Endoscopic Treatment for Variceal Bleeding Caused by Cirrhosis

Topic Overview

In people who have cirrhosis, high pressure in the veins that carry blood from the intestines to the liver (portal hypertension) causes many problems. Variceal bleeding -bleeding from enlarged veins (varices) in the digestive tract-is an extremely serious complication of portal hypertension. For people who have advanced cirrhosis and varices, especially in the esophagus, the risk of variceal bleeding is high. After varices have bled the first time, there is a high risk of bleeding again. The chance of bleeding again is highest right after the first bleed stops. Then the chance of bleeding again gradually goes down over the next several weeks. If varices are not treated, bleeding can lead to death.

Endoscopic therapy is the method most commonly used to treat immediate (acute) variceal bleeding. It also may be used to prevent recurrent episodes of variceal bleeding, which are common. The two forms of endoscopic therapy are:

• Endoscopic variceal banding (also called ligation).
• Endoscopic sclerotherapy.

Endoscopic therapy is usually used along with medicines such as beta-blockers and vasoconstrictors.

Endoscopic variceal banding (or ligation)

During variceal banding, a doctor uses an endoscope to place an elastic ring that looks like a rubber band around an enlarged vein. Banding the vein in this manner will cut off blood flow through the vein. It may be difficult to use this procedure while someone is actively bleeding, because the device used to place the bands obscures the doctor's vision.

Variceal banding has been shown to be as effective as sclerotherapy in treating episodes of bleeding. And it has fewer complications.^{footnote 1}

Variceal banding is often done several times to control the varices and prevent bleeding. For example, banding might be repeated every 2 to 4 weeks for 3 to 4 sessions. Your doctor will monitor (check) the varices every 3 to 12 months after that for the rest of your life.

Endoscopic sclerotherapy

During endoscopic sclerotherapy, a chemical called a sclerosant may be injected directly into an enlarged vein or into the wall of the esophagus next to the enlarged veins. The substance causes inflammation of the inside lining of the vein, which over time causes the vein to close off and scar. When the vein is closed off, blood cannot flow through it.

Endoscopic sclerotherapy may be effective for stopping immediate (acute) bleeding caused by esophageal varices.

Sclerotherapy is still done in emergencies, but it is not as popular as it was in the past. More than before, doctors are using variceal banding to treat and prevent esophageal variceal bleeding. Even if sclerotherapy is done at first, variceal banding is usually done later to prevent future bleeding. Both procedures work. But variceal banding has less chance of complication than sclerotherapy.

Complications of endoscopic therapy

Complications of endoscopic sclerotherapy are not common. And complications of variceal banding are even less common. If complications do occur, they may include:

• Infection.
• Puncture of the wall of the esophagus (esophageal perforation).
• Sores in the esophagus (esophageal ulcers).
• Narrowing of the esophagus (esophageal stricture).
• Aspiration pneumonia.