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At least 109 records · Page 6Linked to original sources
PubMed2001

Feasibility and potential benefit of maintenance endoscopic variceal ligation in patients with unresectable hepatocellular carcinoma and acute esophageal variceal hemorrhage: a controlled trial.

BACKGROUND: Patients with unresectable hepatoma and acute esophageal variceal bleeding have extremely high rates of recurrent bleeding and mortality. This controlled study evaluates the feasibility and potential benefit of maintenance endoscopic variceal ligation in these patients. METHODS: Patients with unresectable hepatoma and acute esophageal variceal bleeding underwent emergent endoscopic variceal ligation. After hemostasis, patients were randomized to undergo maintenance or esophageal variceal ligation (EVL) as necessary (demand ligation). RESULTS: Fifty-four patients underwent maintenance EVL and 55 demanded EVL. One or more subsequent EVL session could be performed in only 30 patients (55.6%) in the maintenance group (actual maintenance ligation). Logistic regression analysis found that hepatic function determines the feasibility of maintenance ligation (Child-Pugh's A+B vs. C, OR 23.00: 95% CI [5.26, 100.66]). The survival and recurrent bleeding rates were similar in both groups. A subgroup analysis of patients with Child-Pugh's A and B hepatic reserve in both the maintenance EVL group (n = 24) and demand EVL group (n = 25) was performed to assess the potential benefit of maintenance ligation. Maintenance ligation reduced the rate of recurrent bleeding compared with demand ligation (p = 0.043). Cox regression showed that portal vein thrombosis and tumors in both hepatic lobes were also factors together with EVL that determined recurrence of bleeding. Survival was similar in both groups. CONCLUSIONS: Maintenance ligation is feasible in patients with unresectable hepatoma and variceal hemorrhage if they have a good hepatic reserve. Maintenance ligation might lower the rate of recurrent bleeding in this subgroup of patients.

Acute Disease↗
PubMed2006

Endoscopic variceal ligation versus propranolol in prophylaxis of first variceal bleeding in patients with cirrhosis.

BACKGROUND AND AIM: To compare the efficacy and safety of endoscopic variceal ligation (EVL) with propranolol in prophylaxis on the rate of first esophageal variceal bleeding in patients with cirrhosis. METHODS: A prospective, randomized trial was conducted in 100 cirrhotic patients with no history of previous upper gastrointestinal bleeding and with esophageal varices endoscopically judged to be at high risk of hemorrhage. The end-points of the study were bleeding and death. RESULTS: Life-table curves showed that prophylactic EVL and propranolol were similarly effective for primary prophylaxis of variceal bleeding (11/50 [22%]vs 12/50 [24%]; P = 0.68) and overall mortality (14/50 [28%]vs 12/50 [24%]; P = 0.49). The 2-year cumulative bleeding rate was 18% (9/50) in the EVL group and 16% (8/50) in the propranolol group. The 2-year cumulative mortality rate was 28% (14/50) in the EVL group and 24% (12/50) in the propranolol group. Comparison of Kaplan-Meier estimates of the time to death of both groups showed no significant difference in mortality in both groups (P = 0.86). Patients undergoing EVL had few treatment failures and died mainly of hepatic failure. In the propranolol group, the mean daily dosage of the drug was 68.2 +/- 32.8 mg, which was sufficient to reduce the pulse rate by 25%. 20% of patients withdrew from propranolol treatment due to adverse events. CONCLUSIONS: Prophylaxis EVL is as effective and as safe as treatment with propranolol in decreasing the incidence of first variceal bleeding and death in cirrhotic patients with high-risk esophageal varices.

Adrenergic beta-Antagonists↗
PubMed1980

Transhepatic embolisation of gastro-oesophageal varices in the management of variceal haemorrhage.

The difficulty of controlling variceal haemorrhage has led to the recent development of methods designed to sclerose the bleeding vessels. This study describes the application of percutaneous transhepatic portal catheterization with embolisation and sclerosis of varices in eight consecutive patients admitted with bleeding oesophago-gastric varices. Portal hypertension was documented and varices demonstrated in each case. Bleeding ceased rapidly in seven patients, two patients rebled 1-3 weeks after the procedure, and five patients were subsequently discharged from hospital. In no instance was death related to continued gastrointestinal haemorrhage. Initial experience with transheptic embolisation of bleeding oesophago-gastric varices indicates that this technique is effective in controlling variceal haemorrhage.

Adult↗
PubMed2005

A randomized control trial of bi-monthly versus bi-weekly endoscopic variceal ligation of esophageal varices.

Endoscopic variceal ligation (EVL) is a safe and simple procedure now being used on a widening scale. Yet most patients who undergo endoscopic treatment for esophageal varices eventually require additional treatment for recurrent varices. In this study, we investigated and compared the efficacy and long-term results of EVL performed in three treatments with a total of sixteen O-rings at two different intervals; bi-weekly (once every 2 wk: the conventional interval) and bi-monthly (once every 2 months). A total of 63 patients with esophageal varices were randomly assigned to groups receiving bi-weekly or bi-monthly EVL treatment. Optimal medical therapy was assessed by one medical doctor who was unaware of the patients' treatment assignments. Three parameters of treatment outcome were evaluated: the rate of recurrence, rate of additional treatment, and overall survival. The overall rates of variceal recurrence and additional treatment were both higher in the bi-weekly group than in the bi-monthly group (p < 0.001). In conclusion, EVL performed for the treatment of esophageal varices at bi-monthly intervals brought about better results than the same treatment performed at bi-weekly intervals. The treatments intercalated by the longer interval obtained a higher total eradication rate, lower recurrence rate, and lower rate of additional treatment.

Esophageal and Gastric Varices↗
PubMed2004

Randomised controlled trial of long term portographic follow up versus variceal band ligation following transjugular intrahepatic portosystemic stent shunt for preventing oesophageal variceal rebleeding.

BACKGROUND/AIMS: Transjugular intrahepatic portosystemic stent shunt (TIPSS) is effective in the prevention of variceal rebleeding but requires invasive portographic follow up. This randomised controlled trial aims to test the hypothesis that combining variceal band ligation (VBL) with TIPSS can obviate the need for long term TIPSS surveillance without compromising clinical efficacy, and can reduce the incidence of hepatic encephalopathy. PATIENTS/METHODS: Patients who required TIPSS for the prevention of oesophageal variceal rebleeding were randomised to either TIPSS alone (n = 39, group 1) or TIPSS plus VBL (n = 40, group 2). In group 1, patients underwent long term TIPSS angiographic surveillance. In group 2, patients entered a banding programme with TIPSS surveillance only continued for up to one year. RESULTS: There was a tendency to higher variceal rebleeding in group 2 although this did not reach statistical significance (8% v 15%; relative hazard 0.58; 95% confidence interval (CI) 0.15-2.33; p = 0.440). Mortality (47% v 40%; relative hazard 1.31; 95% CI 0.66-2.61; p = 0.434) was similar in the two groups. Hepatic encephalopathy was significantly less in group 2 (20% v 39%; relative hazard 2.63; 95% CI 1.11-6.25; p = 0.023). Hepatic encephalopathy was not statistically different after correcting for sex and portal pressure gradient (p = 0.136). CONCLUSIONS: TIPSS plus VBL without long term surveillance is effective in preventing oesophageal variceal rebleeding, and has the potential for low rates of encephalopathy. Therefore, VBL with short term TIPSS surveillance is a suitable alternative to long term TIPSS surveillance in the prevention of oesophageal variceal rebleeding.

Adult↗
PubMed1990

Endoscopic variceal sclerosis compared with distal splenorenal shunt to prevent recurrent variceal bleeding in cirrhosis. A prospective, randomized trial.

STUDY OBJECTIVE: To define the roles of endoscopic variceal sclerosis and distal splenorenal shunt in the prevention of recurrent variceal bleeding in patients with cirrhosis. DESIGN: A prospective, randomized clinical trial with crossover for those failing therapy. The median follow-up was 61 months. SETTING: A private, tertiary-referral university hospital. PATIENTS: Seventy-two patients fulfilling inclusion criteria were drawn from a total of 420 patients treated during a 4.5-year interval. TREATMENTS: Endoscopic variceal sclerosis or distal splenorenal shunt. MEASUREMENTS AND MAIN RESULTS: Survival was significantly (P = 0.02) improved in patients randomly assigned to receive sclerotherapy: 13 of these 37 (35%) patients failed sclerotherapy and required surgical rescue. A survival advantage (P = 0.01) was seen in patients with alcoholic cirrhosis who had this combined therapy; however, in patients with nonalcoholic cirrhosis, survival for those receiving sclerotherapy and surgical rescue was not significantly (P = 0.36) different from that of patients receiving distal splenorenal shunt. Control of variceal bleeding was significantly (P less than 0.001) better in the distal splenorenal shunt group (34 of 35 [97%] compared with 15 of 37 [41%] in the sclerotherapy group). Using death, uncontrolled rebleeding, or shunt thrombosis as the endpoints resulted in no significant difference between treatment groups. Hepatocyte function and portal perfusion were significantly better maintained in patients with alcoholic cirrhosis who were managed by sclerotherapy rather than shunt (P = 0.01 and P = 0.001, respectively). CONCLUSIONS: Endoscopic sclerotherapy with surgical rescue for uncontrolled bleeding is the optimum therapy for patients with alcoholic cirrhosis and variceal bleeding. Survival is similar in nonalcoholic patients treated with either distal splenorenal shunt or endoscopic sclerotherapy, but shunting provides better control of variceal bleeding.

Endoscopy↗
PubMed1991

[Endoscopic sclerotization of esophageal varices and nitrates in the treatment of portal hypertension with bleeding esophageal varices].

The authors investigated changes of some haemodynamic parameters after sclerotization of oesophageal varices and after administration of isosorbide dinitrate in the preparation Iso Mack retard. Twenty patients with cirrhosis of the liver with oesophageal varices grade 3-4 were treated by endoscopic sclerotization only, while to a second comparable group of cirrhotic patients from the first stage of sclerotization oral Iso Mack retard was administered in daily doses of 80-120 mg, depending on tolerance. The haemodynamic parameters were investigated before the onset of treatment and again after completed sclerotherapy or at least three-month treatment with ISDN. After sclerotization of oesophageal varices the pressure in the portal circulation rises significantly as well as the flow through the portal vein due above all to an accelerated blood flow. On the other hand, ISDN prevents a rise of portal hypertension and leads even to a slight decline which is, however, not associated with a decline of the portal flow. A relative disadvantage is the adverse effect on systemic haemodynamics after large nitrate doses. The decline of the portal pressure caused by the vasodilatating effect of ISDN in the splanchnic and portal area is manifested in a very positive way by reduction of relapses of haemorrhage from oesophageal varices. ISDN may play a positive role in the treatment of portal hypertension with oesophageal varices, during acute haemorrhage as well as in the prevention of relapses of haemorrhage. A particularly favourable procedure is the combination with sclerotherapy of oesophageal varices. None of the procedures leads to reduction of the portal flow and preserves hepatic function.

Blood Pressure↗
PubMed1982

[Fiberendoscopic sclerotherapy of esophageal varices: relationship of varices size, quantity of sclerosing agent used and number of sessions].

By means of fiberendoscopic injection sclerotherapy, it was possible to achieve eradication of esophageal varices in 18 patients. At the onset of treatment 9 patients had small varices (grade II) and other 9 had big varices (grade III). It was found in the big varices group there was needed more courses (p less than 0.01) and a greater amount of sclerosing agent (p less than 0.001) than in the group with small varices. Since those patients with big varices required more courses and more volume of sclerosing agent, and in fact they have more risk to rebleed during the pre-eradication period. It is proposed as a solution during this period, the use of a B receptor blocking agent (Propranolol) simultaneously with sclerotherapy.

Adult↗
PubMedDate not supplied

Repeated injection sclerotherapy is preferable to combined therapy with variceal ligation to avoid recurrence of esophageal varices:--a prospective randomized trial.

BACKGROUND/AIMS: The aim of this prospective randomized study is to investigate the safety, efficacy, complications and recurrence of varices after repeated endoscopic injection sclerotherapy (EIS), and combined therapy of endoscopic variceal ligation (EVL) and repeated EIS, for the treatment of esophageal varices. MATERIAL AND METHODS: Sixty-one consecutively treated cirrhotic patients were examined. Thirty patients were placed randomly in the EIS group and the other 31 in the EVL+EIS group. For the EIS group, EIS was repeated at weekly intervals using 5% ethanol- amine oleate (EO) until all the varices had been eradicated. In the EVL+EIS group, EVL was done at the initial session, then EIS was repeated at weekly intervals from one week after EVL. RESULTS: There was no significant difference between the EIS and EVL+EIS groups with regard to the rate of eradication (80.0% vs 74.2%), the total number of treatment (4.1 +/- 0.8 sessions of EIS vs EVL and 3.0 +/- 0.5 sessions of EIS) and hospitalization time (4.9 +/- 1.6 vs 4.4 +/- 1.0 weeks). The total volume of EO used for the EVL+EIS group was significantly less than that for the EIS group (26.3 +/- 8.3 vs 47.1 +/- 11.6 ml, p < 0.01) and the incidence of minor complications at the initial treatment in the EVL+EIS group was significantly (p < 0.01) lower than that in the EIS group. Follow-up endoscopy showed that the rate of attaining circumferential ulceration and the following fibrotic scarring in the EVL+EIS group was significantly lower than that in the EIS group (21.7% vs 91.7%, p < 0.01) and that the incidence of variceal recurrence was significantly higher in the EVL+EIS group than in the EIS group (39.1% vs 8.3%, p < 0.05) over a median follow-up of 12.3 months. CONCLUSION: The combined therapy of EVL and repeated EIS seems favorable from the viewpoint of fewer complications, but repeated EIS is preferable to combined therapy to avoid recurrence of the esophageal varices.

Adult↗
PubMed1996

Balloon-occluded retrograde transvenous obliteration (BRTO), a promising nonsurgical therapy for ectopic varices: a case report of successful treatment of duodenal varices by BRTO.

We present a patient with massive tarry stool, diagnosed as duodenal varices bleeding. Endoscopic ligation (EL) therapy was carried out for the varices, but because the possibility of re-bleeding remained, we treated the varices with balloon-occluded retrograde transvenous obliteration (BRTO), and duodenal varices were successfully decompressed without any complications. BRTO might be a novel therapeutic approach for ectopic varices, including duodenal varices.

Catheterization↗
PubMed1999

Esophageal varices before and after endoscopic variceal ligation: evaluation using helical CT.

The purpose of this study was to demonstrate the utility of helical CT in assessing the therapeutic effects of endoscopic variceal ligation (EVL). Twenty-four patients with esophageal varices were examined. Helical scanning was initiated 60 s after intravenous injection (Iopamidol 300 mgI/ml, total 120 ml, 3 ml/s) was started. Esophageal varices were clearly depicted as high-density areas. Multiplanar reformation and 3D images demonstrated collateral circulation three-dimensionally. After EVL, mucosal high-density areas had diminished markedly, but collateral veins around the esophagus, and gastro- and/or spleno-renal shunts, were unchanged in all patients. Of 21 patients with collateral circulation, esophageal varices recurred endoscopically in 6 patients within 12 months. In 3 patients without collateral circulation, esophageal varices did not recur within 12 months. From these findings, we conclude that helical CT is a useful method for assessing the therapeutic effects of EVL.

Collateral Circulation↗
PubMed1989

Role of endoscopic variceal sclerotherapy in the long-term management of variceal bleeding: a meta-analysis.

Seven randomized clinical trials evaluating the effect of repeated endoscopic variceal sclerotherapy on the long-term survival of patients with variceal hemorrhage have been published in the English-language literature. In four trials, the sclerotherapy-treated patients showed an improved long-term survival (follow-up periods longer than a year) when compared with patients in the medical regimen group, whereas in the other three trials, the long-term survival did not differ between the compared groups. Sample sizes in these "negative" trials were too small to detect a true moderate effect for serial sclerotherapy. To resolve this controversy, we combined the findings from all trials using a meta-analysis and determined the overall effect of repeated endoscopic variceal sclerotherapy on the survival of patients who had previously bled from esophageal varices. An overall risk difference of -0.15 (95% confidence limits, -0.21 to -0.08; p less than 0.0005) was estimated, indicating that sclerotherapy reduced the number of deaths by 25%. The estimated overall risk difference remained negative even when all patients in the sclerotherapy group with an unknown survival status were pessimistically considered dead at the end of the follow-up period. The results of this quantitative synthesis suggest that patients with bleeding esophageal varices benefit from the inclusion of repeated sclerotherapy in their long-term management regimen.

Esophageal and Gastric Varices↗
PubMed1995

Endoscopic variceal ligation versus conservative treatment for patients with hepatocellular carcinoma and bleeding esophageal varices.

BACKGROUND: Endoscopic variceal ligation (EVL) is currently a favored treatment for control of bleeding from esophageal varices. However, little is known about the treatment of bleeding varices in hepatocellular carcinoma. METHODS: EVL was performed in 16 patients with bleeding esophageal varices due to concomitant hepatocellular carcinoma. Treatment results were compared with those of another 23 patients who were conservatively treated. RESULTS: Comparing the two groups, ligation significantly reduced the risk of fatal bleeding (44% vs 70%; P < 0.05). Significantly fewer patients in the ligation group died at the time of the index hemorrhage (11% vs 52%; P < 0.05). Rebleeding occurred in 44% of the ligation group and 73% in the control group (P > 0.05). The mean days of survival were 40 +/- 20 (range, 7 to 103) in the ligation group and 20 +/- 30 (range, 1 to 136) in the control group (P = 0.08). In the absence of portal vein thrombosis, ligation significantly reduced the rebleeding rate (17% vs 50%, P < 0.05) and the mortality rate (0% vs 100%, P < 0.05). CONCLUSION: EVL is a good choice for palliation in patients with esophageal variceal bleeding and hepatocellular carcinoma. Aggressive use of EVL may be tried in those patients without portal venous thrombosis.

Adult↗
PubMed1999

Evaluation of endoscopic variceal ligation in prophylactic therapy for bleeding of oesophageal varices: a prospective, controlled trial compared with endoscopic injection sclerotherapy.

BACKGROUND: To evaluate the efficacy of endoscopic variceal ligation (EVL) in prophylactic therapy for oesophageal varices, we performed a randomized prospective trial to compare the recurrence of oesophageal varices treated by EVL with those treated by endoscopic injection sclerotherapy. METHODS: Fifty patients with liver cirrhosis were divided into two groups at random, after informed consents were obtained, to receive prophylactic therapy for bleeding of oesophageal varices. Group 1 patients underwent sessions of sclerotherapy with 5% ethanolamine oleate used as the sclerosant. Group 2 patients underwent EVL followed by one or two sessions of sclerotherapy. RESULTS: During the 18 month follow-up period, both the recurrence rate in group 2 (56%) and the incidence of bleeding (20%) were significantly higher compared with group 1 (recurrence rate 16%, bleeding 0%). CONCLUSIONS: This result indicates that EVL is not effective for prophylactic therapy for oesophageal varices in liver cirrhosis.

Esophageal and Gastric Varices↗
PubMed2002

Transjugular intrahepatic portosystemic shunting is not superior to endoscopic variceal band ligation for prevention of variceal rebleeding in cirrhotic patients: a randomized, controlled trial.

BACKGROUND: The aim of the present study was to compare the transjugular intrahepatic portosystemic shunt (TIPS) with variceal band ligation (VBL) in the prophylaxis of variceal rebleeding in patients with cirrhosis of the liver. METHODS: Fifty-four cirrhotic patients (21 Child-Pugh class A, 27 class B, 6 class C) were randomized to TIPS (n = 28) or VBL (n = 26) within 2 months after control of esophageal variceal hemorrhage. Statistical analysis was performed on the intention-to-treat principle. RESULTS: Mean follow-up was 2 years. Mortality risk at 1 and 2 years of follow-up was 7.8% +/- 5.3% and 19.9% +/- 8.8% in the TIPS group and 16.5% +/- 7.6% and 16.5% +/- 7.6% in the VBL group, respectively (n.s.); actuarial probability of remaining free from rebleeding was 83.7% +/- 77.4% and 71.4% +/- 10.4% in the TIPS group and 83.9% +/- 7.3% and 78.1% +/- 8.8% in the VBL group at 1 and 2 years, respectively (n.s.). Hepatic encephalopathy within 1 month after randomization was observed in 2 patients in the TIPS group and in 1 in the VBL group. CONCLUSION: TIPS is not superior to VBL in the prevention of variceal rebleeding. Furthermore, similar mortality rates in patients treated with TIPS or VBL negate TIPS as the preferred strategy for prevention of variceal rebleeding.

Endoscopy↗
PubMedDate not supplied

Emerging role of endoscopic variceal band ligation in the treatment of esophageal varices.

Bleeding from esophageal varices is the most catastrophic complication of portal hypertension. The associated high morbidity and mortality have necessitated the development of safe and efficacious therapeutic modalities. In recent years, endoscopic band ligation of esophageal varices has proved to be a useful tool in the control of acute variceal bleeding and the prevention of recurrent bleeding. This endoscopic technique is faster than sclerotherapy in obliterating esophageal varices, and is associated with significantly lower local esophageal complications. In the forthcoming years, endoscopic band ligation is expected to gain wider popularity as a definitive therapy for bleeding varices.

Esophageal and Gastric Varices↗
PubMed2006

[Comparison of terlipressin and octreotide with variceal ligation for controlling acute esophageal variceal bleeding--a randomized prospective study].

BACKGROUND/AIMS: Terlipressin and octreotide had been used to control acute variceal bleeding and to prevent early rebleeding after endoscopic hemostasis. We compared the efficacy and safety of terlipressin and octreotide combined with endoscopic variceal ligation (EVL) for the treatment of acute esophageal variceal bleeding and we evaluated their clinical significance as related to rebleeding. METHODS: The eighty eight cirrhotic patients were randomized to the terlipressin group (n=43; 2 mg i.v. initially and 1 mg i.v. at every 4 hours for 3 days) or the octreotide group (n=45; continuous infusion of 25 microgram/h for 5 days) combined with EVL for the treatment of acute esophageal variceal bleeding. RESULTS: The initial hemostasis rates were 98% (42/43 cases) in the terlipressin group and 96% (43/45 cases) in the octreotide group. The 5-day and 42-day rebleeding rates were 12% (5/43 cases) and 28% (12/43 cases), respectively, in the terlipressin group and 9% (4/45 cases) and 24% (11/45 cases), respectively, in the octreotide group. No significant difference was demonstrated between the terlipressin and octreotide groups. The mortality at 42 days was similar in both group, but a high mortality rate (48%) was shown to be related to 42-day rebleeding. The risk factors related to 42-day rebleeding were Child-Pugh class C (aOR=30.2, 95% CI=7.7-117.9), ascites above grade II (aOR=6.6, 95% CI=2.2-19.2) and advanced hepatocellular carcinoma (aOR=4.6, 95% CI=1.1-18.9). CONCLUSIONS: Comparing terlipressin and octreotide combined with EVL showed them to be equally safe and effective therapeutic agents in patients with acute esophageal variceal bleeding. The high risk factors related to early rebleeding were poor liver function and advanced hepatocellular carcinoma.

Acute Disease↗
PubMed1979

[Transmural varices ligation and fundoplication as an emergency operation in acute esophageal varices hemorrhage].

In patients with bleeding esophageal varices the main purpose of the treatment is to stop the bleeding at a justifiable risk. The so-called blocking procedures reach this purpose most consistently. We report the results on transmural variceal ligation plus fundoplication in 16 patients in whom the bleeding esophageal varices were not stopped by conservative means. 75% of these patients belonged to group B and C in Child's classification. Postoperative lethality was 18,7%, in all cases bleeding was stopped. These results favour trasmural varices ligation as an emergency procedure in bleeding esophageal varices.

Emergencies↗