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Krishnan A, Srinivasan V, Venkataraman J. Variceal recurrence, rebleeding rates and alterations in clinical and laboratory parameters following post-variceal obliteration using endoscopic sclerotherapy. J Dig Dis 2012; 13:596-600. [PMID: 23107447 DOI: 10.1111/j.1751-2980.2012.00633.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To study the rates of variceal recurrence and rebleeding following sclerotherapy and its effect on clinical and laboratory parameters in patients with portal hypertension. METHODS A total of 237 patients with portal hypertension together with esophageal variceal bleeding were included in the study. There were 138 patients with cirrhosis (group I), 42 with non-cirrhotic portal fibrosis (group II), and 57 with extrahepatic portal vein obstruction (group III). Baseline data and post-obliteration follow-up for rebleeding rates and changes in clinical and laboratory parameters were recorded. RESULTS In all, 106 patients in group I, 31 in group II and 43 in group III experienced obliteration of varices. The recurrence of grade II varices occurred in 17 patients (9.4%) during a mean period of 9 months. Rebleeding from varices was observed in 4 patients (3.8%) in group I and 1 (3.2%) in group II, while none in group III experienced rebleeding. There was a significant improvement in ascites, jaundice, liver status, international normalized ratio and platelet count in group I patients after variceal eradication (P < 0.05). The main cause of death in the cirrhotic patients was active liver disease but not rebleeding. CONCLUSIONS Following obliterative endoscopic sclerotherapy, rates of recurrence and rebleeding were significantly low when patients are kept under close observation. Disappearance of varices or reduction of variceal size improves the liver status in surviving cirrhotic patients.
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Affiliation(s)
- Arunkumar Krishnan
- Department of Gastroenterology and Hepatology, Stanley Medical College Hospital, Chennai, India
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2
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Arrault M, Gaouar F, Vignes S. Le syndrome des grosses mains. Rev Med Interne 2009; 30:460-4. [DOI: 10.1016/j.revmed.2008.11.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2008] [Accepted: 11/26/2008] [Indexed: 11/17/2022]
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Park WG, Yeh RW, Triadafilopoulos G. Injection therapies for variceal bleeding disorders of the GI tract. Gastrointest Endosc 2008; 67:313-23. [PMID: 18226695 DOI: 10.1016/j.gie.2007.09.052] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 09/27/2007] [Indexed: 02/07/2023]
Affiliation(s)
- Walter G Park
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California 94305, USA.
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Croffie J, Somogyi L, Chuttani R, DiSario J, Liu J, Mishkin D, Shah RJ, Tierney W, Wong Kee Song LM, Petersen BT. Sclerosing agents for use in GI endoscopy. Gastrointest Endosc 2007; 66:1-6. [PMID: 17591465 DOI: 10.1016/j.gie.2007.02.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Zargar SA, Javid G, Khan BA, Shah OJ, Yattoo GN, Shah AH, Gulzar GM, Singh J, Shah NA, Shafi HM. Endoscopic ligation vs. sclerotherapy in adults with extrahepatic portal venous obstruction: a prospective randomized study. Gastrointest Endosc 2005; 61:58-66. [PMID: 15672057 DOI: 10.1016/s0016-5107(04)02455-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic sclerotherapy is a well-established treatment for bleeding esophageal varices, although it has a substantial complication rate. A prospective randomized trial was conducted to determine whether endoscopic variceal ligation is safer and more effective than sclerotherapy in adults with bleeding esophageal varices because of extrahepatic portal venous obstruction. METHODS Thirty-six patients underwent sclerotherapy and 37 had band ligation. RESULTS Ligation and sclerotherapy were equally effective for achieving variceal eradication (94.6% vs. 91.7%, respectively; p=0.67). However, ligation achieved eradication with fewer endoscopic sessions (3.7 [1.2] vs. 7.7 [3.3]; p <0.0001) and within a shorter time interval (50.1 [17.7] days vs. 99 [54.8] days; p <0.0001). In the ligation group, recurrent bleeding was less frequent (2.7% vs. 19.4%; p=0.028; however, Bonferroni correction for multiple testing removes this significance) and the rate of major complications was lower (2.7% vs. 22.2%; p=0.014). Total cost per patient was significantly higher in the sclerotherapy vs. the ligation group ($216.6 [71.8] vs. $182.6 [63.4]; p=0.035). During the follow-up period after variceal eradication, no significant differences were found between the sclerotherapy and the ligation groups with respect to recurrent bleeding (3% vs. 2.9%; p=1.0), esophageal variceal recurrence (9.1% vs. 11.4%; p=1.0), and formation of new gastric varices (9.1% vs. 14.3%; p=0.51). CONCLUSIONS Variceal band ligation is superior to sclerotherapy, because it is less costly and achieves variceal eradication more quickly, with lower relative frequencies of recurrent variceal bleeding and complications.
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Affiliation(s)
- Showkat Ali Zargar
- Department of Gastroenterology and General Sugery, Sher-i-Kashmir Institute of Medical Sciences, Sringar, Kashmir, India
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Coumaros D. [Gastrointestinal hemorrhage. Prevention of recurrent bleeding: modalities of endoscopic treatments]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2004; 28 Spec No 2:B83-97. [PMID: 15150500 DOI: 10.1016/s0399-8320(04)95243-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Dimitri Coumaros
- Service d'Hépato-Gastroentérologie, Hôpitaux Universitaires, F 67091 Strasbourg Cedex
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Sethy PK, Kochhar R, Behera D, Bhasin DK, Raja K, Singh K. Pleuropulmonary complications of esophageal variceal sclerotherapy with absolute alcohol. J Gastroenterol Hepatol 2003; 18:910-4. [PMID: 12859719 DOI: 10.1046/j.1440-1746.2003.03094.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND Esophageal variceal sclerotherapy (EVS) is an effective means of controlling variceal hemorrhage. However, it causes a wide variety of local and systemic complications. The present study was performed to document pleuropulmonary complications of EVS with absolute alcohol. METHODS Twenty-six patients of portal hypertension of different etiologies were subjected to EVS with absolute alcohol. Baseline arterial blood gas analysis (PaO2, PaCO2, pH, HCO3, SaO2), chest X-ray and pulmonary function tests (forced expiratory volume at 1 s (FEV1), forced expiratory vital capacity (FVC), FEV1/FVC, maximum mid-expiratory flow rate (MMFR), and peak expiratory flow rate (PEFR)) were performed 4-6 h before the first session of EVS. These investigations were repeated within 24 h of EVS. Patients were asked to maintain a symptom diary and to record symptoms such as fever, chest pain, dysphagia and dyspnea during the study period. RESULTS Ten patients (38.46%) had chest pain and four patients (15.68%) had fever after sclerotherapy. Eight patients (30.54%) complained of dyspnea and six patients (23.08%) developed pleural effusion. There was a significant decline in FVC and FEV1 after EVS as compared with baseline values. However, FEV1/FVC ratio, MMFR and PEFR did not have any significant change. CONCLUSIONS Chest pain (38.46%), dyspnea (30.54%) and fever (15.68%) were the common symptoms after EVS while chest X-ray showed pleural effusion in 23.08%. Pulmonary function tests revealed a significant decline in FEV1 and FVC without change in FEV1/FVC ratio after EVS, suggesting a restrictive type of defect.
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Affiliation(s)
- Pradeepta K Sethy
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Mullick T, Falk GW. Esophageal strictures: Etiology and diagnosis. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2001. [DOI: 10.1053/tgie.2001.24017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Helmy A, Hayes PC. Review article: current endoscopic therapeutic options in the management of variceal bleeding. Aliment Pharmacol Ther 2001; 15:575-94. [PMID: 11328251 DOI: 10.1046/j.1365-2036.2001.00950.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Variceal bleeding is a frequent and life-threatening complication of portal hypertension. The first episode of variceal bleeding is not only associated with a high mortality, but also with a high recurrence rate in those who survive. Therefore, many studies and randomized clinical trials have focused on different therapeutic strategies aiming to prevent the first episode of variceal bleeding (primary prophylaxis), to control haemorrhage during the acute bleeding episode (emergency treatment), and to prevent re-bleeding (secondary prophylaxis). These strategies involve pharmacological, endoscopic, surgical, and interventional radiological modalities. This review concentrates on the clinical aspects of the endoscopic modalities used to treat oesophageal variceal haemorrhage, including variceal injection sclerotherapy, variceal band ligation, and the use of tissue adhesives (glue) and their substitutes. We also draw conclusions from the available literature regarding the use of endoscopic modalities in primary prophylaxis, emergency treatment, and secondary prophylaxis of variceal re-bleeding. The management of gastric varices and variceal bleeding during pregnancy is also addressed.
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Affiliation(s)
- A Helmy
- Liver Unit, Department of Medicine, Royal Infirmary and University of Edinburgh, Edinburgh, Scotland, UK.
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Schmitz RJ, Sharma P, Badr AS, Qamar MT, Weston AP. Incidence and management of esophageal stricture formation, ulcer bleeding, perforation, and massive hematoma formation from sclerotherapy versus band ligation. Am J Gastroenterol 2001; 96:437-41. [PMID: 11232687 DOI: 10.1111/j.1572-0241.2001.03460.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of this study was to compare the incidence and endoscopic management of esophageal stricture formation, significant ulcer bleeding, massive esophageal hematoma, and perforation resulting from endoscopic band ligation or sclerotherapy of esophageal varices. METHODS Consecutive esophagogastroduodenoscopies in which band ligation or sclerotherapy was performed for acute or obliterative therapy were entered into a computerized endoscopy database during a 7-yr period. Patients were excluded if they died within 72 h of treatment session from complications unrelated to the procedure. Sclerotherapy was performed using a 25-gauge needle with 1.5% sodium tetradecyl sulfate and banding was primarily performed with a Wilson-Cook 6 or 10 shooter. Complications were assessed at scheduled endoscopy and outpatient clinic visits, review of quality assurance data tallied on a monthly basis, and patient records. RESULTS Two hundred twenty-one cases of sclerotherapy were performed in 59 patients compared to 110 cases of band ligation in 52 patients. Five patients were excluded because of death within 72 h of the procedure. The incidence of complications from sclerotherapy:banding on a per patient basis included: esophageal stricture formation 25.6%:1.9%, ulcer bleed 25.4%:5.7%, esophageal perforation 2.2%:0%, and massive esophageal hematoma 1.6%:0%. A significant difference in complications between sclerotherapy and band ligation was noted for both stricture formation (p < 0.0005) and ulcer bleeding (p < 0.0001). The majority of ulcer bleeds required no therapeutic intervention, whereas stricture formation required multiple dilation sessions. CONCLUSIONS Band ligation has a significantly lower incidence of stricture formation and ulcer bleeding compared to sclerotherapy. The majority of complications can be managed with endoscopic interventions.
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Affiliation(s)
- R J Schmitz
- Department of Veterans Affairs, Kansas City VAMC, Missouri 64128, USA
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Abstract
Endoscopic sclerotherapy has emerged as an effective and safe mode of treatment for long-term management of esophageal varices due to cirrhosis of liver and extrahepatic portal venous obstruction. There are few studies that have evaluated the role of sclerotherapy in the management of esophageal varices in patients with noncirrhotic portal fibrosis (NCPF). We report our results of long-term sclerotherapy in patients with NCPF. Seventy-two consecutive patients (men 29, women 43; age 32.9 +/- 11.8 years) with recurrent variceal bleeding due to NCPF were entered into the sclerotherapy program. Forty-eight patients received intravariceal absolute alcohol and 24 patients received intravariceal sodium tetradecyl sulfate (STD). Variceal obliteration was achieved in 65 (90.3%) patients with a mean of 5.7 +/- 3.0 (range 1-14) sessions. These patients were followed-up for a mean of 21.4 +/- 20.4 (range 1-96) months. Thirteen (17.3%) patients had episodes of upper gastrointestinal bleeding during sclerotherapy. Rebleed after obliteration was seen in 6 (9.2%) patients. Sclerotherapy was associated with a significant reduction in bleeding rate (bleeds per month per patient) during sclerotherapy and after obliteration of varices as compared to presclerotherapy period (P < 0.000001 for both). Recurrence of esophageal varices after obliteration was seen in 9 (13.9%) patients with reobliteration of varices in five patients in whom sclerotherapy was attempted. Complications including esophageal ulcer and stricture formation were seen in 18 (25%) and 4 (5.6%) patients respectively; strictures were restricted to patients who received absolute alcohol. Two (2.77%) patients died of massive upper gastrointestinal bleed during follow-up. We conclude that sclerotherapy is an effective and safe modality in the prevention of variceal bleeds in patients with NCPF.
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Cheng CY, Chen GH, Chang CS, Tseng CC, Pan HK, Huang CK, Hsieh PF. Sclerotherapy for esophageal variceal bleeding in advanced hepatocellular carcinoma: an 8-year experience in Taiwan. J Gastroenterol 1994; 29:474-8. [PMID: 7951859 DOI: 10.1007/bf02361246] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Between August 1983 and December 1991 at the Taichung Veterans General Hospital, Taiwan, 65 advanced hepatocellular carcinoma (HCC) patients with esophageal variceal bleeding received endoscopic injection sclerotherapy (EIS) and 60 such patients received conservative medical treatment without EIS. The rate of successful control of acute bleeding was 72.5% (27/40 patients) in the EIS group and 56.7% (34/60 patients) in the non-EIS group. The rebleeding rate was lower in the EIS group than in the non-EIS group (26.9% vs 73.5%). Thirty-one of the EIS and 44 of the non-EIS treatment patients, mainly Child's B and C patients, died within 2 months after the first bleeding. In the short term, EIS decreased the mortality due to esophageal variceal bleeding, but the survivors still had to face hepatic failure and tumor growth. Thus, benefits of EIS were noted on short- but not on long-term survival. The mean survival times were 2.38 months for the EIS group and 1.79 months for the non-EIS group. Since EIS had no beneficial effects on long-term survival it is doubtful whether sclerotherapy applied to esophageal variceal bleeding in patients with advanced HCC would be worthwhile, as the endoscopic procedure would only add to their suffering.
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Affiliation(s)
- C Y Cheng
- Department of Internal Medicine, Chung Shan Medical and Dental College Hospital, Taichung, Taiwan
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Kochhar R, Goenka MK, Mehta SK. Esophageal strictures following endoscopic variceal sclerotherapy. Antecedents, clinical profile, and management. Dig Dis Sci 1992; 37:347-52. [PMID: 1735357 DOI: 10.1007/bf01307726] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We have evaluated 169 patients with portal hypertension receiving endoscopic variceal sclerotherapy in order to assess the predisposing factors, clinical profile, and treatment response of sclerotherapy-induced esophageal strictures. Of the 129 patients included in the final analysis, 20 (15.5%) developed persistent esophageal stricture. No significant difference was found with respect to age, nature of sclerosant (absolute alcohol, ethanolamine oleate, or sodium tetradecyl sulfate), etiology of portal hypertension, Child's class, initial variceal score, or intensity of sclerotherapy schedule between the patients who developed strictures and those who did not. However, female sex (P less than 0.01) and persistent esophageal ulceration (P less than 0.05) did predispose to stricture formation. Sclerotherapy-induced strictures presented with a variable grade of dysphagia, were always solitary, and were localized to the lower end of esophagus. Most of these could be dilated rapidly using Eder-Puestow metal olives (3.15 +/- 0.80 dilatation sessions per patient). Stricture formation did interrupt an effective sclerotherapy program but only temporarily, and successful variceal obliteration could be obtained after stricture dilatation.
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Affiliation(s)
- R Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Kochhar R, Goenka MK, Mehta SK. Outcome of injection sclerotherapy using absolute alcohol in patients with cirrhosis, non-cirrhotic portal fibrosis, and extrahepatic portal venous obstruction. Gastrointest Endosc 1991; 37:460-4. [PMID: 1916169 DOI: 10.1016/s0016-5107(91)70780-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In order to assess the comparative efficacy and safety of endoscopic injection sclerotherapy in patients with portal hypertension of different etiology, i.e., cirrhosis, non-cirrhotic portal fibrosis, and extrahepatic portal venous obstruction, 87 patients with variceal bleeding were initiated on sclerotherapy using absolute alcohol. There was no significant difference in the success rate of sclerotherapy as well as in the number of sessions and volume of alcohol required for variceal obliteration between the three groups. Major complications included esophageal ulcers (30.0%), symptomatic strictures (18.6%), and interval re-bleed (17.1%) with similar complication rates for the three groups (p greater than 0.05). There was no difference between patients with Child's class A cirrhosis compared with classes B and C together with respect to efficacy and complications of sclerotherapy. Fifty patients (25 cirrhosis, 11 non-cirrhotic portal fibrosis, and 14 extrahepatic portal venous obstruction) with complete variceal obliteration were followed up for a mean period of 16.5 months. Sixteen patients (32%) had variceal recurrence, but bleeding due to recurrent varices occurred in only one case. There was no difference among the three groups for overall variceal recurrence, although recurrence tended to be somewhat later in extrahepatic portal venous obstruction (9.4 +/- 4.0 months) compared with that in cirrhosis (5.1 +/- 3.6 months) and non-cirrhotic portal fibrosis (4.8 +/- 2.6 months).
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Affiliation(s)
- R Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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