Esophageal varices (EV) sclerotherapy
The efficacy of endoscopic sclerotherapy was first demonstrated by Swedish physicians Crafoord and Frenekuer in 1939, and gradually gained attention in the 1970s and clinical studies in the 1980s, and the efficacy was gradually confirmed.
1, indications: acute EV rupture bleeding; previous history of EV rupture bleeding; EV recurrence after surgery; those who are not suitable for surgical treatment. Liu Xiaofeng, Department of Gastroenterology, General Hospital of Jinan Military Region
2.Contraindications: hepatic encephalopathy stage R2; with serious liver and kidney dysfunction, large amount of ascites, severe jaundice, bleeding rescue may be flexible.
3.Preoperative preparation
Prepare for routine gastroscopy; for massive bleeding, apply pressure to stop bleeding with a three-chambered two-cystic tube, and administer blood and fluid transfusions and other anti-shock treatments; apply drugs to lower portal pressure such as posterior pituitary hormone, growth inhibitors and their derivatives as appropriate.
4.Apparatus preparation: gastroscope, sclerosing injection needle, commonly used sclerosing agent: 1% ethoxylated sclerosing alcohol; anhydrous alcohol can also be used.
5.Operation method: simple endoscopic freehand manipulation method; endoscopic end additional balloon injection sclerosing agent; sclerosing agent can be injected in the varicose vein or paravalvular + intravenous injection.
6.Injection method
(1) Intravenous injection: Injecting into the vein near the bleeding, and injecting into the varicose vein about 2cm above the dentate line if active bleeding is not found. Inject 3ml-10ml of sclerosing agent at each point, or increase or decrease as appropriate according to the degree of varicose veins, the total amount should not exceed 40ml. 1 point to 4 points each time, endoscopic observation after injection, to ensure no active bleeding when the mirror is withdrawn.
(2) Para-venous injection: Inject 0.5~1m1 of each dose under the mucosa around the varicose vein to form a bulge in the mucosa around the vein and compress the vein to achieve the purpose of auxiliary hemostasis.
7.Course of treatment: after the first sclerotherapy, the interval time is 1 week to about 10 days before the next sclerotherapy until the varicose vein disappears or basically disappears. The gastroscopy will be reviewed 1 month after the course of treatment, and the 2nd and 3rd gastroscopy will be reviewed every 3 months thereafter, and the 4th gastroscopy will be reviewed after an interval of 6 months.
8.Postoperative treatment
(1) Diet postoperative fasting for 8 hours, later into the liquid, strict dietary supervision within 2 weeks after surgery, into the liquid or no dregs of semi-liquid diet, forbidden to eat rough food.
(2) Prevent infection by applying antibiotics appropriately.
(3) Apply drugs to lower portal pressure such as oxytetracycline or growth inhibitors as appropriate.
(4) Use acid-suppressing drugs and esophageal mucosal protective agents.
(5) Monitor closely for complications such as ectopic embolism, bleeding, perforation, fever, and sepsis.
9. Complications
(1) Fever and injection-related infection: apply antibiotics appropriately after surgery.
(2) Posterior sternal pain: mostly seen and tolerated; those who cannot tolerate it can be injected intramuscularly with pethidine hydrochloride or prednisolone.
(3) Intraoperative bleeding: mostly caused by improper operation or failure of sclerosing agent to adequately occlude blood vessels.
(4) Esophageal stricture and esophageal ulcer: the latter can lead to late bleeding
(5) Esophageal perforation, ARDS and esophage-tracheal fistula: rare.
10.Application status and evaluation
(1) Sclerotherapy has a high rate of hemostasis for acute EV bleeding, and is safe and effective in controlling acute bleeding and preventing rebleeding.
(2) Complete disappearance of EV and good long-term efficacy are its non-negligible advantages.
(3) Intraoperative and long-term serious complications of sclerotherapy injection are relatively more than those of ligation, so more scholars advocate that ligation is preferred for esophageal varices.
(4) Ultrasound endoscopy-guided sclerotherapy through branch vessels is expected to further improve the immediate and long-term efficacy of sclerotherapy, which makes people re-examine the role and status of EV sclerotherapy.