2 days. This was not accompanied by any decrease in collagen content or mechanical strength. Ten days after sclerotherapy a slight but non-significant increase in collagen content and mechanical strength at middle and distal levels was observed. After 30 days the increase in collagen content at middle and distal levels was significant, and the mechanical strength was significantly increased at the middle level.