Sclerotherapy for Esophageal Varices

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Sclerotherapy for esophageal varices, also called endoscopic sclerotherapy, is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.

Purpose

Esophageal varices are enlarged or swollen veins on the lining of the esophagus which are prone to bleeding. They are life-threatening; each episode of bleeding carries a 20-30% risk of death. 70% of patients who do not receive treatment for their varices die of bleeding within a year of their first episode of bleeding. Esophageal varices are a complication of portal hypertension, a condition characterized by increased blood pressure in the portal vein resulting from liver disease, such as cirrhosis. Increased pressure causes the veins to balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools.

In most hospitals, sclerotherapy for esophageal varices is the treatment of choice to stop esophageal bleeding during acute episodes, and to prevent further incidences of bleeding. Emergency sclerotherapy is often followed by preventive treatments to eradicate distended esophageal veins.

Demographics

Bleeding esophageal varices are a serious complication of liver disease. In the United States, at least 50% of people who survive bleeding esophageal varices are at risk of recurrent bleeding during the next one to two years.

KEY TERMS

Cirrhosis— A chronic degenerative liver disease causing irreversible scarring of the liver.

Endoscope— An instrument used to examine the inside of a canal or hollow organ. Endoscopic surgery is less invasive than traditional surgery.

Esophagus— The part of the digestive canal located between the pharynx (part of the digestive tube) and the stomach. Also called the food pipe.

Portal hypertension— Abnormally high pressure within the veins draining into the liver.

Sclerosant— An irritating solution that stops bleeding by hardening the blood or vein it is injected into.

Varices— Swollen or enlarged veins, in this case on the lining of the esophagus.

Description

Sclerotherapy for esophageal varices involves injecting a strong and irritating solution (a sclerosant) into the veins and/or the area beside the distended vein. Sclerosant injected directly into the vein causes blood clots to form and stops the bleeding, while sclerosant injected into the area beside the distended vein stops the bleeding by thickening and swelling the vein to compress the blood vessel. Most physicians inject the sclerosant directly into the vein, although injections into the vein and the surrounding area are both effective. Once bleeding has been stopped, the treatment can be used to significantly reduce or destroy the varices.

Sclerotherapy for esophageal varices is performed with the patient awake but sedated. Hyoscine butyl-bromide (Buscopan) may be administered to freeze the esophagus, making injection of the sclerosant easier. During the procedure, an endoscope is passed through the patient’s mouth to the esophagus to allow the surgeon to view the inside. The branches of the blood vessels at or just above where the stomach and esophagus come together, the usual site of variceal bleeding, are located. After the bleeding vein is identified, along, flexible sclerotherapy needle is passed through the endoscope. When the tip of the needle’s sheath is in place, the needle is advanced, and the sclerosant is injected into the vein or the surrounding area. The most commonly used sclerosants are ethanolamine and sodium tetradecyl sulfate. The needle is withdrawn. The procedure is repeated as many times as necessary to eradicate all distended veins.

Diagnosis/Preparation

A radiologist assesses patients for sclerotherapy based on blood work and liver imaging studies performed using CT scans, ultrasound, or MRI scans, and in consultation with the treating gastroenterologist, hepatologist, or surgeon. Tests to localize bleeding and detect active bleeding are also performed.

Before a sclerotherapy procedure, the patient’s vital signs and other pertinent data are recorded, an intravenous line is inserted to administer fluid or blood, and a sedative is prescribed.

Aftercare

After sclerotherapy for esophageal varices, the patient will be observed for signs of blood loss, lung complications, fever, a perforated esophagus, or other complications. Vital signs are monitored, and the intravenous line maintained. Pain medication is usually prescribed. After leaving the hospital, the patient follows a diet prescribed by the physician, and, if appropriate, can take mild pain relievers.

Risks

Risks associated with sclerotherapy include complications that can arise from use of the sclerosant or from the endoscopic procedure. Minor complications, which cause discomfort but do not require active treatment or prolonged hospitalization, include transient chest pain, difficulty swallowing, and fever, which usually go away after a few days. Some patients may have allergic reactions to the sclerosant solution. Infection occurs in up to 50% of cases. In 2-10% of patients, the esophagus tightens, but this can usually be treated with dilatation. More serious complications may occur in 10-15% of patients. These include perforation or bleeding of the esophaggus and lung problems, such as aspiration pneumonia. Long-term sclerotherapy can also damage the esophagus, and increase the patient’s risk of developing cancer.

Patients with advanced liver disease complicated by bleeding are very poor risks for this procedure. The surgery, premedications, and anesthesia may be sufficient to tip the patient into protein intoxication and hepatic coma. The blood in the bowels acts like a high-protein meal and may induce protein intoxication.

Normal results

Normal sclerotherapy results include the control of acute bleeding if present and the shrinking of the esophageal varices.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Sclerotherapy for esophageal varices is performed by a surgeon specialized in gastroenterology or hepatology in a hospital setting, very often as an emergency procedure.

Morbidity and mortality rates

Sclerotherapy for esophageal varices has a 20-40% incidence of complications and a 1-2% mortality rate. The procedure controls acute bleeding in about 90% of patients, but it may have to be repeated within the first 48 hours to achieve this success rate. During the initial hospitalization, sclerotherapy is usually performed two or three times. Preventive treatments are scheduled every few weeks or so, depending on the patient’s risk level and healing rate. Several studies have shown that the risk of recurrent bleeding is much lower in patients treated with sclerotherapy: 30-50% as opposed to 70-80% for patients not treated with sclerotherapy.

Alternatives

Pharmacological agents are also used in the treatment of esophageal varices. Drugs such as vasopressin and somatostatin are administered to actively bleeding patients on admission, while propranolol, nadolol or subcutaneous octreotide are used to prevent subsequent bleeding after successful endoscopic variceal eradication. Vasopressin or vasopressin with nitroglycerin has been proven effective in the acute control of variceal hemorrhage. Somatostatin is more effective in the control of active bleeding when compared to vasopressin, glypressin, endoscopic sclerotherapy or balloon tamponade. Octreotide has comparable outcomes to vasopressin, terlipressin or endoscopic sclerotherapy. Liver transplantation should be considered as an alternative for patients with bleeding varices from liver disease.

Another alternative treatment is provided by Transjugular intrahepatic portal-systemic shunting (TIPS). In TIPS, a catheter fitted with a stent, a wire mesh tube used to prop open a vein or artery, is inserted through a vein in the neck into the liver. Under x ray guidance, the stent is placed in an optimal position within the liver so as to allow blood to flow more easily through the portal vein. This treatment reduces the excess pressure in the

QUESTIONS TO ASK THE DOCTOR

• What are esophageal varices?
• Are there alternatives to sclerotherapy?
• How do I prepare for surgery?
• What type of anesthesia will be used?
• How is the surgery performed?
• How long will I be in the hospital?
• How many sclerotherapy procedures do you perform in a year?

esophageal varices, and thus decreases the risk of recurrent bleeding.

Resources

BOOKS

Feldman, M, et al.. Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. 8th ed. St. Louis: Mosby, 2005.

Khatri, VP and JA Asensio. Operative Surgery Manual. 1st ed. Philadelphia: Saunders, 2003.

Townsend, CM et al. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Saunders, 2004.

PERIODICALS

Dhiman, R. K., and Y. K. Chawla. “A new technique of combined endoscopic sclerotherapy and ligation for variceal bleeding.” World Journal of Gastroenterology 9 (May 2003): 1090–1093.

Mahesh, B., S. Thulkar, G. Joseph, A. Srivastava, and R. K. Khazanchi. “Colour duplex ultrasound-guided sclerotherapy. A new approach to the management of patients with peripheral vascular malformations.” Clinical Imaging 27 (May-June 2003): 171–179.

Miyazaki, K., T. Nishibe, F. Sata, T. Imai, F. A. Kudo, J. Flores, Y. J. Miyazaki, and K. Yasuda. “Stripping Operation with Sclerotherapy for Primary Varicose Veins Due to Greater Saphenous Vein Reflux: Three-Year Results.” World Journal of Surgery 27 (May 2003): 551–553.

ORGANIZATIONS

Society of American Gastrointestinal Endoscopic Surgeons (SAGES). 2716 Ocean Park Boulevard, Suite 3000, Santa Monica, CA 90405. (310) 314-2404. http://www.sages.org.

OTHER

SAGES: The Role of Endoscopic Sclerotherapy. http://www.sages.org/sg_asgepub1019.html.

Lori De Milto

Monique Laberge, Ph.D.

Sclerotherapy for esophageal varices

Definition

Sclerotherapy for esophageal varices, also called endoscopic sclerotherapy, is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.

Purpose

Esophageal varices are enlarged or swollen veins on the lining of the esophagus which are prone to bleeding. They are life-threatening and can be fatal in up to 50% of patients. Esophageal varices are a complication of portal hypertension, a condition characterized by increased blood pressure in the portal vein resulting from such liver disease, as liver cirrhosis. Increased pressure causes the veins to balloon outward. The vessels may rupture, causing vomiting of blood and bloody stools.

In most hospitals, sclerotherapy for esophageal varices is the treatment of choice to stop esophageal bleeding during acute episodes, and to prevent further incidences of bleeding. Emergency sclerotherapy is often followed by preventive treatments to eradicate distended esophageal veins.

Demographics

Bleeding esophageal varices are a serious complication of liver disease. In the United States, at least 50% of people who survive bleeding esophageal varices are at risk of recurrent bleeding during the next one to two years.

Description

Sclerotherapy for esophageal varices involves injecting a strong and irritating solution (a sclerosant) into the veins and/or the area beside the distended vein. Sclerosant injected directly into the vein causes blood clots to form and stops the bleeding, while sclerosant injected into the area beside the distended vein stops the bleeding by thickening and swelling the vein to compress the blood vessel. Most physicians inject the sclerosant directly into the vein, although injections into the vein and the surrounding area are both effective. Once bleeding has been stopped, the treatment can be used to significantly reduce or destroy the varices.

Sclerotherapy for esophageal varices is performed with the patient awake but sedated. Hyoscine butylbromide (Buscopan) may be administered to freeze the esophagus, making injection of the sclerosant easier. During the procedure, an endoscope is passed through the patient's mouth to the esophagus to allow the surgeon to view the inside. The branches of the blood vessels at or just above where the stomach and esophagus come together, the usual site of variceal bleeding, are located. After the bleeding vein is identified, a long, flexible sclerotherapy needle is passed through the endoscope. When the tip of the needle's sheath is in place, the needle is advanced, and the sclerosant is injected into the vein or the surrounding area. The most commonly used sclerosants are ethanolamine and sodium tetradecyl sulfate. The needle is withdrawn. The procedure is repeated as many times as necessary to eradicate all distended veins.

Diagnosis/Preparation

A radiologist assesses patients for sclerotherapy based on blood work and liver imaging studies performed using CT scans , ultrasound or MRI scans, and in consultation with the treating gastroenterologist, hepatologist, or surgeon. Tests to localize bleeding and detect active bleeding are also performed.

Before a sclerotherapy procedure, the patient's vital signs and other pertinent data are recorded, an intravenous line is inserted to administer fluid or blood, and a sedative is prescribed.

Aftercare

After sclerotherapy for esophageal varices, the patient will be observed for signs of blood loss, lung complications, fever, a perforated esophagus, or other complications. Vital signs are monitored, and the intravenous line maintained. Pain medication is usually prescribed. After leaving the hospital, the patient follows a diet prescribed by the physician, and, if appropriate, can take mild pain relievers.

Risks

Risks associated with sclerotherapy include complications that can arise from use of the sclerosant or from the endoscopic procedure. Minor complications, which cause discomfort but do not require active treatment or prolonged hospitalization, include transient chest pain, difficulty swallowing, and fever, which usually go away after a few days. Some patients may have allergic reactions to the sclerosant solution. Infection occurs in up to 50% of cases. In 2-10% of patients, the esophagus tightens, but this complication can usually be treated with dilatation. More serious complications may occur in 10-15% of patients. These include perforation or bleeding of the esophaggus and lung problems, such as aspiration pneumonia. Long-term sclerotherapy can also damage the esophagus and increase the patient's risk of developing cancer.

Patients with advanced liver disease complicated by bleeding are very poor risks for this procedure. The surgery, premedications, and anesthesia may be sufficient to tip the patient into protein intoxication and hepatic coma. The blood in the bowels acts like a high protein meal and may induce protein intoxication.

Normal results

Normal sclerotherapy results include the control of acute bleeding if present and the shrinking of the esophageal varices.

Morbidity and mortality rates

Sclerotherapy for esophageal varices has a 20-40% incidence of complications and a 1–2% mortality rate. The procedure controls acute bleeding in about 90% of patients, but it may have to be repeated within the first 48 hours to achieve this success rate. During the initial hospitalization, sclerotherapy is usually performed two or three times. Preventive treatments are scheduled every few weeks or so, depending on the patient's risk level and healing rate. Several studies have shown that the risk of recurrent bleeding is much lower in patients treated with sclerotherapy: 30-50% as opposed to 70–80% for patients not treated with sclerotherapy.

Alternatives

Pharmacological agents are also used in the treatment of esophageal varices. Such drugs as vasopressin and somatostatin are administered to actively bleeding patients on admission, while propranolol, nadolol or subcutaneous octreotide are used to prevent subsequent bleeding after successful endoscopic variceal eradication. Vasopressin or vasopressin with nitroglycerin has been proven effective in the acute control of variceal hemorrhage. Somatostatin is more effective in the control of active bleeding when compared to vasopressin, glypressin, endoscopic sclerotherapy or balloon tamponade. Octreotide has comparable outcomes to vasopressin, terlipressin or endoscopic sclerotherapy. Liver transplantation should be considered as an alternative for patients with bleeding varices from liver disease.

Another alternative treatment is provided by Transjugular intrahepatic portal-systemic shunting (TIPS). In TIPS, a catheter fitted with a stent, a wire mesh tube used to prop open a vein or artery, is inserted through a vein in the neck into the liver. Under x ray guidance, the stent is placed in an optimal position within the liver so as to allow blood to flow more easily through the portal vein. This treatment reduces the excess pressure in the esophageal varices, and thus decreases the risk of recurrent bleeding.

See also Portal vein bypass.

Resources

books

belcaro, g., and g. stansby. the venous clinic: diagnosis, prevention, investigations, conservative and medical treatment, sclerotherapy and surgery. river edge, nj: world scientific pub. co., 1999.

green, frederick l., and jeffrey l. ponsky, eds. "endoscopic management of esophageal varices." in endoscopic surgery. philadelphia: w. b. saunders co., 1994.

sadick, n. s. manual of sclerotherapy. philadelphia: lippincott, williams & wilkins, 2000.

shearman, david j. c., et al., eds. "endoscopy" and "gastrointestinal bleeding." in diseases of the gastrointestinal tract and liver. new york: churchill livingstone, 1997.

yamada, tadataka, et al., eds. "endoscopic control of upper gastrointestinal variceal bleeding." in textbook of gastroenterology. philadelphia: j. b. lippincott co., 1995.

periodicals

dhiman, r. k., and y. k. chawla. "a new technique of combined endoscopic sclerotherapy and ligation for variceal bleeding." world journal of gastroenterology 9 (may 2003): 1090–1093.

mahesh, b., s. thulkar, g. joseph, a. srivastava, and r. k. khazanchi. "colour duplex ultrasound-guided sclerotherapy. a new approach to the management of patients with peripheral vascular malformations." clinical imaging 27 (may-june 2003): 171–179.

miyazaki, k., t. nishibe, f. sata, t. imai, f. a. kudo, j. flores, y. j. miyazaki, and k. yasuda. "stripping operation with sclerotherapy for primary varicose veins due to greater saphenous vein reflux: three-year results." world journal of surgery 27 (may 2003): 551–553.

organizations

society of american gastrointestinal endoscopic surgeons (sages). 2716 ocean park boulevard, suite 3000, santa monica, ca 90405. (310) 314-2404. <http://www.sages.org>.

other

sages: the role of endoscopic sclerotherapy. <http://www.sages.org/sg_asgepub1019.html>.

Lori De Milto Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Sclerotherapy for esophageal varices is performed by a surgeon specialized in gastroenterology or hepatology in a hospital setting, very often as an emergency procedure.

QUESTIONS TO ASK THE DOCTOR

• What are esophageal varices?
• Are there alternatives to sclerotherapy?
• How do I prepare for surgery?
• What type of anesthesia will be used?
• How is the surgery performed?
• How long will I be in the hospital?
• How many sclerotherapy procedures do you perform in a year?

Sclerotherapy for Esophageal Varices

Definition

Sclerotherapy for esophageal varices (also called endoscopic sclerotherapy) is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.

Purpose

In most hospitals, sclerotherapy for esophageal varices is the treatment of choice to stop esophageal bleeding during acute episodes, and to prevent further incidences of bleeding. Emergency sclerotherapy is often followed by preventive treatments to eradicate distended esophageal veins.

Precautions

Sclerotherapy for esophageal varices cannot be performed on an uncooperative patient, since movement during the procedure could cause the vein to tear or the esophagus to perforate and bleed. It should not be performed on a patient with a perforated gastrointestinal tract.

Description

Esophageal varices are enlarged or swollen veins on the lining of the esophagus which are prone to bleeding. They are life-threatening, and can be fatal in up to 50% of patients. They usually appear in patients with severe liver disease. Sclerotherapy for esophageal varices involves injecting a strong and irritating solution (a sclerosant) into the veins and/or the area beside the distended vein. The sclerosant injected into the vein causes blood clots to form and stops the bleeding. The sclerosant injected into the area beside the distended vein stops the bleeding by thickening and swelling the vein to compress the blood vessel. Most physicians inject the sclerosant directly into the vein, although injections into the vein and the surrounding area are both effective. Once bleeding has been stopped, the treatment can be used to significantly reduce or destroy the varices.

Sclerotherapy for esophageal varices is performed by a physician in a hospital, with the patient awake but sedated. Hyoscine butylbromide (Buscopan) may be administered to freeze the esophagus, making injection of the sclerosant easier. During the procedure, an endoscope is passed through the patient's mouth to the esophagus to view the inside. The branches of the blood vessels at or just above where the stomach and esophagus come together, the usual site of variceal bleeding, are located. After the bleeding vein is identified, a long, flexible sclerotherapy needle is passed through the endoscope. When the tip of the needle's sheath is in place, the needle is advanced, and the sclerosant is injected into the vein or the surrounding area. The most commonly used sclerosants are ethanolamine and sodium tetradecyl sulfate. The needle is withdrawn. The procedure is repeated as many times as necessary to eradicate all distended veins.

Sclerotherapy for esophageal varices controls acute bleeding in about 90% of patients, but it may have to be repeated within the first 48 hours to achieve this success rate. During the initial hospitalization, sclerotherapy is usually performed two or three times. Preventive treatments are scheduled every few weeks or so, depending on the patient's risk level and healing rate. Several studies have shown that the risk of recurrent bleeding is much lower in patients treated with sclerotherapy: 30-50%, as opposed to 70-80% for patients not treated with sclerotherapy.

Preparation

Before sclerotherapy for esophageal varices, the patient's vital signs and other pertinent data are recorded, an intravenous line is inserted to administer fluid or blood, and a sedative is prescribed.

Aftercare

After sclerotherapy for esophageal varices, the patient will be observed for signs of blood loss, lung complications, fever, a perforated esophagus, or other complications. Vital signs are monitored, and the intravenous line maintained. Pain medication is usually prescribed. After leaving the hospital, the patient follows a diet prescribed by the physician, and, if appropriate, can take mild pain relievers.

Risks

Sclerotherapy for esophageal varices has a 20-40% incidence of complications, and a 1-2% percent mortality rate. Complications can arise from the sclerosant or the endoscopic procedure. Minor complications, which are uncomfortable but do not require active treatment or prolonged hospitalization, include transient chest pain, difficulty swallowing, and fever, which usually go away after a few days. Some people have allergic reactions to the solution. Infection occurs in up to 50% of cases. In 2-10% of patients, the esophagus tightens, but this can usually be treated with dilatation. More serious complications may occur in 10-15% of patients treated with sclerotherapy. These include perforation or bleeding of the esophagus and lung problems, such as aspiration pneumonia. Long-term sclerotherapy can damage the esophagus, and increase the patient's risk of developing cancer.

Patients with advanced liver disease complicated by bleeding are very poor risks for this procedure. The surgery, premedications, and anesthesia may be sufficient to tip the patient into protein intoxication and hepatic coma. The blood in the bowels acts like a high protein meal; therefore, protein intoxication may be induced.

Resources

PERIODICALS

Cello, J. P. "Endoscopic Management of Esophageal VaricealHemorrhage: Injection, Banding, Glue, Octreotide, or a Combination?" Seminars in Gastrointestinal Diseases 8 (October 1997): 179-187.

KEY TERMS

Endoscope— An instrument used to examine the inside of a canal or hollow organ. Endoscopic surgery is less invasive than traditional surgery.

Esophagus— The part of the digestive canal located between the pharynx (part of the digestive tube) and the stomach.

Sclerosant— An irritating solution that stops bleeding by hardening the blood or vein it is injected into.

Varices— Swollen or enlarged veins, in this case on the lining of the esophagus.