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Diagnostic et traitement endoscopique des varices gastriques

Endoscopic diagnosis and treatment of gastric varices

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Acta Endoscopica

Résumé

La formation des varices œsophago-gastriques est directement corrélée à la manifestation d’un état d’hypertension du territoire splénoportal. Environ 30% des cirrhotiques développent des varices œsophagiennes et/ou gastriques; la mortalité au premier épisode hémorragique reste encore très élevée (environ 30–40%) représentant 13% de toutes les causes de décès chez les patients cirrhotiques.

Depuis que la sclérotérapie s’est imposée comme traitement de premier choix en cas d’hémorragie des varices œsophagiennes, à la place de la chirurgie, il est devenu important de distinguer la source de l’hémorragie, car les techniques endoscopiques pour la sclérose des varices œsophagiennes ou gastriques varient surtout en fonction de la localisation où est pratiqué le geste thérapeutique.

De nombreux auteurs ont utilisé différentes techniques de sclérose, mais les meilleurs résultats ont été obtenus avec la technique proposée par Sohendra et Gotlieb qui utilisent une résine synthétique l’isobutyl-2-cyanoacrylate dilué avec Lipiodol à 50%.

Dans notre casuistique de 68 patients traités avec cette technique (32 en urgence, 29 en élection et 7 en prophylaxie), l’arrêt de l’hémorragie chez les patients traités a été de 96,8%.

En urgence, 11 récidives hémorragiques précoces ont été signalées (34,3%): 1 cas de varices gastriques, 3 de varices œsophagiennes, 4d’escarre du fundus gastrique et 3 d’autres causes. La mortalité pour ce groupe a été de 18,7%.

En élection, on a seulement 4/36(11%) récidives hémorragiques et aucun patient n’est décédé.

Sur les 62 patients encore vivants un mois après le début du traitement (suivi moyen 38,5 mois, extrêmes 2–108), l’éradication a été observée chez 42 patients, les varices sont oblitérées chez 10 patients et 9 ne sont pas éradiquées; pour 1 patient, l’appréciation n’est pas possible en raison de contrôles cliniques uniquement et non endoscopiques.

On a observé 72% de survie à 1 an, 57% à 5 ans et 51% à 8 ans.

La mortalité à distance est de toute façon satisfaisante si l’on considère que 40% des patients étaient à risque C de Child.

Nos résultats confirment qu’actuellement la sclérothérapic endoscopique avec cyanoacrylate soit en urgence soit en élection est une alternative valable au traitement des varices gastriques «difficiles et méconnues».

Summary

The development of gastrooesophageal varices is directly related to the hypertension in the spleno-portal district. About 30% of patients with liver cirrhosis develop oesophageal or gastric varices. The mortality of the first bleeding episode is still very high (30–40%) and represents 13% of the overall causes of death in these patients.

An increasing interest in gastric varices, as far as incidence, frequency and relationship with oesophageal varices are concerned, has been developed in the last fifteen year. In consideration of the excellent results obtained with the sclerotherapy of oesophageal varices, there has also been a revaluation of this technique for the treatment of gastric varices, which formerly had been strictly surgical.

In literature a large variety of sclerosing agents have been used, but there is evidence that the best results are obtained by using the technique suggested by Sohendra and Gottlib, which has been adopted by us. This implies the use of isobutyl-2-cyanoacrylate, a synthetic resin diluted in Lipiodol 50%.

In our experience of 68 patients who underwent sclerotherapy of the gastric varices, we obtained the control of active haemorrhage in 96.8%.

Early rebleeding occurred in 34.4% of the patients. In only one case this was related to gastric varices bleeding, whereas in 3 cases the rebleeding was related to oesophageal varices, in 4 cases to an ulcer on the injection site and in 3 cases to other causes. The mortality rate of this group was 18.7%.

The efficacy of this technique has also been demonstrated in a group of patients treated prophylactically or with elective treatment. In fact, rebleeding occurred in 11.8% and no patients died. In 62 patients we obtained long term survival, eradication of gastric varices was obtained in 42 patients (67.7%); in 10 additional patients, the varices resulted obliterated whereas in 10 patients eradication could not be achieved.

Long term mortality was satisfying, if we consider that 40% of the patients were classified as Child-risk category «C». After one year, survival rate was 72%. Varices, after 5 years, 57% and after 8 years 51%. Of the 19 long-term deaths we recorded, 63% were not related to gastro-oesophageal varices, this demonstrates that the hepatic disease influences mortality more heavily than haemorrhagic recurrences.

These data confirm that at present, the endoscopic sclerotherapy with cyanoacrylate, both in emergency and in election, is a valid alternative to surgical therapy of the «awkward and disregarded» gastric varices.

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  1. Clinique Chirurgicale IV, Université de Padova, Italy

    G. Battaglia, T. Morbin, E. Patarnello, A. Carta, F. Coppa & A. Ancona

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Battaglia, G., Morbin, T., Patarnello, E. et al. Diagnostic et traitement endoscopique des varices gastriques. Acta Endosc 29, 97–114 (1999). https://doi.org/10.1007/BF03020277

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