Management of acute esophageal variceal bleeding by endoscopic sclerotherapy in technically difficult endoscopic band ligation cases—A population based cohort study

doi:10.4236/ojgas.2013.35048

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Open Journal of Gastroenterology, 2013, 3, 281-287 OJGas

http://dx.doi.org/10.4236/ojgas.2013.35048 Published Online September 2013 (http://www.scirp.org/journal/ojgas/)

Management of ac ute esophageal variceal b le ed i ng by

endoscopic sclerotherapy in technically difficult endoscopic

band ligation cases—A population based cohort study

Gamal E. Esmat1, Iman M. Hamza1*, Bahaa E. Abbas2, Ahmed M. Hashem1, Hossam S. Ghoneim3

1Endemic Medicine Department, Division of Endoscopy, Cairo University, Giza, Egypt

2Division of Endoscopy, Air Force Hospital, Cairo, Egypt

3Tropical Medicine Department, Beni Sweif University, Cairo, Egypt

Email: *[email protected]

Received 14 June 2013; revised 15 July 2013; accepted 29 July 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Endoscopic band ligation is regarded as the main

therapeutic option for acute esophageal variceal bleed-

ing, while sclerotherapy may be used in the acute set-

ting if ligation is technically difficult. The incidence of

difficult-to-perform band ligation in acute esophageal

variceal bleeding, as well as the outcome of patients

subjected to injection sclerotherapy as an alternative

treatment, has not been clearly investigated. Our aim

is to study the outcome of patients subjected to injec-

tion sclerotherapy in the acute setting of esophageal

variceal bleeding when endoscopic band ligation is

technically difficult to perform. We included 151 pa-

tients with acute esophageal variceal bleeding origin-

nating from medium or large sized varices. All pa-

tients were planned for EBL as the 1st treatment op-

tion (EBL group 61.6%), meanwhile, EIS using 5%

ethanolamine oleate was reserved as the 2nd treat-

ment option when EBL was technically difficult (EIS

group 38.4%). The mean time to restore hemody-

namic stability was significantly prolonged in the EIS

group (11.5 ± 6.5 hrs versus 9.5 ± 5.0 hrs, p 0.05). Ini-

tial control of bleeding was significantly higher in the

EBL group versus the EIS group (96.7% vs 84.5%, p

0.021). Re-bleeding was more among the EIS group

(42.9% vs 24.2%, p 0.04). There were no significant

differences as regarding mortality and duration of

hospital stay. So, a considerable proportion of cases

presenting with acute variceal bleeding will have dif-

ficulty in performing EBL. In these patients, sclero-

therapy is not a waning procedure with an accepted

success rate, without much additional complications

and without dera nging mortality.

Keywords: Esophageal Varices; Band Ligation;

Injection Sclerotherapy

1. INTRODUCTION

The management of acute variceal bleeding remains a

clinical challenge. Regarding the best endoscopic thera-

peutic option, a meta-analysis of 10 randomized con-

trolled trials including 404 patients showed an almost

significant benefit of endoscopic band ligation in the

initial control of bleeding compared to sclerotherapy [1].

At the same time, Baveno IV and V consensuses had re-

peatedly confirmed that ligation is the recommended me-

thod of endoscopic therapy for acute esophageal variceal

bleeding although sclerotherapy may be used in the acute

setting if ligation is technically difficult [2,3].

The incidence of difficulty to perform band ligation in

acute esophageal variceal bleeding, as well as the out-

come of patients subjected to injection sclerotherapy as

an alternative treatment, has not been clearly investi-

gated.

2. AIM OF THE WORK

Our aim is to study the outcome of patients subjected to

injection sclerotherapy in the setting of acute esophageal

variceal bleeding in case of technical difficulty to per-

form band ligation.

3. PATIENTS AND METHODS

This study was approved by the Hepatogastroenterology

Department and the Research Board of Cairo University.

It included 151 patients with acute bleeding from eso-

phageal varices originating from medium and large sized

varices. They were admitted to Gastroenterology unit of

*Corresponding author.

OPEN ACCESS

G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287

282

Air force Hospital, Cairo; during the period from 15

January 2010 till 15 July same year. Patients with bleed-

ing gastric varices, bleeding small sized oesophageal

varices, bleeding portal hypertensive gastropathy, hepatic

coma or hepatocellular carcinoma were not included in

the study.

Patients were resuscitated after relevant history taking

and clinical examination. Stabilization of hemodynamics

was firstly performed. Blood transfusion was initiated

depending upon the severity of bleeding and hemo-dy-

namic status with a transfusion target hematocrit of 24%

and/or hemoglobin of 8 g/dl. I.V antibiotics were rou-

tinely given. Octreotide was started whenever indicated

in a dose of 50 μg IV bolus, followed by continuous in-

fusion 50 μg/hr for 2 - 5 days. Further assessment was

done including laboratory investigations and abdominal

ultrasonography. The severity of bleeding was consid-

ered as: mild when pulse rate <100/min, orthostatic hy-

potension or cold extremities, moderate when pulse rate

100 - 120 beats/min with restlessness or severe when

pulse rate >120 beats/min, systolic blood pressure <60

mmHg, severe pallor or oliguria [4]. Endoscopy session

was scheduled once the patient’s hemodynamics permit-

ted after an informed and written consent. Emergency

endotherapy was performed by a single endoscopist, all

patients were planned for endoscopic band ligation (EBL)

using the Saeed multi-band ligators manufactured by the

Wilson-Cook Medical GI endoscopy company as the 1st

treatment option to control the acute bleeding episode

(EBL group) (Figure 1), meanwhile, endoscopic injec-

tion sclerotherapy (EIS) using ethanolamine oleate was

reserved as a 2nd treatment option when EBL was tech-

nically difficult (only when the view of the bleeding

source was obscured) (sclerotherapy group) (Figure 2).

Varices were assigned grades according to their shape

and size: grade F1, small straight veins; grade F2,

Figure 1. EVL to bleeding varices.

Figure 2. Sclerotherapy for bleeding varices.

slightly enlarged tortuous veins occupying less than one-

third of the esophageal lumen; and grade F3, large coil-

shaped varices that occupied more than one-third of the

esophageal lumen [5].

The assessment for treatment side-effects was per-

formed during hospital stay and included monitoring of

symptoms, physical examination and laboratory data.

Complications were defined as untoward events related

to treatment and require active therapy or prolonged hos-

pitalization. All available patients in both groups were

followed up for 42 days for clinical assessment, variceal

re-bleeding, and hepatic de-compensation. Failure to

control active bleeding was considered according to the

UK guidelines [6] as transfusion requirement of 4 units

or more and inability to achieve an increase in systolic

blood pressure by 20 mm Hg or to 70 mm Hg or more,

and/or inability to achieve a pulse rate reduction to less

than 100 beat/min or a reduction of 20 beat/min from

baseline pulse rate (within the first six hours). Or the

occurrence of haematemesis from the six hour point,

reduction in blood pressure of more than 20 mm Hg from

the six hour point and/or increase in pulse rate of more

than 20 beat/min from the six hour point on two con-

secutive readings an hour apart, transfusion of 2 units of

blood or more (over and above the previous transfusions)

required to increase the haematocrit to above 27%, or

haemoglobin to above 9 g/l. Re-bleeding: was considered

as the occurrence of new hematemesis or melena after a

period of 24 hours or more of stable vital signs and he-

matocrit/hemoglobin following an episode of acute bleed-

ing up to 42 days from the acute bleeding episode. Stop-

page of bleeding: is considered when there is no he-

matemesis, stable hemoglobin concentration without blood

transfusions, stable hemodynamic conditions at the be-

ginning of the first 24-hour interval from time zero [2].

G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287

283

OPEN ACCESS

Patients’ data were tabulated and processed using

SPSS (10.0) statistical package. Quantitative variables

were expressed by means and standard deviation. While

qualitative data were expressed by frequency and percent.

Qualitative variables were analyzed using Chi-square or

Ficher’s exact test when appropriate. Quantitative vari-

ables were analyzed using student’s T-test or Fried-

mann’s test when appropriate. In all tests p value was

significant when <0.05.

4. RESULTS

This study included 151 patients with acute esophageal

variceal bleeding. They were sub-grouped based on the

type of endoscopic intervention into EBL (band ligation)

group (93 patients 61.6%) and EIS (sclerotherapy group)

(58 patients 38.4%).

The majority of patients in the EBL group had a mild

bleeding episode (64.5%) versus none in the sclerother-

apy group. While the majority of those in the scerother-

apy group had a moderate bleeding episode (67.2%, p

0.38). Time from admission to patient stabilization was

significantly prolonged in the EIS group 11.5 ± 6.5 hrs

versus 9.5 ± 5.0 hrs (p 0.05) (Tab le 1). The post endo-

scopy outcome is demonstrated in (Table 2).

5. DISCUSSION

Bleeding from esophageal varices is a life-threatening

complication of portal hypertension which accounts for

most of cirrhosis-related mortalities [7,8]. Endoscopic

therapy is an integral component of the management of

acute variceal bleeding as well as prevention of recurrent

bleeding [8,9]. Since it first evolved as a new therapeutic

option, EBL has been regarded as a more effective mo-

dality than endoscopic injection sclerotherapy in the con-

trol of acute hemorrhage with less reported adverse

events [10-12]. On the other hand, some studies still ad-

vocate the use of sclerotherapy as a better treatment op-

tion up to regarding it as the gold-standard treatment

[13,14].

Despite the routine standard of care given to patients

presenting with hematemesis such as pharmacotherapy

and gastric lavage, still up to one third of cases are ac-

tively bleeding during endoscopy, and it is this group of

patients that poses a challenge to endoscopists and en-

Table 1. Base-line characteristics of EIS and EVL groups.

EVL group

N: 93 (61.6%)

EIS Group

N: 58 (38.4%)

Parameters

No/% Mean/SD No/% Mean/SD

Age (years) 52 ±3 53 ±3 0.89

Sex

Male 52 56% 42 72.5%

Female 41 44% 16 27.5%

0.33

Previous bleeding attacks 48 51.6% 33 56.9% 0.63

Child Pugh class:

A 9 9.7% 4 6.9%

B 37 39.8% 25 43.1%

C 47 50.5% 29 50%

0.057

Grade of varices

Grade F2 48 51.6% 28 48.2%

Grade F3 45 48% 30 51.7%%

0.85

Hemodynamic instability 81 87.1% 53 91.4% 0.53

Severity of bleeding

Mild 60 64.5% 0 0%

Moderate 24 25.8% 39 67.2%

Severe 9 9.7% 19 32.8%

<0.01

Time from admission to endoscopy (hrs) 9.5 ±5 11.5 ±6.5 0.05

G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287

284

Table 2. Post-endoscopy outcome in both groups.

EVL group

N: 93 (61.6%)

EIS Group

N: 58 (38.4%)

Parameters

No/% Mean/SD No/% Mean/SD

Control of acute bleeding 90 96.7% 49 84.5% 0.021

Re-bleeding 22 24.2% 21 42.9% 0.04

Control of re-bleeding 17/22 77.35 11/19 57.9% 0.23

Incidence of complications among

different child-Pugh cases

Child A 1 1.1% 2 3.4%

Child B 8 8.6% 14 24.1%

Child C 6 6.4% 13 22.4%

0.079

Bacterial peritonitis 6 6.4% 11 19% 0.01

Aspiration pneumonia 0 0% 1 1.7% 0.41

Sepsis 1 1.1% 2 3.4% 0.065

Bleeding esophageal ulcer 1 1.1% 2 3.4% 0.065

Chest pain 2 2.2% 5 8.6% 0.01

Fever 1 1.1% 2 3.4% 0.065

Transient arrhythmias 1 1.1% 1 1.7% 0.1

Nausea 1 1.1% 2 3.4% 0.068

Transient dysphagia 2 2.2% 3 5.2% 0.012

Mean hemoglobin (gm/dl)

Day 1 8.6 ±0.34 8.1 ±0.36 0.18

Day 5 8.8 ±0.34 8.4 ±0.31 0.45

Units of packed RBCs 3.1 ±1.07 4.1 ±1.2 0.01

Hospital stay in days 8.3 ±1.9 9.1 ±2.6 0.27

Total Mortality 19 20.4% 21 36.2% 0.19

dangers the life of the patient as it has been found to

have a negative impact on survival [7,15,16]. In this

situation banding may be technically difficult to perform

in the presence of continued bleeding, and sclerotherapy

may then be necessary [2,3,9,17]. So this means that,

whether endoscopists fall for band ligation or sclero-

therapy as the preferred treatment, the set up of an emer-

gency endoscopic unit should be equipped with both and

the endoscopists should be ready to switch between the 2

modalities.

How frequent is this situation encountered, what is the

outcome and what are the sequaele, remained to be in-

vestigated. This was the rational to conduct this study. It

was carried in the Air Force hospital on 151 patients with

acute variceal bleeding. All included patients had acute

esophageal variceal bleeding from medium or large sized

varices, while other portal hypertensive bleeding sources

were not included. To ensure homogeneity among these

patients, they were all given the same standards of care

such as gastric lavage and pharmacotherapy with oc-

terotide and judicious volume expanders. All of them

underwent endoscopy whenever they reached hemodya-

mic stability irrespective of time and all were endo-

scoped by a single operator. The plan at the time of en-

doscopy was to perform band ligation as a primary treat-

ment option unless profuse bleeding was encountered to

the extent of posing technical difficulty in visualizing

and banding the bleeding varix, in the latter condition,

switch to sclerotherapy was done.

The studied cases in both groups were comparable in

terms of their demographic features. All patients had

received pharmacotherapy by octerotide and yet, 38.4%

of the studied cases were actively bleeding at endoscopy,

profusely enough, to change the decision of treatment

G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287 285

from band ligation to sclerotherapy. Terblanche et al.

[16], stated that one third of cases are actively bleeding

at the time of endoscopy, this finding was made before

the advent of octreotide as a recommended treatment. In

our study although octreotide was given, still a subset of

patients similar to those reported by Terblanche were

bleeding profusely at the time of endoscopy (38%). Ac-

tually the therapeutic effects of octreotide on the portal

and systemic hemmodynamics in patients with liver cir-

rhosis have yielded conflicting results, while some au-

thors showed beneficial effects on the portal hemody-

namics, others failed to show any beneficial effects. In an

interesting study, Baik et al. [18] demonstrated that in

patients with acute variceal bleeding, the main effect of

octreotide on the HVPG was during the first minute after

therapy, whereas thereafter the effect is not sustained and

soon the HVPG reverts to base line after 5 mins of ther-

apy. This might explain why patients were still bleeding

during endoscopy.

The profuse bleeding at the time of endoscopy (as

represented in the sclerotherapy group) was not influ-

enced by the severity of liver disease (as both groups

were comparable regarding Child-Pugh class), nor by the

grade of varices at the time of endoscopy probably be-

cause bleeding might have temporarily reduced variceal

size during endoscopy.

All patients underwent endoscopy after attaining he-

modynamic stability, and yet the majority of these pa-

tients were hemodynamically unstable at the time of pre-

sentation (87.1% in the EBL group and 91.4% in the

scerotherapy group), this emphasizes the role of the pre-

endoscopic standards of care given to the patients like

volume restitution and maintaining the aerobic metabo-

lism by restoring an appropriate delivery of oxygen to

the tissues (which depends on oxygen saturation, cardiac

output, and hemoglobin concentration) [19]. This also

explains why the scerotherapy group underwent endo-

scopy after a significantly longer time than the EBL

group (9.5 ± 5 hrs in the EBL group versus 11.5 ± 6.5 hrs

in the sclerotherapy group) and had a significantly more

amount of transfused packed RBCs as compared to the

EBL group (4.1 ± 1.2, versus 3.1 ± 1.07; p 0.01).

The next point to highlight in this study is the outcome

of patients following the emergency endoscopy, it is

clear that rapid switching from conventional EBL to

sclerotherapy in our patients saved the time that could

have been spent over getting a clear view so as to per-

form EBL, which of course could have endangered the

patients' lives. That is why there were no reported dif-

ferences in the mortalities between the 2 groups nor the

duration of hospital stay. However, some of the unfavor-

able outcomes were significantly reported among the

sclerotherapy than the EBL groups. The initial success to

control bleeding for both techniques is compatible with

the universally reported figures (around 90%) [20]. How-

ever, it was significantly higher in the EBL versus EIS

groups (96.7% versus 84.5%; p 0.02). Also, bleeding re-

currence was significantly less in the EBL versus the EIS

groups (24.2% versus 42.9%; p 0.04). Lo et al. [7], re-

ported 17% rate of re-bleeding with EBL vs. 33% with

EIS, Villanueva et al. [11], reported 12% incidence rate

for re-bleeding for EBL versus 21% for EIS. Krige et al.

[14], reported that even under optimal conditions, cur-

rently available treatment options fail to control initial

variceal bleeding or prevent early re-bleeding in up to

20% of patients. The overall analysis of these figures

reveals that they match those reported by other authors.

However, it is important to emphasize that these studies

were randomized and it is supposed that patients with

severe bleeding were homogenously distributed among

both the EBL and EIS groups. This was not the case in

this study, where the EIS group was a special grouping

for those who were actively bleeding and difficult to

perform EBL as explained by the significantly higher in-

cidence of moderate and severe bleeding attacks among

the EIS group. So the less success rates we encountered

in this situation, where the technique might have been

deranged due to the severe bleeding, is rather accepted.

On the other hand, since the severity of the initial re-

bleed has been one of the contributing factors to recur-

rent bleeding [21], this again explains why the sclero-

therapy group had a higher incidence of variceal re-

bleeding.

The other reported adverse events like chest pain, dys-

phagia and bacterial peritonitis were significantly higher

in the EIS than the EBL group. These can be attributed

mainly to the type of the technique and to a less extent to

the severity of bleeding. Randomized trials that com-

pared EBL to scerotherapy have yielded similar findings,

without essentially having difference in the severity of

bleeding between both arms. Most of these studies have

reported that EBL is generally a safer technique than EIS

because it involves a mechanical, less invasive method of

variceal obliteration with less systemic and local com-

plications involving the esophageal wall [7,11,22-29].

For example our data of peritonitis were 19% with EIS

versus 6.4% with EBL (p 0.01). This matches with Laine

et al. [24], who reported 18% incidence rate of peritonitis

in EIS vs. 15.8% in EBL.

6. CONCLUSION

About one third of cases presenting with acute variceal

bleeding will have difficult-to-perform EBL due to the

severity of active bleeding at the time of endoscopy. In

these patients, sclerotherapy is not a waning procedure

and is still a technique that can be resorted to with an

accepted success rate, without additional complications

and without deranging mortality.

G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287

286

7. ACKNOWLEDGEMENTS

The authors appreciate the contribution made by Dr Mohamed El-

Gouhary in the execution of this work

REFERENCES

[1] Garcia-Pagan, J.C. and Bosch, J. (2005) Endoscopic band

ligation in the treatment of portal hypertension. Nature

Clinical Practice Gastroenterology & Hepatology, 2, 526-

535. doi:10.1038/ncpgasthep0323

[2] De Franchis, R. (2005) Evolving consensus in portal hy-

pertension. Report of the Baveno IV consensus workshop

on methodology of diagnosis and therapy in portal hy-

pertension. Journal of Hepatology, 43, 167-176.

doi:10.1016/j.jhep.2005.05.009

[3] De Franchis, R., Bosch, J., Burroughs, A.K., D’Amico G.,

Garcia-Tsao, G., Grace, N.D., et al. (2010) Revising con-

sensus in portal hypertension: Report of the Baveno V

consensus workshop on methodology of diagnosis and

therapy in portal hypertension. Journal of Hepatology, 53,

762-768. doi:10.1016/j.jhep.2010.06.004

[4] Del Olmo, J.A., Peña, A., Serra, M.A., Wassel, A.H.,

Benages, A. and Rodrigo, J.M. (2000) Predictors of mor-

bidity and mortality after the first episode of upper gas-

trointestinal bleeding in liver cirrhosis. Journal of Hepa-

tology, 32, 19-24. doi:10.1016/S0168-8278(01)68827-5

[5] Japanese Research Society for Portal Hypertension (1980)

The general rules for recording endoscopic findings on

esophageal varices. Japanese Journal of Surgery, 10, 84-

87. doi:10.1007/BF02468653

[6] Jalan, R. and Hayes, P.C. (2000) UK guidelines on the

management of variceal haemorrhage in cirrhotic patients.

Gut, 46, iii1-iii15. doi:10.1136/gut.46.suppl_3.iii1

[7] Lo, G.H., Lai, K.H., Cheng, J.S., Lin, C.K., Huang, J.S.,

Hsu, P.I., et al. (1997) Emergency banding ligation ver-

sus sclerotherapy for the control of active bleeding from

esophageal varices. Hepatology, 25, 1101-1104.

doi:10.1002/hep.510250509

[8] Krige, J.E., Shaw, J.M. and Bornman, P.C. (2005) The

evolving role of endoscopic treatment for bleeding eso-

phageal varices. World Journal of Surgery, 29, 966-973.

doi:10.1007/s00268-005-0138-2

[9] Garcia-Tsao, G., Sanyal, A.J., Grace, N.D. and Carey, W.

(2007) Prevention and management of gastroesophageal

varices and variceal hemorrhage in cirrhosis. Hepatology,

46, 922-938. doi:10.1002/hep.21907

[10] Avgerinos, A., Armonis, A., Stefanidis, G., Mathou, N.,

Vlachogiannakos, J., Kougioumtzian, A., et al. (2004)

Sustained rise of portal pressure after sclerotherapy, but

not band ligation, in acute variceal bleeding in cirrhosis.

Hepatology, 39, 1623-1630. doi:10.1002/hep.20236

[11] Villanueva, C., Piqueras, M., Aracil, C., Gómez, C., Ló-

pez-Balaguer, J.M., Gonzalez, B., et al. (2006) A ran-

domized controlled trial comparing ligation and sclero-

therapy as emergency endoscopic treatment added to so-

matostatin in acute variceal bleeding. Journal of Hepa-

tology, 45, 560-567. doi:10.1016/j.jhep.2006.05.016

[12] Garcia-Tsao, G., Bosch, J. and Groszmann, R.J. (2008)

Portal hypertension and variceal bleeding—Unresolved

issues. Summary of an American Association for the

study of liver diseases and European Association for the

study of the liver single-topic conference. Hepatology, 47,

1764-1772. doi:10.1002/hep.22273

[13] Burroughs, A.K. and Triantos, C.K. (2008) Predicting

failure to control bleeding and mortality in acute variceal

bleeding. Journal of Hepatology, 48, 185-188.

doi:10.1016/j.jhep.2007.11.006

[14] Krige, J.E., Shaw, J.M., Bornman, P.C. and Kotze, U.K.

(2009) Early re-bleeding and death at 6 weeks in alco-

holic cirrhotic patients with acute variceal bleeding

treated with emergency endoscopic injection sclerother-

apy. South African Journal of Surgery, 47, 72-74,76-79.

[15] Cello, J.P., Grendell, J.H., Crass, R.A., Trunkey, D.D.,

Cobb, E.E. and Heilbron, D.C. (1984) Endoscopic scle-

rotherapy versus portacaval shunt in patients with severe

cirrhosis and variceal hemorrhage. New England Journal

of Medicine, 311, 1589-1594.

doi:10.1056/NEJM198412203112501

[16] Terblanche, J., Kahn, D. and Bornman, P.C. (1989) Long-

term injection sclerotherapy treatment for esophageal

varices. A 10-year prospective evaluation. Annals of Sur-

gery, 210, 725-731.

doi:10.1097/00000658-198912000-00006

[17] Bendtsen, F., Krag, A. and Møller, S. (2008) Treatment

of acute variceal bleeding. Digestive and Liver Disease,

40, 328-336. doi:10.1016/j.dld.2007.12.005

[18] Baik, S.K., Jeong, P.H., Ji, S.W., Yoo, B.S., Kim, H.S.,

Lee, D.K., et al. (2005) Acute hemodynamic effects of

octreotide and terlipressin in patients with cirrhosis: A

randomized comparison. American Journal of Gastroen-

terology, 100, 631-635.

doi:10.1111/j.1572-0241.2005.41381.x

[19] García-Pagán, J.C., Reverter, E., Abraldes, J.G. and

Bosch, J. (2012) Acute variceal bleeding. Seminars in

Respiratory and Critical Care Medicine, 33, 46-54.

doi:10.1055/s-0032-1301734

[20] Sarin, S.K., Govil, A., Jain, A.K., Guptan, R.C., Issar,

S.K., Jain, M., et al. (1997) Prospective randomized trial

of endoscopic sclerotherapy versus variceal band ligation

for esophageal varices: Influence on gastropathy, gastric

varices andvariceal recurrence. Journal of Hepatology, 26,

826-832. doi:10.1016/S0168-8278(97)80248-6

[21] de Franchis, R. and Primignani, M. (2001) Natural his-

tory of portal hypertension in patients with cirrhosis.

Clinics in Liver Disease, 5, 645-663.

doi:10.1016/S1089-3261(05)70186-0

[22] Stiegmann, G.V., Goff, J.S., Michaletz-Onody, P.A.,

Korula, J., Lieberman, D., Saeed, Z.A., et al. (1992) En-

doscopic sclerotherapy as compared with endoscopic li-

gation for bleeding esophageal varices. New England

Journal of Medicine, 326, 1527-1532.

doi:10.1056/NEJM199206043262304

[23] Jensen, D.M., Kovacs, T.O.G. and Randall, G.M. (1993)

Initial results of randomised prospective study of emer-

gency banding versus esclerotherapy for bleeding gastric

or esophageal varices. Gastrointestinal Endoscopy, 39.

G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287

287

OPEN ACCESS

[24] Laine, L., El-Newihi, H.M. and Migikovsky, B. (1993)

Endoscopic ligation compared with sclerotherapy for the

treatment of bleeding esophageal varices. Annals of In-

ternal Medicine, 119, 1-7.

doi:10.7326/0003-4819-119-1-199307010-00001

[25] Lo, G.H., Lai, K.H., Chang, C.F., Shen, M.T., Jeng, J.S.,

Huang, R.L., et al. (1994) Endoscopic injection sclero-

therapy vs. endoscopic variceal ligation in arresting acute

variceal bleeding for patients with advanced hepatocellu-

lar carcinoma. Journal of Hepatology, 21, 1048-1052.

doi:10.1016/S0168-8278(05)80616-6

[26] De la Peña, J., Rivero, M., Sanchez, E., Fábrega, E., Cre-

spo, J. and Pons-Romero, F. (1999) Variceal ligation

compared with endoscopic sclerotherapy for variceal

hemorrhage: Prospective randomized trial. Gastrointes-

tinal Endoscopy , 49, 417-423.

doi:10.1016/S0016-5107(99)70036-2

[27] Patch, D. and Dagher, L. (2001) Acute variceal bleeding:

General management. World Journal of Gastroenterology,

7, 466-475.

[28] Zargar, S.A., Javid, G., Khan, B.A., Shah, O.J., Yattoo,

G.N., Shah, A.H., et al. (2005) Endoscopic ligation vs.

sclerotherapy in adults with extrahepatic portal venous

obstruction: A prospective randomized study. Gastroin-

testinal Endoscopy, 61, 58-66.

doi:10.1016/S0016-5107(04)02455-1

[29] Xu, L., Ji, F., Xu, Q.-W. and Zhang, M.-Q. (2011) Risk

factors for predicting early variceal re-bleeding after en-

doscopic variceal ligation. World Journal of Gastroen-

terology, 17, 3347-3352. doi:10.3748/wjg.v17.i28.3347