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 one to two 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.

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.

Further Reading

For Your Information

Books

• Green, Frederick L., and Ponsky, Jeffrey L., eds. "Endoscopic Management of Esophageal Varices." In Endoscopic Surgery. Philadelphia: W.B. Saunders Company, 1994.
• 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 Company, 1995.

  Periodicals

• Cello, J.P. "Endoscopic Management of Esophageal Variceal Hemorrhage: Injection, Banding, Glue, Octreotide, or a Combination?" Seminars in Gastrointestinal Diseases. 8 (Oct. 1997):179-187.
• Fass, Ronnie, et al. "Esophageal Motility Abnormalities in Cirrhotic Patients Before and After Endoscopic Variceal Treatment." The American Journal of Gastroenterology. 92 (1997): 941-945.

Gale Encyclopedia of Medicine. Gale Research, 1999.