Tamponade and injection sclerotherapy in the management of bleeding oesophageal varices

Barsoum, Mohsen Samy; Bolous, Fathi Iskander; El-Rooby, Abushady Ahmed; Rizk-Allah, Mounir Azmy; Ibrahim, Amal Sami

doi:10.1002/bjs.1800690206

Cited by 168 publications

(48 citation statements)

References 13 publications

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“…Conventional measures therapy, including blood and frozen plasma transfusion, fluid and including balloon tamponade, vasoconstrictors, and surgical electrolytes replacement, and lactulose, was administered to patients intervention did not substantially improve survival. [1][2][3] In the in both groups as clinically indicated. Oximeter monitoring was roupast 2 decades, endoscopic injection sclerotherapy (EIS) has tinely performed for both treatment groups during endoscopic therbeen widely employed in the management of bleeding from apy.…”

Section: Tion Was Associated With a Lower Complication Rate Thanmentioning

confidence: 99%

Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices

et al. 1997

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acute variceal bleeding proved to be superior to vasoconstricActive bleeding varices are a great challenge to endostors or balloon tamponade in the control of hemorrhages. [5][6][7] copists. In this study, we compared the short-term effiNevertheless, substantial complications may be associated cacy and safety of banding ligation with injection sclerowith EIS. 8 Furthermore, while EIS has been used extentherapy in the arresting of active bleeding from sively, it also has not had a significant impact on survival.4 esophageal varices. Seventy-one cirrhotic patients with Endoscopic variceal ligation (EVL) has been adopted in recent active variceal bleeding were randomized to receive years to substitute for EIS in managing bleeding esophageal banding ligation (37 patients) or sclerotherapy (34 pavarices.9 tients) immediately after endoscopic examinations. PriMost controlled studies comparing EVL with EIS favored mary success rate (bleeding stopped for 72 hours) was EVL in terms of sessions required to achieve variceal oblitera-97% in the ligation group and 76% in the sclerotherapy tion, rebleeding rate, and complication rate. [10][11][12][13] On the other group (P Å .009). The efficacy of ligation was similar to hand, EIS and EVL were found to be of similar effectiveness sclerotherapy in the control of oozing varices (100% vs.in terms of arresting active bleeding. 14 However, all of those 89%, P Å .23), whereas ligation was superior to sclerostudies comprised only a small number of patients with active therapy in the control of spurting varices (94% vs. 62%, variceal bleeding. Thus, a larger study comparing EVL with P Å .012). The requirement of vasoconstrictors after EIS for the control of active variceal bleeding is mandatory. emergency endoscopic treatment was lower in the ligaThis study was undertaken to investigate the efficacy and tion group than in the sclerotherapy group (11% vs. 41%, safety of EIS and EVL in the control of active bleeding from P Å .007). Treatment failure within 1 month was 8% in esophageal varices. the ligation group vs. 30% in the sclerotherapy group (P Å .02). Blood transfusion requirements were signifi-PATIENTS AND METHODS cantly lower in the ligation group than in the sclerotherapy group (3.2 { 1.2 vs. 4.5 { 1.8 units, P õ .01). RebleedBetween October 1991 and June 1995, seventy-one consecutive ing rate within 1 month was 17% in the ligation group cirrhotic patients with active variceal bleeding admitted to Veterans and 33% in the sclerotherapy group (P Å .19). Significant General Hospital-Kaohsiung (Taiwan, Republic of China) were enrolled in the study. All of the patients were proven to be actively complications were encountered in 5% of the ligation bleeding from esophageal varices by emergency endoscopy within 12 group and 29% of the sclerotherapy group (P Å .007).hours of admission. Among them, emergency endoscopy was perMortality rates within 1 month were 19% in the ligation formed in forty-two patients within 6 hours of entry to the emergency group and 35% in the sclerotherapy gr...

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Section: Tion Was Associated With a Lower Complication Rate Thanmentioning

confidence: 99%

Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices

et al. 1997

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“…1 rate could be lowered [3][4][5][6][7][8] and survival prolonged. 4,6,9,10 Studies Patients who have bled from varices remain at risk with rubber band ligation have shown that in addition to for rebleeding.…”

mentioning

confidence: 99%

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: A multicenter prospective randomized trial

et al. 1997

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rate could be lowered [3][4][5][6][7][8] and survival prolonged. 4,6,9,10 Studies Patients who have bled from varices remain at risk with rubber band ligation have shown that in addition to for rebleeding. There is interest in methods that would being safer than sclerotherapy, 11-14 ligation can further lower enable rapid eradication of varices. The present trial the rebleeding rate 12,13 and further improve survival. 11 Howwas designed to study whether combining ligation with ever, the problem of rebleeding has not been eliminated. Besclerotherapy will allow quicker eradication of varices cause most episodes of rebleeding occur early, methods that than either modality alone. Patients with bleeding eradicate varices more rapidly by reducing the ''period at esophageal varices were randomized into ligation or risk'' might further improve outcome. combination therapy groups. Patients in the ligationIn our first multicenter trial, an average of five sessions group were treated with endoscopic rubber band ligawere required to eradicate varices with sclerotherapy, tion alone. In combination group patients, each variceal whereas four sessions were required with ligation. 11 To furcolumn was ligated distally and 1 mL of ethanolamine ther optimize efficiency, we asked whether a lower dose of was injected proximal to each ligated site. Subsequent sclerotherapy in conjunction with ligation would eradicate treatment sessions were at 7-to 14-day intervals until esophageal varices more quickly than either modality alone, varices were eradicated. The clinical and endoscopic while maintaining the lower complication rate associated characteristics of 25 patients in the ligation group were with ligation. In an initial single-arm study, we ligated each similar to those of 22 patients in the combination group.variceal column distally and injected 1 mL of sclerosing soluFollow-up was up to 30 months. Active bleeding was contion proximal to each ligated site. With this approach, varices trolled in 100% of patients in the ligation group and 75%were eradicated with an average of approximately three sesof those in combination group (P Å NS). It took 3.3 { .4sions. 15 The aim of the present prospective randomized trial (range, 1-7) sessions to eradicate varices with ligation was to determine whether combination therapy would eradiand 4.1 { .6 (1-7) with combination therapy (P Å NS).cate varices more quickly than ligation alone. The rebleeding rate in patients who survive an episode of geal varices with red color signs, and absence of other lesions such as variceal hemorrhage is higher than that associated with any ulcers, erosions, vascular malformations, or mucosal tears. Exclusion other cause of upper gastrointestinal hemorrhage.1 An early criteria were (1) previous endoscopic or operative treatment, i.e., study of the ''natural history'' of variceal bleeding showed rubber band ligation, sclerotherapy, or shunt; (2) gastric varices more that approximately one third of patients who survived the than 2 cm from the gastroesophageal jun...

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“…Randomized trials comparing tamponade to sclerotherapy for EVB show trends or significant benefit for sclerotherapy in initial hemostasis, and all indicate better sustained or definitive hemostasis with sclerotherapy. (6)(7)(8) Thus, tamponade for acute EVB is not better than medical therapy, is less effective than endoscopic therapy, and not uncommonly causes serious and sometimes fatal complications. My view has been that the use of tamponade should be exceedingly rare: e.g., patients with persistent massive known EVB awaiting endoscopy or awaiting transjugular intrahepatic portosystemic shunt after unsuccessful endoscopic intervention.…”

Section: Balloon Tamponadementioning

confidence: 99%

Deflating balloon tamponade: Should we expand the use of stents for severe refractory esophageal variceal bleeding?

Laine

2016

Hepatology

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A cute esophageal variceal bleeding (EVB) remains among the most serious emergencies managed by gastroenterologists and hepatologists. Most patients do well during the acute episode with current endoscopic and pharmacologic therapy. In this issue of HEPATOLOGY, Escorsell and colleagues report a randomized trial comparing a very old and a very new intervention for the challenging minority of patients with refractory acute EVB.(1) Acute EVBCurrent guidelines recommend endoscopic ligation and vasoactive medication for treatment of acute EVB, with consideration of transjugular intrahepatic portosystemic shunt in high-risk patients.(2) Randomized trials indicate that 2%-13% of patients with acute EVB treated as recommended have persistent or recurrent bleeding over 5 days or during hospitalization. (3,4) Consensus guidelines recommend transjugular intrahepatic portosystemic shunt for patients who have persistent bleeding despite initial endoscopic and medical therapy, while a second endoscopic treatment may be tried if bleeding recurs after initial hemostasis. (2) Balloon tamponade is currently recommended only for refractory EVB as a temporary bridge to definitive therapy.(2) However, randomized trials have not focused solely on patients with persistent active bleeding despite endoscopic and medical intervention, the high-risk group in whom balloon tamponade may be considered. Balloon TamponadeBalloon tamponade is among the oldest therapies used for variceal bleeding. Case series suggest initial bleeding control in 90% of patients.(5) Major complications, including esophageal rupture, airway obstruction, and aspiration pneumonia, occur in 12% of patients and may be lethal.(5) Deaths attributed to use of balloon tamponade occurred in 6% of patients in these series. (5) Randomized trials comparing tamponade to medical therapy with vasopressin, somatostatin, or terlipressin reveal no significant difference in initial control of bleeding or mortality. Randomized trials comparing tamponade to sclerotherapy for EVB show trends or significant benefit for sclerotherapy in initial hemostasis, and all indicate better sustained or definitive hemostasis with sclerotherapy. (6)(7)(8) Thus, tamponade for acute EVB is not better than medical therapy, is less effective than endoscopic therapy, and not uncommonly causes serious and sometimes fatal complications. My view has been that the use of tamponade should be exceedingly rare: e.g., patients with persistent massive known EVB awaiting endoscopy or awaiting transjugular intrahepatic portosystemic shunt after unsuccessful endoscopic intervention. Self-Expanding Metal StentsThe removable covered self-expanding metal stent used by Escorsell et al. was designed specifically to treat EVB Abbreviation: EVB, esophageal variceal bleeding.

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Tamponade and injection sclerotherapy in the management of bleeding oesophageal varices

Cited by 168 publications

References 13 publications

Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices

Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices

Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: A multicenter prospective randomized trial

Deflating balloon tamponade: Should we expand the use of stents for severe refractory esophageal variceal bleeding?

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