Sclerotherapy for esophageal varices
Sclerotherapy for esophageal varices, also called endoscopic sclerotherapy, is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.
Esophageal varices are enlarged or swollen veins on the lining of the esophagus which are prone to bleeding. They are life-threatening and can be fatal in up to 50% of patients. Esophageal varices are a complication of portal hypertension, a condition characterized by increased blood pressure in the portal vein resulting from such liver disease, as liver cirrhosis. Increased pressure causes the veins to balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools.
In most hospitals, sclerotherapy for esophageal varices is the treatment of choice to stop esophageal bleeding during acute episodes, and to prevent further incidences of bleeding. Emergency sclerotherapy is often followed by preventive treatments to eradicate distended esophageal veins.
Bleeding esophageal varices are a serious complication of liver disease. In the United States, at least 50% of people who survive bleeding esophageal varices are at risk of recurrent bleeding during the next one to two years.
Sclerotherapy for esophageal varices involves injecting a strong and irritating solution (a sclerosant) into the veins and/or the area beside the distended vein. Sclerosant injected directly into the vein causes blood clots to form and stops the bleeding, while sclerosant injected into the area beside the distended vein stops the bleeding by thickening and swelling the vein to compress the blood vessel. Most physicians inject the sclerosant directly into the vein, although injections into the vein and the surrounding area are both effective. Once bleeding has been stopped, the treatment can be used to significantly reduce or destroy the varices.
Sclerotherapy for esophageal varices is performed with the patient awake but sedated. Hyoscine butylbromide (Buscopan) may be administered to freeze the esophagus, making injection of the sclerosant easier. During the procedure, an endoscope is passed through the patient's mouth to the esophagus to allow the surgeon to view the inside. The branches of the blood vessels at or just above where the stomach and esophagus come together, the usual site of variceal bleeding, are located. After the bleeding vein is identified, a long, flexible sclerotherapy needle is passed through the endoscope. When the tip of the needle's sheath is in place, the needle is advanced, and the sclerosant is injected into the vein or the surrounding area. The most commonly used sclerosants are ethanolamine and sodium tetradecyl sulfate. The needle is withdrawn. The procedure is repeated as many times as necessary to eradicate all distended veins.
A radiologist assesses patients for sclerotherapy based on blood work and liver imaging studies performed using CT scans , ultrasound or MRI scans, and in consultation with the treating gastroenterologist, hepatologist, or surgeon. Tests to localize bleeding and detect active bleeding are also performed.
Before a sclerotherapy procedure, the patient's vital signs and other pertinent data are recorded, an intravenous line is inserted to administer fluid or blood, and a sedative is prescribed.
After sclerotherapy for esophageal varices, the patient will be observed for signs of blood loss, lung complications, fever, a perforated esophagus, or other complications. Vital signs are monitored, and the intravenous line maintained. Pain medication is usually prescribed. After leaving the hospital, the patient follows a diet prescribed by the physician, and, if appropriate, can take mild pain relievers.
Risks associated with sclerotherapy include complications that can arise from use of the sclerosant or from the endoscopic procedure. Minor complications, which cause discomfort but do not require active treatment or prolonged hospitalization, include transient chest pain, difficulty swallowing, and fever, which usually go away after a few days. Some patients may have allergic reactions to the sclerosant solution. Infection occurs in up to 50% of cases. In 2-10% of patients, the esophagus tightens, but this complication can usually be treated with dilatation. More serious complications may occur in 10-15% of patients. These include perforation or bleeding of the esophaggus and lung problems, such as aspiration pneumonia. Long-term sclerotherapy can also damage the esophagus and increase the patient's risk of developing cancer.
Patients with advanced liver disease complicated by bleeding are very poor risks for this procedure. The surgery, premedications, and anesthesia may be sufficient to tip the patient into protein intoxication and hepatic coma. The blood in the bowels acts like a high protein meal and may induce protein intoxication.
Normal sclerotherapy results include the control of acute bleeding if present and the shrinking of the esophageal varices.
Morbidity and mortality rates
Sclerotherapy for esophageal varices has a 20-40% incidence of complications and a 1–2% mortality rate. The procedure controls acute bleeding in about 90% of patients, but it may have to be repeated within the first 48 hours to achieve this success rate. During the initial hospitalization, sclerotherapy is usually performed two or three times. Preventive treatments are scheduled every few weeks or so, depending on the patient's risk level and healing rate. Several studies have shown that the risk of recurrent bleeding is much lower in patients treated with sclerotherapy: 30-50% as opposed to 70–80% for patients not treated with sclerotherapy.
Pharmacological agents are also used in the treatment of esophageal varices. Such drugs as vasopressin and somatostatin are administered to actively bleeding patients on admission, while propranolol, nadolol or subcutaneous octreotide are used to prevent subsequent bleeding after successful endoscopic variceal eradication. Vasopressin or vasopressin with nitroglycerin has been proven effective in the acute control of variceal hemorrhage. Somatostatin is more effective in the control of active bleeding when compared to vasopressin, glypressin, endoscopic sclerotherapy or balloon tamponade. Octreotide has comparable outcomes to vasopressin, terlipressin or endoscopic sclerotherapy. Liver transplantation should be considered as an alternative for patients with bleeding varices from liver disease.
Another alternative treatment is provided by Transjugular intrahepatic portal-systemic shunting (TIPS). In TIPS, a catheter fitted with a stent, a wire mesh tube used to prop open a vein or artery, is inserted through a vein in the neck into the liver. Under x ray guidance, the stent is placed in an optimal position within the liver so as to allow blood to flow more easily through the portal vein. This treatment reduces the excess pressure in the esophageal varices, and thus decreases the risk of recurrent bleeding.
See also Portal vein bypass .
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Sadick, N. S. Manual of Sclerotherapy. Philadelphia: Lippincott, Williams & Wilkins, 2000.
Shearman, David J. C., et al., eds. "Endoscopy" and "Gastrointestinal Bleeding." In Diseases of the Gastrointestinal Tract and Liver. New York: Churchill Livingstone, 1997.
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Society of American Gastrointestinal Endoscopic Surgeons (SAGES). 2716 Ocean Park Boulevard, Suite 3000, Santa Monica, CA 90405. (310) 314-2404. http://www.sages.org .
SAGES: The Role of Endoscopic Sclerotherapy. http://www.sages.org/sg_asgepub1019.html .
Lori De Milto Monique Laberge, Ph.D.
WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?
Sclerotherapy for esophageal varices is performed by a surgeon specialized in gastroenterology or hepatology in a hospital setting, very often as an emergency procedure.
QUESTIONS TO ASK THE DOCTOR
- What are esophageal varices?
- Are there alternatives to sclerotherapy?
- How do I prepare for surgery?
- What type of anesthesia will be used?
- How is the surgery performed?
- How long will I be in the hospital?
- How many sclerotherapy procedures do you perform in a year?