Sclerotherapy and esophageal variceal bleeding: time to forget it, or not?

With great interest, we have read the article of Triantos et al. on evaluation of emergency sclerotherapy of varices [1]. Recently, the role of endoscopic injection sclerotherapy (EIS) has been challenged by endoscopic variceal ligation (EVL) and vasoactive drug therapy [2] [3], the latter being considered by many physicians to be the treatment of choice for patients with bleeding esophageal varices. Triantos et al. have questioned this interpretation [4], and we agree with them. In our opinion, EIS has been censured because is a technique that requires competence in endoscopy. By contrast, EVL is a simple technique with comparable results that does not require an experienced endoscopist. For this reason, the efficacy and safety of EIS are tied to the endoscopist, so there are wide variations in reported efficacy rates - the main reason is technique. On the basis of our experience, we know that a properly performed EIS needs paravariceal and intravariceal injection.

We report here a study performed to assess the efficacy of EIS (paravariceal plus intravariceal injection using 1 % polidocanol) combined with somatostatin (administered for 120 h). The endpoints were (i) failure to control bleeding, (ii) prevention of early (within 5 days) or late rebleeding (within 6 - 42 days), (iii) short-term mortality (during hospitalization or within 4 - 6 weeks), (iv) complications, and (v) the number of sessions required to eradicate varices.

The study was retrospective and describes the results we achieved in a group of 274 cirrhotic patients with acute esophageal variceal bleeding, who were treated over a period of 10 years (January 1997 to December 2006). Patient characteristics are shown in [Table 1] and the outcome of treatment in [Table 2]. Failure to control bleeding occurred in 12 cases (4.4 %). Early rebleeding occurred in 50 of the 274 patients (18.2 %) and late rebleeding in 32 patients (11.7 %). Short-term mortality was 15.3 %, and complications occurred in 20 patients (7.3 %). The number of sessions required to eradicate varices was 3.35 ± 1.81 (range: 1 - 10), and the total volume of 1 % polidocanol used for each patients was 110.13 ± 51 ml (range: 20 - 269 ml).

Table 1 Characteristics of patients with liver cirrhosis treated by EIS and vasoactive drug therapy No. of patients 274 Age (years) 60 ± 12.6 Sex (M/F) 196/78 Etiology of liver cirrhosis: Viral hepatitis Alcohol Alcohol + HCV Others 108 (39.4 %)96 (35 %)36 (13.1 %)34 (12.8 %) Child classification of patients (A/B/C) 78/140/56 Patients with active bleeding during endoscopy 110 (40.1 %) Patients with portal thrombosis 60 (21.9 %) Mean follow-up period (months) 17.8 ± 16.3 HCV, hepatitis C virus.

Table 2 Outcome of treatment (n = 274) Failure to control bleeding 12 (4.4 %) Early rebleeding 50 (18.2 %) Late rebleeding 32 (11.7 %) Death 42 (15.3 %) Complications 20 (7.3 %) No. of treatment sessions per patient 3.35 ± 1.81 Total volume 1 % polidocanol (ml) per patient 110.3 ± 51.3

These results are comparable with those obtained with EVL [1], and their interpretation suggests that emergency endoscopic treatment with EIS combined with vasoactive drugs should remain the first-choice therapy for physicians with competence in endoscopy.

Competing interests: None

References

• 1 Triantos C K, Goulis J, Patch D. et al . An evaluation of emergency sclerotherapy of varices in randomized trials: looking the needle in the eye.  Endoscopy. 2006;  38 797-808
• 2 Villanueva C, Piqueras M, Aracil C. et al . A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding.  J Hepatol. 2006;  45 560-567
• 3 D’Amico G, Pietrosi G, Tarantino I. et al . Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis.  Gastroenterology. 2003;  124 1277-1291
• 4 Triantos C, Samonakis D, Patch D. et al . Sclerotherapy versus vasoactive drugs.  Are all meta-analyses the same? Gastroenterology. 2004;  127 358-359