Esophagogastric Varices and Nonvariceal Bleeding

Esophagogastric Varices

General and Diagnostic Aspects

The controversial issue of the cost-effectiveness of screening all cirrhotic patients for esophageal varices was raised in a number of abstracts. In one study using the Markov model, universal endoscopic screening was found not to be cost-effective when compared to empirical medical prophylaxis for variceal bleeding [1]. The cost-effectiveness of screening endoscopy could, however, be improved if a subgroup of cirrhotic patients could be identified that would not need screening for large varices. In this context, absence of splenomegaly and a platelet count > 100 000 were found to be associated with a low risk of developing varices, particularly large varices [2]. This was confirmed in another study in which predictors of the presence of esophageal varices in patients with a recent histological diagnosis of cirrhosis were investigated in 250 patients. Among various clinical, biochemical, and ultrasound variables, a longitudinal spleen diameter of > 112 mm was found to be an independent predictor of the presence of esophageal varices [3].

Endoscopic Techniques

The importance of identifying the exact site of variceal rupture at endoscopy and subsequent targeted endoscopic treatment was underlined in one study, as it was found to be associated with a significantly lower rebleeding rate [4]. In a study aiming to detect risk factors associated with rebleeding 1 - 5 days after variceal ligation, it was found that active bleeding at the index endoscopy was associated with early rebleeding [5]. The short-term and medium-term mortality rates from bleeding varices treated using endoscopic band ligation were found to be better than those reported in the literature, in a retrospective analysis of data obtained from a North American center [6]. In order to facilitate injection sclerotherapy, a Japanese group designed a transparent hood to be mounted on the tipp of the endoscope, provided with three U-shaped slits to fix the targeted varix during injection [7]. Mini-loop ligation of esophageal varices was tried in another study and was compared to sclerotherapy. It was found to be effective, relatively easy to use, and more tolerable for patients. However, the variceal recurrence rate after 1 year was higher in the mini-loop group [8]. Guiding sclerotherapy with endoscopic ultrasonography to ensure periesophageal vein obliteration was found to be a safe and effective method of treating esophageal varices [9]. However, the authors did not state clearly the advantages achieved by this technique over conventional sclerotherapy.

The use of argon plasma coagulation for the eradication of esophageal varices was a topic of one study again this year, in which it was used 7 days after one session of sclerotherapy with 5 % ethanolamine oleate. The entire mucosa of the distal 4 - 5 cm of the esophagus was circumferentially coagulated in one session. This was found to be an effective and relatively safe procedure, which was associated with fewer complications in comparison with subjecting the patient to a second sclerotherapy session [10]. High-intensity focused ultrasound has been presented as a new method of hemostasis of lacerated veins, which may have applications in bleeding esophageal varices. This new therapeutic modality was tested on lacerated rabbit auricular veins [11].

The effect of a single session of endoscopic ligation of bleeding esophageal varices on lower esophageal sphincter pressure was studied and compared to the effect of a single session of sclerotherapy and metoclopramide. Ligation produced a higher earlier increase in pressure. This effect may contribute to the successful control of bleeding varices [12].

The prophylactic management of variceal bleeding was the topic of several abstracts. Endoscopic variceal ligation for large esophageal varices was found to be at least as effective as propranolol for the primary prevention of variceal bleeding [13] [14]. With regard to secondary prophylaxis, a prospective randomized controlled study including 104 patients demonstrated the comparable efficacy and safety of a combination of propranolol and isosorbide mononitrate with band ligation. The authors of this abstract recommend studying the combination of both therapeutic modalities to decrease post-banding ulcer-related bleeding, which occurred in about 10 % of patients in the band ligation group [15]. In patients with liver cirrhosis complicated by hepatocellular carcinoma, prophylactic sclerotherapy of esophageal varices was found to be associated with a more prolonged survival [16].

A group of abstracts dealt with different modalities of endoscopic management of gastric varices. The safety and efficacy of cyanoacrylate glue in the management of bleeding gastric varices was confirmed in a retrospective study from the UK [17]. A Japanese group investigated a protocol for the endoscopic injection of bleeding gastric varices, in which the injected substance was selected according to the blood-flow velocity within the varix: cyanoacrylate glue was chosen if there was a high blood-flow velocity, and ethanolamine oleate was used with low blood-flow velocity. Aethoxysclerol was injected extravariceally when there were small residual varices. The blood-flow velocity within the varix, whether high or low, was judged by negative or positive imaging, respectively, of contrast injected into the varix under fluoroscopy. Ten of 30 patients received cyanoacrylate injections, and 20 patients received ethanolamine oleate. Polidocanol injections were required in five patients. Variceal bleeding recurred in only three patients. Leakage of glue into the inferior vena cava occurred in one patient, but without any major embolic complications. The authors conclude that this type of approach is safe and useful for controlling bleeding as well as for eradicating gastric varices [18]. In a canine model of bleeding gastric varices, five different substances for endoscopic injection were evaluated: saline, cyanoacrylate glue, a mixture of ethanolamine oleate (3.3 %) and alcohol (32 %), and a new polysaccharide gel at two different concentrations (1 % and 3 %). The new agent was found to be very effective for gastric variceal hemostasis and in reducing the variceal size, with a low ulceration rate [19]. In a prospective, randomized trial, balloon-occluded endoscopic injection sclerotherapy was compared with balloon-occluded retrograde transvenous obliteration for the prophylactic obliteration of gastric varices. The former technique was found to be safe and effective [20].

References

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