Archives of the Balkan Medical UnionCopyright © 2017 Balkan Medical Union

vol. 52, no. 2, pp. 172-175June 2017

RÉSUMÉ

Traitement de l’hémorragie gastro-intestinale su-périeure causée par les varices oesophagiennes par sclérose et ligature endoscopique: bénéfices et com-plications

Introduction. Les principales complications de la cir-rhose hépatique suite à l’hypertension portale sont les varices œsophagiennes, l’encéphalopathie hépatique et l’ascite. L’hémorragie digestive haute sur la rupture des varices œsophagiennes est la cause la plus fréquente et constitue une urgence majeure en gastro-entérolo-gie. Les principales méthodes thérapeutiques utilisées sont la sclérose des varices et la ligature endoscopique, avec des taux de réussite assez élevés dans les centres spécialisés. Les complications suivant les procédures commencent à partir de symptômes modérés, comme la douleur thoracique, jusqu’à des complications sé-vères – les ulcères post-ligature, la pneumonie d’inha-lation ou la perforation œsophagienne avec début de la médiastinite.

ABSTRACT

Introduction. Esophageal varices, hepatic encephalo-pathy, and ascites are the major complications of liver cirrhosis as a result of portal hypertension. Upper gas-trointestinal bleeding (UGIB) from ruptured esopha-geal varices is the most common cause and represents a major emergency in gastroenterology. The main thera-peutic methods are the sclerosis of the varices and the endoscopic variceal ligation with a quite high success rate in centers where they are available. Post-procedural complications can range from mild symptoms, such as chest pain, to severe complications like rebleeding from post-ligation ulcers, aspiration pneumonia and esophageal perforation with the onset of mediastinitis.Methods. We have retrospectively analyzed a num-ber of 30 patients admitted between January 2016 – December 2016 to the department of Gastroenterology of the Saint Mary’s Clinical Hospital Bucharest with upper gastrointestinal bleeding from ruptured eso-phageal varices, who were treated either by sclerosis or endoscopic ligation.

ORIGINAL PAPER

TREATMENT OF UPPER GASTROINTESTINAL BLEEDING FROM ESOPHAGEAL VARICES BY SCLEROSIS AND ENDOSCOPIC LIGATION: BENEFITS AND COMPLICATIONS

Gelu-Cristian Rosianu1,2, Madalina Greere2, Anca Evsei1, Adelina Birceanu-Corobea3, Narcis Copca4

1 CESITO Center, “ Sfanta Maria“ Clinical Hospital, Bucharest, Romania2 Department of Gastroenterology, “Sfanta Maria“ Clinical Hospital, Bucharest, Romania3 Department of Pathology, “Sfanta Maria“ Clinical Hospital, Bucharest, Romania4 Department of Surgery, “Sfanta Maria“ Clinical Hospital, Bucharest, Romania

Corresponding author: Cristian Rosianu

CESITO Center, “Sfanta Maria“ Clinical Hospital, Bucharest, Romania

e-mail: Rosianu_Cristian@yahoo.com

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INTRODUCTION

Liver cirrhosis is the final stage of many chronic liver disease. Esophageal varices are the most com-mon complication in patients with portal hyperten-sion1. Upper gastrointestinal bleeding from ruptured esophageal varices is one of the complications of cir-rhosis with the highest mortality2,3.

The treatment of upper gastrointestinal bleeding is represented by hemodynamic fluid resuscitation

and electrolyte replacement, antibiotics, administra-tion of vasopressors, endoscopic treatment (sclero-therapy, ligation, installation of esophageal expand-able fully covered stents and hemoclips), esophageal tamponade (Blakemore probe), surgical (portosystemic shunts ) and TIPS (transjugular intrahepatic porto-systemic shunt)4,5,6. Endoscopic treatment (ligation + sclerotherapy), combined with the use of vasopressors, represents the treatment of choice for upper gastroin-testinal bleeding from ruptured esophageal varices7,8,9.

Results. From all the 30 patients who were included in this study, all of them have been previously diag-nosed with liver cirrhosis. Regarding etiology, alcohol was incriminated in 15 patients (50%), hepatitis C infection in 9 patients (30%), and hepatitis B infec-tion in 6 patients (20% ). 2 patients belonged to the Child-Pugh A class (6.66%), 10 patients were classified as Child-Pugh B (33.33%) and 18 patients were classi-fied as Child C (60%).Efficient endoscopic hemostasis (sclerotherapy and liga-tion) was performed in 28 patients (93.3%). Endoscopic ligation was performed in 26 patients (86%) and scle-rotherapy in 4 patients (13.33%). The death occurred in 2 patients (6.66%). Chest pain was the most com-mon complication and affected 14 patients (46.66%). Other adverse events included postligation ulcers – 10 patients (33.33%), transient dysphagia which occurred in 10 patients (33.33%), fever – 2 patients (6.66%), eso-phageal stricture in 1 patient (3.33%) and aspiration pneumonia in 1 patient (3.33%).Conclusions. The main therapeutic options of up-per gastrointestinal bleeding from ruptured esopha-geal varices are sclerotherapy and endoscopic ligation, with a success rate of up to 93.3%. Complications of sclerosis and endoscopic ligation are classified as fol-lows: during procedure – aspiration of gastric con-tents resulting in aspiration pneumonia; immediately post-procedure: chest pain, transient dysphagia, fever that precedes the development of bacterial infections and post-ligation ulcers. Late complications were rare and included esophageal strictures.

Keywords: upper gastrointestinal bleeding, esopha-geal varices, sclerotherapy, endoscopic ligation.

Abbreviations: UGIB-upper gastrointestinal bleeding

Méthodes. Il s’agit d’une étude rétrospective mono-centrique sur tous les patients admis dans le dépar-tement de Gastroentérologie de L’Hôpital Clinique Sainte Marie, Bucarest, entre janvier 2016 et décembre 2016, avec une hémorragie digestive haute sur la rup-ture des varices œsophagiennes, la plupart d’eux ayant reçu un traitement endoscopique (sclérose ou ligature endoscopique).Résultats. Au total, nous avons admis 30 patients avec varices œsophagiennes provoquées par une cir-rhose hépatique, dont l’origine alcoolique était connue pour 15 patients (15%), une infection virale C pour 9 patients (30%) et une infection virale B pour 6 patients (20 %). Comme score pronostique, 2 patients avaient un score Child A (6,66%), 10 patients avec Child B (33,33%) et 18 patients avec Child C (60%).Une hémostase endoscopique efficace (sclérothérapie ou ligature) a été réalisée chez 28 patients (93,3%), avec ligature endoscopique chez 26 patients (86%) et une sclérothérapie chez 4 patients (13,33%). Deux patients (6,66%) ont décédé. La douleur thoracique était la complication la plus fréquente chez 14 patients (46,66%). D’autres complications étaient: les ulcères post-ligature chez 10 patients (33,33%), une dysphagie transitoire chez 10 patients (33,33%), chez 2 patients (6,66%) une hyperthermie, une sténose œsophagienne symptomatique chez 1 patient (3,33%), et une pneumo-nie d’inhalation chez 1 patient (3,33%).Conclusions. Les principaux traitements endosco-piques dans l’hémorragie digestive haute sur les varices œsophagiennes sont la sclérothérapie et la ligature endoscopique, avec un taux de réussite allant jusqu’à 93,3%. Les complications qui surviennent à cause du traitement sont liées au procédé, par exemple, la pneu-monie d’inhalation, immédiatement après la douleur thoracique, la fièvre ou la dysphagie transitoire qui peut précéder le développement d’infections bacté-riennes, les complications précoces comme les ulcères post-ligature, ou les complications tardives, assez rares, comme le rétrécissement œsophagien.

Mots-clés: hémorragie digestive haute, varices œso-phagiennes, sclérothérapie, ligature endoscopique.

Treatment of upper gastrointestinal bleeding from esophageal varices by sclerosis and... – ROSIANU et al

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Endoscopic treatment, represented by instal-lation of esophageal expandable fully covered stents,argon plasma coagulation and hemoclips, is very little used in practice10.

MATERIALS AND METHODS

We conducted a retrospective study on a group of 30 patients with upper gastrointestinal bleeding from ruptured esophageal varices in the Department of Gastroenterology of St. Mary’s Clinical Hospital, Bucharest, Romania, admitted between January 2016-December 2016.

The diagnosis was confirmed by performing up-per gastrointestinal endoscopy in these patients.

Endoscopic treatment consisted of sclerotherapy and endoscopic ligation (Figure 1 and 2). Endoscopic sclerotherapy consisted in injecting intra and pa-ra-variceal of oleat ethanolamine 5%. Endoscopic ligation was carried out starting with the bleeding varix or stigmata with recent bleeding.

For many years, the treatment by endoscopic sclerotherapy was the basic treatment in upper gastro-intestinal bleeding from ruptured esophageal varices, but nowadays endoscopic ligation is the first thera-peutic option. Endoscopic sclerotherapy is indicated in massive upper gastrointestinal bleeding from rup-tured varices and if the endoscopic ligation method is not available.

RESULTS AND DISCUSSION

In a group of 30 patients with upper gastroin-testinal bleeding from ruptured esophageal varices, endoscopic hemostasis (sclerotherapy + ligation) was effective in 28 patients (93.33%).

Endoscopic ligation was carried out in 26 pa-tients (86%), sclerotherapy in 4 patients (14%). The death occurred in 2 patients (6.66%).

The rate of complications was as follows: 14 pa-tients (46.66%) presented chest pain, post-ligation ulcers appeared in 10 patients (33.3%), transient

Figures 1, 2. Variceal hemorrhage with band ligation.

Figure 3. The percentage of endoscopic hemostasis complications in variceal bleeding

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dysphagia in 10 patients (33.3%), fever in 2 patients (6.66 %), esophageal stricture and aspiration pneumo-nia in one patient each (Figures 3). In patients with post-ligation ulcers, rebleeding occurred in 2 patients.

Bleeding of esophageal varices is a common com-plication of portal hypertension and a leading cause of mortality in patients with cirrhosis.

Treatment of upper gastrointestinal bleeding from ruptured esophageal varices has evolved in re-cent years, with decreasing mortality and morbidity. Current endoscopic combined treatment (ligation + sclerotherapy ) and drug treatment (vasopressors) sig-nificantly increase survival.

Complications that occurred after sclerotherapy and endoscopic ligation are: chest pain, post-ligation ulcers, dysphagia, fever, aspiration pneumonia and esophageal strictures.

A rare complication is esophageal perforation, associated with high mortality. Esophageal perfora-tion is more frequent in the case of endoscopic sclero-therapy and quite rare after endoscopic ligation.

CONCLUSIONS

) Endoscopic ligation is the treatment of choice for bleeding from esophageal varices.

) Endoscopic sclerotherapy and ligation are safe en-doscopic hemostasis methods in upper gastrointes-tinal bleeding from ruptured esophageal varices.

) Complications are common after endoscopic he-mostasis, and thus they can significantly increase morbidity, without significant influence on mor-tality.

) The most common complications of endoscopic sclerotherapy and band ligation are:

– aspirations of gastric contents resulting in as-piration pneumonia;

– chest pain after band ligation and sclerosis;– transient dysphagia;– esophageal ulcers;– fever;– esophageal strictures.

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