Annals of the Royail College of Surgeons of England (1977) v0ol 59
ASPECTS OF TREATMENT*
Injection sclerotherapy in the emergency and elective treatment of oesophageal varices A G Johnson Mchir FRCS Reader in Surgery, Charing Cross Hospital Medical School, London
Summary Injection sclerotherapy with careful attention to initial diagnosis and technique is an effective way of stopping oesophageal variceal bleeding. It can also be used electively at 3-monthly intervals to obliterate varices after they have once bled. It is relatively safe and simple, but patients must be followed up and reassessed at least every 6 months, when new varices may be injected if they occur. It is particularly suitable when the experience and facilities for emergency portacaval shunts are not available.
Introduction Bleeding oesophageal varices are usually a complication of an underlying disease, not a disease in themselves, though occasionally, as in portal vein thrombosis, there is a primary venous problem. Moreover, they are often common in areas of the world where facilities for complicated operations are poor. The ideal form of treatment should be simple and with a low mortality; it should not require expensive facilities and shouild not make the underlying liver disease worse. Transthoracic ligation of varices (Borema-Crile or Milnes-Walker operations), although better than non-surgical treatment, still carries a high mortality1. Emergency portacaval shunt, while influencing long-term sturvival, has a high operative mortality of about 50%, even in specialist centres2, and it may make hepatic encephalopathy worse. It is for this reason that there is a renewed interest in injection sclerotherapy. When Macbeth3 reported the first significant results of injection in Britain he pointed out that only the subepithelial and submucous
veins need be treated. The subserosal veins and extrinsic veins act as a useful portacaval bypass and are not in danger of bleeding. He treated patients ranging from 5 tO 72 years old with and without liver damage; in the first group he had some patients alive and well 712 years after the initial injection and in the second group up to i i years after a mean of 7 injections. Johnston and Rodgers4 reported remarkable results in the emergency treatment of bleeding varices, 93% of patients leaving hospital. Although the place of injection has not been fully established by adequate trials, much depends on the technique. This paper reports precise details of technique based on experience with emergency and elective sclerotherapy on 40 occasions.
Emergency haemorrhage Resuscitation The patient must be given blood and resuscitated as quickly as possible. Delay in getting to hospital and delay in hospital increase the risk of hepatic and renal failure. Patients with known varices should. if they bleed, have direct access to the hospital where they are being treated without having to go through their general practitioner or the regional bed bureau. Once the blood Emergency endoscopy is being replaced emergency endoscopy should be performed to confirm the site of bleeding. This is most important because even the patient with known varices may equally well be bleeding from duodenal ulcer, gastric ulcer, erosions, or gastric varices5, and a Sengstaken tube will not stop the bleeding from a duodenal
*Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor.
498
A G Johnson
ulcer! The modem fibreoptic endoscope allows inspection of oesophagus, stomach, and duodenum without traumatizing the vanices, but if this is not available a rigid oesophagoscope, passed with care, can confirm bleeding from oesophageal varices, though it cannot exclude lesions elsewhere. We perform endoscopy under general anaesthesia and are prepared to proceed to injection treatment if this proves necessary. Tranquillizers like diazepam can produce prolonged unwanted sedation in patients with liver failure. If the bleeding is too severe to get a good view for injection a Sengstaken tube is put down to control bleeding and injectio-n performed I2-24 h later, the patient coming to the operating theatre with the tube in
position. Injection sclerotherapy We inject down the 5o-mm Negus rigid oesophagoscope. This has been modified by Bailey and Dawson' to make injection easier. It has been suggested that the flexible oesophagoscope could be used as it is safer and less traumatic to pass. However, the rigid oesophagoscope has four advantages: i) It is available in operating theatres in all parts of the world. 2) A large-bore sucker can be used to clear blood and clots.
3) The tip can be rotated to compress the varix that has just been injected. 4) It obstructs the flow in the veins up the oesophagus, keeping the sclerosant solution in the vein. Figure I shows an X-ray during injection with Hypaque (sodium and meglumine diatrizoates) added to the injecting solution. The contrast stayed in the vein as long as the oesophagoscope was in position but quickly disappeared into the circulation when the oesophagoscope was withdrawn. Recent tests at King's College Hospital7 have shown rapid dissemination into the circulation after injection down the flexible gastro-oesophagoscope. The standard technique now is to leave the rigid oesophagoscope compressing the veins for 3 min, giving the sclerosant time to damage the intima of the vein. The injection is performed with a Macbeth or Roberts needle (Fig. 2). The tip of the Roberts needle is thinner and so does not lead to much bleeding afterwards, but greater pressure is needed to inject through it. It is helpful to mark on the shaft of the needle beforehand the point that enters the oesophagoscope when the needle is just protruding at the lower end. Ethanolamine 5 % is injected into the veins as low down as possible. The oesophagoscope can be advanced a little and rotated to compress each vein and about 5-6 ml is injected into each vein, up to 25 ml in all. Almost certainly some leaks out of the veins or is injected into the submucosal tissues. This may be an advantage in producing fibrosis and thickening the mucosa, but this is why we have preferred ethanolamine to sodium tetradecyl sulphate, which is much more irritant outside the vein. If the needle is in the vein there is little resistance to injection. but there is difficulty in injection if the needle is in the muscle or submucosal tissues.
Fegan8 has shown the of varicose veins in the treatment importance, in the leg, of keeping the sclerosant in a small segment of vein and then compressing the vein so that the walls become adherent. preventing later recanalization. The same principles apply to oesophageal varices, though they are not so easy to achieve. After injection a Sengstaken tube is passed with the patient
Compression
Radiograph during screening while Hypaque was injected into varices.
FIG. I
Injection sclerotherapy in the emergency and elective treatment of oesophageal varices
499
FIG. 2 Needles and syringe used in injection of varices: above, 50-cm Negus oesophagoscope; centre, Macbeth needle and syringe; below, Roberts needle and syringe.
quired a fine water-filled catheter connected to a syringe barrel can be positioned with radiological screening between the oesophagus and the balloo before the balloon is inflated. After inflation of the oesophageal balloon the syringe barrel is elevated up a graduated scale until the water starts to flow and then brought down until the water just stops flowing9' ". This is the transmitted pressure in cm H20 and should same way. The Sengstaken tube is passed, with both be about 40 cm. The Sengstaken tube, with continuous balloons deflated, with the help of a flexible guidewire down the gastric aspiration channel. aspiration from the fourth channel (or a The gastric balloon is then inflated and pulled separate catheter above the oesophageal back against the cardia. The balloon pressure balloon) is kept in position for 24-30 h. Drugs measured on the manometer will be very such as lactulose and magnesium sulphate can similar to that recorded beforehand and can be put down the tube into the stomach. The oesophageal balloon is deflated at I 2-I6 h, be used to detect any spontaneous deflation. The oesophageal balloon is then inflated but the gastric balloon remains inflated so with the previously measured volume of air, that the oesophageal balloon can be immedigentle traction being applied to the tube to ately reinflated in the right position should keep it in position. The pressure now measured bleeding occur. If there has been no bleeding in the oesophageal balloon will be higher for 12-I4 h after deflation of the oesophageal because of the tone in the oesophageal wall; balloon the gastric balloon can be deflated and it is recorded. If a more accurate measurement the whole tube removed. If rebleeding occurs in the next few days of transmitted pressure to the varices is re-
still under the anaesthetic. The balloons are tested for leaks beforehand and the gastric balloon can normally be inflated with 300 ml of air; the balloon inflation channel is then connected to an ordinary mercury manometer and the pressure measured and recorded. The volume of air that evenly distends the oesophageal balloon without distortion is then measured and the pressure recorded in the
500
A G Johnson
::ik * X o_
sF
$. v
risk of rebleeding is high. Macbeth' advocated re-examination and injectioni of new varices every 6-I2 months, but it may need several injections at i-month intervals to oibliterate all the visible veins initially. The alternative is to wait until there is another haemorrhage. The policy may depend on whether the patient has liver disease or not. In those with liver disease a haemorrhage is always serious and liver function deteriorates, whereas those with normal liver function and normal clotting factors can perhaps be left until they bleed. One patient aged I 2 years has had injections each time he has a slight bleeding episode, at intervals of about 6-I2 months, since the age m22 .of 8 and remains well; similarly a woman of 75 had 3 injections at 3-monthly intervals and needed no, further treatment before dying of a stroke 3 years later (Fig. 3). On the other hand a man of 6 i with severe liver disease was injected 3 times at 4-monthly intervals and has so far been well for I 1 years, with no radiological evidence of varices. Another patient of 62 with severe liver disease needed 3 injections at 2-monthly intervals until all varices were thrombosed on endoscopy.
FIG. 3 Barium meal showing severe varices before they were controlled for 4 years by 3 injections in the first i8 months. a repeat gastroscopy is advisable before replacing the tube. We have seen a patient bleeding from oesophageal varices on one day and rebleeding from a large superficial gastric ulcer 3 days later.
Elective injections Can injection treatment be used for non-
emergency treatment of varices? Although some patients are suitable for shunts, there are many patients with varices who for various reasons are unsuitable. It seems reasonable to try to obliterate the varices in these patients before they bleed again, and the procedure is easier when they are not bleeding. As many patients have varices for years without bleeding and injection carries some risk it would probably not be right to inject before any bleeding has occurred; but once it has the
FIG. 4 Section of oesophagus 2 weeks after injection showing thrombosed varix (X8).
Injection sclerotherapy in the emergency and elective treatment of oesophageal varices
Local effects of injection The aim is to thrombose varices if possible with the veins compressed. Histological section obtained from a patient who died of respiratory and liver failure 2 weeks after injection showed thrombosis of varices and of some small submucosal veins (Fig. 4). It is highly likely that some ethanolamine leaks out or is injected into the submucosa. This produces some fibrosis and thickening of the mucosa, which looks greyer on endoscopy. Sometimes a varix is thrombosed but still visible and this can be checked by its failure to collapse when gently pressed with a closed biopsy forceps. In one patient there has been slight narrowing of the lower part of the oesophagus with some dysphagia, probably due to submucosal fibrosis.
501
has had no further bleeding for up to I years. There has been no serious complication attributable to the injection itself. On the other hand chest infections are conumon and no procedure requiring a general anaesthetic should be undertaken lightly in a patient with severe liver disease. As in many other aspects of treatment the results of injection therapy of varices depends to a large extent on careful attention to the details of technique. I am grateful to Professor H W Rodgers for initially showing me the technique, to Dr B Fox for the histology, and to the Medical Illustration Department, Charing Cross Hospital, for the figures. I am also grateful to the staff of the operating theatre and intensive care unit for their careful attention to detail in the care of the patients and to Miss H Wright for secretarial assistance.
Clinical results References In the treatment X Orloff, M J (I966) in Portal Hypertension, ed. Control of bleeding of 25 bleeding episodes initial bleeding has Longmire, W P, p.I3. Chicago, Year Book Medical always been controlled by i or at the most 2 Publications. injections. No patient has died from continued 2 Orloff, M J, Chandler, J G, Charters, C, et al (I974) Archives of Surgery, Io8, 293. bleeding from oesophageal varices. 3 Macbeth, R (I955) British Medical Journal, 2, 877. Obliteration, 4 Johnston, G W, and Rodgers, H W (I973) Obliteration of varices British Journal of Surgery, 60, 797. as opposed to thrombosis, has been achieved Waldram, R, Davis, M, Nunnerley, H, and in some patients as judged by barium swallow 5 Williams, R (I974) British Medical Journal, 4, or gastroscopy, especially those with small 94. varices initially. Although both methods may 6 Bailey, M E, and Dawson, J L (I975) British Medical Journal, 2, 540. be unreliable in showing varices, this is sufficient indication to stop elective injections 7 Taylor, S, and Nunnerley, H (I977) Personal communication. and reassess at 6-monthly intervals. 8 Fegan, W G (I967) Annals of the Royal College Complications The only complications so, far have been occasional slight retrostemal pain and one late case of oesophageal narrowing, but this patient
of Surgeons of England, 41, 364.
9 Johnson, A G, Baxter, H K, Kirk, C J C, Murray-
Lyon, I M, and Reynolds, K W (1976) Lancet, 1, I 053. io Johnson, A G, and Kirk, C J C (1976) Lancet, 2, 582.
ASPECTS OF TREATMENT*
Injection sclerotherapy in the emergency and elective treatment of oesophageal varices A G Johnson Mchir FRCS Reader in Surgery, Charing Cross Hospital Medical School, London
Summary Injection sclerotherapy with careful attention to initial diagnosis and technique is an effective way of stopping oesophageal variceal bleeding. It can also be used electively at 3-monthly intervals to obliterate varices after they have once bled. It is relatively safe and simple, but patients must be followed up and reassessed at least every 6 months, when new varices may be injected if they occur. It is particularly suitable when the experience and facilities for emergency portacaval shunts are not available.
Introduction Bleeding oesophageal varices are usually a complication of an underlying disease, not a disease in themselves, though occasionally, as in portal vein thrombosis, there is a primary venous problem. Moreover, they are often common in areas of the world where facilities for complicated operations are poor. The ideal form of treatment should be simple and with a low mortality; it should not require expensive facilities and shouild not make the underlying liver disease worse. Transthoracic ligation of varices (Borema-Crile or Milnes-Walker operations), although better than non-surgical treatment, still carries a high mortality1. Emergency portacaval shunt, while influencing long-term sturvival, has a high operative mortality of about 50%, even in specialist centres2, and it may make hepatic encephalopathy worse. It is for this reason that there is a renewed interest in injection sclerotherapy. When Macbeth3 reported the first significant results of injection in Britain he pointed out that only the subepithelial and submucous
veins need be treated. The subserosal veins and extrinsic veins act as a useful portacaval bypass and are not in danger of bleeding. He treated patients ranging from 5 tO 72 years old with and without liver damage; in the first group he had some patients alive and well 712 years after the initial injection and in the second group up to i i years after a mean of 7 injections. Johnston and Rodgers4 reported remarkable results in the emergency treatment of bleeding varices, 93% of patients leaving hospital. Although the place of injection has not been fully established by adequate trials, much depends on the technique. This paper reports precise details of technique based on experience with emergency and elective sclerotherapy on 40 occasions.
Emergency haemorrhage Resuscitation The patient must be given blood and resuscitated as quickly as possible. Delay in getting to hospital and delay in hospital increase the risk of hepatic and renal failure. Patients with known varices should. if they bleed, have direct access to the hospital where they are being treated without having to go through their general practitioner or the regional bed bureau. Once the blood Emergency endoscopy is being replaced emergency endoscopy should be performed to confirm the site of bleeding. This is most important because even the patient with known varices may equally well be bleeding from duodenal ulcer, gastric ulcer, erosions, or gastric varices5, and a Sengstaken tube will not stop the bleeding from a duodenal
*Fellows and Members interested in submitting papers for consideration with a view to publication in this series should first write to the Editor.
498
A G Johnson
ulcer! The modem fibreoptic endoscope allows inspection of oesophagus, stomach, and duodenum without traumatizing the vanices, but if this is not available a rigid oesophagoscope, passed with care, can confirm bleeding from oesophageal varices, though it cannot exclude lesions elsewhere. We perform endoscopy under general anaesthesia and are prepared to proceed to injection treatment if this proves necessary. Tranquillizers like diazepam can produce prolonged unwanted sedation in patients with liver failure. If the bleeding is too severe to get a good view for injection a Sengstaken tube is put down to control bleeding and injectio-n performed I2-24 h later, the patient coming to the operating theatre with the tube in
position. Injection sclerotherapy We inject down the 5o-mm Negus rigid oesophagoscope. This has been modified by Bailey and Dawson' to make injection easier. It has been suggested that the flexible oesophagoscope could be used as it is safer and less traumatic to pass. However, the rigid oesophagoscope has four advantages: i) It is available in operating theatres in all parts of the world. 2) A large-bore sucker can be used to clear blood and clots.
3) The tip can be rotated to compress the varix that has just been injected. 4) It obstructs the flow in the veins up the oesophagus, keeping the sclerosant solution in the vein. Figure I shows an X-ray during injection with Hypaque (sodium and meglumine diatrizoates) added to the injecting solution. The contrast stayed in the vein as long as the oesophagoscope was in position but quickly disappeared into the circulation when the oesophagoscope was withdrawn. Recent tests at King's College Hospital7 have shown rapid dissemination into the circulation after injection down the flexible gastro-oesophagoscope. The standard technique now is to leave the rigid oesophagoscope compressing the veins for 3 min, giving the sclerosant time to damage the intima of the vein. The injection is performed with a Macbeth or Roberts needle (Fig. 2). The tip of the Roberts needle is thinner and so does not lead to much bleeding afterwards, but greater pressure is needed to inject through it. It is helpful to mark on the shaft of the needle beforehand the point that enters the oesophagoscope when the needle is just protruding at the lower end. Ethanolamine 5 % is injected into the veins as low down as possible. The oesophagoscope can be advanced a little and rotated to compress each vein and about 5-6 ml is injected into each vein, up to 25 ml in all. Almost certainly some leaks out of the veins or is injected into the submucosal tissues. This may be an advantage in producing fibrosis and thickening the mucosa, but this is why we have preferred ethanolamine to sodium tetradecyl sulphate, which is much more irritant outside the vein. If the needle is in the vein there is little resistance to injection. but there is difficulty in injection if the needle is in the muscle or submucosal tissues.
Fegan8 has shown the of varicose veins in the treatment importance, in the leg, of keeping the sclerosant in a small segment of vein and then compressing the vein so that the walls become adherent. preventing later recanalization. The same principles apply to oesophageal varices, though they are not so easy to achieve. After injection a Sengstaken tube is passed with the patient
Compression
Radiograph during screening while Hypaque was injected into varices.
FIG. I
Injection sclerotherapy in the emergency and elective treatment of oesophageal varices
499
FIG. 2 Needles and syringe used in injection of varices: above, 50-cm Negus oesophagoscope; centre, Macbeth needle and syringe; below, Roberts needle and syringe.
quired a fine water-filled catheter connected to a syringe barrel can be positioned with radiological screening between the oesophagus and the balloo before the balloon is inflated. After inflation of the oesophageal balloon the syringe barrel is elevated up a graduated scale until the water starts to flow and then brought down until the water just stops flowing9' ". This is the transmitted pressure in cm H20 and should same way. The Sengstaken tube is passed, with both be about 40 cm. The Sengstaken tube, with continuous balloons deflated, with the help of a flexible guidewire down the gastric aspiration channel. aspiration from the fourth channel (or a The gastric balloon is then inflated and pulled separate catheter above the oesophageal back against the cardia. The balloon pressure balloon) is kept in position for 24-30 h. Drugs measured on the manometer will be very such as lactulose and magnesium sulphate can similar to that recorded beforehand and can be put down the tube into the stomach. The oesophageal balloon is deflated at I 2-I6 h, be used to detect any spontaneous deflation. The oesophageal balloon is then inflated but the gastric balloon remains inflated so with the previously measured volume of air, that the oesophageal balloon can be immedigentle traction being applied to the tube to ately reinflated in the right position should keep it in position. The pressure now measured bleeding occur. If there has been no bleeding in the oesophageal balloon will be higher for 12-I4 h after deflation of the oesophageal because of the tone in the oesophageal wall; balloon the gastric balloon can be deflated and it is recorded. If a more accurate measurement the whole tube removed. If rebleeding occurs in the next few days of transmitted pressure to the varices is re-
still under the anaesthetic. The balloons are tested for leaks beforehand and the gastric balloon can normally be inflated with 300 ml of air; the balloon inflation channel is then connected to an ordinary mercury manometer and the pressure measured and recorded. The volume of air that evenly distends the oesophageal balloon without distortion is then measured and the pressure recorded in the
500
A G Johnson
::ik * X o_
sF
$. v
risk of rebleeding is high. Macbeth' advocated re-examination and injectioni of new varices every 6-I2 months, but it may need several injections at i-month intervals to oibliterate all the visible veins initially. The alternative is to wait until there is another haemorrhage. The policy may depend on whether the patient has liver disease or not. In those with liver disease a haemorrhage is always serious and liver function deteriorates, whereas those with normal liver function and normal clotting factors can perhaps be left until they bleed. One patient aged I 2 years has had injections each time he has a slight bleeding episode, at intervals of about 6-I2 months, since the age m22 .of 8 and remains well; similarly a woman of 75 had 3 injections at 3-monthly intervals and needed no, further treatment before dying of a stroke 3 years later (Fig. 3). On the other hand a man of 6 i with severe liver disease was injected 3 times at 4-monthly intervals and has so far been well for I 1 years, with no radiological evidence of varices. Another patient of 62 with severe liver disease needed 3 injections at 2-monthly intervals until all varices were thrombosed on endoscopy.
FIG. 3 Barium meal showing severe varices before they were controlled for 4 years by 3 injections in the first i8 months. a repeat gastroscopy is advisable before replacing the tube. We have seen a patient bleeding from oesophageal varices on one day and rebleeding from a large superficial gastric ulcer 3 days later.
Elective injections Can injection treatment be used for non-
emergency treatment of varices? Although some patients are suitable for shunts, there are many patients with varices who for various reasons are unsuitable. It seems reasonable to try to obliterate the varices in these patients before they bleed again, and the procedure is easier when they are not bleeding. As many patients have varices for years without bleeding and injection carries some risk it would probably not be right to inject before any bleeding has occurred; but once it has the
FIG. 4 Section of oesophagus 2 weeks after injection showing thrombosed varix (X8).
Injection sclerotherapy in the emergency and elective treatment of oesophageal varices
Local effects of injection The aim is to thrombose varices if possible with the veins compressed. Histological section obtained from a patient who died of respiratory and liver failure 2 weeks after injection showed thrombosis of varices and of some small submucosal veins (Fig. 4). It is highly likely that some ethanolamine leaks out or is injected into the submucosa. This produces some fibrosis and thickening of the mucosa, which looks greyer on endoscopy. Sometimes a varix is thrombosed but still visible and this can be checked by its failure to collapse when gently pressed with a closed biopsy forceps. In one patient there has been slight narrowing of the lower part of the oesophagus with some dysphagia, probably due to submucosal fibrosis.
501
has had no further bleeding for up to I years. There has been no serious complication attributable to the injection itself. On the other hand chest infections are conumon and no procedure requiring a general anaesthetic should be undertaken lightly in a patient with severe liver disease. As in many other aspects of treatment the results of injection therapy of varices depends to a large extent on careful attention to the details of technique. I am grateful to Professor H W Rodgers for initially showing me the technique, to Dr B Fox for the histology, and to the Medical Illustration Department, Charing Cross Hospital, for the figures. I am also grateful to the staff of the operating theatre and intensive care unit for their careful attention to detail in the care of the patients and to Miss H Wright for secretarial assistance.
Clinical results References In the treatment X Orloff, M J (I966) in Portal Hypertension, ed. Control of bleeding of 25 bleeding episodes initial bleeding has Longmire, W P, p.I3. Chicago, Year Book Medical always been controlled by i or at the most 2 Publications. injections. No patient has died from continued 2 Orloff, M J, Chandler, J G, Charters, C, et al (I974) Archives of Surgery, Io8, 293. bleeding from oesophageal varices. 3 Macbeth, R (I955) British Medical Journal, 2, 877. Obliteration, 4 Johnston, G W, and Rodgers, H W (I973) Obliteration of varices British Journal of Surgery, 60, 797. as opposed to thrombosis, has been achieved Waldram, R, Davis, M, Nunnerley, H, and in some patients as judged by barium swallow 5 Williams, R (I974) British Medical Journal, 4, or gastroscopy, especially those with small 94. varices initially. Although both methods may 6 Bailey, M E, and Dawson, J L (I975) British Medical Journal, 2, 540. be unreliable in showing varices, this is sufficient indication to stop elective injections 7 Taylor, S, and Nunnerley, H (I977) Personal communication. and reassess at 6-monthly intervals. 8 Fegan, W G (I967) Annals of the Royal College Complications The only complications so, far have been occasional slight retrostemal pain and one late case of oesophageal narrowing, but this patient
of Surgeons of England, 41, 364.
9 Johnson, A G, Baxter, H K, Kirk, C J C, Murray-
Lyon, I M, and Reynolds, K W (1976) Lancet, 1, I 053. io Johnson, A G, and Kirk, C J C (1976) Lancet, 2, 582.
