BACKGROUND/AIMS:We observed that the formation of a fibrous ring following variceal eradication appeared to be associated with less variceal recurrence. We aimed to evaluate this formally.METHODOLOGY:Twenty-one cirrhotic patients with a fibrous ring formation in the esophagus after eradication of varices (FR group) were compared with 21 controls of similar age, gender and liver function but without ring formation after eradication in terms of variceal recurrence, portal hypertension related bleeding and survival.RESULTS:Both groups were similar with regard to baseline demographic and clinical data. During a mean follow-up period of 28.8+/-18.3 (SD) months, variceal recurrence occurred in 2 (9.5%) patients in the FR group compared to 10 (47.6%) in the control group (p=0.005). Cox regression model revealed a significant difference in probability of variceal recurrence between the two groups (p=0.006). In the FR group 1 patient bled and 3 died vs. 2 and 6 patients in the control group respectively. The differences between the groups in relation to bleeding and death were not statistically significant.CONCLUSIONS:In cirrhotic patients undergoing band ligation for eradication of esophageal varices, the formation of a fibrous ring is followed by a lower variceal recurrence rate.

Management of patients with malignant obstructive jaundice is often challenging for all specialists involved in their care. In cases of unresectable tumors, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC) can be used to palliate the symptoms of biliary obstruction. However, despite successful initial stent placement, tumoral ingrowth may occur, resulting in recurrence of jaundice. Deployment of a new endoprosthesis can be technically problematic, since both tumoral ingrowth and the previously placed stent make attempts for bile duct cannulation troublesome. We report a case of a difficult malignant biliary stricture successfully drained endoscopically, using established, as well as novel techniques.

SUMMARY Different treatment strategies have been used to control variceal haemorrhage including drugs, oesophageal tambonade, endoscopie sclerotherapy or ligation, TIPS, and surgery. Optimal therapy should stop bleeding and prevent early rebleeding. The initial resuscitation of patients is as important as the other specific measures to promote haemostasis. Balloon tambonade is a highly effective treatment to achieve a temporary control of bleeding but it carries a very high risk of complications. Pharmacologie treatment has the theoretical advantage of allowing specific therapy without requiring any complicated equipment and experienced personnel. Drugs currently used in the treatment include vasopressin, terlipressin and somatostatin or its analogues octreotide and vapreotide. In clinical studies somatostatin was more effective than vasopressin and as effective as terlipressin but with improved safety profile. Endoscopie treatments (sclerotherapy and ligation) are highly effective in achieving haemostasis but they are largely depended on the experience of the endoscopist. The association of endoscopie with pharmacologie therapy (preferably somatostatin), used as soon as the diagnosis is suspected (before the endoscopy) and continued for five days, currently appears to be the best approach to treatment. TIPS is indicated in patients in whom bleeding cannot be controlled or recurs after two sessions of endoscopie treatment. Keywords: Portal hypertension, bleeding oesophageal varices, cirrhosis, sclerotherapy, lipation, vasoactive drugs.

AIM:To compare endoscopic banding ligation vs. no treatment in cirrhotics with intolerance or contraindications to beta-blockers for prevention of first bleeding in portal hypertension.METHODS:A sample size of 214 was planned with all sizes of varices. However, the trial was stopped due to increased bleeding in 52 patients in the ligation group. The baseline severity liver disease and endoscopic features were similar. Ligation group: 25 (M/F = 21/4, mean age: 60 +/- 9.37 years); 27 not-treated group: 27 (M/F = 17/10, mean age: 63 +/- 10.27).RESULTS:The mean follow-up period was 19.5 +/- 13.3 months: five bled in the ligation group (20%), three from varices (two after banding at 11 and 17 days; one during the procedure), and two from gastropathy; two bled in the not-treated group (7%- two both varices) (P = 0.24). There were seven deaths in the ligation group and 11 in the not-treated group (P = 0.39).CONCLUSION:Sixty per cent of the bleeding in the banding group was probably iatrogenic, requiring the study to be stopped. Endoscopic banding ligation was no better than no treatment. This study suggests that ligation may be harmful when used as primary prophylaxis, similar to prophylactic sclerotherapy in the past.

During variceal bleeding, several factors may increase portal pressure, which in turn may precipitate further bleeding. This study investigates the early effects of endoscopic injection sclerotherapy (EIS) and endoscopic band ligation (EBL) on hepatic venous pressure gradient (HVPG) during acute bleeding and the possible influence in outcome. In 50 cirrhotic patients with bleeding esophageal varices treated with EIS (n = 25) or EBL (n = 25), we performed repeated HVPG measurements before and immediately after endoscopic treatment (time 0) and every 24 hours for a 5-day period. Endotherapy was continued until the varices were too small for further treatment. Both groups were comparable with regard to age, gender, Child-Turcotte-Pugh grade, and HVPG. In the EBL and EIS groups, a significant (P < .0001) increase was observed in mean portal pressure (20.7 mm Hg +/- 4.4 SD and 21.5 mm Hg +/- 4.5 SD, respectively) immediately after treatment (time 0) as compared with pretreatment (18.1 +/- 4.5 and 18.1 +/- 4.0). However, HVPG in the EBL group returned to baseline values within 48 hours after treatment, while in the EIS group it remained high during the 120-hour study period (P < .0001). Bleeding stopped in all patients after endotherapy. During the 42-day follow-up period, the rebleeding rate over time was lower in the EBL group compared with the EIS group (P = .024). Patients with an initial HVPG greater than 16 mm Hg had, despite endoscopic treatment, a significantly higher likelihood of rebleeding (P = .05) and death (P = .024) and overall failure (P = .037). In conclusion, during acute variceal bleeding EIS, but not EBL, causes a sustained increase in HVPG, which is followed by a higher rebleeding rate.

AIM:We conducted a prospective, randomized comparison of endoscopic variceal ligation, sclerotherapy and metoclopramide injection in order to evaluate their early effect on lower oesophageal sphincter pressure. METHODS:Twenty-six patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to undergo an oesophageal manometry. The patients' lower oesophageal sphincter pressure was evaluated, prior to and immediately after a single session of ligation (n = 10), a single session of sclerotherapy (n = 8) or a bolus injection of 20 mg metoclopramide hydrochloride (n = 8). RESULTS:Ligation produced a higher early increase in lower oesophageal sphincter pressure (from 12.3 +/- 2.3 to 27.8 +/- 3.0 mmHg) as compared with sclerotherapy (from 13.6 +/- 2.5 to 22.4 +/- 4.5 mmHg) or metoclopramide injection (from 14.6 +/- 3.2 to 22.5 +/- 2.9 mmHg); (P = 0.0001). CONCLUSION:Our data indicate that ligation of oesophageal varices produces an early increase in lower oesophageal sphincter pressure in cirrhotic patients.

Aim: We conducted a prospective, randomized comparison of endoscopic variceal ligation, sclerotherapy and metoclopramide injection in order to evaluate their early effect on lower esophageal sphincter pressure, an effect that may play some role to the control of variceal hemorrhage.Methods: Twenty-four patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to undergo an esophageal manometry, in order to evaluate the lower esophageal sphincter pressure, prior to and immediately after a single session of ligation (n = 8), a single session of sclerotherapy (n = 8) or the bolus injection of 20 mg of metoclopramide hydrochloride (n = 8).Results: Ligation produced a higher (p = 0.0001) early increase (from 12.3 plusminus 2.3 to 27.8 plusminus 3.0 mm Hg) in lower esophageal sphincter pressure as compared to sclerotherapy (from 13.6 plusminus 2.5 to 22.4 plusminus 4.5 mm Hg) or metoclopramide injection (from 14.6 plusminus 3.2 to 22.5 plusminus 2.9 mm Hg).Conclusion: Our data indicate that ligation produces an early increase in esophageal sphincter pressure.This elevation of the sphincter tone compress veins, and may increase vascular resistance between portal vein territory and esophageal varices, thus decreasing variceal blood flow.This mechanism may contribute to the successful control of acute variceal hemorrhage.

BACKGROUND:Octreotide is a potent inhibitor of pancreatic secretion, and corticosteroids suppress humoral and cellular activity. Both agents may reduce the frequency of post-ERCP pancreatitis. The aim of this study was to determine the effectiveness of octreotide and hydrocortisone in preventing post-ERCP pancreatitis.METHODS:Three hundred fifty-four patients were entered in to a multicenter randomized controlled trial of 100 microg subcutaneous octreotide (Group 1) versus 100 mg intravenous hydrocortisone (Group 2) versus normal saline solution as placebo (Group 3). All medications were administered approximately 30 minutes before the procedure. Patients were assessed clinically and serum amylase was also measured before the procedure and 3, 12, and 24 hours after the procedure.RESULTS:Three hundred forty patients were included in the analysis. Pancreatitis was observed in 11 of 112 patients (9.8%) in Group 1, 8 of 113 (7.1%) patients in Group 2, and in 15 of 115 (13.0%) patients in Group 3 (p = 0.32). The mean length of hospitalization in days was similar in all 3 groups: mean (SD) for Groups 1, 2, and 3 were, respectively, 3.6 (1.6) versus 2.9 (0.6) versus 4.3 (1.8) (p = 0.13). Multivariate logistic regression analysis showed that number of pancreatic injections, suspicion of sphincter dysfunction, therapeutic procedure, and age were risk factors for pancreatitis.CONCLUSIONS:The results of this trial indicate that octreotide and hydrocortisone do not prevent ERCP-induced pancreatitis.

Aim Endoscopic methods are currently the most widely used techniques for the treatment of bleeding oesophageal varices (BOV). However, a number of complications may limit their usefulness. We conducted a prospective, randomized comparison of variceal ligation versus sclerotherapy in cirrhotics after the control of variceal haemorrhage to study the relative short-term risks of these two procedures with respect to oesophageal motility and gastro-oesophageal reflux. Methods Seventy-three patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to treatment with sclerotherapy or ligation until variceal eradication. In 60 of these patients, oesophageal manometry and 24-h intra-oesophageal pH monitoring were performed at inclusion and 1 month after variceal eradication. Results After variceal eradication with sclerotherapy, peristaltic wave amplitude decreased from 76.2 ± 14.7 mmHg to 61.6 ± 17.7 mmHg (P = 0.0001), simultaneous contractions increased from 0% to 37.9% (P = 0.0008), and the percentage of time with pH < 4 increased from 1.60 ± 0.25 to 4.91 ± 1.16% in channel 1 (P = 0.0002) and from 1.82 ± 0.27 to 5.69 ± 1.37% in channel 2 (P = 0.0006). In contrast, the above parameters were not disturbed with ligation. Conclusion Our data define the advantages of ligation over sclerotherapy with respect to post-treatment oesophageal dysmotility and associated gastro-oesophageal reflux.

BACKGROUND:Analysis of primary prevention studies of the use of beta-blockers has shown clear reductions in variceal bleeding in cirrhotic patients with varices. In contrast, the usefulness of prophylactic endoscopic sclerotherapy, alone or in combination with propranolol, in the management of these patients is still under investigation. The present study compared the efficacy of combined sclerotherapy and propranolol versus propranolol alone in the primary prevention of hemorrhage in cirrhotic patients with varices and high (greater than 18 mm Hg) intraesophageal variceal pressure.METHODS:Patients were randomly assigned to propranolol (42 patients) or to propranolol plus sclerotherapy (44 patients). The mean duration of follow-up was 26.8 +/- 7.7 and 24.6 +/- 9.8 months, respectively.RESULTS:During this period 23% of the patients in the combination group experienced at least 1 episode of bleeding due to varices or congestive gastropathy as compared with 14% in the propranolol group (not significant). Twenty-three patients (52%) in the combination group developed complications as compared with 8 (19%) in the propranolol group (p = 0.002). The mortality rate was similar in both groups (14% and 18%, respectively). The only independent factor predictive of survival was the level of serum albumin.CONCLUSIONS:Endoscopic sclerotherapy should not be used for the primary prevention of hemorrhage in cirrhotic patients at high risk of variceal bleeding who are undergoing treatment with propranolol.