Eleven-Year Survey of Safety and Efficacy of Endoscopic Injection Sclerotherapy Using 2% Sodium Tetradecyl Sulfate and Contrast Medium
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Abstract:
We conducted a retrospective 11-year survey to evaluate the post-treatment course in 285 patients with esophagogastric varices following administration of endoscopic injection sclerotherapy as an emergency, elective, or prophylactic procedure using freshly prepared 2% sodium tetradecyl sulfate not containing benzyl alcohol. These agents were injected into the varices and the supplying veins under fluoroscopic observation, usually in a single treatment. In all patients the variceal size was greatly reduced following one treatment. The amount of sclerosant necessary to fill the varices and the supplying veins varied widely among the patients. Acute variceal bleeding was controlled in 80 (96.4%) of the 83 patients, and the risk of rebleeding during the first month was 0.0548 in the emergency procedures. The serious complication of perforation was observed in one patient. The cause of death was established in the 122 patients who died and included esophageal variceal bleeding in eight (6.6%) and gastric variceal bleeding in one (0.8%). The overall 50% survival period was 5 years and 4 months. Multivariate analysis disclosed that the factors with the greatest negative effect on survival were poor hepatic status and the presence of hepatocellular carcinoma. The method of preparation and the procedure itself may be considered safe and effective in the treatment of esophagogastric varices.Keywords:
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The optimum treatment of gastric varices has still to be defined. Lesser curve gastric varices may be treated by injection sclerotherapy, but this has a limited role in the treatment of fundal gastric varices. Surgical intervention is commonly needed but carries a high mortality in patients with advanced liver disease. This study evaluated the use of thrombin for the treatment of gastric varices in 11 consecutive patients (nine with fundal, two with high lesser curve varices), identified as having bled from this site. Bovine thrombin (1000 U/ml) was injected intravariceally (mean volume 5.5 ml, range 2-10 ml) producing initial haemostasis in all 11 cases. Varices were considered thrombosed or obliterated in all patients after a median of two injection episodes (range 1-3). After a median follow up of nine months only one patient had rebled from a gastric varix. Thrombin may represent a valuable alternative injectate for the treatment of gastric varices.
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Goals: This study investigated the feasibility of using erythrocyte (RBC) lifespan determined by Levitt’s CO breath test (LCOBT) to predict esophageal varices needing treatment (VNT) in patients with cirrhosis. Background: Esophageal varix bleeding is a common fatal complication of cirrhosis and portal hypertension. The gold standard for identifying VNT is esophagogastroduodenoscopy (EGD), an invasive procedure with low patient compliance. VNT screening based on Baveno VI criteria has mediocre specificity. Study: RBC lifespan was determined by LCOBT in 53 cirrhotic patients (13 without varices, 11 mild/moderate varices, and 29 severe varices). Correlation of varix severity with RBC lifespan and other variables was analyzed. Rates of shortened RBC lifespan and thrombocytopenia (Baveno VI criteria) were compared. Results: RBC lifespan correlated inversely with severity of varices ( r =−0.793, P <0.001). Mean RBC lifespans were 129±31, 96±21, and 59±21 days for Nonvarix, Mild/Moderate, and Severe groups. Shortened RBC lifespan (<75 d) was observed in 79.3% (23/29) of patients with severe varices, a frequency similar or identical to thrombocytopenia rates [original Baveno VI criteria, 86.2% (25/29), P =0.487; expanded criteria, 79.3% (23/29), P >0.999]. Among 24 patients without severe varices, shortened RBC lifespan was observed in 1 patient whereas thrombocytopenia was detected in 13 and 8 patients based on the original ( P <0.001) and expanded criteria ( P =0.010), respectively. Conclusions: RBC lifespan correlates inversely with varix severity in patients with cirrhosis. LCOBT may enable specific screening for VNT.
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Thirty-three children with esophageal varices due to portal hypertension underwent injection sclerotherapy over a period of 6 yr. Thirty-one completed the sclerotherapy course, and the varices were eradicated in all. In nine, the procedure was performed as an emergency because of continued bleeding and, in each case, a gastric fundal varix was the source of the blood loss. Sclerotherapy successfully controlled the bleeding in four of these, whereas five required surgical underrunning of the fundal varix. After surgery, these five continued sclerotherapy until the esophageal varices were eradicated. Complications included transient pyrexia (39%), retrosternal discomfort (30%), esophageal ulceration (18%), and esophageal stricture (12%). Rebleeding before initial eradication of the varices occurred in 12 patients but, thereafter, was very uncommon and always small in amount. Esophageal varices recurred after initial eradication in 33% of cases but were easily sclerosed with further injections. This study demonstrates that sclerotherapy is effective in reducing bleeding frequency in children with portal hypertension, but emphasizes the need for regular follow-up endoscopy after initial eradication of esophageal varices.
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A novel use of multidetector computed tomographic intravenous (MDCT IV) portography in the evaluation of gastric varices treated with tissue adhesive is described. A 55-year-old man presented with upper gastrointestinal hemorrhage as a result of bleeding gastric varices. The patient was stabilized and the gastric varices were treated with n-butyl-2-cyanoacrylate (two injections, total 7.5 mL). MDCT IV portography performed after injection revealed thrombosis of all but one of the submucosally based gastric varices. The endoscopist who performed repeat endoscopy three weeks later was then able to direct therapy at the remaining patent submucosally based gastric varix. This represents the first reported use of MDCT IV portography in the evaluation of treatment adequacy in a patient with gastric varices treated with n-butyl-2-cyanoacrylate.
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Balloon-occluded retrograde transvenous obliteration is an effective new method for treating gastric fundal varices, but subsequent occurrence of esophageal varices creates a problem. The relationship between portal hemodynamics and the occurrence of esophageal varices after prophylactic balloon-occluded retrograde transvenous obliteration was investigated.Ten cirrhotic patients considered to have high risk gastric fundal varices underwent angiography. Six patients showed a communication between blood flow in gastric wall vessels and that in the gastrorenal shunt (type I), whereas the others (type II) did not. Depending on the flow direction in the left gastric vein, the two groups were further divided into hepatopetal (a) and hepatofugal (b) subgroups. The therapeutic effect on portal hemodynamics and the relationship between pretreatment portal hemodynamics and posttreatment occurrence of esophageal varices were investigated.Fundal varices disappeared endoscopically in all 10 patients and the gastrorenal shunt was also occluded after the procedure. No patient showed worsening of liver function or systemic complications during follow-up. The increase in portal blood flow was more significant in type Ib patients than in the others. Esophageal varices occurred in all type I patients, and as to those in type Ib, high risk varices developed within 6 months after treatment. On the other hand, esophageal varices did not occur in type II patients.This procedure was effective for treating gastric fundal varices. However, type Ib patients are likely to develop high risk esophageal varices after occlusion of the gastrorenal shunt.
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Aim: Because the procedure of balloon‐occluded retrograde transvenous obliteration (B‐RTO) causes extensive thrombosis of the major shunt that connects the spleen and gastric/renal venous systems, an increase in portal pressure is unavoidable. The aim of the present study was to assess the long‐term outcome of B‐RTO, including changes in esophageal varices. Methods: B‐RTO was conducted in 22 patients with gastric varices, who were divided according to the severity of esophageal varices at baseline; there were no esophageal varices ( n = 7), F 1 varices ( n = 11), and F 2 varices ( n = 4). The outcome measures included the development/worsening of esophageal varices after B‐RTO and survival rates. Results: The cumulative bleeding‐free probability for all 22 patients at 3 years after B‐RTO was 100%. The overall 3‐year survival was 94.4%. Seven patients who had no esophageal varices prior to B‐RTO did not develop any after the procedure. Seven (63.6%) of the 11 patients with stage F 1 esophageal varices prior to B‐RTO showed no changes in the varices after B‐RTO, while two patients progressed to F 2 varices and two developed F 3 varices. The cumulative treatment‐free probability of the esophageal varices at 24 months after B‐RTO was 100% for patients without esophageal varices at baseline, 80.8% for patients with pre‐existing F 1 varices, and 75% for those with pre‐existing F 2 varices. Conclusion: Although the B‐RTO procedure is considered useful for the treatment of gastric varices, changes in hemodynamics due to obliteration of this major shunt must be taken into account and observed closely.
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Tissue adhesive agents, such as the cyanoacrylates, have been used as an alternative to conventional sclerotherapy to treat gastric varices, but the long-term efficacy of this approach has not been determined. We evaluated the efficacy and long-term outcome of injection sclerotherapy with n-butyl-2-cyanoacrylate and ethanolamine oleate in 16 patients with gastric varices.We evaluated the effect of injection sclerotherapy in 16 Japanese patients with gastric varices. Injection sclerotherapy was performed on an emergency basis in 6 patients, an elective basis in 5 patients, and as prophylaxis in 5 patients.No bleeding was observed in the 7 patients in whom gastric varices disappeared during the 51 month follow-up period. The non-bleeding rate after treatment was significantly higher in this group than in the 9 patients in whom gastric varices did not disappear (p<0.05). Acute bleeding was stopped in 5 (83.3%) of 6 patients. The single failure was a patient in whom the sclerosant could not be injected into the gastric varices. No serious complications, such as emboli in other organs, were observed.The results suggest that this therapy is a safe and useful treatment for gastric varices and that the goal of injection sclerotherapy should be the disappearance of gastric varices.
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Forty-five cirrhotic patients with oesophageal varices were randomized to receive endoscopic injection sclerotherapy with either 5% ethanolamine oleate (EO), or 5% sodium morrhuate (SM). In the EO group, there was a statistically significant higher rate of disappearance of red colour signs on the varices a week after the initial session of sclerotherapy than in the SM group (91.3% vs 45.5%, P less than 0.05). A jet-like bleeding from injection sites at the second session of sclerotherapy occurred in three patients in the SM group and they experienced blurred vision. There was no such occurrence in the EO group. Oesophageal bleeding requiring blood transfusion during the course of repeated sclerotherapy occurred only in the SM group (five patients): bleeding was from a partly thrombosed varix and in four was from oesophageal ulcers. We found that EO administered intravariceally is more efficacious than SM for sclerotherapy of oesophageal varices.
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