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Background and Aims Recommendations for the treatment of lower GI bleeding do not include bleeding from venous malformations (VMs). The aim of this study was to delineate the usefulness of a novel hybrid intervention (fluoroscopy-guided endoscopic sclerotherapy) for the treatment of symptomatic VMs in the rectosigmoidal colon with bleeding. Methods The magnetic resonance images of 421 patients with VM, referred to multicenter vascular anomaly centers from 2009 to 2017, were analyzed retrospectively. Treatment was performed for all patients who experienced bleeding from rectosigmoidal VMs using fluoroscopy-guided endoscopic sclerotherapy with polidocanol foam as a novel approach. Results A total of 27 patients displayed VM in the rectosigmoidal area. Eleven of these presented with acute or previous bleeding and received treatment. Active bleeding was observed in 8 patients (72.7%), whereas 3 patients (27.3%) had signs of previous bleeding. Six of the 11 patients had anemia (54.5%). There were no adverse events within 24 hours of the intervention. In a 2-year follow-up period, only 1 patient (9.1%) presented with recurrent bleeding after 13 months and was successfully treated again with fluoroscopy-guided endoscopic sclerotherapy. Conclusions Fluoroscopy-guided endoscopic sclerotherapy was shown to be a safe and effective treatment of symptomatic VMs of the rectosigmoidal area. Thus, fluoroscopy-guided endoscopic sclerotherapy should be considered for patients with bleeding from VMs of the rectosigmoid after a comprehensive workup and interdisciplinary case discussion.

To improve prediction of recurrent bleeding after endoscopic sclerotherapy of esophageal varices.A prospective, observational, case-control study was performed. Immediate and long-term results of endoscopic sclerotherapy of esophageal varices were studied in 91 patients for the period from 2002 to 2016. Multiple regression analysis with binary response model was applied to analyze the prediction models.Recurrent bleeding occurred in 80.5 (20; 182) days after sclerotherapy (range 0-2557 days). Spearman's correlation analysis revealed a significant relationship between bleeding recurrence and erythrocyte count (R= -0.32), Child-Pugh class of liver cirrhosis (R=0.49), Child-Pugh score (5-15) (R=0.54), content of amino acids, HPro/Pro ratio (R=0.71). Prognostic indicators were selected by stepwise inclusion of predictors. Thus, the final version of regression equation is as follows: Y=exp (-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)/[1+exp(-0.17+0.93×Child-Pugh score-106.42×HPro/Pro)]. High risk of recurrent bleeding from esophageal varices within 1 year after endoscopic sclerotherapy is determined by Y-value0.5. An accuracy of this model is 89.6%, Se 94.3%, Sp 79.2%, PPV 90.9%, NPV 86.4%, OR 63.3, LR + 4.53, LR - 0.07.Thus, the proposed method is highly informative, effective, available and can be widely used in clinical practice.Расширение арсенала способов прогнозирования развития рецидива кровотечения после эндоскопического склерозирования варикозно расширенных вен (ВРВ) пищевода.В ходе проспективного, обсервационного исследования с дизайном случай—контроль изучены результаты лечения 91 пациента в период с 2002 по 2016 г. Для расчета моделей прогнозирования рецидива кровотечения из ВРВ пищевода проведен множественный регрессионный анализ с использованием logit-модели бинарных откликов.В среднем рецидив кровотечения из ВРВ пищевода возникал через 80,5 (20; 182) сут после выполнения склерозирования. При проведении рангового корреляционного анализа Спирмена статистически значимая корреляция возникновения рецидива кровотечения отмечена с количеством эритроцитов (R= –0,32,Предлагаемый способ является высокоинформативным. Он эффективен, доступен и может найти широкое применение в клинической практике.

Background: Cap-assisted endoscopic sclerotherapy is a new interventional therapy for internal hemorrhoids and rectal prolapse under colonoscopy. The proper length of the endoscopic injection needle is the core for performing cap-assisted endoscopic sclerotherapy well with more benefits and less complications. However, no data are currently available to guide endoscopists to consider the length of injection needle before cap-assisted endoscopic sclerotherapy. This study is designed to evaluate the efficacy and safety of cap-assisted endoscopic sclerotherapy with long or short injection needle in the treatment of internal hemorrhoids. Methods: This is a nationwide multi-center, prospective, single-blind and randomized controlled trial. Patients with grade I-II internal hemorrhoids who have failed to conservative treatments and grade III internal hemorrhoids who are not suitable for surgery or refuse surgery will be included. Participants will be randomized 1:1 into either long or short injection needle group. The primary outcome is the recurrence rate of internal hemorrhoids 24 weeks after cap-assisted endoscopic sclerotherapy. The secondary outcomes are as follows: (1) symptom severity score, (2) three-level EuroQoL five dimensions health scale scores, (3) occurrence of adverse events and severe adverse events, and (4) patients’ attitudes toward cap-assisted endoscopic sclerotherapy. Data collection will be conducted before and during operation, the 1st day, 1st week, 2nd week, and 24th week after cap-assisted endoscopic sclerotherapy. Discussion: The outcome of this study is expected to provide a practical clinical protocol of cap-assisted endoscopic sclerotherapy for patients with internal hemorrhoids and promote the use of this new endoscopic technique. Trial registration: ClinicalTrials.gov, NCT03917056. Registered on 12 April 2019.

Introduction: Filarial chyluria is a frequent problem in India. While endoscopic therapy is the mainstay of treatment, it is not always successful. We aimed to determine parameters that affect outcomes of endoscopic sclerotherapy for filarial chyluria (FC). Methods: Prospectively maintained data of FC patients who received endoscopic sclerotherapy between June 2011 and March 2015 were analyzed. Sclerotherapy included either povidone-iodine (0.1%) or silver nitrate (1%). The parameters recorded included clinical evaluation, urinary triglyceride (TG)/cholesterol, sclerotherapy treatment, and follow-up. Results: One hundred and fifty-seven patients (male: female, 104:53) with a mean age (± standard deviation [SD]) 41.12 ± 13.68 years underwent endoscopic sclerotherapy. Grade II (68.88%) chyluria was a most common presentation followed by Grade III (25.69%). One hundred and forty-four patients responded whereas six patients failed to respond; another seven were lost to follow up, and twenty patients had recurrence. Overall success rate was 86.11%. Baseline urinary TG (mean ± SD) between success and recurrence group was 195.51 ± 164.73 mg/dl and 652.65 ± 62.55 mg/dl and cholesterol (mean ± SD) was 16.99 ± 10.08 mg/dl and 89.07 ± 39.87 mg/dl, respectively. Patient with urinary TGs >300 mg/dl and urinary cholesterol >30 mg/dl had 3.2 and 1.3 times higher chance to have recurrence after endoscopic sclerotherapy, respectively. Choice of sclerosing agent (silver nitrate 1% versus povidone-iodine 0.1%) had no difference in success rate, but silver nitrate had slightly higher complications rate (25% vs. 20%). A higher number of instillations (>3) was associated with better success rate. Majority of the complications were either Clavien Grade 1 or 2. Conclusions: The factors predicting recurrence were higher clinical grade, higher number of pretreatment courses, and high urinary TG and cholesterol.

Background and study aim : Endoscopic treatment has become the principal first-line intervention in patients with bleeding oesophegeal varices, both during the acute event and for long-term therapy to prevent recurrent bleeding. Several clinical considerations affect the prognosis in individual patients including the severity portal hypertension, the location of the bleeding varices, residual hepatic function, the presence of associated systemic disease, and others. Early rebleeding has been shown to be a strong predictor of mortality and recurrent variceal bleeding substantially increases the risk of complications which further contribute to mortality. This study aimed to evaluate early rebleeding after different methods of endoscopic intervention and investigate the different parameters of the patient that can be correlated to it. Patients and methods: Hundred and four cirrhotic patients with first attack of variceal bleeding were included in this study. They were randomly allocated to two groups, group I: 52 patients who were managed by endoscopic variceal sclerotherapy and group II: 52 patients who were managed by endoscopic variceal band ligation to control their attack. The patients were followed up for six weeks and all their clinical, laboratory, endoscopic parameters were monitored. The rate of mortality and early rebleeding was measured and correlated to these different patients' parameters Results: There was no significant difference between the two groups as regards rate of early rebleeding (15.4% in group I vs 9.6% in group II P= 0.374). The rate of early rebleeding was significantly correlated to Child's score (r=+0.136 P=0.014), PT (r=+0.35 P

Patients surviving a variceal bleed are at high risk of re-bleeding with a mortality of 25-50% during a 1-2 year follow-up. Several studies and meta-analyses have demonstrated reduced rates of oesophageal variceal rebleeding with the use of β-blockers. However, their use can be limited by contraindications or intolerance to therapy. Other trials have shown that addition of nitrates may improve the efficacy of β-blockers in prevention of variceal re-bleeding. Endoscopic variceal band ligation (VBL) has been shown in meta-analyses to decrease the rates of rebleeding and mortality compared with endoscopic sclerotherapy. Studies comparing combined drug therapy with VBL have shown similar rebleeding rates although there is a suggestion that survival may be higher in those given drug therapy. Recent data suggest that combined VBL and drug therapy reduces the risk of rebleeding from oesophageal varices compared with either therapy alone; however there appears to be no reduction in overall mortality.

The present study was designed to compare elective transjugular intrahepatic portosystemic shunts (TIPS) and endoscopic sclerotherapy (EST) in terms of their efficacy in preventing recurrent bleeding from gastro-oesophageal varices in patients with advanced liver cirrhosis and portal hypertension. Of 96 patients with at least three gastro-oesophageal variceal rebleeds, 50 were treated with elective TIPS and 46 with EST. Recurrent variceal bleeding was significantly more frequent in patients receiving EST treatment compared with those receiving TIPS (45.7% versus 6.3%, respectively). Cumulative 1- and 4-year survival in the TIPS group was 83.0% and 73.5%, respectively, compared with 69.8% and 39.8% in the EST group, respectively. The rate of portosystemic encephalopathy was 33.3% in the TIPS group and 37.0% in the EST group. Elective TIPS was more effective than EST in the prevention of gastro-oesophageal variceal rebleeding in cirrhotic patients, it improved survival and it was associated with a similar rate of portosystemic encephalopathy.

Gastric varices are present in 5–33% of patients with portal hypertension and have a reported bleeding incidence of approximately 25% in 2 years. Gastric varices are more common in patients with noncirrhotic portal hypertension and extrahepatic portal vein obstruction. The risk of bleeding from gastric varices is lower than that of esophageal variceal bleeding but is generally more severe, and the associated mortality is significantly higher. The management of gastric varices remains a therapeutic challenge. Because there are few controlled clinical trials, the strength of the evidence underlying guidelines for management of gastric varices is weaker compared to their esophageal counterparts. Traditional endoscopic sclerotherapy is ineffective because gastric varices are usually associated with a gastrorenal shunt or a gastrocaval shunt resulting in outflow into the systemic circulation and high flow rate with a resultant rapid escape of sclerosant into the systemic circulation, delayed onset of local thrombosis, and a higher risk of distal serious complications. Obturation or obliteration is the term used for gastric varices treated with glue rather than eradication, as the varix itself can remain visible even when effectively treated, as will be demonstrated in the video. This article is part of an expert video encyclopedia.

While endoscopic sclerotherapy is effective for management of variceal bleeding, significant local and systemic side effects promoted the development of alternative endoscopic therapies. Endoscopic band ligation has emerged as a technique with equal or greater efficacy and fewer local and systemic complications. New multibanded ligation systems have enhanced the speed and efficiency of endoscopic variceal ligation therapy and eliminated the need for an esophageal over tube. Endoscopic hemostatic clipping is another means of achieving directed, mechanical endoscopic hemostasis that has a limited role in variceal bleeding.

Diffuse gastric antral vascular ectasia (DAVE) による消化管出血に対して, 無抗凝固剤透析 (NAHD) と内視鏡的硬化療法が有効であった透析症例を経験した. 症例は63歳, 透析歴9年の男性で肝硬変を合併していた. タール便が出現したため内視鏡検査を行ったところ, 胃前庭部全域に散在するoozingを伴う小発赤斑を認めた. DAVEからの出血と診断し, 透析方法をNAHDに変更, 抗潰瘍剤, 粘膜保護剤を投与したところ一時的に出血は止まった. しかし, CTで発見された肝癌に対してTAE治療を行った後, 再度出血が認められた. 内視鏡下でのclipping法やheat probe法では止血できなかったが, polidocanol局注療法にて永続的な止血に成功した. DAVEによる出血は保存的治療に抵抗することが多く, 胃切除を必要とする場合も多い. 本症例は肝硬変を合併し全身状態から外科治療の適応はなかったが, 内視鏡的治療が奏効した貴重な1症例と考えられた.

The effect of epidermal growth factor (EGF) on the biomechanical properties of the oesophagus subjected to sclerotherapy was studied in Goettingen minipigs by means of impedance planimetry.Seventeen animals underwent three sessions of weekly endoscopic sclerotherapy. During these 3 weeks and for the subsequent 2 weeks they were treated with either EGF or placebo. After another 3 weeks an impedance planimetric study was done. Ten healthy non-sclerosed pigs were studied as controls. Impedance planimetry was performed by stepwise pressure-induced balloon inflation for analysis of oesophageal cross-sectional area 5 and 10 cm above the gastro-oesophageal junction (GEJ).Systemic treatment with EGF (total daily dose of 30 micrograms/kg/day, administered subcutaneously) for 3 to 7 days per week combined with a weekly paravenous injection of 20-40 micrograms/kg attenuated the oesophageal damage caused by sclerotherapy, implying less pronounced narrowing 5 cm above and less dilation 10 cm above the GEJ.These observations suggest a potential therapeutic role for EGF in attenuating sclerotherapy-induced oesophageal injury.

AIM: To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices.METHODS: Retrospective observational study in a Tertiary Referral Centre. Between January 1999-October 2005, we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices. Patient details including age, gender and aetiology of liver disease/segmental portal hypertension were documented. The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle. All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded. Initial haemostasis rates, rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy. The duration of follow up was also listed. The study was conducted according to the United Kingdom research ethics guidelines.RESULTS: Thirty-seven patients were included. 33 patients (89%) had thrombin (250 U/mL) for gastric varices, 2 (5.4%) for duodenal varices, 1 for rectal varices and 1 for gastric and rectal varices. (1) Gastric varices, an average of 15.2 mL of thrombin was used per patient. Re-bleeding occurred in 4 patients (10.8%), managed in 2 by a transjugular intrahepatic portosystemic shunt (TIPSS) (one unsuccessfully who died) and in other 2 by a distal splenorenal shunt; (2) Duodenal varices (or type 2 isolated gastric varices), an average of 12.5 mL was used per patient over 2-3 endoscopy sessions. Re-bleeding occurred in one patient, which was treated by TIPSS; and (3) Rectal varices, an average of 18.3 mL was used per patient over 3 endoscopy sessions. No re-bleeding occurred in this group.CONCLUSION: Human thrombin is a safe, easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices. (C) 2012 Baishideng. All rights reserved.

内視鏡的硬化療法は1978年高瀬により本邦に導入されて以来急速に普及して, 食道胃静脈瘤の第1選択の治療法となるに至った.内視鏡的硬化療法の原理, 再発・再出血しない硬化療法の手技につき解説した.また, 巨木型静脈瘤や胃底部静脈瘤など血流量の多い静脈瘤に対しては, 濃度の高い無水エタノールやcyanoarylateを用いること.肝機能不良例には全身的影響の少ないesophageal varices ligation (EVL) やcyanoacrylateを用いること.肝癌合併例に対する硬化療法の適応や胃静脈瘤に対する硬化療法の注意点などにつき述べた.

Background Weight regain after Roux-en-Y gastric bypass (RYGB) is common. Endoscopic sclerotherapy is increasingly used to treat this weight regain. Objectives To report safety, outcomes, durability, and predictors of response to sclerotherapy in a large prospective cohort. Design Retrospective analysis of a prospective cohort study of patients with weight regain after RYGB. Patients A total of 231 consecutive patients undergoing 575 sclerotherapy procedures between September 2008 and March 2011. Interventions Single or multiple sclerotherapy procedures to inject sodium morrhuate into the rim of the gastrojejunal anastomosis. Main Outcome Measurements We report weight loss, complications, and predictors of response. We also used Kaplan-Meier survival analysis and log-rank test to compare time to continuation of weight regain after sclerotherapy in patients undergoing a single versus multiple sclerotherapy procedures. Results At 6 and 12 months from the last sclerotherapy procedure, weight regain stabilized in 92% and 78% of the cohort, respectively. Those who underwent 2 or 3 sclerotherapy sessions had significantly higher rates of weight regain stabilization than those who underwent a single session (90% vs 60% at 12 months; P = .003). The average weight loss at 6 months from the last sclerotherapy session for the entire cohort was 10 lb (standard deviation 16), representing 18% of the weight regained after RYGB. A subset of 73 patients (32% of the cohort) had greater weight loss at 6 months (26 lb, standard deviation 12), representing 61% of the weight regained. Predictors of a favorable outcome included greater weight regain and the number of sclerotherapy procedures. Bleeding was reported in 2.4% of procedures and transient diastolic blood pressure increases in 15%, without adverse health outcomes. No GI perforations were reported. Conclusions Endoscopic sclerotherapy appears to be a safe and effective tool for the management of weight regain after RYGB.

A setrospective study to determine the influence of prophylactic endoscopic sclerotherapy on the survival rate of patients with hepatocellular carcinoma complicated by esophageal varices was conducted. The subjects included 132 patients without esophageal varices at the time of diagnosis (NV group), 37 patients with hepatocellular carcinoma for whom prophylactic sclerotherapy had been performed for risky esophageal varices (PS group) and 26 patients with hepatocellular carcinoma and risky varices for whom prophylaxis was not performed (NPS group). Multiple regression analysis was used to identify factors affecting the survival rate of the 132 patients without esophageal varices. A tumor embolus in the primary branch or main trunk of the portal vein adversely affected long-term survival in these patients. The patients were further divided into 2 subgroups, namely those with (Vp3) and without (Vp0-Vp2) tumor emboli in the main trunk and primary branch of the portal vein. In the Vp0– Vp2 emboli subgroup, the patients who received prophylactic sclerotherapy and the patients without varices had similar survival rates. Patients without prophylactic sclerotherapy had a significantly shorter survival rate than the group without varices and the prophylactic sclesotherapy group (p

Shunt surgery, endoscopic sclerotherapy, and drug treatment with beta-blockers have been evaluated as prophylaxes for the first variceal bleed. Shunt surgery is associated with increased mortality and the risk of encephalopathy. Endoscopic sclerotherapy is relatively ineffective invasively and may be harmful. Beta- receptor blockers are inexpensive, easy to administer, and are moderately effective in preventing bleeding. They are currently the treatment of choice for primary prophylaxis of variceal bleeding.

内視鏡的食道静脈瘤硬化療法にて治療した精神分裂病を伴う先天性肝線維症の1例を報告する.症例は29歳,男性.1991年2月,吐血にて発症.腹腔鏡検査,肝生検にて先天性肝線維症と診断した.著明な肝脾腫を認めたが,黄疸,腹水はなく,肝機能も軽度の異常を認めるのみであった.画像診断上,肝末梢に多発する嚢胞がみられたがERCP,CT cholangiographyで胆道との交通はなくCaroli病とは区別された.これまで知能低下を合併した報告例はあるものの精神分裂病の合併例は見あたらず,われわれの報告が初めてとおもわれる.先天性肝線維症に対してはこれまで主に外科的治療が施行され良好な結果がえられていた,本症例では合計4回の内視鏡的食道静脈瘤硬化療法で静脈瘤はほぼ消失しその後の経過も良好である.近年,内視鏡の進歩,手技や方法の改良により内視鏡的食道静脈瘤硬化療法は治療法としての安全性や有効性が確立されてきており,今後外科的治療にとってかわりうるものと考えられた.

5%ethanolamine oleateを用いた内視鏡的食道静脈瘤硬化療法を1から9回 (平均3.8回) 施行した後7日から15か月 (平均8か月) に直達手術を施行した.15例でfundic patch法応用の食道離断術, 1例でEEAによる食道離断後に大弯側2/3周のfundoplicationを付加し, また全例で傍胃傍食道血行郭清, 脾摘を行った.硬化療法の回数の多い症例では下部食道壁の炎症性肥厚, 硬化, 食道周囲組織との癒着がみられ, これらの症例では手術時間, 術中出血量が大きく, また迷走神経が切離される場合が多かった, しかし術後縫合不全はなく, 術死, 入院死亡例はなかった.術後の静脈瘤再発率, 遠隔生存率においても, 硬化療法の既往のない手術症例と比較して同等の成績が得られた.Fundic patch応用食道離断術は頻回の硬化療法を受けた症例にたいする待期手術, 硬化療法後早期の出血例にたいする緊急手術においては有力な手術オプションと考えられた.

Endoscopic sclerotherapy has been used to manage esophageal varices. Severe complications resulting from this therapy including renal dysfunction have been reported. Therefore, particular caution must be taken with patients who have serious renal damage. Sclerotherapy was performed for esophagogastric varices in a patient that had received a kidney transplant following chronic renal dysfunction. Ethanolamine oleate was used as the sclerosant, and contained a contrast medium for varicealography in order that the flow of the sclerosant be monitored by fluoroscopy. Varicography during the injection allowed us to stop injection into the varices and into the irregular passageways of the feeders to the varices before the agent entered the systemic circulation. There were no complications during therapy. The patient died due to respiratory failure 41 months after the first treatment. Macroscopic findings of the autopsied specimens showed no esophagogastric varices and microscopic findings showed organized varices with recanalization into the submucosal layer of the esophagogastric lesions. Injection sclerotherapy using varicography with sclerosant-contrast medium mixture allowed treatment of this patient without incurring renal dysfunction.

The 'mosaic-like' pattern of portal hypertensive gastric mucosa has been evaluated endoscopically in 38 patients referred for elective sclerotherapy, before the first session, after the complete eradication of varices and six months later. Of 38 patients studied, 18 patients exhibited mild, and 20 patients exhibited negative, findings of congestive gastropathy prior to sclerotherapy. Seventeen and 18 patients, respectively, developed aggravated changes of congestive gastropathy after the completion of sclerotherapy (P = 0.003). We consider that obliteration of varices by means of endoscopic sclerotherapy influences the development of gastric congestion changes in the majority of patients. However, further studies are required to relate the direction of blood flow in the portal system as well as the level of portal pressure with the congestive gastropathy findings in such patients.

Endoscopic sclerotherapy is an effective method for treating and eradicating acutely bleeding varices in repeated sessions; however, it is not ideal because of numerous serious complications. Endoscopic variceal ligation, developed to circumvent some of the side effects of sclerotherapy, controls actively bleeding varices in about 90% of cases. Of 146 patients treated with endoscopic variceal ligation, variceal eradication was achieved in 80% of surviving patients in a mean of 5.5 treatment sessions. Recurrent bleeding developed in 39%. Complications were very rare. It is concluded that endoscopic variceal ligation is at least as effective as sclerotherapy but associated with fewer complications.

Prevention of the first variceal haemorrhage should start when the patients have developed medium-sized to large varices. Non-selective beta-blockers and band ligation are equally effective in preventing the first bleeding episode. Rubber band ligation is the first choice for patients with contraindications or intolerance to beta-blockers. Treatment of acute bleeding should aim at controlling bleeding and preventing early rebleeding and complications, especially infections. Combined endoscopic (band ligation or sclerotherapy) and pharmacological treatment with vasoactive drugs can control bleeding in up to 90% of patients. Antibiotic prophylaxis is an integral part of the treatment of acute variceal haemorrhage, and must be started as soon as possible. Emergency transjugular intrahepatic portosystemic stent shunt (TIPS) is the standard rescue therapy for patients failing combined endoscopic and pharmacological treatment. All patients who survive a variceal bleed should be treated with beta-blockers or band ligation to prevent rebleeding. All patients in whom bleeding cannot be controlled or who continue to rebleed can be treated with salvage TIPS or, in selected cases, with surgical shunts. Liver transplantation should be considered for patients with severe liver insufficiency in which first-line treatments fail.

Endoscopic sclerotherapy or ligation and/or drugs are the standard treatments for the prevention of variceal rebleeding. Failure of this treatment indicates the need for rescue transjugular intrahepatic portosystemic shunt (TIPS) implantation. The current practice to use endoscopic treatment as first-line and TIPS as second-line treatment is, however, not based on evidence since, in unselected patients, both treatments have a comparable survival. In addition, the timing for a change from endoscopic treatment to TIPS is not exactly defined. According to the randomized studies available a change may be recommended when uncontrolled rebleeding or more than two rebleedings within a time interval of 6-12 months indicate failure of the endoscopic treatment. This regimen may be reconsidered when future developments improve outcome of one or the other treatment. In this regard the TIPS treatment has a potential of improvement if further reduction of the rate of rebleeding can be achieved with less stenosis, and/or reduced encephalopathy.

Comparação da eficácia da somatostatina e da escleroterapia no sangramento digestivo proveniente da ruptura de varizes do esôfago. Foram avaliados prospectivamente 40 pacientes com hemorragia digestiva. Vinte e um pacientes foram randomizados a receber somatostatina (dose inicial de 250 mig seguida de infusão contínua de 250 µg/h por 48 h com reforços de 250 µg de 6/6 h nas primeiras 24 h) e 19 realizaram escleroterapia com oleato de etanolamina a 5%, sendo avaliados em 48 horas e no sétimo dia após o tratamento. Os grupos eram semelhantes quanto a sexo, idade, gravidade do sangramento e grau de falência hepatocelular. Falha terapêutica ocorreu em 48 h e 7 dias, respectivamente, em 26,3% e 35,7% no grupo da escleroterapia e em 23,8% e 21,4% no da somatostatina. A necessidade de transfusão (3,38 U no grupo da escleroterapia e 2,42 U no da somatostatina) e a mortalidade (31,6% no grupo da escleroterapia e 28,6% no grupo da somatostatina) também foram semelhantes (P >0,05). Conclui-se que a somatostatina é tão efetiva quanto a escleroterapia, devendo ser considerada no tratamento do sangramento agudo decorrente de ruptura de varizes do esôfago. The aim of this study was to compare the efficacy of somatostatin versus endoscopic sclerotherapy in the management of digestive bleeding caused by rupture of esophageal varices. Forty patients were evaluated; 21 were randomly assigned to receive somatostatin (initial 250 mug followed by a 48-hour continuous infusion of 250 mug/h and 250 mug 6/6h bolus in the first 24 hours) and 19 to receive endoscopic sclerotherapy with ethanolamine oleate 5%. The patients were evaluated after 48 hours and after 7 days of treatment. Both groups of patients were similar in sex, age, gravity of the hemorrhage and liver dysfunction. Therapeutic failure occurred in 26,3% and 35,7% in the group of endoscopic sclerotherapy (48 h and 7 days respectively), and in 23,8% and 21,4% in the group of somatostatin. The need of blood transfusion (3,38 U in the group of endoscopic sclerotherapy and 2,42 U in the group of somatostatin) and the mortality rate (31,6% in the group of endoscopic sclerotherapy and 28,6% in the group of somatostatin) were also similar (P >0,05). The authors conclude that somatostatin is as effective as endoscopic sclerotherapy and that it should be considered in the treatment of acute esophageal variceal bleeding.

The aims of the present study were to evaluate, by means of impedance plainmetry, regional differences in biomechanical properties in the normal oesophagus and the oesophagus damaged by sclerotherapy.Four minipigs underwent a weekly session of sclerotherapy for 4 weeks. Impedance planimetry was performed before the first session of sclerotherapy and 1 week after the last session of sclerotherapy. Investigations were performed by stepwise pressure-induced balloon distensions with concomitant measurements of pressure and luminal cross-sectional area (CSA) in the oesophagus 5 and 10 cm above the gastro-oesophageal junction (GEJ).The normal oesophagus had significantly larger CSAs 5 cm than 10 cm above the GEJ (P0.05). Endoscopic sclerotherapy entailed an inversion (P0.05) of the normal oesophageal configuration, with narrowing 5 cm above the GEJ (P0.05) and increased CSAs 10 cm above the GEJ (P0.05).Regional differences in CSA occur in the normal oesophagus, and sclerotherapy produces profound changes in the oesophageal configuration.

Transection and devascularization procedures (Sugiura procedure and transabdominal transection of oesophagus and devascularization) had been the most popular modality of treatment for oesophagogastric varices until the 1970s but the trends of treatment for varices have changed drastically during the last decade. This is partly due to the recent development of endoscopic sclerotherapy and partly due to the patient's increasing demand for less invasive treatment. Recently most patients with oesophagogastric varices are treated initially by endoscopic sclerotherapy and surgical treatment is only called for after sclerotherapy has failed.