Sclerotherapy of Esophageal Varices: An Endoscopic and Portographic Study

Abstract

A prospective series of 26 patients with portal hypertension and recent bleeding from esophageal varices was investigated with percutaneous transhepatic selective portography (PTP). PTP was performed immediately prior to and, in 23 patients, just after the initial endoscopic injection sclerotherapy (ST) session to study the acute effects of ST on the mediastinal portal-systemic collaterals. Late follow-up PTP was performed after a median of 8 months in 21 of 26 patients considered endoscopically to be free from esophageal varices after a median of 6 ST sessions. Five patients rebled from esophageal or gastric varices during the follow-up period of 15 months, but there were no fatalities due to variceal hemorrhage. In all patients, the initial PTP showed portal-systemic mediastinal collaterals. Immediately after ST, it was not possible to opacify esophageal varices at all (10 patients) or only partially (7 patients). Five patients died prior to late follow-up PTP. Endoscopic judgment of complete eradication of esophageal varices after repeated ST was in agreement with the late PTP results in 18 of 21 patients. In one patient, PTP showed residual esophageal varices subsequently confirmed by endoscopy. The results were uncertain in two patients for technical reasons. This study supports the opinion that submucosal esophageal varicose veins, as visualized by PTP, can be efficiently eradicated by serial ST, leaving the other mediastinal collaterals unaffected.

Influence of paraesophageal venous collaterals on efficacy of endoscopic sclerotherapy for esophageal varices

“…It has also been reported that the recurrence rate is lower among patients whose treatment includes esophageal transection and devascularization than those without devascularization (32 ). Conversely, Soderlund et al (20) suggested that the selective eradication of submucosal varices, leaving the periesophagdparaesophageal collaterals unaffected, were the mechanism counteracting variceal recurrence after EIS.…”

“…There still remains some confusion on terminology of collateral veins around the esophagus in patients with portal hypertension. Using percutaneous transhepatic portography, Soderlund et al delineated two parts of collateralsnamely, periesophageal and paraesophageal varicesaround the lower esophagus (20). Periesophageal varices are situated in the connective tissue surrounding the esophagus, whereas paraesophageal varices are mediastinal veins running longitudinally distant to or overlying the esophagus.…”

“…Factors affecting these variables have been studied but are still unclear (13)(14)(15)(16)(17)(18)(19). PeriesophageaVparaesophageal venous collaterals located at the adventitial aspect of the esophagus in patients with portal hypertension were noted recently (20,211. Studies on these collaterals are scarce, probably because of the difficulty of studying these veins in clinical practice.…”

“…The CT diagnosis of paraesophageal varices could not be confidently made in these patients. Of the remaining four patients, CT showed, in addition to the esophageal wall abnormalities, paraesophageal 18.1 2 5.5 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28) 10.9 z 3.2 (5-21) < 0.001 "Data expressed as mean z S.D. {ranget vascular structures at the level of lower esophagus near esophagogastric junction.…”

Usefulness of Eus in Portal Hypertension With Esophageal Varices

“…Vessels feeding the esophageal varices have been recognized to be important for recurrence after EIS as well as occurrence of esophageal varices before EIS in patients with portal hypertension. Soderlund et al 17 . reported that selective elimination of submucosal varices without embolization of the periesophageal and paraesophageal collaterals resulted in a higher recurrence rate of varices.…”