Endoscopic ligation of esophageal varices compared with injection sclerotherapy: a prospective randomized trial

[Diagnosis and Management of Esophageal and Gastric Variceal Bleeding: Focused on 2019 KASL Clinical Practice Guidelines for Liver Cirrhosis]

Varices are a frequent complication of liver cirrhosis and a major cause of mortality in patients with liver cirrhosis. Patients with decompensated cirrhosis complications have a poor prognosis and require careful management. Portal hypertension is the most common complication of liver cirrhosis, which is the key determinant for varices development. Increased intrahepatic vascular resistance to portal flow leads to the development of portal hypertension. Collateral vessels develop at the communication site between the systemic and portal circulation with the progression of portal hypertension. Varices are the representative collaterals, develop gradually with the progression of portal hypertension and may eventually rupture. Variceal bleeding is a major consequence of portal hypertension and causes the death of cirrhotic patients. The present paper reviews the latest knowledge regarding the diagnosis and management of esophageal and gastric variceal bleeding.

Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis

BACKGROUND

Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years. There are several different treatments to prevent bleeding, including: beta-blockers, endoscopic sclerotherapy, and variceal band ligation. However, there is uncertainty surrounding their individual and relative benefits and harms.

OBJECTIVES

To compare the benefits and harms of different treatments for prevention of first variceal bleeding from oesophageal varices in adults with liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for prevention of first variceal bleeding from oesophageal varices according to their safety and efficacy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers to December 2019 to identify randomised clinical trials in people with cirrhosis and oesophageal varices with no history of bleeding.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and oesophageal varices with no history of bleeding. We excluded randomised clinical trials in which participants had previous bleeding from oesophageal varices and those who had previously undergone liver transplantation or previously received prophylactic treatment for oesophageal varices.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR), and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute for Health and Care Excellence Decision Support Unit guidance. We performed the direct comparisons from randomised clinical trials using the same codes and the same technical details.

MAIN RESULTS

We included 66 randomised clinical trials (6653 participants) in the review. Sixty trials (6212 participants) provided data for one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those at high risk of bleeding from oesophageal varices. The follow-up in the trials that reported outcomes ranged from 6 months to 60 months. All but one of the trials were at high risk of bias. The interventions compared included beta-blockers, no active intervention, variceal band ligation, sclerotherapy, beta-blockers plus variceal band ligation, beta-blockers plus nitrates, nitrates, beta-blockers plus sclerotherapy, and portocaval shunt. Overall, 21.2% of participants who received non-selective beta-blockers ('beta-blockers') - the reference treatment (chosen because this was the most common treatment compared in the trials) - died during 8-month to 60-month follow-up. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates all had lower mortality versus no active intervention (beta-blockers: HR 0.49, 95% CrI 0.36 to 0.67; direct comparison HR: 0.59, 95% CrI 0.42 to 0.83; 10 trials, 1200 participants; variceal band ligation: HR 0.51, 95% CrI 0.35 to 0.74; direct comparison HR 0.49, 95% CrI 0.12 to 2.14; 3 trials, 355 participants; sclerotherapy: HR 0.66, 95% CrI 0.51 to 0.85; direct comparison HR 0.61, 95% CrI 0.41 to 0.90; 18 trials, 1666 participants; beta-blockers plus nitrates: HR 0.41, 95% CrI 0.20 to 0.85; no direct comparison). No trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation had a higher number of serious adverse events (number of events) than beta-blockers (rate ratio 10.49, 95% CrI 2.83 to 60.64; 1 trial, 168 participants). Based on low-certainty evidence, beta-blockers plus nitrates had a higher number of 'any adverse events (number of participants)' than beta-blockers alone (OR 3.41, 95% CrI 1.11 to 11.28; 1 trial, 57 participants). Based on low-certainty evidence, adverse events (number of events) were higher in sclerotherapy than in beta-blockers (rate ratio 2.49, 95% CrI 1.53 to 4.22; direct comparison rate ratio 2.47, 95% CrI 1.27 to 5.06; 2 trials, 90 participants), and in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison rate ratio 1.72, 95% CrI 1.08 to 2.76; 1 trial, 140 participants). Based on low-certainty evidence, any variceal bleed was lower in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison HR 0.21, 95% CrI 0.04 to 0.71; 1 trial, 173 participants). Based on low-certainty evidence, any variceal bleed was higher in nitrates than beta-blockers (direct comparison HR 6.40, 95% CrI 1.58 to 47.42; 1 trial, 52 participants). The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons.

AUTHORS' CONCLUSIONS

Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease mortality compared to no intervention in people with high-risk oesophageal varices in people with cirrhosis and no previous history of bleeding. Based on low-certainty evidence, variceal band ligation may result in a higher number of serious adverse events than beta-blockers. The evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding. The evidence also indicates considerable uncertainty about the effect of the interventions in most of the remaining comparisons.

Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis

BACKGROUND

Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms.

OBJECTIVES

To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons.

AUTHORS' CONCLUSIONS

The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.

Endoscopic Therapy and Radiologic Intervention of Acute Gastroesophageal Variceal Bleeding

Acute gastroesophageal variceal hemorrhage is a dreaded complication in patients with liver cirrhosis. Endoscopic therapy and radiologic intervention for gastroesophageal bleeding have rapidly developed in the recent decades. Endoscopic treatment is initially performed to stop variceal hemorrhage. For the treatment of esophageal variceal bleeding, endoscopic variceal ligation (EVL) is considered the endoscopic treatment of choice. In cases of gastric variceal hemorrhage, the type of gastric varices (GVs) is important in deciding the strategy of endoscopic treatment. Endoscopic variceal obturation (EVO) is recommended for fundal variceal bleeding. For the management of gastroesophageal varix type 1 bleeding, both EVO and EVL are available treatment options; however, EVO is preferred over EVL. If endoscopic management fails to control variceal hemorrhage, radiologic interventional modalities could be considered. Transjugular intrahepatic portosystemic shunt is a good option for rescue treatment in refractory variceal bleeding. In cases of refractory hemorrhage of GVs in patients with a gastrorenal shunt, balloon-occluded retrograde transvenous obliteration could be considered as a salvage treatment.

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.

A Prospective Study of Endoscopic Injection Sclerotherapy and Endoscopic Variceal Ligation in the Treatment of Esophageal Varices

INTRODUCTION

The aim of this study was to compare the effectiveness and safety of endoscopic injection sclerotherapy (EIS) with endoscopic variceal ligation (EVL) in the management of esophageal variceal bleeding (EVB).

PATIENTS AND METHODS

In this prospective study, we compared the EIS and EVL in 124 patients who had endoscopically proved bleeding from esophageal varices. According to different treatment methods, they were randomly divided into the EIS and the EVL groups. Sixty-four patients were treated with sclerotherapy and 60 with ligation. The patients were followed for a mean of 2 years, during which we determined the incidence of complications and recurrences of bleeding and the number of treatment sessions needed to eradicate varices, mortality, and survival.

RESULTS

Active bleeding at the first treatment was controlled by EIS in 19 of 19 patients and by EVL in 16 of 16 patients. The likelihood of early rebleeding was slightly smaller in the patients treated with EIS (7.8% versus 11.7%, P = .47). However, late rebleeding rate was slightly more in EIS patients (28.1% versus 23.3%, P = .54) without statistical significance. The rate of eradication of varices in the EIS group was slightly lower than in the EVL group (79.7% versus 86.7%, P = .30). There were also no statistically significant differences in mortality (1.6% versus 3.3%, P = .61) or survival rate (71.9% versus 78.3%, P = .41) (all P > .05) after EIS and EVL. However, fever in the EIS group was significantly higher compared to that of in the EVL group (n = 17, 26.6% versus n = 6, 10.0%, P = .02).

CONCLUSIONS

Both EIS and EVL produce excellent results, are safe, effective, feasible, and acceptable for EVB with minimum complications and obviate need for subsequent procedures in the short term. To make better choice, we should consider the hospital conditions, operator experience, and the characteristics of esophageal varices.

Emergency endoscopic variceal ligation following variceal rupture in patients with advanced hepatocellular carcinoma and portal vein tumor thrombosis: a retrospective study

BACKGROUND

The outcomes of treatment of ruptured varices in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) are unclear. We therefore evaluated the long- (rebleeding and death) and short-term (immediate death within 24 h of variceal bleeding diagnosis) outcomes of patients with PVTT who underwent emergency variceal band ligation.

METHODS

Data on 62 patients with PVTT and endoscopically proven esophageal or gastric variceal bleeding from 2007 to 2012 were studied. In most cases, the varices were treated using endoscopic variceal band ligation (EVL). We assessed the patients' rebleeding-free and overall survival using the Kaplan-Meier method, and a Cox proportional hazard model was used to analyze effect of independent factors on rebleeding-free and overall survival times.

RESULTS

Most patients had decompensated cirrhosis and were classified as Child-Pugh class B (56%) or C (36%). A total of 35 patients (56%) had PVTT in the main portal trunk. Among all patients, 58 (94%) and 4 (6%) had esophageal and gastric variceal bleeding, respectively. Bleeding was managed using EVL in all, but one patient (98%) who was treated with a Sengstaken-Blakemore tube. A total of 24 patients (39.3%) experienced rebleeding, and these patients had a median overall survival time of 36 days. A PVTT in the main portal trunk was predictive of rebleeding (hazard ratio 3.706, p = .0223), and α-fetoprotein-L3 levels <37.4% (hazard ratio 0.464, p = 0.015) and Child-Pugh class A/B (hazard ratio 0.398, p = 0.007) were associated with overall survival. We observed 95 bleeding events in 62 patients. EVL achieved hemostasis in 92 of the 95 bleeding events, whereas seven immediate deaths occurred due to variceal bleeding (7/92, 7.6%). All three bleeding events treated with modalities other than EVL resulted in immediate deaths.

CONCLUSIONS

EVL is a safe and effective treatment of variceal ruptures in patients with HCC and PVTT. After successful hemostasis, alleviation of the underlying liver function impairment and tumor control are equally important for a good prognosis.

Merits of prophylactic sclerotherapy for esophageal varices concomitant unresectable hepatocellular carcinoma: prospective randomized study

BACKGROUND

Several clinical studies of prophylactic therapy for esophageal varices have led to the conclusion that prophylactic therapy is of no value, and it is generally not accepted in the Western world. However, this is not the case in Japan. The present study evaluated the efficacy of prophylactic endoscopic injection sclerotherapy (EIS) in patients with unresectable hepatocellular carcinoma (HCC) and risky esophageal varices.

PATIENTS AND METHODS

Twenty-seven patients with 'likely-to-bleed' esophageal varices concomitant with unresectable HCC were randomly allocated to two groups. Thirteen patients underwent prophylactic EIS (EIS group), whereas the remaining 14 patients were observed conservatively (control group).

RESULTS

No bleeding from esophageal varices occurred in the EIS group during the entire period of this study, whereas in thecontrol group the cumulative bleeding rate was 44.8% in 6 months. Cumulative survival rates of patients in the EIS group and in the control group were 48.8% and 7.7% in 2 years, respectively. There was a statistically significant difference between the two groups in cumulative bleeding rate and survival rate (P < 0.01).

CONCLUSION

This prospective study demonstrated that prophylactic EIS could prolong the survival of the patients with esophageal varices concomitant with unresectable HCC. Prophylactic EIS for patients with unresectable HCC may be, in part, justified according to the present study.

Portal hypertension and gastrointestinal bleeding: Diagnosis, prevention and management

Bleeding from esophageal varices is a life threatening complication of portal hypertension. Primary prevention of bleeding in patients at risk for a first bleeding episode is therefore a major goal. Medical prophylaxis consists of non-selective beta-blockers like propranolol or carvedilol. Variceal endoscopic band ligation is equally effective but procedure related morbidity is a drawback of the method. Therapy of acute bleeding is based on three strategies: vasopressor drugs like terlipressin, antibiotics and endoscopic therapy. In refractory bleeding, self-expandable stents offer an option for bridging to definite treatments like transjugular intrahepatic portosystemic shunt (TIPS). Treatment of bleeding from gastric varices depends on vasopressor drugs and on injection of varices with cyanoacrylate. Strategies for primary or secondary prevention are based on non-selective beta-blockers but data from large clinical trials is lacking. Therapy of refractory bleeding relies on shunt-procedures like TIPS. Bleeding from ectopic varices, portal hypertensive gastropathy and gastric antral vascular ectasia-syndrome is less common. Possible medical and endoscopic treatment options are discussed.

Gastrointestinal Bleeding in Cirrhotic Patients with Portal Hypertension

Gastrointestinal bleeding related to portal hypertension is a serious complication in patients with liver cirrhosis. Most patients bleed from esophageal or gastric varices, but bleeding from ectopic varices or portal hypertensive gastropathy is also possible. The management of acute bleeding has changed over the last years. Patients are managed with a combination of endoscopic and pharmacologic treatment. The endoscopic treatment of choice for esophageal variceal bleeding is variceal band ligation. Bleeding from gastric varices is treated by injection with cyanoacrylate. Treatment with vasoactive drugs as well as antibiotic treatment is started before or at the time point of endoscopy. The first-line treatment for primary prophylaxis of esophageal variceal bleeding is nonselective beta blockers. Pharmacologic therapy is recommended for most patients; band ligation is an alternative in patients with contraindications for or intolerability of beta blockers. Treatment options for secondary prophylaxis include variceal band ligation, beta blockers, a combination of nitrates and beta blockers, and combination of band ligation and pharmacologic treatment. A clear superiority of one treatment over the other has not been shown. Bleeding from portal hypertensive gastropathy or ectopic varices is less common. Treatment options include beta blocker therapy, injection therapy, and interventional radiology.

Successful endoscopic injection sclerotherapy of high-risk gastroesophageal varices in a cirrhotic patient with hemophilia A

A 68-year-old man with hemophilia A and liver cirrhosis caused by hepatitis C virus was referred to our hospital to receive prophylactic endoscopic treatment for gastroesophageal varices (GOV). He had large, tense, and winding esophageal varices (EV) with cherry red spots extending down to lesser curve, predicting the likelihood of bleeding. Esophageal endoscopic injection sclerotherapy (EIS) was performed with a total 15 mL of 5% ethanolamine oleate with iopamidol (EOI). Radiographic imaging during EIS demonstrated that 5% EOI reached the afferent vein of the varices. He was administered sufficient factor VIII concentrate before and after EIS to prevent massive bleeding from the varices. Seven days after EIS, upper gastrointestinal endoscopy (UGIE) showed that the varices were eradicated almost completely. Eighteen months after EIS, the varices continued to diminish. We report a successful case of safe and effective EIS for GOV in a high-risk cirrhotic patient with hemophilia A.

White ball appearance: predictor of effective variceal ligation in massive bleeding with an obscure bleeding point

Although a purple-colored ball-like appearance (purple ball appearance) is typically observed on ligated varices during endoscopic variceal ligation (EVL), another endoscopic appearance of ligated varices (white ball appearance), which is observed after EVL at the bleeding site, have been reported. We encountered a case of massive variceal bleeding with an obscure bleeding point, where this appearance was useful in the confirmation of effective ligation. A 66-year-old man, who had liver cirrhosis with hepatocellular carcinoma, presented with hematemesis and melena. Although emergent endoscopy revealed a fibrin-plug on the esophageal varix, massive esophageal bleeding occurred and precluded direct visualization of the bleeding point during endoscopy. After multiple EVL, one ball-like elevation with a white color (white ball appearance) and multiple ball-like elevations with a red or purple color (purple ball appearance) were observed in the esophagus. Based on the presence of the white ball appearance, a predictor of effective ligation, we confirmed the ligation of the exact site of bleeding and complete cessation of bleeding. In fact, the ligated varix with the white ball appearance contained a ruptured point. This characteristic endoscopic appearance is useful for the assessment of effective ligation in massive variceal bleeding with an obscure bleeding point.

A modified percutaneous transhepatic variceal embolization with 2-octyl cyanoacrylate versus endoscopic ligation in esophageal variceal bleeding management: randomized controlled trial

BACKGROUND

Conventional percutaneous transhepatic varices embolization (PTVE) has rarely been used in recent years due to high rates of variceal recurrence and rebleeding. Herein we report a modified PTVE with 2-octyl cyanoacrylate (2-OCA) in which the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the advertitial plexus of the cardia and fundus were sufficiently obliterated. We compared this PTVE with endoscopic band ligation (EVL) in the treatment of esophageal variceal bleeding.

METHODS

In this prospective randomized controlled trial, cirrhotic patients with acute or recent esophageal variceal bleeding were assigned randomly to PTVE (52 patients) or EVL (50 patients) groups. Upper gastrointestinal (UGI) rebleeding, esophageal variceal rebleeding, and survival were followed-up. Computerized tomography (CT) scanning and portal venography were used to observe 2-OCA distribution.

RESULTS

During the follow-up period (median 24 and 25 months in the PTVE and EVL groups, respectively) UGI rebleeding developed in eight patients in the PTVE group and 21 patients in EVL group (P = 0.004). Recurrent bleeding from esophageal varices occurred in three patients in the PTVE group and twelve in the EVL group (P = 0.012, relative risk 0.24, 95% confidence interval 0.05-0.74). Multivariate Cox analysis indicated that the treatment was the only factor predictive of rebleeding. A Kaplan-Meier curve showed there was no significant difference between survival in the two groups (P = 0.054).

CONCLUSIONS

With the whole lower esophageal and peri or para-esophageal varices, the submucosal varices, and the adventitial plexus of the cardia and fundus sufficiently obliterated by 2-OCA, this modified PTVE was more effective than EVL in the management of esophageal varices recurrence and rebleeding. Survival in these two groups was not significantly different, however.

Efficacy of absolute alcohol injection compared with band ligation in the eradication of esophageal varices

BACKGROUND

Endoscopic sclerotherapy is an absolute indication for treating esophageal varices. Re-bleeding is common during the treatment period, before all varices become eradicated.

AIM

To compare two techniques of endoscopic esophageal varices eradication: sclerotherapy with absolute alcohol and banding ligation.

PATIENTS AND METHOD

Forty-six patients with liver cirrhosis and esophageal varices were prospectively randomized into two treatment groups: endoscopic sclerotherapy with absolute alcohol and banding ligation. Patients were included if they had large varices with signs of high bleeding risk. Informed writing consent was obtained from every patient and the Ethics Committee of Federal University of São Paulo, SP, Brazil, approved the study. After eradication, all patients were followed up to 1 year to look for re-bleeding episodes and variceal recurrence.

RESULTS

Both groups were similar except that male gender was more common in the sclerotherapy group. There was no statistical difference regarding variceal eradication (78.3% in sclerotherapy group vs 73.9% in the ligation group), recurrence (26.7% vs 42.9%, respectively) and death related to any cause (21.7% vs 13.9%). In the sclerotherapy group more sessions were need to obtain complete variceal eradication. In this group we did observe a high re-bleeding rate (34.8%) and more ulcers associated with retrosternal pain right after the procedure. There was no difference regarding overall morbidity and mortality.

CONCLUSIONS

Banding ligation requires fewer sessions than sclerotherapy with absolute alcohol to eradicate esophageal varices. Both methods are equally efficient regarding variceal eradication and recurrence during a short follow-up period.

Band ligation plus sclerotherapy versus sclerotherapy alone in children with extrahepatic portal venous obstruction

Although endoscopic band ligation (EVL) plus sclerotherapy (EST) has shown to be superior to any individual method, there is no study in children. We therefore analyzed our experience of EST and EVL + EST in children with extrahepatic portal venous obstruction (EHPVO). Over a period of 8 years, 136 children who presented with a history of recent variceal bleeding due to EHPVO were studied; 30 of them received EVL + EST and 106 received EST alone. In the EVL + EST group, after the first session of EVL, EST was done three times weekly until variceal eradication was achieved. The mean age of these children was 7 +/- 3.6 years with a male-to-female ratio of 2.6:1. The rate of eradication was comparable in both groups (100% in EVL + EST and 96% in EST). However, EVL + EST group required a significantly fewer sessions and lower volume of sclerosant (2 +/- 1 vs. 4.4 +/- 2 sessions, P < 0.001 and 3.1 +/- 2 mL versus 7.5 +/- 4 mL, P < 0.001 respectively). There were significantly less complications in EVL + EST group (10% vs. 36%, P < 0.01). Over a mean follow-up of 27 months, varices recurred in 6.6% and 10% cases, respectively. EVL + EST is a better method in the treatment of esophageal varices in children with EHPVO than EST alone, as it required fewer session and had fewer complication.

Impact of transjugular intrahepatic portosystemic stent-shunt for secondary prophylaxis of oesophageal variceal haemorrhage: a single-centre study over an 11-year period

AIMS

The role of various treatments for variceal haemorrhage is currently being evaluated. The purpose of this study was to analyse the impact of the use of endoscopic variceal sclerotherapy (EVS), variceal band ligation (VBL) and transjugular intrahepatic portosystemic stent-shunt (TIPSS) for secondary prophylaxis on the outcome of cirrhotic patients with the first episode of variceal haemorrhage presenting to a single centre.

METHODS

Between 1986 and 1996, data from 225 consecutive patients with the first episode of variceal haemorrhage were analysed. The modality of treatment for secondary prophylaxis between 1986 and 1991 was EVS (group I: n = 83; Child class C, 29%; mean follow-up 36 +/- 3 months), between 1991 and 1993 VBL (group II: n = 56; Child class C, 38%; mean follow-up 24 +/- 3 months), and between 1995 and 1996 TIPSS (group III: n = 86; Child class C, 60%; mean follow-up 17 +/- 1 months). Half of the patients between 1993 and 1995 underwent VBL and the other half had TIPSS. Data regarding rebleeding, mortality and encephalopathy were analysed using the Kaplan-Meier method. Cox's proportional hazard regression was used to test the significance of prognostic factors.

RESULTS

Seventy-five per cent of patients re-bled in group I, 40% in group II, and 16% in group III (P < 0.0001). Mortality was significantly lower in the patients with Child class C disease in group III patients compared with those in groups I and II (P < 0.02). TIPSS was associated independently with reduced early mortality and re-bleeding.

CONCLUSION

The results of this study suggest that TIPSS improves survival in patients with advanced liver disease and variceal haemorrhage, and should be considered for secondary prophylaxis in high-risk patients.

Photodynamic effects on rabbit auricular veins after photosensitization with porfimer sodium: Implications of the results with respect to the treatment of esophageal varices with photodynamic therapy

BACKGROUND

There are numerous clinical applications for photodynamic therapy in the GI tract. The principal reason for the wide variety of lesions amenable to photodynamic therapy is the ability to treat large areas of mucosa without the need for complete visualization. This report describes observed hemodynamic and histologic changes in rabbit auricles after photodynamic therapy and the feasibility of photodynamic therapy for esophageal varices.

METHODS

Porfimer sodium and an argon-dye laser (630 nm, 300 mW/cm(2)) were used. Twenty rabbits were grouped according to porfimer sodium dose: group 1 (2.0 mg/kg, n = 10); group 2 (1.0 mg/kg, n = 6); group 3 (0.2 mg/kg, n = 4). Rabbit auricular veins were classified according to time duration of laser illumination: V(0), no illumination; V(5), 5 minutes; V(10), 10 minutes; V(15), 15 minutes. Hemodynamic changes were observed with a laser Doppler blood flow meter. Histologic changes were evaluated by light microscopy.

RESULTS

For groups 1 and 2, there was a significant decrease in blood flow for V(15) after photodynamic therapy, but not in group 3. There was a significant difference in the grade of thrombus between V(5) and V(15) in groups 1 and 2, and between V(10) and V(15) in group 2. There was a significant difference in the grade of venous dilation (congestion) for V(15) between groups 1 and 3 (p < 0.05, Kruskal-Wallis test).

CONCLUSIONS

Endoscopic photodynamic therapy could possibly improve the outcome for endoscopic treatment of esophageal varices beyond that achieved by sclerotherapy or band ligation alone.

Adjuvant sclerotherapy after ligation for the treatment of esophageal varices: a prospective, randomized long-term study

BACKGROUND

To assess the efficacy of adjuvant sclerotherapy after banding for the treatment of esophageal varices, a randomized trial was carried out of endoscopic variceal ligation (EVL) alone with sequential sclerotherapy versus sequential ligation-sclerotherapy (SLS) after banding with respect to variceal eradication, associated complications, and recurrence of varices.

METHODS

One hundred patients qualified for this study. Fourteen patients were not included for the following reasons: 6 chose not to participate, 4 had fundal varices, and 4 had some form of cancer. Of the remaining 86 patients in the study, 42 underwent EVL alone and the other 44 SLS. Variceal ligation was begun in the region of the gastroesophageal junction, with subsequent ligatures applied cephalad 3 to 5 cm; ligation was repeated every 2 weeks until variceal obliteration. For SLS, ligation was also begun in the region of the gastroesophageal junction and repeated until varices were reduced to F1 size. Subsequently, these patients underwent sclerotherapy with between 6 and 8 mL of sodium tetradecyl sulfate (free hand technique).

RESULTS

No significant differences were found between EVL alone and SLS with regard to variceal eradication, development of associated complications, and recurrent bleeding during a follow-up of 2 years. The probability of variceal recurrence requiring further treatment after 1 year was 14% for the SLS group and 26% for EVL group patients. Another year later, the probability of variceal recurrence was 24% and 45%, respectively, for the SLS and EVL groups.

CONCLUSIONS

Because a significantly lower rate of variceal recurrence was found for SLS patients, sequential sclerotherapy followed by ligation to eradicate those varices too small to easily band may be a better procedure.

Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery

Interventional endoscopic techniques have been indespensible in almost every area of modern surgery. As surgeons, we need to continue to advance our skills in these areas if we expect to continue to be involved in these aspects of patient care.

Mechanical endoscopic methods of haemostasis for bleeding peptic ulcers: a review

Re-bleeding following endoscopic therapy for gastrointestinal bleeding remains common probably because injection and thermal methods for treating bleeding are of limited efficacy, especially in the presence of a large bleeding artery. This chapter reviews mechanical methods of endoscopic haemostasis. The design of clips, which can be delivered through flexible endoscopes, is reviewed with experimental and clinical data of their efficacy. The need for improvements in clip design is stressed. Experimental studies and preliminary clinical data where available on a variety of other mechanical methods of haemostasis are presented, including band ligation, endoloops, sewing machines, stapling machines, ulcer clamps, corkscrews, balloon tamponade and ferromagnetic tamponade. New, less invasive, surgical methods which might have a place in ulcer haemostasis, including transgastric endoluminal surgery and flexible endoscopic ulcer excision with wound closure, are discussed. Mechanical methods offer the best prospect for improvements in security of endoscopic haemostasis for bleeding peptic ulcer. More development is required if the results are to improve.

Management of gastrointestinal bleeding induced by gastrointestinal endoscopy

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

Variceal band ligation and variceal band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding in cirrhotic patients: a randomized, prospective and controlled trial

BACKGROUND

The combination treatment of band ligation plus sclerotherapy has been proposed to hasten variceal eradication. The aim of this study was to assess the efficacy of band ligation alone versus band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding.

METHODS

Eighty cirrhotic patients were randomized to group I (band ligation) with 41 patients or to group II (band ligation plus sclerotherapy) with 39 patients in whom polidocanol (2%) was injected 1 to 2 cm proximal to each band.

RESULTS

At baseline, both groups were similar with regard to clinical, demographic and laboratory data. Mean follow-up time (standard error) for group I was 336.5 +/- 43.4 days and for group II 386.1 +/- 40.1 days (p = 0.4). No statistical differences were observed between group I and group II in relation to recurrence of bleeding (31.7% vs. 23%, p = 0.38), treatment failure (24.4% vs. 12. 8%, p = 0.18), death (39% vs. 30.8%, p = 0.44) and variceal eradication (65.8% vs. 74.4%, p = 0.40). Group II had a significantly higher number of complications than group I, 30.8% versus 7.3%, respectively (p = 0.05). The number of bleeding related deaths was higher in group I than in group II (22% vs. 10.3%, respectively; p = 0.15).

CONCLUSIONS

No significant difference was observed between band ligation and band ligation plus sclerotherapy in prevention of recurrent variceal bleeding. Furthermore, there was a higher incidence of complications in the latter group.

Development and application of endoloops for the treatment of bleeding esophageal varices

BACKGROUND

Endoloops are detachable nylon snares. The aims of this study were to develop an endoscopic method for repeated delivery of endoloops to arrest variceal bleeding, to compare efficacy of endoloop hemostasis with injection and band ligation in experimental models of bleeding, and to test the reliability and safety of endoloops in a pilot study in patients with varices.

METHODS

Technical modifications including ridged endcaps and alterations in angulation of endoloops were developed to speed delivery and improve efficacy. Hemostatic efficacy of endoloops was compared with sclerotherapy and band ligation in animal studies before studies in patients.

RESULTS

Modified endcap and endoloops allowed repeated applications without withdrawal of the endoscope. Right-angled endoloops ensnared more (p < 0.0001) gastric tissue and were more reliable (p < 0.05) than straight endoloops. Injection therapy and prestretched bands appeared ineffective, whereas band ligation was only effective on vessels up to 2 mm in diameter. Only endoloops achieved hemostasis on vessels of 3 to 5 mm (p < 0.05). No significant complications occurred using endoloops in animal (esophagus n = 20, stomach n = 20) or human (n = 11) studies.

CONCLUSIONS

Endcap and endoloop modifications simplified repeated application to varices. Endoloops were more effective than injection or band ligation in experimental hemostasis and appeared safe and effective in patients.

Comparison of endoscopic variceal sclerotherapy with sequential endoscopic band ligation plus low-dose sclerotherapy for secondary prophylaxis of variceal hemorrhage: a prospective randomized study

BACKGROUND

Endoscopic variceal sclerotherapy and band ligation both have certain limitations such as, respectively, esophageal complications and early recurrence of varices.

METHODS

From February 1994 to March 1996, all consecutive patients with portal hypertension due to either cirrhosis or noncirrhotic portal fibrosis and a history of variceal bleeding were included in a prospective study and randomly assigned to receive either endoscopic variceal sclerotherapy alone or endoscopic variceal band ligation plus low-dose endoscopic variceal sclerotherapy.

RESULTS

Of 69 patients, 34 were randomly assigned to receive endoscopic variceal sclerotherapy alone; 35 received endoscopic variceal band ligation plus endoscopic variceal sclerotherapy. Complete variceal eradication rates (85% vs. 80%) and the number of endoscopic sessions required for eradication (6.61 +/- 2.94 vs. 7.85 +/- 3.31) were similar in the endoscopic variceal sclerotherapy and endoscopic variceal band ligation plus endoscopic variceal sclerotherapy groups, respectively. The mean volume of sclerosant required in the combined group (54.94 +/- 33.74 mL) was significantly less than that in the endoscopic variceal sclerotherapy group (81.91 +/- 34.80 mL). The complication and recurrent bleeding rates were significantly higher in the endoscopic variceal sclerotherapy group than those in the combined group (20% and 16% vs. 3% and 3%, respectively).

CONCLUSIONS

Both endoscopic variceal sclerotherapy and endoscopic variceal band ligation plus endoscopic variceal sclerotherapy were comparable in eradicating varices but the combined technique was associated with significantly lower complication and recurrent bleeding rates.

Sclerotherapy plus ligation versus ligation for the treatment of esophageal varices: a prospective randomized study

BACKGROUND

We devised a new combined method of endoscopic variceal ligation and injection sclerotherapy, namely, endoscopic scleroligation, for the treatment of esophageal varices. The aim of this prospective randomized trial was to compare endoscopic scleroligation with endoscopic variceal ligation alone with regard to efficacy, complications, variceal recurrence, and survival.

METHODS

Fifty-one patients with cirrhosis and esophageal varices were randomly assigned to be treated by endoscopic scleroligation (n = 25) or endoscopic variceal ligation (n = 26). In the initial session in the endoscopic scleroligation group, endoscopic injection sclerotherapy was performed with injection of 5% ethanolamine oleate around the lower esophagus to obliterate the feeding veins. This was followed by endoscopic variceal ligation from the injection site to the most orad varix. In subsequent sessions, endoscopic injection sclerotherapy was performed with 1% polidocanol. In the endoscopic variceal ligation group, that procedure was performed in all treatment sessions.

RESULTS

Both methods were equally effective in achieving complete eradication of esophageal varices. Among the cases in which complete eradication was achieved, the 1- and 3-year cumulative recurrence rates in the endoscopic scleroligation group (9.5%, 22.1%) were significantly lower than those in the endoscopic variceal ligation group (61.9%, 72.2%) (p < 0.01). The survival rates and incidences of treatment-related complications have been similar among patients treated by both methods.

CONCLUSIONS

Endoscopic scleroligation is superior to endoscopic variceal ligation in preventing variceal recurrence.

Evaluation of endoscopic variceal ligation in prophylactic therapy for bleeding of oesophageal varices: a prospective, controlled trial compared with endoscopic injection sclerotherapy

BACKGROUND

To evaluate the efficacy of endoscopic variceal ligation (EVL) in prophylactic therapy for oesophageal varices, we performed a randomized prospective trial to compare the recurrence of oesophageal varices treated by EVL with those treated by endoscopic injection sclerotherapy.

METHODS

Fifty patients with liver cirrhosis were divided into two groups at random, after informed consents were obtained, to receive prophylactic therapy for bleeding of oesophageal varices. Group 1 patients underwent sessions of sclerotherapy with 5% ethanolamine oleate used as the sclerosant. Group 2 patients underwent EVL followed by one or two sessions of sclerotherapy.

RESULTS

During the 18 month follow-up period, both the recurrence rate in group 2 (56%) and the incidence of bleeding (20%) were significantly higher compared with group 1 (recurrence rate 16%, bleeding 0%).

CONCLUSIONS

This result indicates that EVL is not effective for prophylactic therapy for oesophageal varices in liver cirrhosis.

The economic impact of esophageal variceal hemorrhage: cost-effectiveness implications of endoscopic therapy

Esophageal variceal hemorrhage (EVH) is a serious and expensive sequela of chronic liver disease, leading to increased utilization of resources. Today, endoscopic sclerotherapy (ES) and endoscopic ligation (EL) are the accepted, community standards of endoscopic treatment of patients with EVH. However, there are no published studies comparing the economic costs of treating EVH using these interventions. As part of a prospective, randomized trial comparing ES and EL for the treatment of EVH, we estimated the direct costs of health care utilization and cost-effectiveness for the prevention of variceal rebleeding and patient survival at 1-year follow-up. Treatment groups were similar in incidence of variceal rebleeding (41.9% vs. 42.9%), variceal obliteration (41.9% vs. 40.0%), hospital days, blood transfusions, shunt requirements, and survival (71.0% vs. 60.0%). There were significantly more treatment failures for active bleeding using EL (42% vs. 0%; P =.027) and esophageal stricture formation in the ES-treated patients (19.4% vs. 2.9%; P = 0.03). Median total direct cost outcomes were similar between groups (EL = $9,696 and ES = $13,197; P =.46). EL and ES had similar cost/variceal rebleeding prevented ($28,678 vs. $29,093) and cost/survival ($27,313 vs. $23,804). In the subgroup of active bleeders, ES had a substantially lower cost/survival ($28,523 vs. $51,696). We conclude that resource utilization was similar between treatment groups and that the choice of endoscopic therapy for EVH must still rely on clinical grounds. Further studies comparing costs and resource utilization in this patient population are needed.

The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: a prospective, randomized trial

Endoscopic variceal ligation (EVL) is a new technique designed to manage esophageal varices. The effect of sclerotherapy following repeated banding ligation remains unknown. Seventy-two patients with a history of esophageal variceal bleeding received regular EVL until variceal disappearance or until left with residual small varices. Subsequently, patients were randomized to receive sclerotherapy (Group 1, 37 patients) or serve as a control (Group 2, 35 patients). Group 1 received one to two sessions of low-dose sclerotherapy to achieve complete variceal disappearance. After a mean follow-up of 2 years, 4 months, recurrent esophageal varices developed in 14% of Group 1 and 43% of Group 2 (P < .02). Rebleeding was encountered in 8% of Group 1 versus 31% of Group 2 (P = .01). One case of esophageal stricture (2.7%) was encountered in Group 1. One patient in Group 1, compared with 3 patients in Group 2, died of massive variceal bleeding (P > .05). The multivariate Cox model indicated that treatment was the only factor predictive of variceal recurrence, and both Child-Pugh class and treatment were factors predictive of variceal rebleeding. The addition of low-dose sclerotherapy following repeated banding ligations proved safe and effective in the prevention of recurrence of esophageal varices and rebleeding.

White ball appearance in endoscopic ligation of bleeding esophageal varices

BACKGROUND

Endoscopic variceal ligation is useful in the control of bleeding from esophageal varices. However, confirmation of ligation precisely at the site of bleeding is usually difficult when treating massive variceal bleeding. Characteristic endoscopic findings that appeared when ligation was performed at the site of bleeding are reported in this article.

METHODS

Emergency endoscopic variceal ligation was performed in 14 patients with active bleeding from esophageal varices. Endoscopic findings after variceal ligation at the site of bleeding were compared with those at sites without bleeding.

RESULTS

Active bleeding ceased just after endoscopic ligation at the site of bleeding in all patients. After ligation of the bleeding site of the varix, an unusual white-colored ball-like appearance (white ball appearance) was observed in all patients. This finding was markedly different from the purple-colored ball-like appearance that is usually observed after ligation of a varix at a site without bleeding.

CONCLUSIONS

White ball appearance was a characteristic finding that appeared after ligation of a varix at the site of bleeding. This finding may be useful in the confirmation of successful ligation of a varix at its bleeding site.

A pilot study on modified endoscopic variceal ligation using endoscopic ultrasonography with color Doppler function

OBJECTIVE

The purpose of the study was to evaluate feasibility of modified endoscopic variceal ligation (EVL), namely the "intensive ligation" method, using endoscopic ultrasonography with color Doppler function (EUS-CD).

METHODS

Forty-five patients with esophageal varices were treated by modified EVL. Variceal hemodynamics in 38 patients were examined using EUS-CD, which showed abdominal hemodynamics in detail under physiological conditions before and after the modified procedure.

RESULTS

1) The median number of treatment sessions was 3.2, and 41 O-rings on average were required per individual patient. 2) The median nonrecurrence period after treatment was 18 months (Kaplan-Meier method). 3) Nine patients with a good response to modified EVL did not have recurrences for 16.9+/-2.8 months, and five with a poor response had recurrences at 5.8+/-2.2 months. Gastric varices were related to the response to modified EVL (p < 0.05, Mann-Whitney's U test). 4) Minor complications in modified EVL as well as standard EVL were experienced; however, we had a patient with the development of meningitis, which was a major septic complication. 5) Before modified EVL, EUS-CD demonstrated that good responders had undeveloped (grade I) gastric varices in five of nine (56%); however, poor responders had developed (grade III) gastric varices in four of five (80%) (p < 0.05, Mann-Whitney's U test]. 6) After modified EVL, EUS-CD revealed that six of nine (67%) good responders and one of five (20%) poor responders showed a decrease in color signals in supplying veins; however, none of the former (0%) and three of the latter (60%) showed an increase (p < 0.05, Mann-Whitney's U test].

CONCLUSION

Modified EVL was safe and effective, at least with regard to intermediate-term outcome, especially when treating patients with undeveloped gastric varices revealed by EUS-CD. Both good and poor responders showed no exacerbation of gastric varices after the modified procedure, ultrasonographically as well as endoscopically.

Clinical economics review: cost-effectiveness in the therapy of liver disease

There have been many advances made in the management of patients with liver disease both in diagnosis and in the treatment of underlying liver disease and its complications, although comparatively few of these have been rigorously subjected to full cost-effectiveness evaluation. In this review, we have analysed a small number of the therapeutic interventions; while these have been well evaluated clinically, very few have been analysed from the viewpoint of cost-effectiveness and, thus, it is difficult to make many definitive claims. It is hoped that future studies will consider these aspects as well.

Management of esophageal varices in children by endoscopic variceal ligation

Endoscopic variceal sclerotherapy (EVS) has been considered the mainstay of therapy for bleeding esophageal varices in adults. However, recent data have shown that endoscopic variceal ligation (EVL) is just as efficacious and has fewer complications than EVS. Although there are many reports concerning EVL in adults, only a few studies have been done in children. This report describes experience with EVL in 22 children with esophageal variceal hemorrhage. Eighty-seven EVL procedures were performed during a 9-year period in 22 children. The causes of portal hypertension were biliary atresia (10), portal vein thrombosis (8), chronic active hepatitis (1), cirrhosis secondary to cystic fibrosis (2), and primary sclerosing cholangitis (1). The age range at the onset of variceal bleeding was 8 months to 19 years. Twelve patients had EVS before EVL treatment was begun. Distal esophageal varices (one to four per session) were mechanically ligated using an elastic band ligature device attached to a flexible endoscope. The aim of therapy was obliteration of distal esophageal varices by EVL, every 2 to 4 weeks, until eradication. Subsequent EVL was dictated by the status of the varices. Outcome was assessed with respect to survival, rebleeding, status of varices, and complications. The patients underwent a mean of four sessions of EVL (range, one to eight). Four patients subsequently underwent liver transplantation. Of the 18 patients remaining (average follow-up period, 5.3 years), 12 had their varices eradicated (average of four EVL sessions), four are still in treatment, one has not been evaluated in the past 4 years, and one died of liver failure. Complications included bleeding between sessions (6 patients), cervical esophageal perforation (1 patient), and transient fever (2 patients). No child has experienced symptoms of esophageal stenosis or gastroesophageal reflux. Two patients died of liver disease, unrelated to bleeding from portal hypertension. EVL is effective in controlling variceal hemorrhage in children with portal hypertension, regardless of etiology. The complication rate is low, and EVL is an acceptable and perhaps preferable alternative to EVS in children with esophageal varices.

Extreme hyperbilirubinemia induced by endoscopic injection sclerotherapy in a patient with esophageal varices and thalassemia: report of a case

We describe herein the case of a 57-year-old man with thalassemia who developed acute liver failure after undergoing endoscopic injection sclerotherapy (EIS) to control hemorrhage from a ruptured esophageal varix. The patient, who had been confirmed as having liver cirrhosis due to chronic hepatitis C with thalassemia in 1989, was admitted to our department to undergo EIS for esophageal varices, at which time his serum total bilirubin level was 5.5 mg/dl. As a small amount of hematemesis occurred just after a percutaneous transhepatic portography was performed, emergency EIS was carried out, following which the serum total bilirubin level markedly increased, mainly with a direct fraction, until it reached 70 mg/dl. The patient eventually died from acute liver failure with extreme hyperbilirubinemia on the 27th day after experiencing hematemesis despite all treatment. This unfortunate case demonstrates that sclerotherapy could be an inappropriate method of treatment for patients with hemolytic disease.

New approaches to endoscopic therapy for a haemostasis upper GI bleed

Haematemesis and/or melaena are the most common presentations of upper gastrointestinal bleeding. Endoscopic haemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. In the present article, four less well-known endoscopic haemostasis techniques are discussed and, if available, comparative studies are reviewed.

The impact of endoscopic variceal ligation on the pressure of the portal venous system

BACKGROUND/AIMS

Endoscopic variceal ligation is a viable substitute for injection sclerotherapy. It is still not known how endoscopic variceal ligation may influence the portal venous system. To clarify this issue we investigated the impact of endoscopic variceal ligation on the pressure of the portal venous system.

METHODS

Twenty-nine patients with a history of esophageal variceal bleeding but without ascites were enrolled. All had cirrhosis; 63% of them were post-hepatitic. Ligation was performed at intervals of 2-3 weeks until all the varices were obliterated. Portal venograms were performed before institution of ligation and after variceal obliteration to assess venographic findings and pressure changes. The pressures of the main portal vein, splenic vein and superior mesenteric vein were recorded.

RESULTS

Twenty-five patients completed the study. A mean of 4.4 sessions (range: 2-7) of ligation over a period of 2 months was needed. Seventeen (68%) patients experienced elevated pressure and eight (32%) patients reduced pressure after ligation. Mean (median) pressure changes were as follows: portal venous pressure, 26.5 +/- 4.7 (25.0) mmHg vs. 28.2 +/- 7.2 (28.0) mmHg (p > 0.05); splenic venous pressure, 28.2 +/- 4.9 (26.0) mmHg vs. 29.0 +/- 6.8 (29.0) mmHg (p > 0.05); superior mesenteric venous pressure, 28.4 +/- 6.0 (27.0) mmHg vs. 29.5 +/- 7.0 (29.0) mmHg (p > 0.05). Five patients (20%) experienced rebleeding before variceal obliteration; all of them presented elevated portal pressures after variceal obliteration. Among the eight patients with decreased portal pressure, seven (87%) had other major collaterals apart from esophageal varices, compared to three out of the 17 (18%) patients with elevated portal pressure who had other major collaterals (p < 0.01).

CONCLUSIONS

Among patients receiving endoscopic variceal ligation, 68% experienced elevated portal pressure, while 32% had decreased portal pressure. Elevation of portal pressure after variceal ligation may be an important factor in variceal rebleeding. The presence of other major collaterals apart from esophageal varices may be responsible for the decrease in portal pressure after obliteration of esophagel varices.

Prospective randomised study of effect of octreotide on rebleeding from oesophageal varices after endoscopic ligation

Up to a third of patients have early rebleeding from oesophageal varices after endoscopic variceal ligation. Octreotide infusion is effective for control of variceal bleeding. We investigated the efficacy of octreotide infusion as an adjunct to endoscopic variceal ligation to prevent early rebleeding from varices. 100 consecutive patients admitted with endoscopically confirmed oesophageal varices and active bleeding or signs of recent haemorrhage were randomly assigned endoscopic variceal ligation alone or octreotide (50 micrograms intravenous bolus injection followed by intravenous infusion at 50 micrograms per h for 5 days) plus endoscopic variceal ligation. Three patients in each group were excluded. Bleeding was controlled in 44 of 47 patients who received variceal ligation alone and in 45 of 47 who received combined treatment (p = 1.0). Recurrent bleeding was documented in 18 (38% [24-52]) patients who received variceal ligation alone and in four (9% [3-21] who received combined treatment (p = 0.0007). The relative risk of rebleeding was lower (0.22 [0.08-0.60]) in the combined therapy group. Ten patients in the variceal ligation group and one in the combined therapy group required balloon tamponade for massive haematesis and haemodynamic instability (p = 0.0039). The in-hospital and 30-day mortality rates were higher in the variceal ligation group than in the combined therapy group (19 vs 9% and 23 vs 11%), but the differences did not reach significance. The relative risks of in-hospital (0.5 [0.04=5.3]) and 30-day (0.45 [0.17-1.2]) mortality were lower in the combined therapy group. Octreotide significantly reduces recurrent bleeding and the need for balloon tamponade in patients with variceal haemorrhage treated by endoscopic variceal ligation.

Current management of oesophageal varices

Patients with chronic liver disease and large varices with endoscopic features which put them at high risk of bleeding, especially if they have a HVPG of more than 12 mmHg, should be treated with beta-blockers at a dose which lowers their pulse by 25%, as prophylaxis against future bleeding. Once a patient bleeds from oesophageal varices, emergency treatment with octreotide should be commenced until endoscopic sclero- or ligation therapy is performed. If these treatments are not readily available, or if bleeding continues in spite of treatment, balloon tamponade is employed to arrest bleeding. In the event of recurrent bleeding, further sclero- or ligation therapy should be attempted, but continued bleeding would dictate surgical therapy or insertion of a TIPS. What operation is performed would depend on the local expertise. In a suitable candidate, liver transplantation would be considered. If bleeding is controlled by sclero- or ligation therapy, chronic sclerotherapy should be continued until the varices are obliterated, and beta-blockers commenced. Regular follow-up should be arranged to encourage abstinence from alcohol if appropriate, and to decide the most opportune time for transplantation if indicated.

A new method of endoscopic variceal ligation-injection sclerotherapy (EVLIS) for gastric varices

OBJECTIVES

For esophageal varices, endoscopic variceal sclerotherapy and band ligation have been effectively and frequently used, but these methods were not effective for gastric varices. In gastric varices, because of rich networks of feeding vessels and shunts that may exist in many cases, an effective therapeutic level of sclerosant is difficult to be maintained. Accordingly, we propose a new method called "Endoscopic Variceal Ligation-Injection Sclerotherapy (abbreviated EVLIS)" for gastiric varices, with focus on maintenance of the effective therapeutic level of a sclerosant by partially blocking the blood flow of gastric varices using the band ligation method. The study was undertaken prospectively to evaluate the efficacy and safety of EVLIS for the treatment of gastric varices.

METHODS

EVLIS was performed in a group of 32 patients with gastric varices. Active bleeding varices were 11 and non-bleeding 21. Five cases were grade A, 12 grade B, and 14 grade C of Child's classification. Nine cases were type 1, 22 type 2, and 1 was type 3 of Hosking-Johnson's classification.

RESULTS

The results of EVLIS were excellent, active bleeding of gastric varices in the 11 cases were successfully controlled and all the gastric varices of 32 cases including those bleeding varices were completely eradicated. The bleeding status, the Child's grade and the Hosking-Johnson's class do not appear to correlate in any way with the efficacy of this technique. No perforation or re-bleeding was observed in any of the patients until the mean 10.6 months of the follow-up period.

CONCLUSIONS

EVLIS should be considered as an effective and safe treatment for gastric varices.

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.

New approaches to endoscopic therapy for hemostasis of upper GI bleed

Hematemesis and/or melena are the most common presentations of upper gastrointestinal bleeding. Endoscopic hemostasis after diagnosis still remains a challenge to the gastroenterologist. Most variceal and peptic ulcer bleeding episodes stop spontaneously, and then prevention of rebleeding might be indicated by endoscopic techniques. Four not so well known endoscopic hemostasis techniques are discussed and comparative studies are reviewed.

Portal vein thrombosis: treatment of variceal hemorrhage by endoscopic variceal ligation

Thirty-one endoscopic variceal ligation (EVL) procedures have been done in seven consecutively treated children who had esophageal varices resulting from portal vein thrombosis. Using an elastic band ligature device attached to a standard flexible endoscope, the varices in the distal 5 cm of the esophagus were mechanically strangulated. Typically, one to three varices were banded at each session. The children were between 8 months and 19 years of age at the onset of variceal bleeding. Treatment initially required frequent procedures (every 2 to 4 weeks), but the interval was gradually extended to biannual or annual. Treatment was assessed by survival, complications, incidence of rebleeding, and obliteration of varices. Each patient had from 3 to 9 EVL sessions. There were no deaths related to EVL. There were no complications. Only one patient had rebleeding in the interval between sessions. The follow-up period is 3 to 12 years. In three of the six surviving patients, the varices have been completely eradicated. The remaining three are completing treatment. Endoscopic variceal ligation is safe efficacious treatment for control of variceal bleeding caused by portal vein thrombosis. In our experience, the technique has eliminated the need for portosystemic shunting in this patient population.