Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomized study

Novel balloon compression-assisted endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices: a prospective randomized study

Background

Herein, our group designed a novel technology, termed balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS), which was applied to improve the efficiency of eradicating esophageal varices (EVs). The present study aimed to compare the rate of eradication and efficacy between bc-EIS and endoscopic variceal ligation (EVL) in the management of EVs.

Methods

Ninety-five patients with esophageal variceal bleeding (EVB) were randomly assigned to receive bc-EIS or ligation alone. Additional treatment sessions were held 1 month later and then at 3-month intervals until eradication of the varices was achieved. Endoscopic follow-up examinations were carried out at 6-month intervals in the absence of recurrence or immediately if there was any recurrent bleeding.

Results

The mean physical injection points per session were 2.89 ± 0.79, and the mean volume of lauromacrogol used per session was 17.74 ± 7.09 ml in the bc-EIS group. The mean band per session was 6.13 ± 0.86. The rate of eradication after one to three rounds of bc-EIS was obviously higher than that of the EVL group (89.36%, 97.87%, and 100% vs. 37.5%, 43.75%, and 47.92%, respectively). Retrosternal pain or discomfort in the bc-EIS group was slightly lower than that in the EVL group (23.4%, 11/47 vs. 31.25%, 15/48). Two and five patients showed mild abdominal bloating and distension between the bc-EIS and EVL groups, respectively (2/47, 4.26% vs. 5/48, 10.42% P > 0.05). Nausea and vomiting were reported in one patient (1/47, 2.13%) in the bc-EIS group and three patients (3/48, 6.25%) in the EVL group. However, there were no statistically significant differences between the two groups (P > 0.05). No fatal or severe complications, such as esophageal perforation, esophageal stricture or ectopic embolism, were observed.

Conclusion

The bc-EIS method was effective in eradicating EVs and was accompanied by fewer complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09412-6.

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.

Defining the advantages and exposing the limitations of endoscopic variceal ligation in controlling acute bleeding and achieving complete variceal eradication

BACKGROUND

Bleeding esophageal varices (BEV) is a potentially life-threatening complication in patients with portal hypertension with mortality rates as high as 25% within six weeks of the index variceal bleed. After control of the initial bleeding episode patients should enter a long-term surveillance program with endoscopic intervention combined with non-selective β-blockers to prevent further bleeding and eradicate EV.

AIM

To assess the efficacy of endoscopic variceal ligation (EVL) in controlling acute variceal bleeding, preventing variceal recurrence and rebleeding and achieving complete eradication of esophageal varices (EV) in patients who present with BEV.

METHODS

A prospectively documented single-center database was used to retrospectively identify all patients with BEV who were treated with EVL between 2000 and 2018. Control of acute bleeding, variceal recurrence, rebleeding, eradication and survival were analyzed using Baveno assessment criteria.

RESULTS

One hundred and forty patients (100 men, 40 women; mean age 50 years; range, 21–84 years; Child-Pugh grade A = 32; B = 48; C = 60) underwent 160 emergency and 298 elective EVL interventions during a total of 928 endoscopy sessions. One hundred and fourteen (81%) of the 140 patients had variceal bleeding that was effectively controlled during the index banding procedure and never bled again from EV, while 26 (19%) patients had complicated and refractory variceal bleeding. EVL controlled the acute sentinel variceal bleed during the first endoscopic intervention in 134 of 140 patients (95.7%). Six patients required balloon tamponade for control and 4 other patients rebled in hospital. Overall 5-d endoscopic failure to control variceal bleeding was 7.1% (n = 10) and four patients required a salvage transjugular intrahepatic portosystemic shunt. Index admission mortality was 14.2% (n = 20). EV were completely eradicated in 50 of 111 patients (45%) who survived > 3 mo of whom 31 recurred and 3 rebled. Sixteen (13.3%) of 120 surviving patients subsequently had 21 EV rebleeding episodes and 10 patients bled from other sources after discharge from hospital. Overall rebleeding from all sources after 2 years was 21.7% (n = 26). Sixty-nine (49.3%) of the 140 patients died, mainly due to liver failure (n = 46) during follow-up. Cumulative survival for the 140 patients was 71.4% at 1 year, 65% at 3 years, 60% at 5 years and 52.1% at 10 years.

CONCLUSION

EVL was highly effective in controlling the sentinel variceal bleed with an overall 5-day failure to control bleeding of 7.1%. Although repeated EVL achieved complete variceal eradication in less than half of patients with BEV, of whom 62% recurred, there was a significant reduction in subsequent rebleeding.

Comparison of Therapies for Secondary Prophylaxis of Esophageal Variceal Bleeding in Cirrhosis: A Network Meta-analysis of Randomized Controlled Trials

PURPOSE

The decision regarding the optimal secondary prophylactic treatment for esophageal variceal bleeding (EVB) in hepatic cirrhosis is controversial. A network meta-analysis was conducted to assess the benefits of various treatments for the secondary prophylaxis of EVB in patients with cirrhosis.

METHODS

A thorough examination of databases, including EMBASE, PubMed, and Cochrane Database of Controlled Trials, was conducted to identify relevant randomized controlled trials up to December 2019. Key primary outcomes included mortality and rebleeding. Within the identified databases, a network meta-analysis was performed. Results were expressed by using a 95% credible interval (CrI) and odds ratios (ORs). The quality of results was assessed by using the Grading of Recommendations, Assessment, Development and Evaluation approach.

FINDINGS

Forty-eight trials with 4415 participants with cirrhosis and portal hypertension who had a history of recent variceal bleeding were included. Carvedilol ranked first (surface under the cumulative ranking curve [SUCRA], 87.4%) in overall survival, and some advantage was suggested; however, the findings were not statistically significant, compared with endoscopic variceal ligation + nonselective beta-blockers (NSBB) (OR, 0.59; CrI, 0.28, 1.3), NSBB + isosorbide mononitrate (OR, 0.67; CrI, 0.33, 1.4), and transjugular intrahepatic portosystemic shunt (TIPS) (OR, 0.52; CrI, 0.24, 1.1). NSBB + isosorbide mononitrate (SUCRA, 63.9%) ranked higher than NSBB + endoscopic variceal ligation (SUCRA, 49.6%) in reducing mortality. TIPS (SUCRA, 98.8%) ranked higher than other treatments in reducing rebleeding but did not confer any survival benefit.

IMPLICATIONS

TIPS ranks first in preventing rebleeding of secondary prophylaxis of EVB and carvedilol shows outstanding efficacy in improving survival. International Prospective Register of Systematic Reviews: identifier CRD42019131814.

Comparison of the effectiveness of 11 mainstay treatments for secondary prophylaxis of variceal bleeding in patients with cirrhosis: A network meta-analysis

The purpose of the present study was to compare the effectiveness of the transjugular intrahepatic portosystemic shunt (TIPS), endoscopic options, medications and mainstay combination therapies for patients with cirrhosis who have had at least one episode of variceal haemorrhage. The PubMed, Embase, Cochrane Library and Web of Science databases, as well as the reference lists of relevant articles, were searched to identify eligible studies. P-scores, that were based solely on the point estimates and standard errors of the network estimates, were performed to rank all treatments, on a scale from 0 (worst) to 1 (best). The odds ratio (OR) was determined to assess effects on mortality, treatment failure and bleeding from gastroesophageal ulcers. A total of 43 randomized controlled trials comprising 3,787 adult patients were included. In total, 26 (61%) trials adopted concealed randomization, while most studies did not specify blinding. The drug combination of nadolol and isosorbide mononitrate (ISMN) ranked first for lowering risks of overall mortality (P-score=0.8162), mortality due to liver failure (P-score=0.7536) and bleeding from gastroesophageal ulcers (P-score=0.7536). This combination was determined to be superior to endoscopic sclerotherapy (ES) alone (OR=0.63, 95% CI: 0.42-0.94) and TIPS alone in reducing overall mortality (OR=0.62, 95% CI: 0.40-0.96). ES was more likely to increase treatment failure compared with TIPS, endoscopic variceal ligation (EVL), ES plus EVL, EVL plus nadolol/propranolol plus ISMN and nadolol/propranolol plus ISMN. In conclusion, the present network meta-analysis suggested that for a decreased mortality due to variceal rebleeding in patients with cirrhosis, nadolol plus ISMN may be a preferable choice, while ES is associated with a higher risk of unfavourable treatment outcomes. Further well-controlled studies are required to further elucidate the appropriate treatment options.

Favorable Effects of Endoscopic Ligation Combined with Drugs on Rebleeding and Mortality in Cirrhotic Patients: A Network Meta-Analysis

BACKGROUND

To assess the effects of combination therapies (endoscopic plus drug[s], drug combinations) on variceal/any-cause rebleeding and mortality among cirrhotic patients with one previous episode of variceal hemorrhage.

SUMMARY

We searched PubMed, Embase, Cochrane Library, and Web of Science for eligible studies. We included 26 randomized controlled trials involving 2,536 adults using OR to measure the effects. Endoscopic variceal ligation (EVL) plus nadolol ranked first for reducing recurrent bleeds. Both EVL + nadolol and EVL + drugs (nadolol, sucralfate) decreased the risk of any-cause rebleeding than EVL alone (OR 0.34, 95% CI 0.12-0.97; OR 0.40, 95% CI 0.18-0.88, respectively). Meanwhile, EVL + drugs ranked first lowering mortality rates (P-score >0.85) with a marginal superiority over EVL alone (OR 0.52, 95% CI 0.26-1.01). Beta-blockers with isosorbide mononitrate (ISMN) also reached a marginal superiority (OR 0.78, 95% CI 0.56-1.09) for improving mortality. Key Messages: Our findings indicated that EVL + nadolol might be the preferred choice to cirrhotic patients with one previous episode of variceal hemorrhage for preventing rebleeding. EVL + nadolol + sucralfate and beta-blockers + ISMN may be potential alternatives to improve mortality. Further, well-controlled studies are warranted to compare the promising combination therapies.

Complications of therapeutic gastroscopy/colonoscopy other than resection

Gastrointestinal (GI) endoscopy is profoundly utilized for diagnostic and therapeutic purposes. The therapeutic potential of GI endoscopy has amplified many folds with the evolution of novel techniques as well as equipments. However, with the augmentation of therapeutic endoscopy, the extent, likelihood and severity of adverse events have increased as well. The attendant risks and adverse events with therapeutic endoscopy are many folds that of diagnostic endoscopy. Besides endoscopic resection, therapeutic endoscopy is widely utilized for hemostasis in GI bleeds, dilatation of stenosis, enteral stenting, foreign body removal, ablation of Barrett's esophagus etc. Major adverse events associated with interventional endoscopic procedures include bleeding and perforation. Adverse events of endoscopic interventions are diverse and related to the underlying disease, therapeutic modality used and operator's experience. Many of these adverse events can be prevented. Early recognition of an unavoidable adverse event is important to minimize the associated morbidity and mortality.

Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines

The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation).

WARFARIN

The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance.

DIRECT ORAL ANTICOAGULANTS DOAC

For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).

Eradication of esophageal varices by sclerotherapy combined with argon plasma coagulation: Effect of portal hemodynamics and longitudinal clinical course

BACKGROUND AND AIM

To demonstrate the effect of endoscopic injection sclerotherapy (EIS) with argon plasma coagulation (APC) as a primary/secondary prophylaxis for esophageal varies (EV) on portal hemodynamics and long-term outcomes in cirrhosis.

METHODS

This prospective study included 48 cirrhotic patients (64.5 ± 11.4 years; 26 bleeders, 22 non-bleeders). Post-treatment outcomes (EIS and APC; median observation period, 12.8 months for recurrence and 21.1 months for prognosis) were evaluated with respect to the findings of hepatic venous catheterization, Doppler ultrasound, and endoscopic ultrasonography (EUS).

RESULTS

All patients showed EV eradication after endoscopic treatment, and a decreased frequency of a patent left gastric vein (pre: 83.3%, post: 27.1%, P < 0.001). However, hepatic venous pressure gradient (HVPG, mmHg) remained unchanged after the treatment, pre: 16.1 ± 3.6, post: 15.6 ± 3.8 (P = 0.269). Cumulative variceal recurrence/rebleeding rates were 25.5%/5.6% and 62.4%/23.1% at 1 and 3 years, respectively. Post-treatment EUS finding, area of submucosal vessels in the cardia ≥12 mm2 was the only significant factor for variceal recurrence (hazard ratio 9.769, 95% confidence interval 3.046-31.337; P < 0.001). Cumulative recurrence rate was significantly higher in patients with area of submucosal vessels in the cardia ≥12 mm2 (58.3% at 1 year and 100% at 3 years) than in those without (11.4% at 1 year and 40.9% at 3 years, P < 0.001). Cumulative overall survival rates were 95.2% and 71.9% at 1 and 3 years, respectively, showing no significant relationship with HVPG.

CONCLUSION

EIS with APC for EV is unlikely to have a significant influence on portal pressure.

Evolving techniques for gastrointestinal endoscopic hemostasis treatment

With mortality due to gastrointestinal (GI) bleeding remaining stable, the focus on endoscopic hemostasis has been on improving other outcomes such as rebleeding rate, need for transfusions, and need for angiographic embolization or surgery. Over the past few years, a number of devices have emerged to help endoscopically assess and treat bleeding GI lesions. These include the Doppler endoscopic probe, hemostatic powder, and over-the-scope clip. Also, new applications have been described for radiofrequency ablation. In this article, we will discuss these evolving tools and techniques that have been developed, including an analysis of their efficacy and limitations.

Argon plasma coagulation is effective for prevention of recurrent esophageal varices after endoscopic injection sclerotherapy: Single-center case-control study

BACKGROUND AND AIM

Esophageal varices are usually treated with endoscopic injection sclerotherapy (EIS) or endoscopic band ligation (EBL). However, frequent recurrences of varices after those procedures have been problematic. Argon plasma coagulation (APC) after EIS may be effective for preventing varix recurrence and, in recent years, we have routinely carried out APC after EIS. The aim of the present study was to verify the effectiveness of APC for preventing recurrence of varices after EIS.

METHODS

A case-control study was carried out using a historical control cohort in a single center. The varix recurrence rate in 62 patients (34 men and 28 women, median age; 69 years) who underwent APC after EIS for hemorrhagic or risky esophageal varices (APC group) was compared with that of control patients who did not undergo APC after EIS (control group). Age-, sex-, and liver function-matched two control subjects were selected for one case subject (control group). Recurrence of varices was defined as rupture of varices or reappearance of risky varices.

RESULTS

The 1-year and 2-year recurrence rates of the APC group were 9.7% and 11.3%, respectively. In contrast, the rates of the control group were 29.0% and 34.7%, respectively. Kaplan-Meier curves showed a significantly lower recurrence rate in the APC group (P = 0.013, log-rank test). No APC-related severe adverse events were observed.

CONCLUSION

APC after EIS was safe and could significantly prevent recurrence of esophageal varices. Therefore, the addition of APC should be routinely carried out after EIS.

The role of collateral veins detected by endosonography in predicting the recurrence of esophageal varices after endoscopic treatment: a systematic review

Endoscopic therapy is the principal method of treatment for esophageal varices. The recurrence of varices is still common following endoscopic treatment. The aim was to identify predictive factors for variceal recurrence detected by endosonography. We performed a systematic review of studies published prior to June 2013. Studies analyzing gastroesophageal collateral veins as risk factors for variceal recurrence after endoscopic treatment were included. The primary outcome was to identify predictive factors for variceal recurrence investigated by endosonography. After a full-text review, 13 studies were included in our analysis. Analysis of risk factors was not possible for all studies included. Perforating veins and periesophageal collateral veins were related to a higher risk of variceal recurrence (OR = 3.93; 95 % CI 1.06-14.51; I (2) = 96 %; OR = 2.29; 95 % CI 1.58-3.33; I (2) = 55 %). Analysis of cardiac intramural veins and paragastric/cardiac collateral veins showed the same trend, but without reaching statistical significance because of the small group size and wide CI (OR = 3.72; 95 % CI 0.14-101.53; I (2) = 91 %; OR = 1.85; 95 % CI 0.84-4.07; I (2) = 0 %). Analysis of other collateral veins as risk factors for variceal recurrence and analysis of risk factors with regard to the endoscopic treatment method was not possible because of the limited number of cases and different methodologies. A positive association between variceal recurrence and type and grade of collateral veins, investigated by endosonography, was demonstrated. Endosonography is a promising tool for predicting recurrence of esophageal varices following endoscopic treatment. These findings should be interpreted with caution because of the heterogeneity of the studies.

Laparoscopic splenectomy plus preoperative endoscopic variceal ligation versus splenectomy with pericardial devascularization (Hassab's operation) for control of severe varices due to portal hypertension

BACKGROUND

Our research was conducted to introduce a new, compound surgical method for laparoscopic splenectomy (LS) with preoperative endoscopic variceal ligation (EVL) and compare the new method's efficiency with that of Hassab's operation in patients with severe esophageal varices due to portal hypertension.

METHODS

Between March 2009 and March 2012, 47 patients with liver cirrhosis, portal hypertension, and severe esophageal varices were retrospectively analyzed. Of these patients, 19 received the combined preoperative EVL and LS (minimally invasive surgery, MIS group), and 28 patients received splenectomy with pericardial devascularization (Hassab's operation, H group).

RESULTS

Before surgery, there were no differences in the patient characteristics of the two groups. There were no significant differences in operating time, but significantly less intraoperative blood loss and shorter postoperative hospital stay were found in the MIS group compared with the H group. The mean follow-up periods of the MIS and H groups were 12.1 and 13.6 months, respectively. No deaths were documented during the follow-up period. Generally, hematological parameters and liver function variables eventually revealed considerable improvement in both groups. In the MIS group, the patients with varices improved significantly from severe to mild, and in some cases, the varices disappeared after treatment. Three patients in the H group suffered rebleeding and were treated with repeated EVL. No bleeding or rebleeding occurred in the MIS group.

CONCLUSIONS

The final results suggest that LS with preoperative EVL provides a restorative efficacy equivalent to that of Hassab's operation. Based on the recurrence rate and the rebleeding rate of severe esophageal varices, our surgical strategy (EVL and LS) is a safe and minimally invasive technique that appears satisfactory in comparison to other open procedures.

Esophageal variceal ligation in the secondary prevention of variceal bleeding: Result of long term follow-up

Introduction

Long-term outcome of patients after band ligation have been poorly defined. Therefore, we conducted a long-term follow-up study to delineate the outcome of ligation in patients with portal hypertension in the Hassan II university hospital, Fes, Morocco.

Methods

Over 118 months patients treated by endoscopic variceal ligation were received regular follow- up and detailed clinical assessment of at least 24 months.

Results

One hundred twenty five patients were followed up for a mean of 31 months (range 12-107 months). Obliteration of the varices was achieved in 89.6 % (N = 112) of patients, with 3 +/-1.99 (range 1-8) endoscopy sessions over a period of 14 + /-6.8 weeks (range 3-28). The percentage of variceal recurrence during follow-up after ligation was 20.5 % (N = 23). Recurrence were observed in a mean of 22 months +/- 7.3 (range 3-48). Bleeding rate from recurrent varices was 30.4 % (7/23). Rebleeding from esophageal ulcers occurred in 5.6 % (7/125) of patients. Portal hypertensive gastropathy before and after eradication of varices was 17.6% (N = 22) and 44.6% (N = 50) respectively; p< 0.05. Fundal gastric varices was 30.4% (N = 38) and 35.7% (N = 40) before and after eradication of varices respectively; p> 0.05. The overall mortality was 4 % (N = 5).

Conclusion

Band ligation was an effective technical approach for variceal obliteration with low rates of variceal recurrence, rebleeding and development of gastric varices. Furthermore, it was associated with frequent development of portal hypertensive gastropathy.

Management of varices in cirrhosis

INTRODUCTION

Acute variceal bleeding is a medical emergency and one of the main causes of mortality in patients with cirrhosis. Timely and effective treatment of the acute bleeding episode results in increased survival, and appropriate prophylactic treatment can prevent bleeding or rebleeding from varices.

AREAS COVERED

We discuss the prevention of development and growth of varices, the primary and secondary prophylaxis of bleeding, the treatment of acute bleeding, and the management of gastric varices. We systematically reviewed studies, without time limits, identified through Medline and searches of reference lists, and provide an overview of the evidence underlying the -treatment options in the management of varices in cirrhosis.

EXPERT OPINION

The management of variceal hemorrhage relies on nonspecific interventions (e.g., adequate fluid resuscitation, airway protection) and on specific interventions. These are routine prophylactic antibiotics, vasoactive drugs and endoscopic treatment. Procedures such as the placement of a Sengstaken-Blakemore tube or a transjugular intrahepatic portosystemic shunt (TIPS) can be lifesaving. The primary and secondary prophylaxis of bleeding is based on nonselective beta-blockers and endoscopy, even though TIPS or, less frequently, surgery have a role in selected cases.

Efficacy and safety of endoscopic variceal ligation and endoscopic injection sclerotherapy in patients with cirrhosis and esophageal varices: a prospective study

AIM: To prospectively determine the efficacy and safety of endoscopic variceal ligation (EVL) and endoscopic injection sclerotherapy (EIS) in patients with esophageal varices.

METHODS: Sixty-three patients with liver cirrhosis and esophageal varices were divided into two groups: EIS group (n = 36) and EVL group (n = 27). To compare the rates of hemostatic success, early rebleeding, delayed rebleeding, mortality, and other complications between the two groups, a 6-month prospective follow-up study was performed in patients after endoscopic therapy.

RESULTS: The patients treated by EVL had a higher rate of hemostatic success than those by EIS though the difference was not significant (P = 0.137). The EVL group had significantly lower rates of early rebleeding (44.4% vs 12%, P = 0.007), delayed rebleeding (52.8% vs 16%, P = 0.004), and better survival (19.4% vs 4%, P = 0.125) than the EIS group. Furthermore, the patients treated by EVL also had a lower probability of fever (63.9% vs 25.9%, P = 0.003), retrosternal pain (69.4% vs 40.7%, P = 0.023), bleeding esophageal ulcer (19.4% vs 0%, P = 0.017), and abdominal distention (47.2% vs14.8%, P = 0.007) than those by EIS.

CONCLUSION: EVL is more effective and safer than EIS in the treatment of esophageal varices because the former is associated with a lower probability of rebleeding and other complications.

Central obesity and atherogenic dyslipidemia in metabolic syndrome are associated with increased risk for colorectal adenoma in a Chinese population

Background

Endoscopic band ligation (EBL) is generally accepted as the treatment of choice for bleeding from esophageal varices. It is also used for secondary prophylaxis of esophageal variceal hemorrhage. However, there is no data or guidelines concerning endoscopic control of ligation ulcers. We conducted a retrospective study of EBL procedures analyzing bleeding complications after EBL.

Methods

We retrospectively analyzed data from patients who underwent EBL. We analyzed several data points, including indication for the procedure, bleeding events and the time interval between EBL and bleeding.

Results

255 patients and 387 ligation sessions were included in the analysis. We observed an overall bleeding rate after EBL of 7.8%. Bleeding events after elective treatment (3.9%) were significantly lower than those after treatment for acute variceal hemorrhage (12.1%). The number of bleeding events from ligation ulcers and variceal rebleeding was 14 and 15, respectively. The bleeding rate from the ligation site in the group who underwent emergency ligation was 7.1% and 0.5% in the group who underwent elective ligation. Incidence of variceal rebleeding did not vary significantly. Seventy-five percent of all bleeding episodes after elective treatment occurred within four days after EBL. 20/22 of bleeding events after emergency ligation occured within 11 days after treatment. Elective EBL has a lower risk of bleeding from treatment-induced ulceration than emergency ligation.

Conclusions

Patients who underwent EBL for treatment of acute variceal bleeding should be kept under medical surveillance for 11 days. After elective EBL, it may be reasonable to restrict the period of surveillance to four days or even perform the procedure in an out-patient setting.

Long-term prognosis of cirrhotics with an upper gastrointestinal bleeding episode: does infection play a role?

BACKGROUND AND AIM

We evaluated the effect of infection on the short- and long-term outcome of cirrhotic patients with upper gastrointestinal bleeding (UGIB), in a series of patients not submitted to antibiotic prophylaxis.

METHODS

The cirrhotic patients hospitalized for UGIB were prospectively followed up until the last visit, death, or transplantation. A standard screening protocol was used for bacterial infection at admission.

RESULTS

In total, 205 patients were included in the study. Antibiotics were administered in 79 (38.5%) patients and an infection was documented in 64 (31.4%) patients. In total, 130 (63.4%) patients died after a mean (SD) follow up of 23.8 (30.9) months. Six-week mortality was higher in the infected patients (P < 0.0001). The mortality of patients who were alive 6 weeks after admission was not different between the infected and non-infected patients. Antibiotic use or bacterial infection, the Child-Pugh score, hepatocellular carcinoma, and creatinine were the independent predictors of 6-week mortality. Age and the Child-Pugh score were the only predictors of mortality of the patients who had survived for more than 6 weeks after acute bleeding. In total, 51 (24.9%) patients rebled, 37 (18.1%) within 5 days of admission. Rebleeding was more frequent (41.8% vs 14.3%, P < 0.0001) in infected patients, mostly due to differences in early rebleeding (31.6% vs 9.5%, P = 0.0001).

CONCLUSION

Bacterial infection is associated with failure to control UGIB and early mortality in cirrhotic patients, but does not seem to affect the outcome of patients who overcome the bleeding episode.

Cost saving by reloading the multiband ligator in endoscopic esophageal variceal ligation: A proposal for developing countries

AIM: To assess the cost savings of reloading the multiband ligator in endoscopic esophageal variceal ligation (EVL) used on the same patient for subsequent sessions.

METHODS: This single centre retrospective descriptive study analysed patients undergoing variceal ligation at a tertiary care centre between 1st January, 2003 and 30th June, 2006. The multiband ligator was reloaded with six hemorrhoidal bands using hemorrhoidal ligator for the second and subsequent sessions. Analysis of cost saving was done for the number of follow-up sessions for the variceal eradication.

RESULTS: A total of 261 patients underwent at least one session of endoscopic esophageal variceal ligation between January 2003 and June 2006. Out of 261, 108 patients (males 67) agreed to follow the eradication program and underwent repeated sessions. A total of 304 sessions was performed with 2.81 sessions per patient on average. Thirty-two patients could not complete the programme. In 76 patients (70%), variceal obliteration was achieved. The ratio of the costs for the session with reloaded ligator versus a session with a new ligator was 1:2.37. Among the patients who completed esophageal varices eradication, cost saving with reloaded ligator was 58%.

CONCLUSION: EVL using reloaded multiband ligators for the follow-up sessions on patients undergoing variceal eradication is a cost saving procedure. Reloading the ligator thus is recommended especially for developing countries where most of the patients are not health insured.

Cost-effectiveness of proton-pump inhibition before endoscopy in upper gastrointestinal bleeding

BACKGROUND & AIMS

Randomized trials suggest high-dose proton-pump inhibitors (PPIs) administered before gastroscopy in suspected upper gastrointestinal bleeding downstage bleeding ulcer stigmata. We assessed the cost-effectiveness of this approach.

METHODS

A decision model compared high-dose IVPPI initiated while awaiting endoscopy with IVPPI administration on the basis of endoscopic findings. IVPPIs were given to all patients undergoing endoscopic hemostasis for 72 hours thereafter. Once the IV regimen was completed or for patients with low-risk endoscopic lesions, an oral daily PPI was given for the remainder of the time horizon (30 days after endoscopy). The unit of effectiveness was the proportion of patients without rebleeding, representing the denominator of the cost-effectiveness ratio (cost per no rebleeding). Probabilities and costs were derived from the literature and national databases.

RESULTS

IVPPIs before endoscopy were both slightly more costly and effective than after gastroscopy in the U.S. and Canadian settings, with cost-effectiveness ratios of US$5048 versus $4933 and CAN$6064 versus $6025 and incremental costs of US$45,673 and CAN$19,832 to prevent one additional rebleeding episode, respectively. Sensitivity analyses showed robust results in the US In Canada, intravenous proton-pump inhibitors (IVPPIs) before endoscopy became more effective and less costly (dominant strategy) when the uncomplicated stay for high-risk patients increased above 6 days or that of low-risk patients decreased below 3 days.

CONCLUSIONS

With conservative estimates and high-quality data, IVPPIs given before endoscopy are slightly more effective and costly than no administration. In Canada, this approach becomes dominant as the duration of hospitalization for high-risk ulcer patients increases or that of low-risk ulcer patients decreases.

Splenectomy with endoscopic variceal ligation is superior to splenectomy with pericardial devascularization in treatment of portal hypertension

AIM: To investigate the therapeutic efficacy and complications of splenectomy with endoscopic variceal ligation (EVL) and splenectomy with pericardial devascularization (i.e. Hassab’s operation) in patients with portal hypertension.

METHODS: A total of 103 patients with liver cirrhosis and portal hypertension were randomly selected to receive either splenectomy with EVL (n = 53, group A) or Hassab’s operation (n = 50, group B).

RESULTS: The portal blood flow volume, the presence of portal vein thrombosis, gastric emptying time and free portal venous pressure (FPP) before and after the operation were determined. Patients were followed up for up to 64 mo with an average of 45 mo, and the Dagradi classification of variceal veins and the grading of portal hypertension gastropathy (PHG) were evaluated. It was found that all esophageal varices were occluded or decreased to grade II or less in both groups. There was little difference in the recurrence rate of esophageal varices (11.9% vs 13.2%) and the re-bleeding rate (7.1% vs 5.3%) between groups A and B. The incidence of complications and the percentage of patients with severe PHG after the operation were significantly higher in group B (60.0% and 52.0%) than in group A (32.1% and 20.8%, P < 0.05). No patients died of operation-related complications. There was no significant difference in gastric emptying time, FPP and portal blood flow volume between the two groups.

CONCLUSION: The results suggest that splenectomy with EVL achieves similar therapeutic efficacy to that of Hassab’s operation in terms of the recurrence rate of esophageal varices and the re-bleeding rate, but the former results in fewer and milder complications.

Comparación de las estenosis esofágicas producidas por escleroterapia o ligadura de varices

INTRODUCTION

Variceal ligation (VL) eradicates esophageal varices faster than endoscopic sclerotherapy (ES) with a lower rebleeding rate and fewer secondary effects. However, most studies have evaluated the short-term effects of these treatments and some late complications may be overlooked.

PATIENTS AND METHODS

To determine the incidence and the characteristics of stenosis, we included 253 cirrhotic patients treated endoscopically for variceal bleeding from 1988 to 2004 in our hospital. ES was carried out with ethanolamine 5% and polidocanol 1.5%. ES and VL were carried out every 15 days until varices were eradicated and then at 3-, 6- and 12-month intervals; if varices reappeared, the initial treatment was repeated. Stenosis was considered mild when esophageal size was more than 10 mm and severe when the endoscope could not be passed through the stricture.

RESULTS

We found stenosis in seven out of 105 (6.7%) ES-treated patients and in 10 out of 148 (6.7%) VL-treated patients. The clinical characteristics of the patients and the previous number of endoscopic sessions were similar in both groups. Four out of seven ES patients developed stenosis during the first eradication process (mean: 11 months, 1-60), but this early stenosis was observed in one out of 10 VL patients (mean: 20 months, 1-72). Stenosis was severe in three out of seven ES patients (43%) but in only two out of ten VL patients (20%) (NS).

CONCLUSIONS

The incidence of esophageal stenosis was similar after treatment of esophageal varices with ES and VL, although VL had a tendency to produce later stenosis.

Treatment of esophageal varices: a randomized controlled trial comparing endoscopic sclerotherapy and EUS-guided sclerotherapy of esophageal collateral veins

BACKGROUND

Endoscopic sclerotherapy (ES) and band ligation are standard treatments for esophageal varices. Unfortunately, recurrence is common and seems to be related to esophageal collateral vessels, easily identified by EUS. Eradication of these vessels might lead to a more durable therapeutic effect.

OBJECTIVE

To compare ES with EUS-guided sclerotherapy of collateral vessels (EUS-ES).

DESIGN

Randomized controlled trial.

SETTING

Endoscopy Unit, Division of Gastroenterology. Universidade Federal de São Paulo, São Paulo, Brazil.

PATIENTS AND INTERVENTIONS

Fifty cirrhotic patients with esophageal varices were randomized into 2 groups: ES (n = 25) and EUS-ES (n = 25). EUS-ES was targeted at collateral veins. Patients were followed-up for at least 6 months after eradication.

MAIN OUTCOME MEASUREMENTS

Efficacy in eradication, complications, and recurrence of varices.

RESULTS

Varices were eradicated in 48 patients who adhered to the study protocol. The mean (SD) number of sessions until eradication was 4.3 (1.5) for the ES group and 4.1 (1.2) for the EUS-ES group. In ES group, 4 patients had mild bleeding. In EUS-ES group, 4 patients had pain. The mean (SD) length of the follow-up period was 22.6 (6.9) months for the ES group and 24.9 (8.1) months for the EUS-ES group. Recurrence was seen in 4 patients after ES and in 2 after EUS-ES (P = .32). The presence of collateral vessels was associated with recurrence (P = .003).

CONCLUSION

EUS-ES is as safe and effective as ES in variceal eradication. Recurrence tends to be less frequent and occurs later. Persistence of esophageal collateral vessels after sclerotherapy is a risk factor for recurrence.

Bleeding caused by portal hypertension

Variceal bleeding is one of the dreaded complications of portal hypertension. Patients who have suspected or proven cirrhosis should undergo diagnostic upper endoscopy to detect medium and large gastro-esophageal varices. Patients with medium and large gastro-esophageal varices should be treated with non-selective beta-blockers (propranolol or nadolol), and these agents should be titrated to a heart rate of 55 beats per minute or adverse effects. If there are contraindications to or if patients are intolerant to beta-blockers, it is appropriate to consider prophylactic banding therapy for individuals with medium-to-large esophageal varices. When patients who have cirrhosis present with GI bleeding, they should be resuscitated and receive octreotide or other vasoactive agents. Endoscopy should be performed promptly to diagnose the source of bleeding and to provide endoscopic therapy (preferably banding). The currently available treatment for acute variceal bleeding provides hemostasis in most patients. These patients, however, are at significant risk for rebleeding unless secondary prophylaxis is provided. Although various pharmacological, endoscopic, radiological, and surgical options are available, combined pharmacological and endoscopic therapy is the most common form of secondary prophylaxis. TIPS is a radiologically placed portasystemic shunt, and if placed in suitable patients, it can provide effective treatment for patients with variceal bleeding that is refractory to medical and endoscopic therapy.

The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.

Pantoprazole reduces the size of postbanding ulcers after variceal band ligation: a randomized, controlled trial

Elective esophageal variceal ligation (EVL) is performed to decrease the risk of variceal hemorrhage. Side effects of EVL include hemorrhage, chest pain, dysphagia, and odynophagia. Because gastric acid may exacerbate postbanding ulcers and delay healing, proton pump inhibition may decrease side effects associated with EVL. The aim of this study was to assess the efficacy of pantoprazole, a proton pump inhibitor, as an adjunct to elective EVL. We performed a double-blinded, randomized, placebo-controlled trial of pantoprazole after elective EVL. Subjects in the pantoprazole arm received 40 mg pantoprazole intravenously after EVL followed by 40 mg oral pantoprazole for 9 days. Control subjects received intravenous and oral placebo. Subjects underwent upper endoscopy 10 to 14 days after banding. Primary outcomes included the size and number of ulcers and the subjects' reports of dysphagia, chest pain, and heartburn. Forty-four subjects were randomized: 42 completed the protocol. At follow-up endoscopy, the mean number of ulcers was similar in the two groups. However, the ulcers in the pantoprazole group were on average half as large as in the placebo group (37 mm(2) vs. 82 mm(2), P < .01). Chest pain, dysphagia, and heartburn scores were not significantly different. Four subjects, all in the placebo group, had adverse outcomes, including 3 who bled from postbanding ulcers and 1 with sepsis. In conclusion, subjects receiving pantoprazole after elective EVL had significantly smaller postbanding ulcers on follow-up endoscopy than subjects receiving placebo. However, the total ulcer number and patient symptoms were not different between the groups.

Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: a multicenter trial

beta-Blockers and endoscopic variceal ligation (EVL) have proven to be valuable methods in the prevention of variceal rebleeding. The aim of this study was to compare the efficacy of EVL combined with nadolol versus EVL alone as secondary prophylaxis for variceal bleeding. Patients admitted for acute variceal bleeding were treated during emergency endoscopy with EVL or sclerotherapy and received somatostatin for 5 days. At that point, patients were randomized to receive EVL plus nadolol or EVL alone. EVL sessions were repeated every 10 to 12 days until the varices were eradicated. Eighty patients with cirrhosis (alcoholic origin in 66%) were included (Child-Turcotte-Pugh A, 15%; B, 56%; C, 29%). The median follow-up period was 16 months (range, 1-24 months). The variceal bleeding recurrence rate was 14% in the EVL plus nadolol group and 38% in the EVL group (P = .006). Mortality was similar in both groups: five patients (11.6%) died in the combined therapy group and four patients (10.8%) died in the EVL group. There were no significant differences in the number of EVL sessions to eradicate varices: 3.2 +/- 1.3 in the combined therapy group versus 3.5 +/- 1.3 in the EVL alone group. The actuarial probability of variceal recurrence at 1 year was lower in the EVL plus nadolol group (54%) than in the EVL group (77%; P = .06). Adverse effects resulting from nadolol were observed in 11% of the patients. In conclusion, nadolol plus EVL reduces the incidence of variceal rebleeding compared with EVL alone. A combined treatment could lower the probability of variceal recurrence after eradication.

Transjugular intrahepatic portosystemic shunt

The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 16 years ago, more than 1,000 publications have appeared demonstrating broad acceptance and increasing clinical use. This review summarizes our present knowledge about technical aspects and complications, follow-up of patients and indications. A technical success rate near 100% and a low occurrence of complications clearly depend on the skills of the operator. The follow-up of the TIPS patient has to assess shunt patency, liver function, hepatic encephalopathy and the possible development of hepatocellular carcinoma. Shunt patency can best be monitored by duplex sonography and can avoid routine radiological revision. Short-term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. Stent grafts covered with expanded polytetrafluoroethylene show promising long-term patency comparable with that of surgical shunts. With respect to the indications of TIPS, much is known about treatment of variceal bleeding and refractory ascites. The thirteen randomized studies that are available to date show that survival is comparable in patients receiving TIPS or endoscopic treatment for acute or recurrent variceal bleeding. Another group comprises patients with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications. Five randomized studies comparing TIPS with paracentesis and one study comparing TIPS with the peritoneo-venous shunt showed good response of ascites but controversial results on survival. In addition, TIPS has been successfully applied to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic variceal bleeding.

The cost-effectiveness of hepatic venous pressure gradient monitoring in the prevention of recurrent variceal hemorrhage

OBJECTIVE

Recurrent variceal hemorrhage is common following an initial bleed in patients with cirrhosis. The current standard of care for secondary prophylaxis is endoscopic band ligation (EBL). Combination of beta-blocker and nitrate therapy, guided by hepatic venous pressure gradient (HVPG) monitoring, is a novel alternative strategy. We sought to determine the cost-effectiveness of these competing strategies.

METHODS

Decision analysis with Markov modeling was used to calculate the cost-effectiveness of three competing strategies: (1) EBL; (2) beta-blocker and nitrate therapy without HVPG monitoring (HVPG-); and (3) beta-blocker and nitrate therapy with HVPG monitoring (HVPG+). Patients in the HVPG+ strategy who failed to achieve an HVPG decline from medical therapy were offered EBL. Cost estimates were from a third-party payer perspective. The main outcome measure was the cost per recurrent variceal hemorrhage prevented.

RESULTS

Under base-case conditions, the HVPG+ strategy was the most effective yet most expensive approach, followed by EBL and HVPG-. Compared to the EBL strategy, the HVPG+ strategy cost an incremental 5,974 dollars per recurrent bleed prevented. In a population with 100% compliance with all therapies, the incremental cost of HVPG-versus EBL fell to 5,270 dollars per recurrent bleed prevented. The model results were sensitive to the cost of EBL, the cost of HVPG monitoring, and the probability of medical therapy producing an adequate HVPG decline.

CONCLUSIONS

Compared to EBL for the secondary prophylaxis of variceal rebleeding, combination medical therapy guided by HVPG monitoring is more effective and only marginally more expensive.

Sustained rise of portal pressure after sclerotherapy, but not band ligation, in acute variceal bleeding in cirrhosis

During variceal bleeding, several factors may increase portal pressure, which in turn may precipitate further bleeding. This study investigates the early effects of endoscopic injection sclerotherapy (EIS) and endoscopic band ligation (EBL) on hepatic venous pressure gradient (HVPG) during acute bleeding and the possible influence in outcome. In 50 cirrhotic patients with bleeding esophageal varices treated with EIS (n = 25) or EBL (n = 25), we performed repeated HVPG measurements before and immediately after endoscopic treatment (time 0) and every 24 hours for a 5-day period. Endotherapy was continued until the varices were too small for further treatment. Both groups were comparable with regard to age, gender, Child-Turcotte-Pugh grade, and HVPG. In the EBL and EIS groups, a significant (P <.0001) increase was observed in mean portal pressure (20.7 mm Hg +/- 4.4 SD and 21.5 mm Hg +/- 4.5 SD, respectively) immediately after treatment (time 0) as compared with pretreatment (18.1 +/- 4.5 and 18.1 +/- 4.0). However, HVPG in the EBL group returned to baseline values within 48 hours after treatment, while in the EIS group it remained high during the 120-hour study period (P <.0001). Bleeding stopped in all patients after endotherapy. During the 42-day follow-up period, the rebleeding rate over time was lower in the EBL group compared with the EIS group (P =.024). Patients with an initial HVPG greater than 16 mm Hg had, despite endoscopic treatment, a significantly higher likelihood of death (P =.024) and overall failure (P =.037) [correction]. In conclusion, during acute variceal bleeding EIS, but not EBL, causes a sustained increase in HVPG, which is followed by a higher rebleeding rate.

Current Management of Esophageal Varices

Acute variceal hemorrhage is the most lethal complication of cirrhosis. The reported mortality rate from a first episode of variceal hemorrhage is 17% to 57%. Management of varices can be categorized into three phases: 1) prevention of initial bleeding, 2) management of acute bleeding, and 3) prevention of rebleeding. Modalities for treatment include pharmacologic, endoscopic, and shunt therapy. For the prevention of first variceal hemorrhage, cirrhotic patients should undergo endoscopy to identify patients with large varices. Priority for screening for varices should be given to patients with low platelet count, splenomegaly, and advanced cirrhosis. Once large varices are identified, patients should be started on beta-blocker therapy, which reduces the risk of bleeding by 50%. If pharmacologic therapy is not tolerated or contraindicated, endoscopic band ligation should be performed, and surveillance of varices should be performed every 6 months thereafter. Shunt procedures are not indicated due to their higher rates of complications compared with medical therapy. For the management of acute variceal hemorrhage, patients should be started on prophylactic intravenous antibiotics and intravenous octreotide. Endoscopy should be performed to diagnose and treat variceal hemorrhage. Band ligation appears to be as effective as sclerotherapy, but with less complications. If hemostasis is not achieved, balloon tamponade can be used as a bridge to definitive therapy, which in this case would be a transjugular intrahepatic portosystemic shunt (TIPS). If TIPS is unavailable, a surgical shunt is indicated. Once an episode of acute bleeding has been controlled, variceal eradication is best accomplished with repeat band ligation every 10 to 14 days until varices are obliterated. Prevention of recurrent bleeding can be achieved with beta-blocker therapy. The addition of isosorbide mononitrate further reduces recurrent bleeding. This combination pharmacologic therapy has been shown to be superior to sclerotherapy and may be superior to band ligation. However, side effects of combination pharmacologic therapy may limit its effectiveness. Band ligation is preferred to sclerotherapy when considering endoscopic therapy due to less complications and lower cost. Surgical shunts should be used for prevention of rebleeding in patients who do not tolerate or are noncompliant with medical therapy and who have relatively preserved liver function. TIPS should be reserved for patients who have poor liver function and who have failed medical therapy.

Update on treatment of variceal hemorrhage

Variceal hemorrhage accounts for one third of all deaths related to cirrhosis. To date, many modalities of treating variceal bleeding have been devised, including pharmacological therapy. Treatment of variceal hemorrhage includes resuscitation, initial hemostasis, and prevention of complications and recurrent bleeding. Intravenous vasoactive agents such as terlipressin, somatostatin, octreotide, or vapreotide should be administered in patients with suspected variceal bleeding. Endoscopic treatment remains the mainstay of treatment. Endoscopic variceal ligation is safer and more efficacious than sclerotherapy as initial treatment of bleeding esophageal varices, whereas cyanoacrylate injection is the endoscopic treatment of choice for gastric varices. An adjuvant vasoactive agent is useful for the prevention of early rebleeding. Prophylactic antibiotics are increasingly used for prevention of infection, notably spontaneous bacterial peritonitis. Follow-up endoscopic treatment is necessary in order to obliterate residual varices. The combination of a beta blocker and nitrate is an essential component of secondary prophylaxis for recurrent variceal bleeding. Transjugular intrahepatic portosystemic shunt or surgery offers the best salvage therapy in patients with failed hemostasis or breakthrough recurrent bleeding despite medical and endoscopic therapy. Endoscopic ultrasonography is useful in the prediction of recurrence of varices and facilitates visualization and guidance of further treatment of gastric varices. Despite advances in the treatment of variceal bleeding, liver function remains the determining factor of patient survival. Liver transplantation is the only definitive treatment that can alter the course of the disease.

Treatment of Variceal Bleeding

Mortality due to variceal bleeding secondary to portal hypertension has decreased significantly in the past 2 decades. Endoscopic therapy has been the mainstay of treatment for acute variceal bleeding. Variceal banding ligation has superceded injection sclerotherapy as the most popular treatment modality for acute bleeding. Multiple banding ligators are widely used with high success in restoring hemostasis. The combination of banding and sclerotherapy may be useful in preventing the early recurrence of varices and rebleeding after initial obliteration of varices. Selective vasoactive agents such as somatostatin analogs also improve the outcome of patients. Radiologic shunting has proven to be an effective salvage procedure when endoscopic treatments fail and may be a good intermediate-stage therapy while the patient is waiting for liver transplantation.

Variceal Bleeding

Primary prophylaxis: Patients with cirrhosis who have esophageal varices but who have never had a bleeding episode may be treated medically or endoscopically. Without treatment, approximately 30% of cirrhotic patients with varices bleed and this risk is reduced by approximately 50% with therapy. Medical therapy includes nonselective beta blockers with or without nitrates. Compliance and side effects limit efficacy. Primary prophylaxis with endoscopic sclerotherapy is not warranted because of evidence suggesting that complications outweigh benefits. Studies of endoscopic therapy with ligation (endoscopic banding) demonstrate that in select patients (those with large varices), endoscopic banding may reduce the risk of first bleeding episode when compared with propranolol. Patients with large varices may benefit from a combination of banding with nonselective beta blockers. Secondary prophylaxis: After an initial variceal bleed, the risk of a second bleed is high and therapy is warranted to reduce the risk of rebleeding. The options are similar to those for primary prophylaxis, and in addition to medical and endoscopic therapy, transjugular intrahepatic portosystemic shunts (TIPS) and surgical shunts are therapeutic options. The combination of endoscopic therapy with medical therapy is the initial approach to prevent variceal rebleeding. Endoscopic banding is preferred to sclerotherapy because banding is associated with lower bleeding rates and fewer complications. TIPS is useful in cases refractory to endoscopic therapy or in uncontrolled variceal hemorrhage. Surgical shunts are typically reserved for patients in whom TIPS cannot be performed for technical reasons or for well-compensated cirrhotic patients. Acute variceal bleeding: Acute bleeding from esophageal varices requires an endoscopic evaluation and therapeutic intervention. Technically, endoscopic banding may not be possible because of limited visualization from bleeding and sclerotherapy is used because it is easier to perform in this setting. A continuous intravenous drip of octreotide should be initiated if variceal bleeding is suspected. If variceal bleeding cannot be controlled, then a Minnesota tube or Sengstaken-Blakemore tube should be placed by someone with experience. TIPS is effective rescue therapy for controlling acute variceal hemorrhage in circumstances when other methods fail.

Early increase of lower oesophageal sphincter pressure after band ligation of oesophageal varices in cirrhotics: an intriguing phenomenon

AIM

We conducted a prospective, randomized comparison of endoscopic variceal ligation, sclerotherapy and metoclopramide injection in order to evaluate their early effect on lower oesophageal sphincter pressure.

METHODS

Twenty-six patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to undergo an oesophageal manometry. The patients' lower oesophageal sphincter pressure was evaluated, prior to and immediately after a single session of ligation (n = 10), a single session of sclerotherapy (n = 8) or a bolus injection of 20 mg metoclopramide hydrochloride (n = 8).

RESULTS

Ligation produced a higher early increase in lower oesophageal sphincter pressure (from 12.3 +/- 2.3 to 27.8 +/- 3.0 mmHg) as compared with sclerotherapy (from 13.6 +/- 2.5 to 22.4 +/- 4.5 mmHg) or metoclopramide injection (from 14.6 +/- 3.2 to 22.5 +/- 2.9 mmHg); (P = 0.0001).

CONCLUSION

Our data indicate that ligation of oesophageal varices produces an early increase in lower oesophageal sphincter pressure in cirrhotic patients.

A randomized, controlled trial of medical therapy versus endoscopic ligation for the prevention of variceal rebleeding in patients with cirrhosis

BACKGROUND & AIMS

Patients who have had one variceal bleed are at high risk of rebleeding. Since its introduction, endoscopic variceal banding has been shown to be superior to needle sclerotherapy. Banding has not been compared with hepatic venous pressure-guided medical therapy (beta-blockers and nitrates).

METHODS

One hundred two patients with cirrhosis and a recent esophageal variceal bleed were randomized to either endoscopic banding (51 patients) or medical therapy (51 patients). The hepatic venous pressure gradient was measured in all patients at baseline, at 3 months (drug therapy arm), and at yearly intervals (all patients). Primary end points were death or rebleeding.

RESULTS

The 2 groups were well matched. Fifty-one percent were Pughs C, with a median Pughs score of 9.5. Nineteen patients rebled in the drug arm (median time, 24 days) and 27 patients in the banding arm (median time, 24 days). At 1 year, 43.7% of patients had bled in the drug arm compared with 53.8% in the banding arm (P = 0.25). Thirty-two percent of patients on medical therapy had died at 1 year, 22.5% on banding (P = 0.97).

CONCLUSIONS

In the prevention of variceal rebleeding, beta-blockers +/- nitrates are as effective as endoscopic banding.

Management of bleeding in the cirrhotic patient

Important advances have been made in the management of variceal bleeding. Despite these advances, bleeding in the patient with cirrhosis remains one of the most demanding clinical challenges that a gastroenterologist or gastrointestinal surgeon may face. The aim is to identify the source of bleeding, control active bleeding and prevent rebleeding. This requires a multidisciplinary team, and the optimal management algorithm depends on the clinical circumstance of the patient and the local availability of endoscopic, radiological and surgical expertise. Injection sclerotherapy is effective in stopping acute variceal bleeding, but has the drawback of a high incidence of complications. Endoscopic variceal ligation is just as effective, and is associated with fewer complications. An overtube allows repeated introductions of the endoscope to be more tolerable for the patient and protects the airway against aspiration of blood; its use should be encouraged in patients with massive bleeding. Newer ligators can deliver multiple bands without removal of the scope but the high cost of these disposable devices limits their widespread use. Bleeding from gastric varices is even more challenging; the treatment of choice is injection with cyanoacrylate glue. To prevent rebleeding, beta-blockers are recommended for all patients with large varices (including those which have never bled). Injection sclerotherapy or band ligation, conducted at weekly intervals after the initial control of bleeding, is equally effective at obliterating varices and decreasing the risk of further hemorrhage; band ligation results in fewer complications. Other newer treatment modalities for variceal bleeding, such as somatostatin analogs, transjugular intrahepatic portasystemic shunt and liver transplantation, offer more optimal approaches to control bleeding and prevent rebleeding, but may be prohibitively expensive. Even for the most affluent communities, affordability, cost-effectiveness, and resource rationing are important considerations in management of patients with cirrhosis complicated by gastrointestinal bleeding.

Effects of endoscopic variceal treatment on oesophageal function: a prospective, randomized study

AIM

Endoscopic methods are currently the most widely used techniques for the treatment of bleeding oesophageal varices (BOV). However, a number of complications may limit their usefulness. We conducted a prospective, randomized comparison of variceal ligation versus sclerotherapy in cirrhotics after the control of variceal haemorrhage to study the relative short-term risks of these two procedures with respect to oesophageal motility and gastro-oesophageal reflux.

METHODS

Seventy-three patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to treatment with sclerotherapy or ligation until variceal eradication. In 60 of these patients, oesophageal manometry and 24-h intra-oesophageal pH monitoring were performed at inclusion and 1 month after variceal eradication.

RESULTS

After variceal eradication with sclerotherapy, peristaltic wave amplitude decreased from 76.2 +/- 14.7 mmHg to 61.6 +/- 17.7 mmHg (P = 0.0001), simultaneous contractions increased from 0% to 37.9% (P = 0.0008), and the percentage of time with pH < 4 increased from 1.60 +/- 0.25 to 4.91 +/- 1.16% in channel 1 (P = 0.0002) and from 1.82 +/- 0.27 to 5.69 +/- 1.37% in channel 2 (P = 0.0006). In contrast, the above parameters were not disturbed with ligation.

CONCLUSION

Our data define the advantages of ligation over sclerotherapy with respect to post-treatment oesophageal dysmotility and associated gastro-oesophageal reflux.

Review article: current endoscopic therapeutic options in the management of variceal bleeding

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.

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.

Approach to the management of bleeding esophageal varices: role of somatostatin

Various treatment strategies have been used to control variceal bleeding, including drugs, esophageal tamponade, endoscopic sclerotherapy (ES), endoscopic variceal ligation, transjugular intrahepatic portosystemic shunt and emergency surgery. None of these procedures are ideal and treatment frequently requires a combination of techniques. Sclerotherapy is one of the most widely used methods to control variceal bleeding; however, success is largely dependent on an experienced endoscopist. Vasoactive drugs act by decreasing pressure and blood flow in the gastroesophageal collaterals and they offer the advantage of being administered by inexperienced personnel. Drugs currently used in the treatment of variceal hemorrhage include vasopressin, terlipressin, somatostatin and octreotide. In the clinical studies to date, somatostatin was more effective than vasopressin and as effective as terlipressin in the control of bleeding esophageal varices (BEV), with an improved safety profile. In contrast, octreotide has shown conflicting results and more data are required to support the drug in this indication. More recently the ABOVE (Acute Bleeding Esophageal Variceal Episodes) study has provided further evidence that early administration of vasoactive drugs such as somatostatin is significantly more effective than placebo in the overall control of acute BEV episodes in cirrhotic patients undergoing ES. Therefore, the administration of a vasoactive drug as early as possible before emergency sclerotherapy is recommended for the effective management of BEV.

Management of upper gastrointestinal haemorrhage

Endoscopic therapy is the first treatment modality in the management algorithm of upper gastrointestinal haemorrhage. In treating bleeding peptic ulcers, diluted epinephrine is first injected followed by targeted treatment to the vessel. Combination therapy adding thermocoagulation or thrombin/fibrin products has been shown to further improve the rate of haemostasis. There is also some evidence to suggest that adjuvant use of optimal acid suppression using high-dose proton pump inhibitors can reduce recurrent bleeding after initial endoscopic control. In treating acute variceal haemorrhage, early administration of vasoactive agents facilitates endoscopic treatment. These drugs should be continued during and after endoscopic therapy to prevent recurrent in-hospital bleeding. Firm evidence exists to date that band ligation is the endoscopic treatment of choice in the acute control of bleeding varices and their secondary prophylaxis against recurrent bleeding. The role of band ligation as primary prophylaxis for first bleeding remains controversial. Transjugular intrahepatic portosystemic shunts are used as a rescue procedure when endoscopic treatment fails. In selected patients with recurrent variceal haemorrhage and good hepatic reserves, surgical shunts may be indicated.

Endoscopic sclerotherapy plus propranolol versus propranolol alone in the primary prevention of bleeding in high risk cirrhotic patients with esophageal varices: a prospective multicenter randomized trial

BACKGROUND

Analysis of primary prevention studies of the use of beta-blockers has shown clear reductions in variceal bleeding in cirrhotic patients with varices. In contrast, the usefulness of prophylactic endoscopic sclerotherapy, alone or in combination with propranolol, in the management of these patients is still under investigation. The present study compared the efficacy of combined sclerotherapy and propranolol versus propranolol alone in the primary prevention of hemorrhage in cirrhotic patients with varices and high (greater than 18 mm Hg) intraesophageal variceal pressure.

METHODS

Patients were randomly assigned to propranolol (42 patients) or to propranolol plus sclerotherapy (44 patients). The mean duration of follow-up was 26.8 +/- 7.7 and 24.6 +/- 9.8 months, respectively.

RESULTS

During this period 23% of the patients in the combination group experienced at least 1 episode of bleeding due to varices or congestive gastropathy as compared with 14% in the propranolol group (not significant). Twenty-three patients (52%) in the combination group developed complications as compared with 8 (19%) in the propranolol group (p = 0.002). The mortality rate was similar in both groups (14% and 18%, respectively). The only independent factor predictive of survival was the level of serum albumin.

CONCLUSIONS

Endoscopic sclerotherapy should not be used for the primary prevention of hemorrhage in cirrhotic patients at high risk of variceal bleeding who are undergoing treatment with propranolol.