Variceal recurrence, rebleeding and survival after injection sclerotherapy in 306 alcoholic cirrhotic patients with bleeding oesophageal varices: original
AbstractEndoscopic therapy is the treatment of choice for bleeding oesophageal varices. This study tested the validity of the hypothesis that eradication of oesophageal varices by repeated injection sclerotherapy would reduce recurrent variceal bleeding and death from bleeding oesophageal varices in a high risk cohort of patients with portal hypertension and cirrhosis.
Patients and Methods: 306 alcoholic cirrhotic patients who presented to hospital with endoscopically proven variceal bleeding were assessed prospectively between 1984 and 2001. Data were entered into a computer based proforma and analysed in April 2004 to allow a minimum 26 months follow-up. The data presented is based on an endoscopic protocol using a standard injection technique, with eradication of varices the predetermined end point. The 306 patients (239 men, 67 women; mean age 51.6, range 24-87 years) underwent 387 emergency and 1067 elective injection treatments with 5% ethanolamine oleate using a combined intra and paravariceal technique during the study period. All patients undergoing endoscopic band ligation were excluded. The Child's grades were A:42, B:122, C:142. All oesophageal complications which occurred during the subsequent 2380 endoscopies following the index sclerotherapy treatment were documented.
Results: Before eradication of varices was achieved 111 (36.2%) of the 306 patients had a total of 191 bleeding episodes after the initial endoscopic intervention during the index hospital admission. Rebleeding was markedly reduced after eradication of varices. In 156 (81.6%) of 191 patients who survived more than 3 months, varices were eradicated after a mean of 5 injections and remained eradicated in 69 (mean follow-up: 34.6 months; range: 1-174 months). Varices recurred in 83 patients and rebled in 43 of these patients. 830 oesophageal complications were identified during follow-up in 249 (81.3%) patients. Mucosal ulceration was noted on 584 occasions in 216 patients. 27 patients developed an oesophageal stenosis of whom 15 required dilatation. Eight patients had an oesophageal perforation after repeated sclerotherapy for recurrent bleeding. Cumulative survival by life table analysis was 56%, 40%, and 24% at 1, 3 and 5 years. 213 patients (69.6%) died during follow-up. Liver failure was the most common cause of death.
Conclusion: Repeated sclerotherapy eradicates esophageal varices in most alcoholic cirrhotic patients with a reduction in rebleeding. Complications related to sclerotherapy were common and were mostly of a minor nature but were cumulative and life-threatening in some patients. Despite control of variceal bleeding, survival at 5 years was only 24% because of death due to liver failure in most patients.
SA Gastroentorology Review Vol.2(2) 2004: 8-13