Abstract
Endoscopic therapy is the primary treatment for esophageal varices. Endoscopic injection sclerotherapy (EIS) with 5% ethanolamine oleate with iopamidol (EOI) is one of the most commonly used techniques. A 25-gauge needle is used for injection. The balloon attached to the endoscope is inflated to over 30 cc and EOI should be injected into the varices near the gastroesophageal junction to prevent the EOI from flowing out of the varices hepatofugally. The injection is halted when the EOI just fills the esophagogastric varices and the supply veins, i.e. the left gastric and short gastric veins, as shown under fluoroscopic observation. At the initial treatment, most varices observed endoscopically can be treated. The amount of EOI injected varies according to the amount required to fill the varices and supply veins, but the maximum dose is 20 ml. Most of the complications occur in association with extravariceal injection of EOI. A severe complication such as perforation can occur if a large amount of EOI leaks into the muscular layer. Therefore, careful infusion of EOI under fluoroscopic observation is needed to avoid unwanted systemic distribution. Additional EIS should be performed if the varices enlarge or display the red color sign, indicating possible hemorrhage.
Endoscopic variceal ligation (EVL) has been considered to be a safe and noninvasive therapy. It is an appropriate procedure for acute variceal bleeding and for patients whose condition is severe. But if it is used alone, recurrence or worsening of varices over a short duration can occur. In combination with EIS it can produce good control for variceal bleeding.
Surgery may become necessary in patients with splenomegaly in whom esophageal variceal bleeding occurs after repeating EIS and EVL.
