Sclerotherapy versus sclerotherapy and propranolol in the prevention of rebleeding from oesophageal varices: a randomised study

BACKGROUND: This trial was carried out to assess the value of propranolol in the prevention of recurrent variceal bleeding when combined with longterm endoscopic sclerotherapy. PATIENTS AND METHODS: Two hundred patients (161 male, 39 female, age range 20-68 years) with portal hypertension resulting mainly from schistosomal periportal fibrosis or posthepatitic cirrhosis presenting with their first episode of haematemesis or melena, or both were included. This was confirmed endoscopically to result from ruptured oesophageal varices. After initial control of bleeding, patients were randomised into two groups: group 1 treated with endoscopic sclerotherapy alone and group 2 treated with sclerotherapy plus propranolol. They were followed up for two years. RESULTS: Group (2) had a lower rebleeding rate (14.3% v 38.6% in group 1), lower variceal recurrence after obliteration (17% v 34% in group 1), longer period between variceal obliteration and recurrence (36 weeks v 21 weeks in group 1); but no change in mortality (12% in both groups). CONCLUSIONS: Patients treated with sclerotherapy should be given propranolol for longterm management.     

Transabdominal extensive oesophagogastric devascularization with gastro-oesophageal stapling in the management of acute variceal bleeding

BACKGROUND: Operation is required for patients with portal hypertension who have failed to respond to emergency sclerotherapy for control of acute variceal bleeding. This study evaluates the role of transabdominal extensive oesophagogastric devascularization combined with gastro-oesophageal stapling for control of acute variceal bleeding in patients with portal hypertension of different aetiologies. METHODS: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling was performed in 65 patients (28 with cirrhosis, 17 with non-cirrhotic portal fibrosis and 20 with extrahepatic portal venous obstruction) in whom emergency endoscopic sclerotherapy, and/or pharmacotherapy and balloon tamponade had failed. The Sugiura procedure was modified to minimize operating time and to reduce the operative difficulties due to oesophageal wall necrosis after sclerotherapy. RESULTS: The operative mortality rate was higher in patients with cirrhosis (P = 0.0003); sepsis was the leading cause of death (in nine of 18). A high mortality rate (12 of 15) was seen in patients with Child grade C cirrhosis. Control of bleeding was achieved in all patients. The procedure-related complication rate was 17 per cent with a 6 per cent oesophageal leak rate; four of 47 surviving patients developed oesophageal stricture. During a mean follow-up of 33 months, residual varices, recurrent varices and rebleeding were seen in three, two and three of 47 survivors. CONCLUSION: Transabdominal extensive oesophagogastric devascularization combined with gastrooesophageal stapling is an effective and safe procedure for control of acute variceal haemorrhage with satisfactory long-term control, especially in patients without cirrhosis and low-risk patients with cirrhosis.     

Primary prophylaxis of variceal bleeding in cirrhosis: a cost-effectiveness analysis

BACKGROUND & AIMS: Prophylaxis against the first variceal bleeding has been proposed to reduce morbidity and mortality in cirrhotic patients. No previous information is available regarding the cost-effectiveness of prophylaxis. The aim of this study was to compare the cost-effectiveness of variceal bleeding prophylaxis with propranolol, sclerotherapy, and shunt surgery in cirrhotic patients stratified by bleeding risk. METHODS: A hypothetical cohort was stratified according to bleeding risk. The natural history of cirrhosis with esophageal varices was simulated using a Markov model. Transitional probabilities extracted from published studies and costs were obtained from our institution's billing department. Sensitivity analyses were performed for important variables. RESULTS: Propranolol results in cost savings ranging between $450 and $14,600 over a 5-year period. The extent of cost savings depended on the individual patient's bleeding risk. In addition, propranolol increased the quality-adjusted life expectancy by 0.1-0.4 years. Sclerotherapy was significantly less cost-effective than propranolol and had no advantage on quality of life. Shunt surgery was effective therapy for prevention of bleeding but decreased life expectancy and quality of life in some risk groups and was not cost-effective. CONCLUSIONS: Propranolol is the only cost-effective form of prophylactic therapy for preventing initial variceal bleeding in cirrhosis regardless of bleeding risk.     

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

BACKGROUND/AIMS: Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage. METHODS: Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment. RESULTS: The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively). CONCLUSIONS: Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.     

Transjugular intrahepatic portosystemic shunt. Treatment of patients with recurrent bleeding from esophageal varices

We report the results of transjugular intrahepatic portosystemic shunt (TIPS) procedure in six patients with liver cirrhosis and recurrent bleeding or acute intractable bleeding from oesophageal varices in spite of multiple sessions of sclerotherapy. Median follow-up was 15 months (range 1-24 months). The procedure was technically successful in all patients without procedure-related morbidity or mortality. Four of the procedures were performed electively and two as an emergency procedure. The portosystemic pressure gradient decreased to below 12 mmHg following TIPS implantation and the shunt bloodflow was one quarter to three-quarters of the portal bloodflow determined by Doppler ultrasound. Recurrent bleeding occurred in one patient but was amenable to endoscopic sclerotherapy. In this patient the shunt had developed a stenosis that was treated by balloondilatation and insertion of an additional stent six months following the initial procedure, and no further bleeding occurred. The remaining five patients had no rebleeding episodes. Repeated Doppler examinations in the followup period demonstrated patency of all shunts. None of the patients developed portosystemic encephalopathy. One patient died of cerebral haemorrhage, unrelated to TIPS, 16 months following implantation. Another patient died 14 months following TIPS due to acute mesenteric occlusion and septicaemia. We conclude that TIPS is feasible and effective in selected patients with liver cirrhosis and persistent or recurrent variceal bleeding following repeated endoscopic therapy.     

Longterm outcome after injection sclerotherapy for oesophageal varices in children with extrahepatic portal hypertension

A consecutive series of 36 children with bleeding from oesophageal varices secondary to extrahepatic portal hypertension was successfully treated by endoscopic injection sclerotherapy and followed up over a mean period of 8.7 years after variceal obliteration. There were no deaths from portal hypertension or its treatment and morbidity related to oesophageal sclerotherapy was minimal. Endoscopic injection sclerotherapy alone proved safe and effective in controlling variceal bleeding from portal hypertension in over 80% of the children. Recurrent variceal bleeding developed in 10 (31%) patients but half of these were effectively treated by further sclerotherapy. Gastric variceal bleeding unresponsive to sclerotherapy necessitated successful portosystemic shunt surgery in four (13%) patients. Two children required splenectomy for painful splenomegaly. In most children injection sclerotherapy is the best treatment for the primary management of bleeding oesophageal varices, reserving portosystemic shunting or other surgical procedures for those with bleeding from gastrointestinal varices.     

Nadolol plus isosorbide mononitrate compared with sclerotherapy for the prevention of variceal rebleeding

BACKGROUND: Patients who have bleeding from esophageal varices are at high risk for rebleeding and death. We compared the efficacy and safety of endoscopic sclerotherapy with the efficacy and safety of nadolol plus isosorbide mononitrate for the prevention of variceal rebleeding. METHODS: Eighty-six hospitalized patients with cirrhosis and bleeding from esophageal varices diagnosed by endoscopy were randomly assigned to treatment with repeated sclerotherapy (43 patients) or nadolol plus isosorbide-5-mononitrate (43 patients). The primary outcomes were rebleeding, death, and complications. The hepatic venous pressure gradient was measured at base line and after three months. RESULTS: Base-line data were similar in the two groups, and the median follow-up was 18 months in both. Eleven patients in the medication group and 23 in the sclerotherapy group had rebleeding. The actuarial probability of remaining free of rebleeding was higher in the medication group for all episodes related to portal hypertension (P = 0.001) and variceal rebleeding (P = 0.002). Four patients in the medication group and nine in the sclerotherapy group died (P = 0.07 for the difference in the actuarial probability of survival). Seven patients in the medication group and 16 in the sclerotherapy group had treatment-related complications (P = 0.03). Thirty-one patients in the medication group underwent two hemodynamic studies; 1 of the 13 patients with more than a 20 percent decrease in the hepatic venous pressure gradient had rebleeding, as compared with 8 of the 18 with smaller decreases in the pressure gradient (P = 0.04) for the actuarial probability of rebleeding at two years). CONCLUSIONS: As compared with sclerotherapy, nadolol plus isosorbide mononitrate significantly decreased the risk of rebleeding from esophageal varices.     

Management of esophageal varices in children by endoscopic variceal ligation

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

Emergency transjugular intrahepatic portasystemic stent shunting as salvage treatment for uncontrolled variceal bleeding

Creation of a transjugular intrahepatic portasystemic stent shunt (TIPSS) was used as a rescue treatment for patients with variceal bleeding refractory to standard medical and endoscopic treatment. Over a 2-year period 242 episodes of variceal bleeding were treated and emergency shunting was performed on 20 patients with uncontrolled bleeding (Pugh grade A, one; B, seven; C, 12). The procedure was technically successful and controlled bleeding in all patients. Six patients had early rebleeding within 5 days, and further shunting was required in two. Two had late rebleeding related to shunt occlusion and had a further TIPSS procedure followed by portacaval shunting. Twelve patients died within 40 days from liver failure and sepsis, and there were two late deaths after 2 and 6 months, unrelated to bleeding. TIPSS insertion is an effective therapeutic option in patients with acute variceal bleeding refractory to medical and endoscopic treatment. However, despite control of bleeding in this group, the hospital mortality rate was high, reflecting the severity of the underlying liver disease.     

Evaluation of trauma care in a developing country highlighted by a major aircraft accident

Transjugular intrahepatic portosystemic shunt (TIPS) is a side-to-side portocaval shunt for threatening complications of portal hypertension. The purpose of this study was to evaluate in first 33 patients indicated for TIPS insertion in our institution the efficacy, complications, and mortality. Indication was failure of sclerotherapy or ligation in control either of acute (n = 4) or repetitive (n = 25) variceal bleeding and refractory ascites (n = 4). The technical success rate was with 70% (21/30) lower than expected, but the complication rate was also very low. There were no fatal complications, only one subcapsular liver hematome, and in one patient repetitive punction of biliary tract. The 30-days mortality was 10% (2/21) and rebleeding was 15% (3/20), caused always by thrombosis of the shunt. TIPS seems to be a promising therapeutic procedure after failed endoscopic therapy of esophageal varices without the mortality and morbidity of an open surgical procedure. Recent indications for TIPS are acute variceal hemorrhage refractory to endoscopic treatment and recurrent variceal bleeding despite sclerotherapy or band ligation. Promising seems to be TIPS insertion in the treatment of refractory ascites.     

Endoscopic variceal ligation in prophylaxis of first variceal bleeding in cirrhotic patients with high-risk esophageal varices

To determine the efficacy of endoscopic variceal ligation (EVL) in prophylaxis on the rate of first esophageal variceal bleeding, we conducted a prospective, randomized trial in 126 cirrhotic patients with no history of previous upper gastrointestinal bleeding and with esophageal varices endoscopically judged to be at high risk of hemorrhage. The end-points of the study were bleeding and death. Life-table curves showed that prophylactic EVL significantly diminished the rate of variceal hemorrhage (12/62 [19%] vs. 38/64 [60%]; P = .0001) and overall mortality (17/62 [28%] vs. 37/64 [58%]; P = .0011). The 2-year cumulative bleeding rate was 19% (12/ 62) in the EVL group and 60% (38/64) in the control group. The 2-year cumulative mortality rate was 28% (17/62) in the EVL group and 58% (37/64) in the control group. Comparison of Kaplan-Meier estimates of the time to death of both groups showed significantly lower mortality in the ligation group (P = .001). Patients undergoing EVL had few treatment failures and died mainly of hepatic failure. The lower risk in the EVL group was attributed to a rapid reduction of variceal size. Prophylactic EVL was more efficient in preventing first bleeding in patients with good condition (Child A) than in those with decompensated disease (Child B and C). We conclude that prophylactic EVL can decrease the incidence of first variceal bleeding and death over a period of 2 years in cirrhotic patients with high-risk esophageal varices.     

Anti-inflammatory drugs and variceal bleeding: a case-control study

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) can have severe gastrointestinal effects and cause peptic ulcers to bleed. Acute bleeding from oesophageal varices is a major complication of cirrhosis of the liver. AIMS: To investigate the role, using a case-control study, of NSAIDs in first bleeding episodes associated with oesophageal or cardial varices in cirrhotic patients. Patients/METHODS: A structured interview was conducted of 125 cirrhotic patients with bleeding mainly related to oesophageal varices and 75 cirrhotic controls with oesophageal varices who had never bled. RESULTS: Cirrhotic patients who were admitted for bleeding related to portal hypertension were more likely to have used NSAIDs during the week before the index day (31 of 125 (25%)) than the cirrhotic controls (eight of 75 (11%); odds ratio = 2.8, p = 0.016). Use of aspirin alone or combined with other NSAIDs was also more prevalent in the cases (21 of 125 (17%)) than in the controls (three of 75 (4%); odds ratio = 4.9, p = 0.007). Logistic regression analysis showed that NSAID use (p = 0.022, odds ratio = 2. 9, 95% confidence interval = 1.8 to 4.7) and variceal size (p<0.001, odds ratio = 4.0, 95% confidence interval = 1.4 to 11.5) were the only variables independently associated with the risk of bleeding. CONCLUSIONS: Aspirin, used alone or combined with other NSAIDs, was associated with a first variceal bleeding episode in patients with cirrhosis. Given the life threatening nature of this complication, the possible benefit of this treatment should be weighed against the risk shown here. No firm conclusions could be drawn on non-aspirin NSAIDs used alone.     

Transjugular intrahepatic portosystemic shunt (TIPS) for variceal bleeding in portal hypertension: comparison of emergency and elective interventions

Nonsurgical reduction of portal hypertension by transjugular intrahepatic portosystemic shunt (TIPS) is widely used for prevention of variceal rebleeding (elective TIPS). Information is limited about the value of emergency TIPS for acute variceal bleeding unresponsive to endoscopic and drug therapy. The aim of the present study was therefore to determine whether the effects and complications differ between emergency and elective TIPS in patients with cirrhosis of the liver. TIPS was performed in 11 patients with acute variceal bleeding unresponsive to endoscopic treatment and 22 patients in stable condition after an episode of variceal bleeding. Clinical examination, blood sampling, Doppler sonography of TIPS flow, and upper gastrointestinal endoscopy were performed at days 1, 7, and 30 and at three-month intervals after TIPS. Mean follow-up was 549 (1-987) days. Bleeding was controlled by emergency TIPS in 10/11 patients. Probability of survival was not different after emergency and elective TIPS (0.73 vs 0.84 at one year). Early rebleeding (< or =2 weeks) occurred more often after emergency TIPS (3/11 vs 0/22 patients; P = 0.03), but there was no significant difference in late rebleeding. Occlusion of TIPS was more frequent after emergency TIPS. Occurrence of TIPS stenoses was identical in both groups (4/11 vs 8/22). De novo or deterioration of preexisting hepatic encephalopathy was similar (18% vs 24%; NS). It is concluded that TIPS is effective for control of acute variceal bleeding unresponsive to endoscopic and drug treatment. Early rebleeding and stent occlusion occurred more often after emergency TIPS. Late rebleeding, complications, and long-term survival did not differ from elective TIPS.     

Comparison of a modified Sugiura procedure with portal systemic shunt for prevention of recurrent variceal bleeding in cirrhosis

BACKGROUND: There is no agreement on the management of patients with cirrhosis and recurrent variceal bleeding after failure of medical or endoscopic treatments or both. Portal systemic shunts are highly effective in preventing rebleeding but are associated with a high incidence of chronic encephalopathy. This study compared the results of a slightly modified Sugiura procedure (esophageal transection plus esophagogastric devascularization plus splenectomy) with those of nonselective portal systemic shunts in patients with previous variceal bleeding. METHODS: Fifty-four patients were included in this randomized controlled study between January 1984 and April 1989. The major end point was chronic encephalopathy. Secondary end points were recurrent variceal bleeding, survival, ascites, and hepatocellular carcinoma. RESULTS: Twenty-seven patients were assigned to each group. The rate of chronic encephalopathy was significantly (p = 0.002) lower after modified Sugiura procedure than after portal systemic shunt. Recurrent variceal bleeding was more frequent after modified Sugiura procedure than after portal systemic shunt, but the difference is not significant. One-, two-, and three-year survival rates were 93%, 81%, and 67%, respectively, in the modified Sugiura group and 78%, 66%, and 39%, respectively, in the portal systemic shunt group (p = 0.044). CONCLUSIONS: These results suggest that the modified Sugiura procedure is better overall than the nonselective portal systemic shunt in the management of patients with cirrhosis and recurrent variceal bleeding. Although the rebleeding rate is higher after the modified Sugiura procedure, this does not seem to affect mortality in these patients.     

Guidance of intracoronary radiation therapy based on dose-volume histograms derived from quantitative intravascular ultrasound

BACKGROUND/AIMS: The risk factors for esophageal variceal rebleeding are little known. Variceal pressure is one of the major determinants of variceal rupture, but the relationship between variceal pressure and variceal rebleeding during maintenance sclerotherapy has not been determined. This study was undertaken to evaluate the relationship between variceal pressure/gradient change and variceal rebleeding during maintenance sclerotherapy. METHODS: Patients with liver cirrhosis and recent esophageal variceal hemorrhage underwent consecutive variceal pressure measurements by direct puncture of the varices before each elective sclerotherapy. RESULTS: In 46 patients, the initial variceal pressure was no different regardless of age, sex, underlying etiology or hepatic reserve. Variceal pressure was higher in large varices, varices with more severe red wale markings, and varices with slower reduction in size during maintenance sclerotherapy. A larger volume of sclerosant was required to eradicate large varices, varices with more severe red wale markings, and varices with slower reduction in size during maintenance sclerotherapy. There was a positive correlation between initial variceal pressure and total amount of sclerosant (r=0.485, p=0.001). Initial variceal pressure was not related to rebleeding. Variceal pressure increased more in patients with rebleeding from varices per se (n=7) than in those without rebleeding (n= 24). There was no difference in pressure change between patients without rebleeding (n=24) and those with rebleeding from variceal ulcers (n=7). CONCLUSIONS: Large varices, severe red color signs and slow reduction in variceal size were associated with higher initial variceal pressure, and more sclerosant was required to eradicate the varices. An increase in variceal pressure during maintenance sclerotherapy indicates a higher risk of variceal rebleeding, but not of variceal ulcer rebleeding.     

Prevalence of hypothalamic-pituitary imaging abnormalities in impotent men with secondary hypogonadism

BACKGROUND & AIMS: Combining endoscopic sclerotherapy with ligation has been proposed to hasten variceal eradication. A randomized trial was performed comparing combination ligation plus sclerotherapy with ligation alone in patients with major bleeding from esophageal varices. METHODS: Forty-one patients were randomly assigned to receive ligation or ligation plus 1 mL 1.5% tetradecyl injected just above each band. Treatment was repeated weekly until varices were eradicated. Repeat endoscopy was performed for rebleeding and every 3 months after eradication. RESULTS: No significant differences were found between combined therapy and ligation in rebleeding (29% vs. 30%), blood transfused (3.1 +/- 1.1 vs. 2.0 +/- 0.8 U), hospital days (9.3 +/- 2.1 vs. 7.5 +/- 1.2), complications (29% vs. 10%), or deaths (14% vs. 15%) during a mean follow-up period of 28 weeks. Combined therapy required significantly more sessions to achieve eradication (4.9 +/- 0.6 vs. 2.7 +/- 0.4) and greater time per treatment session (18.3 +/- 1.7 vs. 13.3 +/- 0.5 minutes). CONCLUSIONS: Combined ligation plus sclerotherapy does not reduce the number of treatment sessions required for variceal eradication as compared with ligation alone. Combined therapy lengthens the time required for treatment without improving efficacy or decreasing complications. Thus, combined ligation and sclerotherapy should not be used to treat patients with bleeding esophageal varices.     

Sclerotherapy versus ligation in hemorrhage caused by rupture of esophageal varices. Direct meta-analysis of randomized trials

OBJECTIVES: To compare the advantages of endoscopic ligation and endoscopic sclerotherapy for bleeding esophageal varices, published randomized clinical trials were critically reviewed by meta-analysis. Only ten clinical trials concerning a history of recent or active bleeding esophageal varices were included. METHODS: The methodology, population, treatment and outcomes of each relevant trial were evaluated by duplicate independent review. RESULTS: Endoscopic sclerotherapy compared to banding ligation significantly increased the rate of rebleeding (OR: 1.6; 95% IC: 1.1-2.3) without increasing early mortality compared to endoscopic banding ligation (OR: 1.3; 95% IC: 0.8-1.9). The rate of varice eradication associated with these two types of treatment was not different (OR: 0.9; 95% IC: 0.6-1.3) but was obtained more quickly with endoscopic banding ligation (3.8 +/- 1.6 versus 5.8 +/- 2.2; P < 0.05). The rate of complications was higher after sclerotherapy (OR: 2.5; 95% IC: 1.7-3.7), in those cases with a positive heterogeneity test. CONCLUSIONS: This meta-analysis shows a lower morbidity with endoscopic banding ligation in patients with variceal hemorrhage. The most important advantage of endoscopic banding ligation was the reduction of the rate of rebleeding.     

Histotopographic distribution of placental inflammation: analysis of 22 cases

OBJECTIVES: Acute bleeding from esophageal varices is a major complication of cirrhosis. Despite the large number of published studies no predictive factors of control of bleeding have been identified. We assessed the clinical and biological factors predictive of bleeding control within the first 2 weeks after a bleeding episode in a homogeneous group of patients enrolled in a large multicenter trial, who underwent a standardized emergency sclerotherapy session. METHODS: 101 patients with cirrhosis were enrolled. All had endoscopy-proven variceal bleeding, and the interval between hematemesis or melena and emergency sclerotherapy was always less than 24 hours. A second sclerotherapy session and other methods for the prevention of rebleeding were allowed after 5 days. RESULTS: Treatment failed in 16 patients after 24 hours and in a total of 33 patients after 15 days. Three of the 17 variables included in multivariate logistic analysis were associated with failure at 24 hours: encephalopathy (P = 0.006, OR = 4.0), blood transfusion prior to sclerotherapy (P = 0.012, OR = 6.2) and previous propranolol therapy (P = 0.022, OR = 4.6). Two variables were associated with failure between 24 hours and day 15 in patients successfully controlled after 24 hours: an interval between the onset of bleeding and sclerotherapy of less than 12 hours (P = 0.010) and blood transfusion (P = 0.018). After 15 days, three variables were associated with failure in a multivariate Cox model: encephalopathy (P = 0.0025, OR = 2.3), time to sclerotherapy (P = 0.022, OR 2.3) and blood transfusion before sclerotherapy (P = 0.0005, OR = 4.0). CONCLUSION: Encephalopathy, the severity of bleeding, assessed in terms of transfusion requirements, and the time between clinically overt bleeding and sclerotherapy are the main predictive factors of failure of the control of bleeding after emergency sclerotherapy for acute bleeding from esophageal varices.     

A prospective randomized trial comparing somatostatin and sclerotherapy in the treatment of acute variceal bleeding

Somatostatin and endoscopic sclerotherapy are widely used in the treatment of acute variceal bleeding. Although objective evidence does exist about the advantages of either treatment, data comparing both procedures are scarce. In order to compare the effectiveness and safety of somatostatin and sclerotherapy in the treatment of acute variceal bleeding, 70 consecutive cirrhotic patients suffering from esophageal variceal hemorrhage and meeting the inclusion criteria were randomly assigned to treatment with somatostatin (35 patients) or sclerotherapy (35 patients). No differences in age, sex, alcohol intake, etiology of cirrhosis and severity of liver failure were found between groups. Failure of treatment (defined as persistence of bleeding despite therapy or subsequent rebleeding within the 48-hr trial period) occurred in seven patients (20%) in the somatostatin group and in six (17.1%) in the sclerotherapy group (NS). Early rebleeding occurred in seven of 28 patients (25%) in the somatostatin group and in five of 29 (17.2%) in the sclerotherapy group (NS). Mortality within the first 6 wk was no different between both groups: 10 (28.5%) and eight (22.8%) in the somatostatin and sclerotherapy groups, respectively. Sclerotherapy, but not somatostatin, was associated with major complications in five cases (14.2%) (p = 0.026), two of which resulted in patient's death. These results suggest that somatostatin is safer, and as effective as sclerotherapy, in controlling acute variceal bleeding until an elective treatment can be established.     

Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices -- a prospective controlled randomized trial

From January 1, 1978 to January 1, 1980 a controlled randomized trial comparing conservative treatment with prophylactic sclerotherapy of esophageal varices prior to hemorrhage was carried out. In all 71 patients liver cirrhosis was histologically confirmed. The two randomly assigned groups were comparable. Indications of endoscopic treatment were the existence of varices III-IV bearing erosions, varices II-IV without erosions but coagulation factors below 30%, or both. Six patients left the trial. In group Ia -- treatment by conservative means -- a high rate of variceal bleeding and death was observed. Comparing these results with those of group Ib treated by sclerotherapy, bleeding and death rates were found to be highly significantly lower. -- Thus the investigated criteria for predicting a recent variceal hemorrhage are confirmed. Prophylactic sclerotherapy in esophageal varices with erosions and/or poor coagulation reserve of the liver can largely prevent an esophageal hemorrhage from varices, and prolongs the life of these chronically ill patients.