Sclerotherapy of Fundic Varices TIPS and Operative Treatment

Principle and Key Characteristics

Principle: The varices are obliterated with a tissue adhesive. Sclerotherapy with cyanoacrylate (Histoacryl) is the treatment of choice for fundic varices (Fig. 4.16).

Materials

Endoscope Suction pumps Water jet

Disposable sclerotherapy needles, 6 mm long with 0.7 mm outer diameter

Histoacryl

Lipiodol

Protective eyewear Distilled water Silicone oil

Technique

► Use protective eyewear.

► Draw Histoacryl and Lipiodol (1:1) into a 2-mL syringe.

► Flush the sclerotherapy needle with distilled water (Histoacryl polymerizes on contact with electrolytes).

► Introduce silicone oil into the working channel.

► Retract the needle into the plastic sleeve, and wait one minute for the Histoacryl to polymerize before completely withdrawing the needle through the endoscope.

► If this is unsuccessful, insert a Linton-Nachlas tube.

Complications

► Histoacryl embolism

► Sclerotherapy ulcer

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Principle and Key Characteristics (Fig. 4.17)

Principle: A connection is established between the hepatic vein and intrahepatic portal vein branch.

A puncture needle is passed to the right hepatic vein through a transjugular catheter, and the intrahepatic portal vein branch is punctured. The puncture tract is dilated and then stabilized with an expanding stent.

Last recourse for refractory bleeding.

Operative Treatment

Principle and Key Characteristics

Principle: surgical creation of a portosystemic anastomosis. Not practical in emergency situations. Considerably higher mortality compared with TIPS.

Fig. 4.17 Schematic diagram of TIPS placement. The shunt establishes a connection between the hepatic vein and portal vein

Fig. 4.16 Sclerotherapy of fundic varices b Histoacryl is injected c Appearance after sclerotherapy with Histoacryl a The presumed bleeding site is identified (varix with a "red spot")

■ Incidence and Symptoms

Fifty percent of all acute upper gastrointestinal hemorrhages are caused by a bleeding ulcer (Fig. 4.18). It is estimated that approximately 20% of all patients with recurrent gastric or duodenal ulcers experience bleeding. This may be an oozing hemorrhage with gradual progression of anemia or may present as an acute, massive, life-threatening hemorrhage.

The symptoms are variable and may be very subtle, particularly in NSAID users. Approximately 80% of bleeding ulcers will stop bleeding spontaneously, and 20% of those will rebleed. The mortality rate is 6-15 %. Acute bleeding can be successfully controlled by endoscopic treatment in over 85 % of cases. The risk of recurrence after primary hemostasis is 20-25%.

■ Indications for Endoscopic Treatment

The Forrest classification is used in selecting patients for endoscopic treatment (Table 4.9; Figs. 4.19, 4.20). Treatment is indicated for Forrest classes Ia and Ib, which are actively bleeding lesions, and for a high percentage of recurrent ulcers of class Ila. For class IIb lesions, an effort is made to flush away the adherent clot. If this is successful, the treatment decision is based on the new finding. Removing the clot may induce active bleeding, leave a "visible vessel," or expose a hematin- or fibrin-covered ulcer base.

If the bleeding cannot be controlled endoscopically, prompt operative treatment is indicated.

■ Nonoperative Treatment Methods

The following nonoperative treatment modalities are used:

► Pharmacological therapy

► Endoscopic techniques

- Injection therapy: epinephrine, physiological saline solution, polidocanol, ethanol, fibrin glue

- Hemostatic clips

- Thermal methods: laser, electrocoagulation, argon plasma coagulation

Table 4.9 Forrest classification

Fig. 4.18 Bleeding gastric ulcer

Table 4.9 Forrest classification

Class

Bleeding activity

Risk of rebleeding

(%%)

I

Active bleeding

Ia

Spurting hemorrhage

90

Ib

Oozing hemorrhage

30

II

Signs of hemorrhage without

active bleeding

IIa

Visible vessel

50-100

IIb

Adherent clot

20

IIc

Hematin on ulcer base

<5

III

Ulcer base with no signs of

<5

bleeding

Forrest Class I-IIa lesions are an indication for endoscopic treatment

Forrest Class I-IIa lesions are an indication for endoscopic treatment

Clot (IIb)

1

Removable by irrigation

Spurting hemorrhage

Oozing hemorrhage

Visible vessel

Hematin on ulcer base

Not removable by irrigation

Ulcer base with no signs of hemorrhage

Endoscopic treatment

No endoscopic treatment

Fig. 4.19 Flowchart for management of an adherent clot

Fig. 4.20 Forrest classification of acute ulcer bleeding a Class Ia: spurting hemorrhage

Fig. 4.20 Forrest classification of acute ulcer bleeding a Class Ia: spurting hemorrhage

b Class Ib: oozing hemorrhage
c Class IIa: visible vessel

d Class IIb: clot adherent to the ulcer

e Class IIc: hematin on the ulcer

f Class III: fibrin-covered ulcer with no signs of hemorrhage

Fig. 4.21 Epinephrine injection for acute ulcer bleeding a Two bleeding ulcers (smaller one at the center, larger one at approximately the 5-o'clock position)

Fig. 4.21 Epinephrine injection for acute ulcer bleeding a Two bleeding ulcers (smaller one at the center, larger one at approximately the 5-o'clock position)

Epinephrine is injected around the base of the larger ulcer

c Appearance after injection

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