Prevention of Recurrent Bleeding: Sclerotherapy

  • Karl-Joseph Paquet


To understand the etiology of acute variceal hemorrhage and the rationale for the success of endoscopic injection sclerotherapy, it is necessary to study the anatomy of esophageal varices and the pathophysiology of portal hypertension. Unfortunately, neither is fully comprehended. Nevertheless, it has become increasingly accepted that esophageal varices usually bleed from the lower 5 cm of the esophagus [1–3], and that the hemorrhage is caused by rupture or disruption of a varix rather than erosion from within the esophageal lumen [3–6]. Although most authors find it difficult to predict which individual patient is likely to bleed, there is an accepted higher risk of hemorrhage in those with large esophageal varices [4,7], and in those with high portal pressure [4,8]. Therefore, our group has introduced a classification of esophageal varices (Fig. 39.1). We found that varices of degree IV have a high risk of bleeding. In this category teleangiectasias (varices on top of varices), signaling an impending danger of bleeding, can be seen endoscopically in more than 50% of the patients. On the other hand, some patients with large varices, particularly those with a congenital or iatrogenic prehepatic block, may never bleed. While it has been shown that the threshold pressure for variceal bleeding is approximately 22 mmHg [8] it is 12 mmHg for the development of varices in alcoholic cirrhosis [4].


Esophageal Varix Variceal Bleeding Gastric Varix Recurrent Bleeding Injection Sclerotherapy 
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  1. 1.
    Chiles NM, Baggenstos AH, Butt HR, Olsen AM (1953) Esophageal varices: Comparative incidence of ulceration and spontaneous rupture as a cause of fatal hemorrhage. Gastroenterology 25: 565–573PubMedGoogle Scholar
  2. 2.
    Paquet K-J, Oberhammer E (1978) Sclerotherapy of bleeding esophageal varices by means of endoscopy. Endoscopy 10: 7–11PubMedCrossRefGoogle Scholar
  3. 3.
    Reynolds DB (1982) Why do varices bleed? In: Westaby D, MacDougall BRD, Williams R (eds) Variceal bleeding. Pitman, London, pp 3–12Google Scholar
  4. 4.
    Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickmann M (1985) Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 5: 419–24PubMedCrossRefGoogle Scholar
  5. 5.
    Reding P, Urbain D, Grivegnee A, Frere D (1986) Portal venous-esophageal luminal pressure gradient in cirrhosis. Hepatology 6: 89–100CrossRefGoogle Scholar
  6. 6.
    Vinel JP, Cassigneul J, Levade M, Voigt JJ, Pascal JP (1986) Assessment of short term prognosis after variceal bleeding in patients with alcoholic cirrhosis by early measuring of portal hepatic radiant. Hepatology 6: 116–117PubMedCrossRefGoogle Scholar
  7. 7.
    Paquet K-J (1982) Prophylactic endoscopic sclerosing treatment of the esophagus wall in varices. A prospective controlled randomised trial. Endoscopy 14: 4–5PubMedCrossRefGoogle Scholar
  8. 8.
    Staritz M, Poralla T, Meyer zum Büschenfelde KH (1985) Intravascular oesophageal pressure (IOVP) assessed by endoscopic fine needle puncture uncer basal conditions, valsalva maneuvre and after glyeryltrinitate application, Gut 26: 525PubMedCrossRefGoogle Scholar
  9. 9.
    Kitano S, Terblanche J, Kahn D, Bornman BC (1986) The venous anatomy of the lower esophagus in portal hypertension: Practical implication. Br J Surg 73: 525–531PubMedCrossRefGoogle Scholar
  10. 10.
    McCormack T, Rose T, Smith DM, Johnson AG (1983) Perforating veins and blood in esophageal varices. Lancet II: 1442–1444CrossRefGoogle Scholar
  11. 11.
    Spence AJ, Terblanche J (1987) Venous anatomy of the lower esophagus: A new perspective on varices. Br J Surg 74: 659–660PubMedCrossRefGoogle Scholar
  12. 12.
    Crawford C, Frenckner T (1939) New surgical treatment of varicous veins of the oesophagus. Acta Otolaryngol 27: 422–429CrossRefGoogle Scholar
  13. 13.
    Johnson AG (1977) Injection sclerotherapy in the emergency and elective treatment of esophageal varices. Ann R Coll Surg Engl 59: 497–502PubMedGoogle Scholar
  14. 14.
    Barsoum MS, Khattar NY, Risk-Allah MA (1978) Technical aspects of injection sclerotherapy of acute oesophageal hemorrhage as seen by radiography. Br J Surg 65: 588–591PubMedCrossRefGoogle Scholar
  15. 15.
    Sugawa C, Okumura Y, Lukas CE, Walt AJ (1978) Endoscopic sclerosis of experimental esophageal varices in dogs. Gastrointest Endosc 24: 114–117PubMedCrossRefGoogle Scholar
  16. 16.
    Doehn M, Polonius MJ, Rödiger W, Soehendra N (1981) Changes in hemodynamics after sclerosing of bleeding esophageal varices (abstract). Crit Care Med 9: 146CrossRefGoogle Scholar
  17. 17.
    Paquet K-J (1972) Indikation und Ergebnisse der Sklerosierungstherapie von Ösophagusvarizen. Therapiewoche 22: 262–265Google Scholar
  18. 18.
    Paquet K-J, Raschke E (1973) Management of hemorrhage from esophageal varices using endoscopic method. Ann Surg 177: 99–102PubMedCrossRefGoogle Scholar
  19. 19.
    Wodak E (1960) Ösophagusvarizenblutung bei portaler Hypertension: Ihre Therapie und Prophylaxe. Wien Med Wochenschr 110: 581–584PubMedGoogle Scholar
  20. 20.
    Denck H (1978) Indikation, Technik und Ergebnisse der endoskopischen Behandlung von Ösophagusvarizen. Zentralbl Chir 103: 213–217PubMedGoogle Scholar
  21. 21.
    Wodak E (1979) Akute gastrointestinale Blutung: Resultate der endoskopischen Sklerosierung von Ösophagusvarizen. Schweiz Med Wochenschr 109: 591–594PubMedGoogle Scholar
  22. 22.
    The Copenhagen Variceal Sclerotherapy Project (1984) Sclerotherapy after first variceal hemorrhage in cirrhosis, a randomized multicenter trial. N Engl J Med 311: 1594–1600CrossRefGoogle Scholar
  23. 23.
    Korula J, Balart LA, Radvan G, Zweiban BE, Larson AW, Kao HW, Jamada S (1985) A prospective randomised controlled trial of chronic esophageal variceal sclerotherapy. Hepatology 5: 584–589PubMedCrossRefGoogle Scholar
  24. 24.
    MacDougall BRD, Westaby D, Theodossi A, Dawson JL, Williams R (1982) Increased long-term survival in variceal hemorrhage using injection sclerotherapy. Results of a controlled trial. Lancet I: 124–127CrossRefGoogle Scholar
  25. 25.
    Sauerbruch T, Wirsching R, Holl J, Gröbl J, Weinzierl M (1986) Effects of repeated injection sclerotherapy on acid gastroesophageal reflux. Gastrointest Endosc 32: 81–83PubMedCrossRefGoogle Scholar
  26. 26.
    Terblanche J. Bornman PC, Kahn D, Jonker MAT, Campbell JAH, Wright U, Kirisch R (1983) Failure of repeated injection sclerotherapy to improve long-term survival after esophageal variceal bleeding. Lancet II: 1328–1333CrossRefGoogle Scholar
  27. 27.
    Westaby D, MacDougall BRD, Williams R (1984) Improved survival following injection sclerotherapy for esophageal varices: Final analysis of a controlled trial. Hepatology 5: 827–830CrossRefGoogle Scholar
  28. 28.
    Burroughs AK, Sanchez H, Buss NM, Sherlock S (1983) Can endoscopic sclerotherapy influence significantly the cause of cirrhotic patients who survive variceal bleeding. Gut 24: 972–977Google Scholar
  29. 29.
    Graham DY, Lacey-Smith J (1981) The cause of patients after variceal hemorrhage. Gastroenterololy 80: 800–809Google Scholar
  30. 30.
    Infante-Rivard CL, Esnaola S, Villeneuve J-P (1989) Role of endoscopie variceal sclerotherapy in the long-term management of variceal bleeding: A meta-analysis. Gastroenterology 96: 1087–92PubMedGoogle Scholar
  31. 31.
    Warren WD, Henderson JN, Millikan WJ, Galambos IT, Brooks WS, Riepe SP, Salam AA, Kutner MH (1986) Distal splenorenal shunt versus endoscopic sclerotherapy for long term management of variceal bleeding. Preliminary report of a prospective, randomised trial. Ann Surg 203: 454–462PubMedCrossRefGoogle Scholar
  32. 32.
    Terblanche J, Nordhover JMA, Bornman PC, Kahn D, Silbee W, Barbezat GO, Seilars S, Campbell JAH, Saunders SI (1979) A prospective controlled trial of sclerotherapy in the long-term management of patients after variceal bleeding. Surg Gynecol Obstet 148: 323–333PubMedGoogle Scholar
  33. 33.
    Kahn B, Jones B, Bornman BC, Terblanche J (1989) Incidence and management of complications after injection sclerotherapy: A 10 year prospective evaluation. Surgury 105: 160–165Google Scholar
  34. 34.
    Paquet K-J (1983) Endoscopic paravariceal injection sclerotherapy of the esophagus—indication, technique, complications: Results of a period of 14 years. Gastrointest Endosc 29: 310–315PubMedCrossRefGoogle Scholar
  35. 35.
    Paquet K-J (1988) Indication and early and long-term results of paravariceal immediate, elective and prophylactic injection sclerotherapy. In: Idezuki I (ed) Excerpta Medica, Amsterdam, pp 1-22Google Scholar
  36. 36.
    Soederlund C, Ihse C (1985) Endoscopic sclerotherapy versus conservative management of bleeding esophageal varices. A five-year prospective controlled trial of emergency and long-term treatment. Acta Chir Scand 151: 449–456Google Scholar
  37. 37.
    Paquet K-J, Koussouris P, Henkel M (1987) Die gastroesophageale Diskonnektion nach HASSAB-PAQUET als Therapie der Wahl beim Leberzirrhotiker mit Blutungen aus Magenvarizen. Ösophagusulcera nach Sonden-oder Sklerosierungstherapie und trotz Sklerosierung wieder auftretender Ösophagusvarizenblutungen. In: Henning H (ed) Fortschritte der gastroenterologischen Endoskopie, Bd. 16. Demeter, Gräfeling-München, pp 102-106Google Scholar
  38. 38.
    Roark G (1984) Treatment of postsclerotherapy esophageal ulcers with sucralfate. Gastrointest Endosc 30: 9–12PubMedCrossRefGoogle Scholar
  39. 39.
    Barsoum MS, Morrow HAW, Bolus FIJ (1982) The complication of injection sclerotherapy of bleeding esophageal varices. Br J Surg 69: 79–81PubMedCrossRefGoogle Scholar
  40. 40.
    Carr-Locke DL, Sidky K (1982) Bronchoesophageal fistula: A late complication of endoscopie variceal sclerotherapy. Gut 23: 1005–1007PubMedCrossRefGoogle Scholar
  41. 41.
    Paquet K-J, Fleig WE (1978) Sclerotherapy of esophageal varices. In: Papp JP (ed) Endoscopic control of gastrointestinal hemorrhage. CRC, Boca Raton, Florida, pp 43–72Google Scholar
  42. 42.
    Barde CJ, Camara DS, Caruana JA, Chung RS (1983) The hemodynamic effects of the sclérosant sodium morrhuate (abstract). Hepatology 3: 798Google Scholar
  43. 43.
    Lange V, Ties E, Miersch W (1983) Komplikationen der Sklerosierungsbehandlung von blutenden Ösophagusvarizen-auch ein Dosisproblem (abstract). Z Gastroenterol 21: 482Google Scholar
  44. 44.
    Hunter GC, Steinkirchner T, Burbige EJ, Guernsey JM, Putnan DHW (1988) Venous complications of sclerotherapy for esophageal varices. Am J Surg 156: 497–501PubMedCrossRefGoogle Scholar
  45. 45.
    Ogle SJ, Kirk CJC, Bailey RJ, Johnson AG, Williams R, Murray-Lyon IM (1978) Esophageal function in cirrhotic patients undergoing injection sclerotherapy for esophageal varices. Digestion 18: 178–185PubMedCrossRefGoogle Scholar
  46. 46.
    Sauerbruch T, Wirsching R, Leitner P, Weinzierl M, Pfahler M, Paumgartner G (1982) Esophageal function after sclerotherapy of bleeding esophageal varices. Scand J Gastroenterol 17: 745–751PubMedCrossRefGoogle Scholar
  47. 47.
    Feussner H, Ultsch B, Weiser HI (1986) Ösophagusfunktion nach Ösophagusvarizer skleroserungstherapie. Largerbecks Arch Chir 369: 79–81CrossRefGoogle Scholar
  48. 48.
    Cohen LB, Simon C, Korsten MA, Scherl EJ, Skorniky J, Guelrud MB, Waye JD (1985) Esophageal motility and symptoms after endoscopic injection sclerotherapy. Dig Dis Sci 30: 29–33PubMedCrossRefGoogle Scholar
  49. 49.
    Larson AW, Vandertoll DJ, Netscher DT, Polk HC Jr (1984) Esophageal motility: Effects of injection sclerotherapy. Surgury 96: 703–710Google Scholar
  50. 50.
    Murray-Lyon IM, Ogle SJ, Johnson AG (1982) Change in esophageal function after injection sclerotherapy. In: Westaby D, MacDougall BRD, Williams R (eds) Variceal bleeding. Pitman, London pp 176–183Google Scholar
  51. 51.
    Reilly JJ Jr, Schade RR, Van Thiel DS (1984) Esophageal function after injection sclerotherapy: Pathogenesis of esophageal stricture. Am J Surg 147: 85–88PubMedCrossRefGoogle Scholar
  52. 52.
    Snady H, Korsten MA (1986) Esophageal acid-clearance and motility after endoscopie sclerotherapy of esophageal varices. Am J Gastroenterol 81: 419–422PubMedGoogle Scholar
  53. 53.
    Siemens F, Paquet K-J, Koussouris P, Mercado MA, Kalk J-F (1989) Long-term endoscopie injection sclerotherapy of bleeding esophageal varices —a prospective analysis of results by endoscopy, manometry and 24-h pH-monitoring. Surg Endosc 3: 137–141PubMedCrossRefGoogle Scholar
  54. 54.
    Paquet K-J, Lindecken KT, Göke H (1979) Massive Ulkusblutung aus der Speiseröhre nach Dislokation einer Doppelballonsonde—Diagnostik und Therapie. Z Kinderchir 27: 303–308Google Scholar

Copyright information

© Springer Japan 1991

Authors and Affiliations

  • Karl-Joseph Paquet
    • 1
  1. 1.Department of SurgeryHeinz Kalk Hospital ClinicBad KissingenGermany

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