Endoscopic sclerotherapy

This method is considered the "gold standard" of emergency treatment of bleeding from varicose-dilated esophagus veins. In skilled hands, it allows you to stop bleeding, but usually to improve the review of a tamponade and prescribe somatostatin. Thrombosis of varicose-dilated veins is achieved by introducing into them an sclerosing solution through an endoscope. Data on the effectiveness of routine sclerotherapy with varicose veins of the esophagus are inconsistent.

Methodology

The procedure is performed in aseptic conditions using sterile needles, the mouth cavity is washed, followed by its hygiene. Commonly used is a conventional fibrogastroscope, local anesthesia and premedication with sedatives. Needle No. 23 should extend 3-4 mm beyond the catheter. A sufficient view and safer administration of the drug provides a large (3.7 mm channel diameter) or a double-lumen endoscope. This is especially important in the treatment of acute bleeding.

The sclerosing agent can be 1% sodium tetradecyl sulfate solution or 5% ethanolamine oleate adduct solution for varicose veins, as well as polydocanol for introduction into surrounding tissues. Injection is performed directly above the gastroesophageal junction in a volume not exceeding 4 ml per 1 varicose node. Preparations can also be administered to varicose-dilated veins of the stomach located within 3 cm of the gastroesophageal junction.

The sclerosing agent can be injected either directly into the varicose-dilated vein to obliterate its lumen, or to its own plate, to cause inflammation and subsequent fibrosis. Introduction to the lumen was more effective for relief of acute bleeding and was less often accompanied by relapses and. When administered together with the sclerosing substance of methylene blue, it becomes evident that in most cases the preparation falls not only in the lumen of the varicose-dilated vein, but also in the surrounding tissues.

In case of emergency sclerotherapy, a repeated procedure may be required. If it has to be repeated three times, then further attempts are inexpedient and one should resort to other methods of treatment.

The algorithm for sclerotherapy, adopted in the Royal Hospital of Great Britain

• Premedication with sedatives (diazepam intravenously)
• Local anesthesia of the pharynx
• Introduction of an endoscope with oblique optics (Olympus K 10)
• Introduction to each site 1-4 ml of a 5% solution of ethanolamine or 5% solution of morruate
• The maximum total amount of sclerosing agent administered during the procedure is 15 ml
• Omeprazole for chronic ulcers of the sclerosed region
• Varicose-dilated veins of the stomach, located distal to the cardiac department, are more difficult to treat.

results

In 71-88% of cases, bleeding can be stopped; the frequency of relapses is reliably reduced. Treatment is ineffective in 6% of cases. In patients with group C, survival does not improve. Sclerotherapy is more effective than a tamponade probe and the administration of nitroglycerin and vasopressin, although the frequency of bleeding recurrence and survival may be the same. The more experienced the operator, the better the results. With insufficient experience, endoscopic sclerotherapy is better not to be performed.

The results of sclerotherapy are worse in patients with large, near-esophagus venous collaterals, detected at CT.

Complications

Complications often develop when injected into tissues surrounding the varicose-dilated vein than in it itself. In addition, the amount of sclerosing agent administered and the classification of Child's cirrhosis are important. With repeated planned sclerotherapy, complications develop more often than with an emergency, performed to stop bleeding.

Almost all patients develop fever, dysphagia and pain in the chest. Usually they quickly pass.

Bleeding often occurs not from the puncture site, but from the remaining varicose veins or from deep ulcers that penetrate into the veins of the submucosal plexus. Approximately 30% of cases, before the veins are obliterated, there is repeated bleeding. If bleeding occurs from varicose veins, repeated sclerotherapy is indicated, if ulcers, then the drug of choice is omeprazole.

The formation of strictures is associated with chemical esophagitis, ulceration and acid reflux; is also a violation of swallowing. Dilation of the esophagus is usually effective, although in some cases it is necessary to resort to surgical intervention.

Perforation (develops in 0.5% of cases of sclerotherapy) is usually diagnosed after 5-7 days; it is probably related to the progression of an ulcer.

Complications from the lungs include pain in the chest, aspiration pneumonia and mediastinitis. In 50% of cases, pleural effusion occurs. After 1 day after sclerotherapy, a restrictive violation of the function of external respiration develops, probably associated with pulmonary embolization of the sclerosing substance. Fever is often observed, clinical manifestations of bacteremia develop in 13% of cases of emergency endoscopic procedures.

Thrombosis of the portal vein is observed in 36% of cases of sclerotherapy. This complication can complicate the subsequent conduct of portocaval shunting or liver transplantation.

After sclerotherapy, varicose veins of the stomach, anorectal area and abdominal wall progress.

Other complications are described: cardiac tamponade, pericarditis | 69 |, brain abscess.

[1], [2], [3], [4]