The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

Abstract

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.

Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

“…Endoscopic therapy is an integral component of the management of acute variceal bleeding as well as prevention of recurrent bleeding [8,9]. Since it first evolved as a new therapeutic option, EBL has been regarded as a more effective modality than endoscopic injection sclerotherapy in the control of acute hemorrhage with less reported adverse events [10][11][12].…”

“…Bleeding from esophageal varices is a life-threatening complication of portal hypertension which accounts for most of cirrhosis-related mortalities [7,8]. Endoscopic therapy is an integral component of the management of acute variceal bleeding as well as prevention of recurrent bleeding [8,9].…”

Outcome in decompensated alcoholic cirrhotic patients with acute variceal bleeding

“…2 Endoscopic control of bleeding is widely used as the emergency treatment of choice for actively bleeding oesophageal varices. [3][4][5] Although treatment advances have reduced overall mortality, 6,7 uncontrolled or recurrent bleeding from varices and the consequences of ensuing liver decompensation remain the most common cause of early death in alcoholic cirrhotic patients. 8 Despite the general use of endoscopic therapy, there are few robust and validated data on the efficacy of endoscopic control of the index variceal bleed, the frequency of early rebleeding, and survival following the initial bleed in alcoholic cirrhotic patients.…”

“…[6][7][8] Published results are inconsistent and conflicting because of small sample sizes, referral bias, dissimilar study end-points, and differences in patient selection, methods and techniques of endoscopic intervention, and the precise definition of rebleeding. 4,9 There is consensus that assessment of intervention efficacy in cirrhotic patients with portal hypertension and bleeding oesophageal varices should be based on the control of bleeding and the risks of rebleeding and death as the 3 major outcomes. 10,11 We aimed to evaluate the efficacy of endoscopic intervention in achieving control of acute variceal bleeding and preventing rebleeding and death during the first hospital admission in a large cohort of consecutively treated alcoholic cirrhotic patients with bleeding oesophageal varices.…”

Intramural esophageal hematoma after elective injection sclerotherapy

“…It is a rare complication of sclerotherapy, with an incidence of 0.3% to 1.6% (7,18,27) . Until now, the risk factors associated with the development of this complication have not been completely established.…”