Endoscopic sclerotherapy

This method is considered the "gold standard" of emergency treatment of bleeding from esophageal varices. In skilled hands, it can stop bleeding, but usually tamponade is performed and somatostatin is prescribed to improve visibility. Varicose vein thrombosis is achieved by introducing a sclerosing solution into them through an endoscope. Data on the effectiveness of planned sclerotherapy for esophageal varices are contradictory.

Methodology

The procedure is performed under aseptic conditions using sterile needles, the oral cavity is washed, and its hygiene is monitored. A conventional fibrogastroscope is most often used, local anesthesia and premedication with sedatives are administered. The #23 needle should protrude 3-4 mm beyond the catheter. A large (channel diameter 3.7 mm) or double-lumen endoscope provides sufficient visibility and safer administration of the drug. This is especially important in the treatment of acute bleeding.

The sclerosing agent may be a 1% solution of sodium tetradecyl sulfate or a 5% solution of ethanolamine oleate for injection into varicose veins, as well as polidocanol for injection into surrounding tissues. The injection is made directly above the gastroesophageal junction in a volume not exceeding 4 ml per 1 varicose node. The drugs can also be injected into varicose veins of the stomach located within 3 cm from the gastroesophageal junction.

The sclerosing agent can be injected either directly into the varicose vein to obliterate its lumen, or into the lamina propria to cause inflammation and subsequent fibrosis. Intraluminal injection has proven to be more effective in stopping acute bleeding and is less likely to result in relapses. When methylene blue is injected with the sclerosing agent, it becomes clear that in most cases the drug enters not only the lumen of the varicose vein, but also the surrounding tissues.

In emergency sclerotherapy, a second procedure may be necessary. If it has to be repeated three times, further attempts are not advisable and other treatments should be considered.

Algorithm for performing sclerotherapy adopted at the Royal Hospital of Great Britain

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

Results

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

The results of sclerotherapy are worse in patients with large periesophageal venous collaterals detected by CT.

Complications

Complications are more likely to develop with injections into the tissues surrounding the varicose vein than into the vein itself. In addition, the amount of sclerosing agent injected and the Child classification of cirrhosis are important. Complications are more likely to develop with repeated planned sclerotherapy than with emergency sclerotherapy performed to stop bleeding.

Almost all patients develop fever, dysphagia, and chest pain, which usually resolve quickly.

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

Stricture formation is associated with chemical esophagitis, ulceration, and acid reflux; swallowing problems are also important. Esophageal dilation is usually effective, although surgery may be necessary in some cases.

Perforation (occurs in 0.5% of sclerotherapy cases) is usually diagnosed after 5-7 days and is probably associated with ulcer progression.

Pulmonary complications include chest pain, aspiration pneumonia, and mediastinitis. Pleural effusion occurs in 50% of cases. Restrictive respiratory failure develops 1 day after sclerotherapy, probably due to embolization of the lungs with the sclerosing agent. Fever is common, and clinical manifestations of bacteremia develop in 13% of emergency endoscopic procedures.

Portal vein thrombosis occurs in 36% of sclerotherapy cases. This complication may complicate subsequent portocaval shunting or liver transplantation.

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

Other complications have also been described: cardiac tamponade, pericarditis |69|, brain abscess.

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