ENDOSCOPIC LIGATION OF ESOPHAGEAL VARICES LONG TERM RESULTS

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1 ENDOSCOPIC LIGATION OF ESOPHAGEAL VARICES LONG TERM RESULTS R. Nikolov, St.Ivan Rilski University Hospital, Clinic of Gastroenterology Sofia, Bulgaria, Medical University Sofia, Bulgaria Contact: R. Nikolov, Clinic of Gastroenterology, St. Ivan Rilski University Hospital 15, Acad. Ivan Geshov, 1431 Sofia, tel , Abstract: Materials and Methods: A retrospective analysis is presented of the long term results following 98 endoscopic ligation procedures of esophageal varices, performed on 76 patients, in the period The patients were divided into two groups ones with history of esophageal varices haemorrhage treatment in a different medical facility and others with no history of such an incident. The procedures were conducted using Wilson-Cook manufactured ligation kit. The patients were primarily monitored 1 month after the ligation procedures and in the cases of good treatment effect - every 6 months afterwards. Results: The average follow up period after the first ligation procedure was 28 months ± 19 months. During this period, 9 patients had post-ligation variceal haemorrhage 1 directly after the procedure, 2 in the 20 th to the 30 th day interval after the procedure and 6 in the 12 th to the 25 th month interval after the endoscopic ligation. Lethal exitus, resulting from acute haemorrhage, occurred in 3 of these patients. From the whole studied group, 16 patients died during the follow up period, and in 13 of them the cause of death was liver failure. The six patients with delayed variceal haemorrhage recurrence for some reason did not comply with the follow up control medical visits. All of them were from the group with a history of esophageal variceal haemorrhage before the ligation procedures. Conclusions: 1. The endoscopic ligation is an effective method for primary and secondary prophylaxis of the esophageal variceal haemorrhage. 2. The long term results depend on the course of the main disease and the regular endoscopic follow up observation. 3. Patients with a history of variceal haemorrhage before the first ligation procedure have worse long term prognosis and the regular follow up endoscopic observation must be more strict. Original Paper Literature review The haemorrhage from gastroesophageal varices is one of the major complications of the portal hypertension. According to various studies, it is the reason for 10% to 30% of all the upper gastrointestinal haemorrhages. 1 Esophageal variceal haemorrhage occurs in 25-30% of all patients with liver cirrhosis and causes 80-90% of all the haemorrhages in these patients 2,3,4. The morbidity, mortality, and the cost-effectiveness of the treatment among these patients are higher, compared to those with other gastrointestinal haemorrhages 5,6,7. In around 30% of the cases the first variceal haemorrhage is lethal and 70% of the patients with history of such haemorrhage are about to have a recurrence 2,8. The therapeutic strategy for this condition includes prevention of the first variceal haemorrhage (primary prophylaxis), control and measures for ceasing the acute variceal bleeding, as well as prevention of haemorrhage recurrence (secondary prophylaxis) 2,8,9. The predictive criteria for an upcoming variceal haemorrhage are mostly clinical: worsening of liver function C class, according to the Child-Pugh classification, and/or continuous alcohol consumption; and endoscopic observation: large esophageal varices with red signs on their surface 2. Materials and Methods We conducted a retrospective analysis over 98 cases of endoscopic esophageal varices ligations, performed on 76 patients. In all of the procedures the Wilson-Cook manufactured endoscopic ligation apparatus was used. The endoscopic ligations were 27

2 performed between 1999 and The average follow up period after the first ligation procedure was 28 months ±19 months. The patients were divided into two groups ones without a history of variceal haemorrhage before the first ligation (primary prophylaxis group) and others with a history of such episodes (one or more), but without previous endoscopic ligation treatment for haemostasis. The average age of the patients was 59 ±33 years; 42 men and 34 women. The distribution of the patients, according to etiology and nosology is presented on table 1. All of the patients, who received endoscopic variceal ligation as a primary prophylaxis treatment, were with liver cirrhosis class C according to Child- Pugh classification. 98 endoscopic esophageal varices ligation procedures were performed on 76 patients. The distribution of the patients according to the number of endoscopic ligation procedures is presented on figure 1. During the follow up period, 9 patients had postligation variceal haemorrhage. The time between the conducted ligation and the post-ligation haemorrhage recurrence is presented on table 3. Follow up period scheme Endoscopic ligation follow up control fibrogastroscopy after 1 month, if residual varices 3 rd or 4 th grade and/or with red signs on surface, a new ligation is applied. If there is good treatment effect with none of the above residual characteristics follow up control fibrogastroscopy every 6 th month and continuous evaluation for new ligation is administered. Results The distribution of patients according to previous history of variceal haemorrhage before the ligation procedures is presented on table 2. Lethal exitus, resulting from acute haemorrhage occurred in 3 of these patients the patient with a recurrence right after the ligation procedure and 2 of those 6 patients with a delayed haemorrhage recurrence (12 th - 25 th month). From the whole studied group, 16 patients died during the follow up period 3 after an acute variceal haemorrhage and 13 as a result of liver failure. The distribution according to cause of death, etiology and number of ligation procedures is presented on table 4. When comparing the two major groups with primary and secondary prophylaxis of the variceal haemorrhage, it was found that only one patient from the group with no history of variceal haemorrhage before the ligation received such afterwards in the observed follow up period. This is presented on figure 2. 28

3 After the endoscopic ligation procedures, all the patients received treatment with propranolol and emergency treatment the result was lethal exitus. In 12 of the cases, there was a retrosternal pain lasting from 2 to 35 hours, which was successfully managed with analgetics and nitrates. 5 patients suffered nausea, which was overcome with gastrointestinal prokinetic drugs. Discussion proton /H+/ inhibitor PPI. The average daily dose of the propranolol was 35mg ±23mg and the PPI dose was 20mg daily. From the presented cases of primary and secondary prophylaxis of esophageal variceal haemorrhage through endoscopic ligation, 12% received postligation haemorrhage compared to the 25%-35% spontaneous variceal bleeding of patients with liver cirrhosis according to data in the literature 1. Only one of the patients from the primary prophylaxis group suffered a post-ligation haemorrhage, while in the secondary prophylaxis group there were 8 Complications resulting from the procedure. In one of the patients there was haemorrhage right after the ligation procedure. This patient was with heavy alcohol induced impairment of the behavioural control and refused any therapeutic cases with such haemorrhage (20%). These rates are significantly lower than the reported 70% recurrence in the spontaneous evolution of the disease 1,8. A strict evaluation and explicit conclusions are quite difficult a task, as the risk of a haemorrhage recurrence depends on many factors, such as: the course and 29

4 progression of the main disease; drug treatment and therapeutic scheme compliance; ceasing alcohol consumption; influence of all other possible Conclusions 1. The endoscopic ligation is an effective method for primary and secondary prophylaxis of the esophageal variceal haemorrhage. Primary prophylaxis Secondary prophylaxis 2. The long term results depend on the course of the main disease and the regular endoscopic follow up observation. 3. p<0.001 complications of the disease 2,8,9. A very important factor is the regular follow up fibrogastroscopic observations on the 1 st and if no progression on every 6 th month afterwards to ensure on time varices ligation if further needed. In the presented study, all of the six patients with delayed variceal haemorrhage recurrence for some reason did not comply with the follow up fibrogastroscopy controls and were admitted into hospital after the bleeding occurred. It is worth noting that the mortality from such haemorrhage (3 of the patients) is significantly lower than that from liver failure (13 patients) p< Patients with a history of variceal haemorrhage before the first ligation procedure have worse long term prognosis and the regular follow up endoscopic observation must be more strict. 30

5 Bibliography 1. Laine L. Upper gastrointestinal tract hemorrhage. West J Med 1991; 155: The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices: a prospective multicenter study. N Engl J Med 1988; 319: Groszmann RJ, Bosch J, Grace ND, et al. Hemodynamic events in a prospective randomized trial of propranolol versus placebo in the prevention of a first variceal hemorrhage. Gastroenterology 1990;99: Gores GJ, Wiesner RH, Dickson ER, Zinsmeister AR, Jorgensen RA, Langworthy A. Prospective evaluation of esophageal varices in primary biliary cirrhosis: development, natural history, and influence on survival. Gastroenterology 1989;96: Mateva L, V.Dimitrova, A.Alexiev et al. Are healthy healthy volunteers? I. Ultrasound steatosis and signs of metabolic syndrome in healthy volunteers. J Clin Med 2009; this issue 2. Jelev D, A.Alexiev, V.Dimitrova et al. Are healthy healthy volunteers? II. Rate of serological markers for HBV infection. J Clin Med 2009; this issue 3. type_ii_errors 4. glossary/hypothesis_testing.html#1err 5. inference 6. _ theorem 5. Gralnek IM, Jensen DM, Kovacs TOG, et al. The economic impact of esophageal variceal hemorrhage: cost-effectiveness implications of endoscopic therapy. Hepatology 1999;29: Burroughs AK, McCormick PA. Natural history and prognosis of variceal bleeding. Baillieres Clin Gastroenterol 1992;6: Cello JP, Grendell JH, Crass RA, Weber TE, Trunkey DD. Endoscopic scleropathy versus portacaval shunt in patients with severe cirrhosis and acute variceal hemorrhage: long-term follow-up. N Engl J Med 1987;316: Graham DY, Smith JL. The course of patients after variceal hemorrhage. Gastroenterology 1981;80: Villanueva, C., Minana, J., Ortiz, J., Gallego, A., Soriano, G., Torras, X., Sainz, S., Boadas, J., Cusso, X., Guarner, C., Balanzo, J. (2001). Endoscopic Ligation Compared with Combined Treatment with Nadolol and Isosorbide Mononitrate to Prevent Recurrent Variceal Bleeding. NEJM 345: дивиди. За да се отговори на въпроса, са необходими адекватно поставени клинико-епидемиологични проучвания, които да поставят мост над пропастта между клиничната медицина и епидемиологията. Литература: 31