Endoscopy 10 (1978) 7-12
Sclerotherapy of Bleeding Oesophageal Varices by Means of Endoscopy K.-J. Paquet, E. Oberhammer Department of Surgery, University of Bonn, Medical School, Bonn-Venusberg
Sklerotherapie blutender tisophagusvarizen auf
From 1.1.1969 up to 1.11.1977, 640 patients with hemorrhage from gastro-oesophageal varices were
managed by sclerotherapy of the oesophageal wall. In 90 °/o this method succeeded in stopping hemorrhage or preventing a new bleeding during
the next four months. Only 43 patients of the total number were treated because of impending hemorrhage under precise indications. After two or three sessions of sclerotherapy the interval of control can be extended up to one years without
new danger of hemorrhage. Overall mortality was 14.5 0/0; main causes of death were liver coma, uncontrollable hemorrhage, mediastinitis If liver function improves, a and pyothorax. porto-systemic-shunt is performed whenever possible. 416 = 65 °/o of the patients are still alive;
500/o longer than one year up to eigth years. Thus sclerotherapy seems to be the method of choice in uncurable massive hemorrhage from varicosities from the oesophagus. It is indicated in patients with decompensated liver function, and whenever a shunt procedure is anatomically or clinically impossible or not advisable, too. Key-Words: Gastrointestinal phageal varices, sclerotherapy.
bleeding,
oeso-
Hemorrhage from gastrooesophageal varices is without doubt the most severe compli-
cation in patients with liver cirrhosis and
endoskopischem Wege
Vom 1. Januar 1969 bis zum 1. November 1977 wurden 640 Patienten mit einer Cisophagusvarizenblutung durch Sklerosierung- der Cisophaguswand behandelt. In 90°/o gelang mit diesem Verfahren eine erfolgreiche Blutstillung oder die Verhinderung eines Blutungsrezidivs während der
nächsten 4 Monate. Nur 43 Patienten wurden wegen drohender Blutung unter besonderer Indi-
kationsstellung therapiert. Nadi zwei oder drei Sklerosierungen kann das Behandlungsintervall auf 1 Jahr ausgedehnt werden, da keine Blutungsgefahr mehr besteht. Die Mortalität betrug 14,5 °/o, Todesfälle gingen in erster Linie auf Leberversagen, unkontrollierbare Blutung, Media-
stinitis und Pyothorax zurii& Sobald die Leberfunktion es zulägt, wird ein porto-systemisdier Shunt durchgeführt. 416 (65 °/o) der Patienten leben noch, 50% länger als 1 Jahr, einige bis zu 8 Jahren. Die Sklero-Therapie scheint die Methode der Wahl bei konservativ unstillbarer massiver Usophagusvarizenblutung zu sein. Sie erscheint angezeigt bei Patienten mit dekompensierter Leberfunktion und bei solchen, bei denen aus anatomischen oder klinisdien Gründen ein Shunt nicht durchführbar ist.
a new way and a method of choice for the management of acute hemorrhage which can't be stopped by conservative treatment in our
portal hypertension. Unfortunately there has never been a uniform concept of emergency management of variceal hemorrhage because of the pitfalls in the surgical as well as the medical therapeutic techniques (3-6).
hospital (Table 1). - Anatomic studies of Stelzner and Lierse (7) and experiences in
Pathophysiological Background and Indications For eight years endoscopic sclerotherapy of the oesophageal wall has to be considered as
(1, 7).
0013-726X178
1300-0007
emergency endoscopy have demonstrated that
varices in the lower third of the oesophagus are localized subepithelially and that hemorrhage occurs in nearly rnost cases in this part Therefore the adequate concept of therapy
should aim at stopping hemorrhage from oesophageal varices by injecting sclerosing
$ 4. (:) 1978 Georg Thieme Publishers
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Summary
K.-J. Paquet, E. Oberhammer
8
Table 1
Indications for sclerotherapy for un-
controllable hemorhage (1. 1. 1969-1. 11. 1977).
Number of patients
Conservatively uncontrollable hemorhage from esophageal varices with compensated liver function with decompensated liver function with prehepatic block with osteomyelosclerosis with Morbus Wilson
Total
Table 2
53
146 10
211
Indications for sclerotherapy in the
bleeding-free-intervall (1. 1. 1969-1. 11. 1977).
Diagnosis
Number of patients
Fig. I Parts of the rigid instrument for sclerotherapy (from left to right). 1 = therapeutical
Decompensated liver function with recurrent hemorrhage Prehepatic block without possibility to shunt Thrombosed shunts Compensated liver cirhosis (shunt refused) Osteomyelosclerosis
part, 2 = Hopkins-optical system, 3 = diagnostical part, 4 = built-in aspirator.
Total
agents near the source of bleeding in the
Table 3 Indications for "prophylactic" sclerotherapy in the bleeding-free-intervall (1.1. 1969
lower part of the oesophagus. Other indications of sclerotherapy are decompensated liver function, hepatic precoma, the absence of anastomosable portal vessels and thrombosed shunts (Table 2). Only few indications remain for patients with impending hemorrhage (Table 3) and portal hypertension. Method
Following general anesthesia and naso-or
orotracheal intubation a special rigid esophagoscope is inserted (Fig. 1). This instrument includes an optical system, a Hopkins-
333 17
12 19 5
386
1. 11. 1977).
Diagnosis
Number of patients
Fully decompensated liver function (coagulation factors about
20 and 30%) Extensive oesophageal varices with erosions Oesophagitis caused by hiatal hernia
Total
18 14 11
43
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Diagnosis
Sclerotherapy of Bleeding Oesophageal Varices by Way of Endoscopy
9
optic, which permits a detailed and enlarged view of the entire inner surface of the esophagus.
The instrument has a built-in aspirator, too, in order to clean the esophagus wall from blood and mucus. After the bleeding varices
base is inserted (Fig. 2). The cannula is placed into the esophagus-epithelium adjacent to the varices in order to inject a maximum of 1 ml 1 0/0 Aethoxysclerol (Fa. Kreussler, Wiesbaden-Biebrich). The total volume of the sclerosing fluid should not exceed 50 ml. After 3 to 10 ml of injections hemorrhage
stops. One, two or three times these injections
have to be repeated in an interval from four to seven days. Results
After two to four sessions the endoscopic (Fig. 3 and 4) or radiographic (Fig. 5 and 6) control demonstrates remission of varices. Four months later an endoscopic control of the oesophagus and stomach is necessary in
order to detect new varices and indicate a new sclerotherapy. Varices IIIII in the bleeding-free interval can be treated without anesthesia and a fiberoptic instrument with flexible needle, too. Moreover such a technique is advisable in patients with new varices after the first sclerotherapy.
Fig. 2
Instrument in function: cannula for injection at the tip, syringe at the basis.
The observed complications are summarized
in Table 4. In case of complete necrosis of the oesophageal wall (Fig. 7), a drainage of the mediastinum and/or pleura, a parenteral nutrition, antibiotics in high doses and a
Figs. 3 and 4 Endoscopic documentation of the esophageal varices before (3) and after (4) sclerotherapy.
Downloaded by: National University of Singapore. Copyrighted material.
have been visualized, the therapeutical system of the instrument with Hopkins optical system, needle at the tip and a syringe at the
K.-J. Paquet, E. Oberhammer
Figs. 5 and 6 Radiographic documentation (upper G.-I.-X-rays) of the esophagus before (5) and after (6) sclerotherapy. Table 4 Complications after sclerotherapy (1.1. 1969-1.11.1977). Complications
Nummer of patients
Pleural effusion Hemorrhage from fundic varices Ulcer of the esophagus (incomplete wallnecrosis) Wallnecrosis of the esophagus, mediastinitis and pyothorax
14
Stenosis for the esophagus to bouginate
Total
19 13 11
7
64 (10.0%)
Table 5 a Causes of death after Sclerotherapy (1.1. 1969-1. 11.1977). Diagnosis
Causes of death
Number
Decompensated liver function Decompensated liver function Decompensated liver function (4) Decompensated liver function Decompensated liver function Decompensated liver function
Hepatic coma
42
Uncontrollable hemorrhage Mediastinitis and pyothorax Hemorrhage from
26 8
stomach varices
6
Bronchopneumonia
7
Myocardial infarction
4
Total
93 (14,5°/o)
Table 5b
stomach tube seem to be effective ways of management.
Hemorrhage from varices of the stomach will arise, if the sclerosing agents are partly or totally injected into the oesophageal van-
Diagnosis
Number
Mortality (°/o)
Acute Chronic "Prophylactic"
41
52
19.5 13.5
Total
93
14.5
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10
Sclerotherapy of Bleeding Oesophageal Varices by Way of Encloscopy
11
Table 6 Late results. Number
Patients still alive
416 (65.0°/o)
Hospital Mortality
93 (14.0°/o)
at home Mortality Fate unknown
96 (15.0°/o)
Table 7
Number of still living patients
months
58
6
73
6-12
years
115
1-2
93
3-4
54
5-6
23
7-8
416
Complete wallnecrosis and mediastinitis after sclerotherapy. Fig. 7
ces, which thrombose and may cause a hemor-
Discussion
rhage from varices in the fornix and fundus region. Therapy consists of the insertion of the one-balloon-tube. If bleeding cannot be stopped, a gastroeosophageal disconnection with splenectomy, as Pettinari and Hassab (2) (Fig. 8) proposed, is done (2). Stenoses of eosophagus are bouginated.
Decisive for the these results is a regular control of patients. They, therefore, have to be submitted to a permanent clinical, radiological and especially endoscopic control in intervals of 4, later of 6 months. After sclero-
Causes of death are summarized in Table 5.
up to one year. If liver function improves, a porto-systemic-shunt should be performed whenever possible. If hemorrhage recurs or if increasing size of the varicosities is ob-
Main causes were liver coma, imitigable hemorrhage and pyothorax. Total mortality was 14,5 %.
Since this technic is considered as palliative
therapy has been performed two or three times, control interval often can be extended
served, the sclerotherapy has to be repeated.
method, as it doesn't decompress the portal
system in any way, we tried do get late results. 650/o of the patients, treated since 1969, are still alive (Table 6). Most of them didn't bleed again. The main cause of death was liver coma. 50 °/o are still alive more than one to eight years (Table 7).
References 1 Dagradi, A. E., S. J. Stempien, L. K. Owens: Bleeding esophageal gastric varices: an endoscopic study. Surgery 92 (1966) 344
2 Hassab, M. A.: Gastroesophageal decongestion and splenectomy: a new method of prevention and treatment of bleeding from esophageal varices. J. Int. Coll. Surg. 41 (1964) 232
Downloaded by: National University of Singapore. Copyrighted material.
35 (5.5°/o)
K.-J. Paquet et al.: Sclerotherapy of Bleeding Oesophageal Varices by Way
12
1
2
3
Fig. 8
Gastro-esophageal disconnection
after PettinariHassabPaquet: (1, 2, 3 = Devascularisation of
9
diaphragma and abdominal esophagus. 4, 5 = ligated vasa gastroepiploica sinistra.
6 = perfused parts of the vasa gastroepiploica dextra. 7 = ligated A. gastrica sinistra and V. coronaria ventriculi. 8,9 = Vagotomy and Pyloroplasty).
6
3 Paquet, K. J.: Indikationen und Ergebnisse der Sklerosierungstherapie von Osophagusvarizen. Therapiewoche 22 (1972) 262
4 Paquet, K.-J., C. Engel: Die Wandsklerosierung des Osophagus in der Therapie der akuten Varizenblutung und der drohenden Hämorrhagie bei dekompensierter Leberfunktion. Z. Gastroent. 12 (1974) 235 5 Paquet, K. J.: Ein neues Instrument zur Wandsklerosie-
rung der Speiseröhre in der Behandlung der akuten rhophagusvarizenblutung bzw. von Varizem im blutungsfreien Intervall. Akt. Gastrol. 4 (1975) 441
6 Rasdzke, E., K.-J. Paquet: Management of hemorrhage from esophageal varices using endoscopic method. Ann. Surg. 177 (1973) 99
7 Stelzner, F., W. Lierse: Der angiomusculfire Verschluß der Speiseröhre. Arch. klin. Chir. 321 (1968) 35
K.-J. Paquet, M.D., Depart. Surg. Univ. of Bonn, D-5300 Bonn-Venusberg, Western Germany
Downloaded by: National University of Singapore. Copyrighted material.
7
Sclerotherapy of Bleeding Oesophageal Varices by Means of Endoscopy K.-J. Paquet, E. Oberhammer Department of Surgery, University of Bonn, Medical School, Bonn-Venusberg
Sklerotherapie blutender tisophagusvarizen auf
From 1.1.1969 up to 1.11.1977, 640 patients with hemorrhage from gastro-oesophageal varices were
managed by sclerotherapy of the oesophageal wall. In 90 °/o this method succeeded in stopping hemorrhage or preventing a new bleeding during
the next four months. Only 43 patients of the total number were treated because of impending hemorrhage under precise indications. After two or three sessions of sclerotherapy the interval of control can be extended up to one years without
new danger of hemorrhage. Overall mortality was 14.5 0/0; main causes of death were liver coma, uncontrollable hemorrhage, mediastinitis If liver function improves, a and pyothorax. porto-systemic-shunt is performed whenever possible. 416 = 65 °/o of the patients are still alive;
500/o longer than one year up to eigth years. Thus sclerotherapy seems to be the method of choice in uncurable massive hemorrhage from varicosities from the oesophagus. It is indicated in patients with decompensated liver function, and whenever a shunt procedure is anatomically or clinically impossible or not advisable, too. Key-Words: Gastrointestinal phageal varices, sclerotherapy.
bleeding,
oeso-
Hemorrhage from gastrooesophageal varices is without doubt the most severe compli-
cation in patients with liver cirrhosis and
endoskopischem Wege
Vom 1. Januar 1969 bis zum 1. November 1977 wurden 640 Patienten mit einer Cisophagusvarizenblutung durch Sklerosierung- der Cisophaguswand behandelt. In 90°/o gelang mit diesem Verfahren eine erfolgreiche Blutstillung oder die Verhinderung eines Blutungsrezidivs während der
nächsten 4 Monate. Nur 43 Patienten wurden wegen drohender Blutung unter besonderer Indi-
kationsstellung therapiert. Nadi zwei oder drei Sklerosierungen kann das Behandlungsintervall auf 1 Jahr ausgedehnt werden, da keine Blutungsgefahr mehr besteht. Die Mortalität betrug 14,5 °/o, Todesfälle gingen in erster Linie auf Leberversagen, unkontrollierbare Blutung, Media-
stinitis und Pyothorax zurii& Sobald die Leberfunktion es zulägt, wird ein porto-systemisdier Shunt durchgeführt. 416 (65 °/o) der Patienten leben noch, 50% länger als 1 Jahr, einige bis zu 8 Jahren. Die Sklero-Therapie scheint die Methode der Wahl bei konservativ unstillbarer massiver Usophagusvarizenblutung zu sein. Sie erscheint angezeigt bei Patienten mit dekompensierter Leberfunktion und bei solchen, bei denen aus anatomischen oder klinisdien Gründen ein Shunt nicht durchführbar ist.
a new way and a method of choice for the management of acute hemorrhage which can't be stopped by conservative treatment in our
portal hypertension. Unfortunately there has never been a uniform concept of emergency management of variceal hemorrhage because of the pitfalls in the surgical as well as the medical therapeutic techniques (3-6).
hospital (Table 1). - Anatomic studies of Stelzner and Lierse (7) and experiences in
Pathophysiological Background and Indications For eight years endoscopic sclerotherapy of the oesophageal wall has to be considered as
(1, 7).
0013-726X178
1300-0007
emergency endoscopy have demonstrated that
varices in the lower third of the oesophagus are localized subepithelially and that hemorrhage occurs in nearly rnost cases in this part Therefore the adequate concept of therapy
should aim at stopping hemorrhage from oesophageal varices by injecting sclerosing
$ 4. (:) 1978 Georg Thieme Publishers
Downloaded by: National University of Singapore. Copyrighted material.
Summary
K.-J. Paquet, E. Oberhammer
8
Table 1
Indications for sclerotherapy for un-
controllable hemorhage (1. 1. 1969-1. 11. 1977).
Number of patients
Conservatively uncontrollable hemorhage from esophageal varices with compensated liver function with decompensated liver function with prehepatic block with osteomyelosclerosis with Morbus Wilson
Total
Table 2
53
146 10
211
Indications for sclerotherapy in the
bleeding-free-intervall (1. 1. 1969-1. 11. 1977).
Diagnosis
Number of patients
Fig. I Parts of the rigid instrument for sclerotherapy (from left to right). 1 = therapeutical
Decompensated liver function with recurrent hemorrhage Prehepatic block without possibility to shunt Thrombosed shunts Compensated liver cirhosis (shunt refused) Osteomyelosclerosis
part, 2 = Hopkins-optical system, 3 = diagnostical part, 4 = built-in aspirator.
Total
agents near the source of bleeding in the
Table 3 Indications for "prophylactic" sclerotherapy in the bleeding-free-intervall (1.1. 1969
lower part of the oesophagus. Other indications of sclerotherapy are decompensated liver function, hepatic precoma, the absence of anastomosable portal vessels and thrombosed shunts (Table 2). Only few indications remain for patients with impending hemorrhage (Table 3) and portal hypertension. Method
Following general anesthesia and naso-or
orotracheal intubation a special rigid esophagoscope is inserted (Fig. 1). This instrument includes an optical system, a Hopkins-
333 17
12 19 5
386
1. 11. 1977).
Diagnosis
Number of patients
Fully decompensated liver function (coagulation factors about
20 and 30%) Extensive oesophageal varices with erosions Oesophagitis caused by hiatal hernia
Total
18 14 11
43
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Diagnosis
Sclerotherapy of Bleeding Oesophageal Varices by Way of Endoscopy
9
optic, which permits a detailed and enlarged view of the entire inner surface of the esophagus.
The instrument has a built-in aspirator, too, in order to clean the esophagus wall from blood and mucus. After the bleeding varices
base is inserted (Fig. 2). The cannula is placed into the esophagus-epithelium adjacent to the varices in order to inject a maximum of 1 ml 1 0/0 Aethoxysclerol (Fa. Kreussler, Wiesbaden-Biebrich). The total volume of the sclerosing fluid should not exceed 50 ml. After 3 to 10 ml of injections hemorrhage
stops. One, two or three times these injections
have to be repeated in an interval from four to seven days. Results
After two to four sessions the endoscopic (Fig. 3 and 4) or radiographic (Fig. 5 and 6) control demonstrates remission of varices. Four months later an endoscopic control of the oesophagus and stomach is necessary in
order to detect new varices and indicate a new sclerotherapy. Varices IIIII in the bleeding-free interval can be treated without anesthesia and a fiberoptic instrument with flexible needle, too. Moreover such a technique is advisable in patients with new varices after the first sclerotherapy.
Fig. 2
Instrument in function: cannula for injection at the tip, syringe at the basis.
The observed complications are summarized
in Table 4. In case of complete necrosis of the oesophageal wall (Fig. 7), a drainage of the mediastinum and/or pleura, a parenteral nutrition, antibiotics in high doses and a
Figs. 3 and 4 Endoscopic documentation of the esophageal varices before (3) and after (4) sclerotherapy.
Downloaded by: National University of Singapore. Copyrighted material.
have been visualized, the therapeutical system of the instrument with Hopkins optical system, needle at the tip and a syringe at the
K.-J. Paquet, E. Oberhammer
Figs. 5 and 6 Radiographic documentation (upper G.-I.-X-rays) of the esophagus before (5) and after (6) sclerotherapy. Table 4 Complications after sclerotherapy (1.1. 1969-1.11.1977). Complications
Nummer of patients
Pleural effusion Hemorrhage from fundic varices Ulcer of the esophagus (incomplete wallnecrosis) Wallnecrosis of the esophagus, mediastinitis and pyothorax
14
Stenosis for the esophagus to bouginate
Total
19 13 11
7
64 (10.0%)
Table 5 a Causes of death after Sclerotherapy (1.1. 1969-1. 11.1977). Diagnosis
Causes of death
Number
Decompensated liver function Decompensated liver function Decompensated liver function (4) Decompensated liver function Decompensated liver function Decompensated liver function
Hepatic coma
42
Uncontrollable hemorrhage Mediastinitis and pyothorax Hemorrhage from
26 8
stomach varices
6
Bronchopneumonia
7
Myocardial infarction
4
Total
93 (14,5°/o)
Table 5b
stomach tube seem to be effective ways of management.
Hemorrhage from varices of the stomach will arise, if the sclerosing agents are partly or totally injected into the oesophageal van-
Diagnosis
Number
Mortality (°/o)
Acute Chronic "Prophylactic"
41
52
19.5 13.5
Total
93
14.5
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10
Sclerotherapy of Bleeding Oesophageal Varices by Way of Encloscopy
11
Table 6 Late results. Number
Patients still alive
416 (65.0°/o)
Hospital Mortality
93 (14.0°/o)
at home Mortality Fate unknown
96 (15.0°/o)
Table 7
Number of still living patients
months
58
6
73
6-12
years
115
1-2
93
3-4
54
5-6
23
7-8
416
Complete wallnecrosis and mediastinitis after sclerotherapy. Fig. 7
ces, which thrombose and may cause a hemor-
Discussion
rhage from varices in the fornix and fundus region. Therapy consists of the insertion of the one-balloon-tube. If bleeding cannot be stopped, a gastroeosophageal disconnection with splenectomy, as Pettinari and Hassab (2) (Fig. 8) proposed, is done (2). Stenoses of eosophagus are bouginated.
Decisive for the these results is a regular control of patients. They, therefore, have to be submitted to a permanent clinical, radiological and especially endoscopic control in intervals of 4, later of 6 months. After sclero-
Causes of death are summarized in Table 5.
up to one year. If liver function improves, a porto-systemic-shunt should be performed whenever possible. If hemorrhage recurs or if increasing size of the varicosities is ob-
Main causes were liver coma, imitigable hemorrhage and pyothorax. Total mortality was 14,5 %.
Since this technic is considered as palliative
therapy has been performed two or three times, control interval often can be extended
served, the sclerotherapy has to be repeated.
method, as it doesn't decompress the portal
system in any way, we tried do get late results. 650/o of the patients, treated since 1969, are still alive (Table 6). Most of them didn't bleed again. The main cause of death was liver coma. 50 °/o are still alive more than one to eight years (Table 7).
References 1 Dagradi, A. E., S. J. Stempien, L. K. Owens: Bleeding esophageal gastric varices: an endoscopic study. Surgery 92 (1966) 344
2 Hassab, M. A.: Gastroesophageal decongestion and splenectomy: a new method of prevention and treatment of bleeding from esophageal varices. J. Int. Coll. Surg. 41 (1964) 232
Downloaded by: National University of Singapore. Copyrighted material.
35 (5.5°/o)
K.-J. Paquet et al.: Sclerotherapy of Bleeding Oesophageal Varices by Way
12
1
2
3
Fig. 8
Gastro-esophageal disconnection
after PettinariHassabPaquet: (1, 2, 3 = Devascularisation of
9
diaphragma and abdominal esophagus. 4, 5 = ligated vasa gastroepiploica sinistra.
6 = perfused parts of the vasa gastroepiploica dextra. 7 = ligated A. gastrica sinistra and V. coronaria ventriculi. 8,9 = Vagotomy and Pyloroplasty).
6
3 Paquet, K. J.: Indikationen und Ergebnisse der Sklerosierungstherapie von Osophagusvarizen. Therapiewoche 22 (1972) 262
4 Paquet, K.-J., C. Engel: Die Wandsklerosierung des Osophagus in der Therapie der akuten Varizenblutung und der drohenden Hämorrhagie bei dekompensierter Leberfunktion. Z. Gastroent. 12 (1974) 235 5 Paquet, K. J.: Ein neues Instrument zur Wandsklerosie-
rung der Speiseröhre in der Behandlung der akuten rhophagusvarizenblutung bzw. von Varizem im blutungsfreien Intervall. Akt. Gastrol. 4 (1975) 441
6 Rasdzke, E., K.-J. Paquet: Management of hemorrhage from esophageal varices using endoscopic method. Ann. Surg. 177 (1973) 99
7 Stelzner, F., W. Lierse: Der angiomusculfire Verschluß der Speiseröhre. Arch. klin. Chir. 321 (1968) 35
K.-J. Paquet, M.D., Depart. Surg. Univ. of Bonn, D-5300 Bonn-Venusberg, Western Germany
Downloaded by: National University of Singapore. Copyrighted material.
7
