Endoscopy and Endosonography in Prevention of Esophageal and Gastric Bleedings and Rebleedings

Background: Esophageal and gastric variceal bleeding is one of the basic reasons of death in patients with the portal hypertension. In spite of improvement of diagnostic and treatment (conservative and operative) this complication causes death in 20–80% cases. Endoscopic varices sclerotherapy (EVS) has many essential lacks. The quantity of complications (ulcers, perforations, bleedings, corrosive strictures) is about 10–70%. The role of endosonography (EUS) in diagnostics of esophageal and gastric varices is unclear.

Aims: Improve methods of treatment and prognosis of the patients with portal hypertension and prevent bleedings and rebleedings using the method of endoscopic varices ligation (EVL) and study the role of (EUS) in diagnostics of varices.

Methods: We applied plastic ligatures and ligating device, beveled and straight distal attachment by “Olympus” in esophagus and stomach. Rarely we applied Six-Shooter by “COOK” only in esophagus. We fulfilled endoscopic ultrasonography (EUS) to detect dilated and perforant veins.

Results: This is our experience since 1998 year. We fulfilled 242 EVL to 160 patients with the portal hypertension and esophageal (and gastric) varices of II-III grade (N. Soehendra, 1997). Positive effect (partial or total varices eradication) was achieved in most cases. EVS was combined with EVL in 25 cases. EVL is easier to fulfill for the endoscopist and safer for the patient than EVS. After ligation all patients felt moderate thoracic pain and disphagia during one-four days. Complications after EVL: cutting of ligated varics –4, delayed bleeding –2, reactive mediastinitis –1. The follow-up period is up to 12 years. Subsequent examinations were held every 6–12 months. Two patients died because of portal bleeding during follow-up period and had severe hepatic chirrhosis (Child-Pugh, C) and accompanying diseases. Patients with relapse of esophageal and gastric varices underwent additional EVL (sometimes in combination with EVS). We fulfilled EUS in 15 patients with variceal bleeding in anamnesis. It helped to reveal undetected during routine endoscopy gastric varices in 6 cases and significant perforant esophageal veins in 3 cases, that specified the sites and methods of endoscopic treatment.

Conclusions: EVL as a single method is effective in prophylaxis of initial variceal bleeding, EVL in combination with EVS (if necessary) can be applied for prevention of variceal rebleeding. Endoscopic treatment of esophageal and gastric varices decreases the rate of death because of variceal bleedings, but does not treats the main disease. EUS can help to receive additional significant information. Gastric varices and perforating veins detected by EUS can be treated endoscopically. The diagnostic value of EUS in esophagus is a problem to discuss.