Variceal rebleeding and recurrence after endoscopic injection sclerotherapy - A prospective evaluation in 204 patients

Hypothesis: Eradication of esophageal varices by repeated injection sclerot herapy and maintenance of eradication using continued surveillance endoscop y may reduce recurrent variceal bleeding and death from esophageal varices. Design: A prospective study of consecutive adult patients with endoscopical ly proved esophageal variceal bleeding. Setting: A tertiary care university hospital in a metropolitan area. Patients: Two hundred four patients (127 men and 77 women; mean age, 50.1 y ears; age range, 16-82 years) underwent 993 emergency and elective variceal endoscopic injection treatments with 5% ethanolamine oleate during 1992 en doscopy sessions. Most (166 [81.4%]) had cirrhosis, mainly due to alcohol a buse (131 [78.9%]). The number of patients with each modified Pugh-Child ri sk grade was as follows: A, 30; B, 91; and C, 83. (The modified Pugh-Child classification comprises ascites, encephalopathy, serum albumin and bilirub in levels, and prothrombin time. Each variable is given a value of 1 to 3 w ith increasing impairment of liver function. Addition of the values leads t o the Pugh-Child risk grades for each patient, with 5 and 6 giving grade A; 7 through 9, grade B;, nd 10 through 15, grade C, respectively.) Results: Ninety-five patients (46.6%) rebled at a median of 17 days (range, 0-2583 days). Seventy-four patients (36.3%) had a total of 112 further ble eding episodes before eradication of varices. Varices were eradicated in 99 (87.6%) of 113 patients who survived longer than 3 months after a median o f 5 injections and remained eradicated in 43 (mean follow-up after eradicat ion, 38 months; range, 4-125 months). Rebleeding was markedly reduced after eradication of varices, Varices recurred in 56 patients, of whom only 10 r ebled from recurrent esophageal varices. Cumulative survival by life table analysis was 55%, 41%, and 30% at 1,3, and 5 years, respectively. One hundr ed thirty-seven patients (67.2%) died during follow-up. Liver failure was t he most common cause of death. Minor complications (mucosal ulceration) occ urred in 105 patients. Major complications, including a localized injection site leak (n=9), esophageal stenosis (n=25), and esophageal perforation (n =5), occurred in 39 patients. Conclusions: Repeated injection sclerotherapy eradicated esophageal varices in most long-term patients. Complications related to injection sclerothera py were mostly minor. Complete eradication of varices reduced rebleeding an d death from esophageal varices.