Evolution of endoscopic therapy for esophageal varices

Endoscopic treatment of gastric varices bleeding with the use of n-butyl-2 cyanoacrylate

INTRODUCTION

Oesophageal varices and gastric varices are naturally-formed, pathological portosystemic shunts that occur in patients with portal hypertension. Gastric varices are responsible for about 10% of variceal bleeding; however, they are also the cause of massive haemorrhage, often with dramatic progress.

AIM

To assess the results of endoscopic treatment of gastrointestinal bleeding from oesophageal and gastric varices using tissue glue Histoacryl.

MATERIAL AND METHODS

From January 2013 to May 2015 170 patients underwent a total of 244 obliterations with the administration of tissue glue due to gastroesophageal varices. We analysed 35 patients who received urgent endoscopic intervention due to life-threatening gastric variceal bleeding.

RESULTS

Thirty-five patients underwent 47 endoscopic procedures of haemorrhage management. Immediate haemostasis was achieved in 32 (91.4%) patients. In 3 (8.6%) cases endoscopy failed. In 2 patients a Linton tube was applied before secondary endoscopy. A single trans jugular portosystemic shunt (TIPS) was performed. Permanent haemostasis during the first endoscopy was achieved in 26 (74%) patients. Six (17%) patients presented recurrent bleeding 1-4 days following the initial treatment. Three patients had a splenic artery embolisation performed. One of the embolised patients required surgery, and a splenectomy was carried out.

CONCLUSIONS

If this kind of therapy is unavailable at the time, it is advised that one of the conventional methods of controlling bleeding is used, introducing basic life support and transporting the patient to a specialist centre with adequate endoscopic facilities, radiological possibilities of endovascular intervention, and surgical treatment of liver transplantation.

Proton pump inhibitors in cirrhosis: tradition or evidence based practice?

Proton pump inhibitors (PPI) are very effective in inhibiting acid secretion and are extensively used in many acid related diseases. They are also often used in patients with cirrhosis sometimes in the absence of a specific acid related disease, with the aim of preventing peptic complications in patients with variceal or hypertensive gastropathic bleeding receiving multidrug treatment. Contradicting reports support their use in cirrhosis and evidence of their efficacy in this condition is poor. Moreover there are convincing papers suggesting that acid secretion is reduced in patients with liver cirrhosis. With regard to Helicobacter pylori (H pylori) infection, its prevalence in patients with cirrhosis is largely variable among different studies, and it seems that H pylori eradication does not prevent gastro-duodenal ulcer formation and bleeding. With regard to the prevention and treatment of oesophageal complications after banding or sclerotherapy of oesophageal varices, there is little evidence for a protective role of PPI. Moreover, due to liver metabolism of PPI, the dose of most available PPIs should be reduced in cirrhotics. In conclusion, the use of this class of drugs seems more habit related than evidence-based eventually leading to an increase in health costs.