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The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices

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Abstract

The treatment of acute and recurrent variceal bleeding is best accomplished by a skilled, knowledgeable, and well-equipped team using a multidisciplinary integrated approach. Optimal management should provide the full spectrum of treatment options including pharmacologic therapy, endoscopic treatment, interventional radiologic procedures, surgical shunts, and liver transplantation. Endoscopic therapy with either band ligation or injection sclerotherapy is an integral component of the management of acute variceal bleeding and of the long-term treatment of patients after a variceal bleed. Variceal eradication with endoscopic ligation requires fewer endoscopic treatment sessions and causes substantially less esophageal complications than does injection sclerotherapy. Although the incidence of early gastrointestinal rebleeding is reduced by endoscopic ligation in most studies, there is no overall survival benefit relative to injection sclerotherapy. Simultaneous combined ligation and sclerotherapy confers no advantage over ligation alone. A sequential staged approach with initial endoscopic ligation followed by sclerotherapy when varices are small may prove to be the optimal method of reducing variceal recurrence. Overall, current data demonstrate clear advantages for using ligation in preference to sclerotherapy. Ligation should therefore be considered the endoscopic treatment of choice in the treatment of esophageal varices.

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References

  1. Bornman PC, Krige JEJ, Terblanche J. Management of esophageal varices. Lancet 1994;343:1079–1084

    Article  CAS  PubMed  Google Scholar 

  2. Krige JE, Bornman PC. Endoscopic treatment of oesophageal varices. S. Afr. J. Surg. 2000;38:82–88

    CAS  PubMed  Google Scholar 

  3. Terblanche J, Burroughs AK, Hobbs KEF. Controversies in the management of bleeding oesophageal varices. N. Engl. J. Med. 1989;320:1393–1398

    Article  CAS  PubMed  Google Scholar 

  4. D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review. Hepatology 1995;22:332–354

    Article  CAS  PubMed  Google Scholar 

  5. Terblanche J, Burroughs AK, Hobbs KEF. Controversies in the management of bleeding oesophageal varices. N. Engl. J. Med. 1989;320:1469–1475

    Article  CAS  PubMed  Google Scholar 

  6. Krige JE, Beckingham IJ. Portal hypertension: varices. Br. Med. J. 2001;322:348–351

    CAS  Google Scholar 

  7. Terblanche J, Krige JEJ, Bornman PC. Endoscopic sclerotherapy. Surg Clin North Am. 1990;70:341–359

    CAS  PubMed  Google Scholar 

  8. Bosch J, Garcia–Pagan JC. Prevention of variceal rebleeding. Lancet 2003;361:952–954

    Article  PubMed  Google Scholar 

  9. Tait IS, Krige JEJ, Terblanche J. Endoscopic band ligation of oesophageal varices. Br. J. Surg. 1999;86:812–817

    Article  Google Scholar 

  10. Krige JEJ, Botha JF, Bornman PC. Endoscopic variceal ligation for bleeding esophageal varices. Dig. Endosc. 1999;11:315–320

    Google Scholar 

  11. Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005;41:386–400

    Article  PubMed  Google Scholar 

  12. Luca A, D’Amico G, La Galla R, et al. TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials. Radiology 1999;212:411–421

    CAS  PubMed  Google Scholar 

  13. Rosemurgy AS, Bloomston M, Clark WC, et al. H-graft portacaval shunts versus TIPS: ten-year follow-up of a randomized trial with comparison to predicted survivals. Ann. Surg. 2005;241:238–246

    Article  PubMed  Google Scholar 

  14. Keeffe EB. Liver transplantation: current status and novel approaches to liver replacement. Gastroenterology 2001;120:749–762

    Article  CAS  PubMed  Google Scholar 

  15. Henderson JM, Barnes DS, Geisinger MA. Portal hypertension. Curr. Prob. Surg. 1998;35:381–452

    Google Scholar 

  16. Crafoord C, Frenkner P. New surgical treatment of varicose veins of the oesophagus. Acta Otolaryngol. 1939;27:422–439

    Google Scholar 

  17. Moersch HJ. The treatment of oesophageal varices by injection of a sclerosing solution. J. Thorac. Surg. 1940;10:300–309

    Google Scholar 

  18. Moersch HJ. Treatment of oesophageal varices by injection of a sclerosing solution. JAMA 1947;135:754–757

    CAS  Google Scholar 

  19. Patterson CO, Rouse MO. The sclerosing therapy of esophageal varices. Gastroenterology 1947;9:391–395

    CAS  PubMed  Google Scholar 

  20. Macbeth R. Treatment of oesophageal varices in portal hypertension by means of sclerosing injections. Br. Med. J. 1955;2:877–880

    Article  PubMed  CAS  Google Scholar 

  21. Blakemore AH. Portacaval anastomosis: a report of fourteen cases. Bull. N. Y. Acad. Med. 1946;22:254

    PubMed  CAS  Google Scholar 

  22. Johnson GW, Rodgers HW. A review of 15 years’ experience in the use of sclerotherapy in the control of acute haemorrhage from oesophageal varices. Br. J. Surg. 1973;60:797–800

    Google Scholar 

  23. Wodak E. Osophagus varigen bei portaler hypertension: ihre therrapie und prophylaxe. Wien Med. Wochenschr. 1960;110:581–587

    CAS  PubMed  Google Scholar 

  24. Paquet KJ, Oberhammer E. Sclerotherapy of bleeding oesophageal varices by means of endoscopy. Endoscopy 1978;10:7–12

    Article  CAS  PubMed  Google Scholar 

  25. Terblanche J, Northover JMA, Bornman P. A prospective controlled trial of sclerotherapy in the long-term management of patients after oesophageal variceal bleeding. Surg. Gynecol. Obstet. 1979;148:323–333

    CAS  PubMed  Google Scholar 

  26. Terblanche J, Bornman PC, Kahn D, et al. Failure of repeated injection sclerotherapy to improve long-term survival after oesophageal variceal bleeding. A five-year prospective, controlled clinical trial. Lancet 1983;2:1328–1332

    Article  CAS  PubMed  Google Scholar 

  27. Terblanche J, Northover JMA, Bornman PC, et al. A prospective evaluation of injection sclerotherapy in the treatment of acute bleeding from esophageal varices. Surgery 1979;85:239

    CAS  PubMed  Google Scholar 

  28. Terblanche J. Treatment of esophageal varices by injection sclerotherapy. In: Maclean LD (ed). Advances in Surgery. Chicago, Year Book. 1981; pp 257–291

    Google Scholar 

  29. Terblanche J, Yakoob HI, Bornman PC, et al. Acute bleeding varices. A five-year prospective evaluation of tamponade and sclerotherapy. Ann. Surg. 1981;194:521

    CAS  PubMed  Google Scholar 

  30. Terblanche J, Kahn D, Bornman PC. Long-term sclerotherapy treatment for oesophageal varices. A ten-year prospective evaluation. Ann. Surg. 1989;210:725–731

    CAS  PubMed  Google Scholar 

  31. Terblanche J, Krige JEJ. Emergency sclerotherapy. In: Bosch J, Groszman RJ (eds). Portal hypertension. Pathophysiology and treatment. Oxford, Blackwell Scientific Publications. 1994; pp 140–153

    Google Scholar 

  32. Terblanche J, Krige JEJ. Endoscopic therapy in the management of oesophageal varices: injection sclerotherapy and variceal ligation. In: Nyhus LM, Baker, RJ, Fischer, JE (eds). Mastery of Surgery, 3rd ed. Little Brown Company, New York 1997; pp 1329–1339

  33. Krige JEJ, Terblanche J. Injection sclerotherapy of oesophageal varices. In: Jamieson GG, DeBas HT (eds). Rob and Smith’s Operative Surgery. Surgery of the Upper Gastrointestinal tract, 5th ed. London, Chapman and Hall Medical, 1994; pp 10–20

    Google Scholar 

  34. Krige JEJ, Terblanche J. Injection sclerotherapy of oesophageal varices. In: Carter D, Russell RCG, Pitt H, et al. (eds). Rob and Smith’s Operative Surgery. Surgery of the Liver, Pancreas and Bile Ducts, 5th ed. London, Chapman and Hall Medical, 1996; pp 163–172

    Google Scholar 

  35. Matloff DS. Treatment of acute variceal bleeding. Gastroenterol. Clin. North Am. 1992;21:103–117

    CAS  Google Scholar 

  36. Krige JEJ, Bornman PC, Terblanche J. Complications of sclerotherapy. In: Sivak MV (ed). Gastrointestinal Endoscopy, 2nd ed. New York, W.B.Saunders, 2000; pp 860–876

    Google Scholar 

  37. Terblanche J, Stiegmann G, Krige JEJ, et al. Long-term management of variceal bleeding: The place of varix injection and ligation. World J. Surg. 1994;18:185–192

    Article  CAS  PubMed  Google Scholar 

  38. Stiegmann GV, Yamamoto M. Endoscopic techniques for the management of active variceal bleeding. Gastrointest. Endosc. Clin. North Am. 1994;2:59–74

    Google Scholar 

  39. Stiegmann GV, Cambre T, Sun J. A new endoscopic elastic band ligating device. Gastrointest. Endosc.1986;32:230–233

    Google Scholar 

  40. Stiegmann, GV, Goff, JS, Sun, JH et al. Endoscopic elastic band ligation for active variceal hemorrhage. the american surgeon 1989; 55: 124–128

  41. Stiegmann GV, Goff JS, Michaletz–Onody et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N. Engl. Med. 1992;326:1527–1632

    Article  CAS  Google Scholar 

  42. Laine L, El Newihi HM, Migikovsky B, et al. Endoscopic ligation compared with sclerotherapy for the treatment of bleeding esophageal varices. Ann. Intern. Med. 1993;119:1–7

    CAS  PubMed  Google Scholar 

  43. Gimson AES, Ramage JK, Panos MZ, et al. Randomised trial of variceal banding ligation versus injection sclerotherapy for bleeding esophageal varices. Lancet 1993;342:391–394

    Article  CAS  PubMed  Google Scholar 

  44. Lo GH, Lai KH, Cheng JS, et al. A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices. Hepatology 1995;22:466–471

    Article  CAS  PubMed  Google Scholar 

  45. Hou MC, Lin HC, Kuo BIT, et al. Comparison of endoscopic variceal injection sclerotherapy and ligation for the treatment of esophageal variceal hemorrhage: A prospective randomized trial. Hepatology 1995;21:1517–1522

    Article  CAS  PubMed  Google Scholar 

  46. Sarin SK, Govil A, Jain AK, et al. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence. Hepatology 1997;26:826–832

    Article  CAS  Google Scholar 

  47. Baroncini D, Milandri GL, Borioni D, et al. A prospective randomized trial of sclerotherapy versus ligation in the elective treatment of bleeding esophageal varices. Endoscopy 1997;29:235–240

    Article  CAS  PubMed  Google Scholar 

  48. Avgerinos A, Armonis A, Manolakopoulos S, et al. Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding. A prospective randomised study. J. Hepatol. 1997;26:1034–1041

    Article  CAS  PubMed  Google Scholar 

  49. Masci E, Stigliano R, Mariani A, et al. Prospective multicenter randomized trial comparing banding ligation with sclerotherapy of esophageal varices. Hepatogastroenterology 1999;46:1769–1773

    CAS  PubMed  Google Scholar 

  50. de la Pena J, Rivero M, Sanchez E, et al. Variceal ligation compared with endoscopic sclerotherapy for variceal hemorrhage: prospective randomized trial. Gastrointest. Endosc. 1999;49:417–423

    Google Scholar 

  51. Fakhry S, Omar M, Gannam M, et al. Endoscopic sclerotherapy versus endoscopic variceal ligation in the management of bleeding esophageal varices: a prospective randomized study in schistosomal hepatic fibrosis. Endosc. Arab Ed. 2000;1:39–44

    Google Scholar 

  52. Zargar SA, Javid G, Khan BA, et al. Endoscopic ligation vs. sclerotherapy in adults with extrahepatic portal venous obstruction: a prospective randomized study. Gastrointest. Endosc. 2005;61:58–66

    Google Scholar 

  53. Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann. Intern. Med. 1995;123:280–287

    CAS  PubMed  Google Scholar 

  54. Fleig W, Strange E, Ruettenauer K, et al. Emergency endoscopic sclerotherapy for bleeding esophageal varices. A prospective study in patients not responding to balloon tamponade. Gastrointest. Endosc. 1983;29:8–14

    CAS  Google Scholar 

  55. Lo G-H, Lai K-H, Cheng J-S, et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. Hepatology 1997;25:1101–1104

    Article  CAS  PubMed  Google Scholar 

  56. Laine L, Stein C, Sharma V. Randomized comparison of ligation versus ligation plus sclerotherapy in patients with bleeding esophageal varices. Gastroenterology 1996;110:529–533

    Article  CAS  PubMed  Google Scholar 

  57. Saeed ZA, Stiegmann GV, Ramirez et al. Endoscopic variceal ligation is superior to combined ligation and sclerotherapy for esophageal varices: A multicenter prospective randomized trial. Hepatology 1997;25:71–74

    CAS  PubMed  Google Scholar 

  58. Umehara M, Onda M, Tajiri T, et al. Sclerotherapy plus ligation versus ligation for the treatment of esophageal varices: a prospective randomized study. Gastrointest. Endosc. 1999;50:7–12

    Article  CAS  Google Scholar 

  59. Al Traif I, Fachartz FS, Al Jumah A, et al. Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices. Gastrointest. Endosc. 1999;50:1–6

    Article  CAS  Google Scholar 

  60. Djurdjevic D, Janosevic S, Dapcevic B, et al. Combined ligation and sclerotherapy versus ligation alone for eradication of bleeding esophageal varices: a randomized and prospective trial. Endoscopy 1999;31:286–290

    Article  CAS  PubMed  Google Scholar 

  61. Argonz J, Kravetz D, Suarez A, et al. Variceal band ligation and variceal band ligation plus sclerotherapy in the prevention of recurrent variceal bleeding in cirrhotic patients: a randomized, prospective and controlled trial. Gastrointest. Endosc. 2000;51:157–163

    CAS  Google Scholar 

  62. Hou MC, Lin HC, Kuo BI, et al. The rebleeding course and long-term outcome of esophageal variceal hemorrhage after ligation: comparison with sclerotherapy. Scand. J. Gastroenterol. 1999;34:1071–1076

    Article  CAS  PubMed  Google Scholar 

  63. Karsan HA, Morton SC, Shekelle PG, et al. Combination endoscopic band ligation and sclerotherapy compared with endoscopic band ligation alone for the secondary prophylaxis of esophageal variceal hemorrhage: a meta-analysis. Dig. Dis. Sci. 2005;50:399–406

    Article  PubMed  Google Scholar 

  64. Bhargava DK, Pokharna R. Endoscopic sclerotherapy versus endoscopic variceal ligation and endoscopic sclerotherapy: a prospective randomized study. Am. J. Gastroenterol. 1997;92:950–953

    CAS  PubMed  Google Scholar 

  65. Lo GH, Lai KH, Cheng JS, et al. The additive effect of sclerotherapy to patients receiving repeated endoscopic variceal ligation: a prospective, randomized trial. Hepatology 1998;28:391–395

    Article  CAS  PubMed  Google Scholar 

  66. Masumoto H, Toyonaga A, Oho K, et al. Ligation plus low-volume sclerotherapy for high-risk esophageal varices: comparisons with ligation therapy or sclerotherapy alone. J. Gastroenterol. 1998;33:1–5

    Article  CAS  PubMed  Google Scholar 

  67. lso Y, Kawanaka H, Tomikawa M, et al. Repeated injection sclerotherapy is preferable to combined therapy with variceal ligation to avoid recurrence of esophagea! varices: A prospective randomized trial. Hepatogastroenterology 1997;44:467–471

    Google Scholar 

  68. Garg PK, Joshi YK, Tandon RK. Comparison of endoscopic variceal sclerotherapy with sequential endoscopic band ligation plus low-dose sclerotherapy for secondary prophylaxis of variceal hemorrhage: a prospective randomized study. Gastrointest. Endosc. 1999;50:369–373

    CAS  Google Scholar 

  69. Shigemitsu T, Yoshida T, Harada T, et al. Endoscopic injection sclerotherapy with ligation versus endoscopic injection sclerotherapy alone in the management of esophageal varices: a prospective randomized trial. Hepatogastroenterology 2000;47:733–737

    CAS  PubMed  Google Scholar 

  70. Nishikawa Y, Hosokawa Y, Doi T, et al. Evaluation of endoscopic injection sclerotherapy with and without simultaneous ligation for the treatment of esophageal varices. J. Gastroenterol. 1999;34:159–162

    Article  CAS  PubMed  Google Scholar 

  71. Hou MC, Chen WC, Lin HC, et al. A new “sandwich” method of combined endoscopic variceal ligation and sclerotherapy versus ligation alone in the treatment of esophageal variceal bleeding: a randomized trial. Gastrointest. Endosc. 2001;53:572–578

    CAS  Google Scholar 

  72. Naga MI, Okasha HH, Foda AR, et al. Detachable endoloop vs. elastic band ligation for bleeding esophageal varices. Gastrointest. Endosc. 2004;59:804–809

    Google Scholar 

  73. Yol S, Belviranli M, Toprak S, et al. Endoscopic clipping versus band ligation in the management of bleeding esophageal varices. Surg. Endosc. 2003;17:38–42

    Article  CAS  PubMed  Google Scholar 

  74. Banares R, Albillos A, Rincon D, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology 2002;35:609–615

    Article  PubMed  Google Scholar 

  75. Papatheodoridis GV, Goulis J, Leandro G, et al. Transjugular intrahepatic portosystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding: A meta-analysis. Hepatology 1999;30:612–622

    Article  CAS  PubMed  Google Scholar 

  76. Burroughs AK, Vangeli M. Transjugular intrahepatic portosystemic shunt versus endoscopic therapy: randomized trials for secondary prophylaxis of variceal bleeding: an updated meta-analysis. Scand. J. Gastroenterol. 2002;37:249–252

    Article  CAS  PubMed  Google Scholar 

  77. Lorgat F, Madden MV, Kew G, et al. Bacteremia after injection of esophageal varices. Surg. Endosc. 1990;4:18–19

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery and Medical Research Council, Liver Research Center, University of Cape Town Health Sciences Faculty, 7925, Observatory, Cape Town, South Africa

    J. E. J. Krige M.B.Ch.B., F.A.C.S., F.R.C.S. (Edinb.), F.C.S. (S.A.) & P. C. Bornman M.B. Ch.B., M.Med., F.R.C.S. (Edinb.), F.R.C.S. (Glasgl.), F.C.S. (S.A.)

  2. Surgical Gastroenterology Unit, Groote Schuur Hospital, Cape Town, South Africa

    J. E. J. Krige M.B.Ch.B., F.A.C.S., F.R.C.S. (Edinb.), F.C.S. (S.A.), J. M. Shaw M.B. B.Ch., F.C.S. (S.A.) & P. C. Bornman M.B. Ch.B., M.Med., F.R.C.S. (Edinb.), F.R.C.S. (Glasgl.), F.C.S. (S.A.)

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Correspondence to J. E. J. Krige M.B.Ch.B., F.A.C.S., F.R.C.S. (Edinb.), F.C.S. (S.A.).

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Krige, J.E.J., Shaw, J.M. & Bornman, P.C. The Evolving Role of Endoscopic Treatment for Bleeding Esophageal Varices. World J. Surg. 29, 966–973 (2005). https://doi.org/10.1007/s00268-005-0138-2

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