Sclerotherapy for esophageal varices (also called endoscopic sclerotherapy)

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Upper Endoscopy The digestive system Upper endoscopy enables the physician to look inside the esophagus, stomach, and duodenum (first part of the small intestine). The procedure might be used to discover the reason for swallowing difficulties, nausea, vomiting, reflux, bleeding, indigestion, abdominal pain, or chest pain. Upper endoscopy is also called EGD, which stands for esophagogastroduodenoscopy (eh-SAH-fuh-goh-GAS-troh-doo-AH-duh-NAH-skuh-pee). For the procedure you will swallow a thin, flexible, lighted tube called an endoscope (EN-doh-skope). Right before the procedure the physician will spray your throat with a numbing agent that may help prevent gagging. You may also receive pain medicine and a sedative to help you relax during the exam. The endoscope transmits an image of the inside of the esophagus, stomach, and duodenum, so the physician can carefully examine the lining of these organs. The scope also blows air into the stomach; this expands the folds of tissue and makes it easier for the physician to examine the stomach. The physician can see abnormalities, like inflammation or bleeding, through the endoscope that don't show up well on x rays. The physician can also insert instruments into the scope to remove samples of tissue (biopsy) for further tests or treat bleeding abnormalities. Possible complications of upper endoscopy include bleeding and puncture of the stomach lining. However, such complications are rare. Most people will probably have nothing more than a mild sore throat after the procedure. The procedure takes 20 to 30 minutes. Because you will be sedated, you will need to rest at the endoscopy facility for 1 to 2 hours until the medication wears off. Preparation Your stomach and duodenum must be empty for the procedure to be thorough and safe, so you will not be able to eat or drink anything for at least 6 hours beforehand. Also, you must arrange for someone to take you home--you will not be allowed to drive because of the sedatives. Your physician may give you other special instructions.

Esophageal Strictures

The esophagus is a relatively simple tubular structure connecting the throat to the stomach. The major functions of the stomach are to transport ingested food from the oropharynx to the stomach and to prevent regurgitation of food and gastric contents from the stomach back up into the esophagus. At the same time it allows air to be vented out of the stomach thus relieving abdominal bloating. On occasion, a narrowed area will occur in the esophagus resulting in an interruption in the normal swallowing mechanism. This may result in dysphagia or difficulty swallowing. Passage of food or liquid may be impaired through the esophagus with a sensation of a fullness in the chest, pressure-like sensation, shortness of breath and inability to swallow food, liquids or saliva. In many cases this is transient in nature and may only last a short time but on occasion may be prolonged requiring emergent intervention.

This narrowing of the esophagus can be caused by many different conditions. The most common of which is a benign stricture. This is the result of peptic esophagitis or gastroesophageal reflux disease and can occur at any age but is more common after the age of 40. The fundamental abnormality is excessive acid reflux from the stomach up into the esophagus resulting in an inflammatory reaction in the lower esophagus that leads to scarring after repeated injury and healing. Eventually, scar tissue is formed and a benign stricture develops which is in the form of a concentric ring that narrows the opening of the esophagus. A hiatal hernia is often present in association with the reflux. This concentric lower esophageal ring sometimes called a Schatzki's ring often occurs at the junction between the esophagus and the stomach and sometimes can be present for years. When diagnosed, it can be easily treated by passage of a dilator through the area to break open the scar tissue and relieve the narrowed area.

Other causes of benign esophageal strictures may be congenital in nature such as a membranous diaphragm or web that can occur anywhere in the esophagus but frequently occurs in the upper portion. This is also treated by dilation either through an endoscope or by passage of Bougie dilator. Other conditions leading to benign strictures include corrosive injury to the esophagus from ingestion of a toxic substance (i.e. cleaning solutions, radiation injury to the esophagus, post surgical strictures, or achalasia, which is a gradual thickening of the musculature at the lower end of the esophagus).

Other conditions could cause dysphagia (difficulty swallowing), even though no stricture is present. In that case, various neurological conditions, vascular abnormalities, diverticulum, spastic motility disorders, or skeletal muscle disorders like muscular dystrophy and myasthenia gravis are possibilities.

In addition to the above, a malignant condition may develop causing a stricture or narrowing of the esophagus. There are about 11,000 new cases of cancer of the esophagus diagnosed yearly and is correlated with smoking or excessive alcohol ingestion, particularly in young adulthood. It is more frequent in men than women and also more frequent in blacks than whites. Esophageal cancer can develop anywhere along the esophagus but is more frequent in the lower portion. A condition called Barrett's esophagus may occur in the lower esophagus due to chronic gastroesophageal reflux disease. This condition is diagnosed by esophageal biopsy and is reflected by a change in the cellular structure of the lower esophagus. Patients who have this condition are at higher risk for developing adenocarcinoma of the lower esophagus and must be screened by performing upper endoscopy on a regular basis.

Treatment of a benign esophageal stricture consists of esophageal dilation. This is most commonly done at the time of an upper endoscopy. The upper endoscopy is where a video endoscope is placed through the mouth into the esophagus while the patient is under an IV sedation. The esophagus is then examined and if a benign stricture is present it can be dilated in various ways. A balloon dilator passed through the endoscope is often inflated within the confines of the stricture, thus opening the area and relieving the patient's symptoms. Other types of dilators may also be passed although not through the endoscope. These are called Mallony or savory dilators in increasing sizes in order to break open the stricture. In either case, the patients are sedated and should not feel anything during the procedure. The risks of a dilation include potential bleeding, infection or a tear. If a tear is deep enough, on rare occasion, it might require surgical repair.

Treatment of a malignant stricture of the esophagus is available but can often be disappointing. If the malignancy is determined to be small and localized without any spread beyond the esophagus then a surgical repair is often opted for and may, on rare occasion cure the cancer. If the tumor is not curable, then often, palliative treatments are employed which include chemotherapy, radiation therapy, esophageal dilation, laser treatments, injections, tumor probes or placement of an esophageal stent (wire mesh tube) to keep the esophagus open. In any situation the patient must work closely with his or her physician to decide what is the best approach for that individual since it varies from patient to patient.

ERCP (Endoscopic Retrograde Cholangiopancreatography)

The digestive system

Endoscopic retrograde cholangiopancreatography (en-doh-SKAH-pik REH-troh-grayd koh-LAN-jee-oh-PANG-kree-uh-TAH-gruh-fee) (ERCP) enables the physician to diagnose problems in the liver, gallbladder, bile ducts, and pancreas. The liver is a large organ that, among other things, makes a liquid called bile that helps with digestion. The gallbladder is a small, pear-shaped organ that stores bile until it is needed for digestion. The bile ducts are tubes that carry bile from the liver to the gallbladder and small intestine. These ducts are sometimes called the biliary tree. The pancreas is a large gland that produces chemicals that help with digestion and hormones such as insulin.

ERCP is used primarily to diagnose and treat conditions of the bile ducts including gallstones, inflammatory strictures (scars), leaks(from trauma and surgery), and cancer. ERCP combines the use of x rays and an endoscope, which is a long, flexible, lighted tube. Through it, the physician can see the inside of the stomach and duodenum, and inject dyes into the ducts in the biliary tree and pancreas so they can be seen on x rays.

For the procedure, you will lie on your left side on an examining table in an x ray room. You will be given medication to help numb the back of your throat and a sedative to help you relax during the exam. You will swallow the endoscope, and the physician will then guide the scope through your esophagus, stomach, and duodenum until it reaches the spot where the ducts of the biliary tree and pancreas open into the duodenum. At this time, you will be turned to lie flat on your stomach, and the physician will pass a small plastic tube through the scope. Through the tube, the physician will inject a dye into the ducts to make them show up clearly on x rays. X rays are taken as soon as the dye is injected.

If the exam shows a gallstone or narrowing of the ducts, the physician can insert instruments into the scope to remove or relieve the obstruction. Also, tissue samples (biopsy) can be taken for further testing.

Possible complications of ERCP include pancreatitis (inflammation of the pancreas), infection, bleeding, and perforation of the duodenum. Except for pancreatitis, such problems are uncommon. You may have tenderness or a lump where the sedative was injected, but that should go away in a few days.

ERCP takes 30 minutes to 2 hours. You may have some discomfort when the physician blows air into the duodenum and injects the dye into the ducts. However, the pain medicine and sedative should keep you from feeling too much discomfort. After the procedure, you will need to stay at the hospital for 1 to 2 hours until the sedative wears off. The physician will make sure you do not have signs of complications before you leave. If any kind of treatment is done during ERCP, such as removing a gallstone, you may need to stay in the hospital overnight.

Preparation

Your stomach and duodenum must be empty for the procedure to be accurate and safe. You will not be able to eat or drink anything after midnight the night before the procedure, or for 6 to 8 hours beforehand, depending on the time of your procedure. Also, the physician will need to know whether you have any allergies, especially to iodine, which is in the dye. You must also arrange for someone to take you home--you will not be allowed to drive because of the sedatives. The physician may give you other special instructions.

Sclerotherapy for esophageal varices (also called endoscopic sclerotherapy)

Author/s: Lori De Milto
 

Definition

Sclerotherapy for esophageal varices (also called endoscopic sclerotherapy) is a treatment for esophageal bleeding that involves the use of an endoscope and the injection of a sclerosing solution into veins.

Purpose

In most hospitals, sclerotherapy for esophageal varices is the treatment of choice to stop esophageal bleeding during acute episodes, and to prevent further incidences of bleeding. Emergency sclerotherapy is often followed by preventive treatments to eradicate distended esophageal veins.

Precautions

Sclerotherapy for esophageal varices cannot be performed on an uncooperative patient, since movement during the procedure could cause the vein to tear or the esophagus to perforate and bleed. It should not be performed on a patient with a perforated gastrointestinal tract.

Description

Esophageal varices are enlarged or swollen veins on the lining of the esophagus which are prone to bleeding. They are life-threatening, and can be fatal in up to 50% of patients. They usually appear in patients with severe liver disease. Sclerotherapy for esophageal varices involves injecting a strong and irritating solution (a sclerosant) into the veins and/or the area beside the distended vein. The sclerosant injected into the vein causes blood clots to form and stops the bleeding. The sclerosant injected into the area beside the distended vein stops the bleeding by thickening and swelling the vein to compress the blood vessel. Most physicians inject the sclerosant directly into the vein, although injections into the vein and the surrounding area are both effective. Once bleeding has been stopped, the treatment can be used to significantly reduce or destroy the varices.

Sclerotherapy for esophageal varices is performed by a physician in a hospital, with the patient awake but sedated. Hyoscine butylbromide (Buscopan) may be administered to freeze the esophagus, making injection of the sclerosant easier. During the procedure, an endoscope is passed through the patient's mouth to the esophagus to view the inside. The branches of the blood vessels at or just above where the stomach and esophagus come together, the usual site of variceal bleeding, are located. After the bleeding vein is identified, a long, flexible sclerotherapy needle is passed through the endoscope. When the tip of the needle's sheath is in place, the needle is advanced, and the sclerosant is injected into the vein or the surrounding area. The most commonly used sclerosants are ethanolamine and sodium tetradecyl sulfate. The needle is withdrawn. The procedure is repeated as many times as necessary to eradicate all distended veins.

Sclerotherapy for esophageal varices controls acute bleeding in about 90% of patients, but it may have to be repeated within the first 48 hours to achieve this success rate. During the initial hospitalization, sclerotherapy is usually performed two or three times. Preventive treatments are scheduled every few weeks or so, depending on the patient's risk level and healing rate. Several studies have shown that the risk of recurrent bleeding is much lower in patients treated with sclerotherapy: 30-50%, as opposed to 70-80% for patients not treated with sclerotherapy.

Preparation

Before sclerotherapy for esophageal varices, the patient's vital signs and other pertinent data are recorded, an intravenous line is inserted to administer fluid or blood, and a sedative is prescribed.

Aftercare

After sclerotherapy for esophageal varices, the patient will be observed for signs of blood loss, lung complications, fever, a perforated esophagus, or other complications. Vital signs are monitored, and the intravenous line maintained. Pain medication is usually prescribed. After leaving the hospital, the patient follows a diet prescribed by the physician, and, if appropriate, can take mild pain relievers.

Risks

Sclerotherapy for esophageal varices has a 20-40% incidence of complications, and a one to two percent mortality rate. Complications can arise from the sclerosant or the endoscopic procedure. Minor complications, which are uncomfortable but do not require active treatment or prolonged hospitalization, include transient chest pain, difficulty swallowing, and fever, which usually go away after a few days. Some people have allergic reactions to the solution. Infection occurs in up to 50% of cases. In 2-10% of patients, the esophagus tightens, but this can usually be treated with dilatation. More serious complications may occur in 10-15% of patients treated with sclerotherapy. These include perforation or bleeding of the esophagus and lung problems, such as aspiration pneumonia. Long-term sclerotherapy can damage the esophagus, and increase the patient's risk of developing cancer.

Patients with advanced liver disease complicated by bleeding are very poor risks for this procedure. The surgery, premedications, and anesthesia may be sufficient to tip the patient into protein intoxication and hepatic coma. The blood in the bowels acts like a high protein meal; therefore, protein intoxication may be induced.

Key Terms

Endoscope

An instrument used to examine the inside of a canal or hollow organ. Endoscopic surgery is less invasive than traditional surgery.

Esophagus

The part of the digestive canal located between the pharynx (part of the digestive tube) and the stomach.

Sclerosant

An irritating solution that stops bleeding by hardening the blood or vein it is injected into.

Varices

Swollen or enlarged veins, in this case on the lining of the esophagus.

Esophageal Varices

Varicose Veins in Esophagus

Varicose veins in the esophagus (known as varices) are similar to the varicose veins often seen in the legs. In short, they are twisted, dilated veins that develop because of increased pressure in the venous system.

In the esophagus, varices often stem from high pressures in the portal venous system, which are veins that normally drain into the liver from the intestinal tract. Increased pressure in the portal venous system is most often the result of cirrhosis in the liver. As the portal venous pressure goes up, the blood must be diverted to other veins, and is then channeled most commonly to varices in the esophagus.

Varices can also occur in the stomach and in the rectum, although less commonly. The problem that is often encountered with varices is their propensity to bleed. Bleeding occurs because of increased tension in the wall of the varices, leading to rupture. Bleeding varices are a dreaded complication of cirrhosis, with the death rate approaching 30 to 50 percent.

Patients with bleeding varices usually vomit blood and/or pass black stools. By the time they get medical help, they often have lost significant amounts of blood and have low blood pressure requiring resuscitation. The therapy for bleeding varices involves an upper endoscopy to pinpoint the site of bleeding, followed by injection of a solution to destroy the varices or, as you mentioned, variceal banding.

Banding involves using an endoscope to place a small, rubber band around a varicose vein. This effectively cuts off the blood flow, and, over the next several days, the rubber band and the tissue within it will spontaneously fall off. The esophagus lining at the site will slowly heal. Banding is very effective in eradicating varices, and it often is repeated at set intervals over weeks until all the varices have been obliterated.

The most common side effect after banding is difficulty swallowing. Some patients feel that food is becoming stuck in their esophagus. The reason for this is that the bands (as many as 12 may be placed at one session) take up space in the esophagus. Thus, food that passes by them may get held up temporarily. The gastroenterologist that performs the banding will usually inform the patient about the possibility of this occurring. Avoiding solid foods such as meat and chicken for the first couple of days after banding will help avoid this side effect.

On the other hand, pain is uncommon after a banding procedure, and medications for pain are not given routinely.

Normal Abnormal

The esophagus is the tube in the chest that carries food from the mouth to the stomach.  It has a system of veins that take blood from the esophagus back to the heart.  This system is connected to the same venous system as the liver (called the portal veins).  When the liver is damaged (most commonly by Cirrhosis), fluid backs up in the portal veins, blocking the veins of the esophagus.  The esophageal veins then dilate (distended much beyond their normal size); the walls weaken and burst like a balloon.  When this occurs, there may be massive bleeding in the esophagus.

Lower GI Series

The digestive system

A lower gastrointestinal (GI) series uses x rays to diagnose problems in the large intestine, which includes the colon and rectum. The lower GI series may show problems like abnormal growths, ulcers, polyps, and diverticuli, and colon cancer.

Before taking x rays of your colon and rectum, the radiologist will put a thick liquid called barium into your colon. This is why a lower GI series is sometimes called a barium enema. The barium coats the lining of the colon and rectum and makes these organs, and any signs of disease in them, show up more clearly on x rays. It also helps the radiologist see the size and shape of the colon and rectum.

You may be uncomfortable during the lower GI series. The barium will cause fullness and pressure in your abdomen and will make you feel the urge to have a bowel movement. However, that rarely happens because the tube used to inject the barium has a balloon on the end of it that prevents the liquid from coming back out.

You may be asked to change positions while x rays are taken. Different positions give different views of the intestines. After the radiologist is finished taking x rays, you will be able to go to the bathroom. The radiologist may also take an x ray of the empty colon afterwards.

A lower GI series takes about 1 to 2 hours. The barium may cause constipation and make your stool turn gray or white for a few days after the procedure.

Preparation

Your colon must be empty for the procedure to be accurate. To prepare for the procedure you will have to restrict your diet for a few days beforehand. For example, you might be able to drink only liquids and eat only nonsugar, nondairy foods for 2 days before the procedure; only clear liquids the day before; and nothing after midnight the night before. A liquid diet means fat-free bouillon or broth, gelatin, strained fruit juice, water, plain coffee, plain tea, or diet soda. To make sure your colon is empty, you will be given a laxative or an enema before the procedure. Your physician may give you other special instructions.

Colonoscopy

The digestive system

Colonoscopy (koh-luh-NAH-skuh-pee) lets the physician look inside your entire large intestine, from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. The procedure is used to look for early signs of cancer in the colon and rectum. It is also used to diagnose the causes of unexplained changes in bowel habits. Colonoscopy enables the physician to see inflamed tissue, abnormal growths, ulcers, and bleeding.

For the procedure, you will lie on your left side on the examining table. You will probably be given pain medication and a mild sedative to keep you comfortable and to help you relax during the exam. The physician will insert a long, flexible, lighted tube into your rectum and slowly guide it into your colon. The tube is called a colonoscope (koh-LON-oh-skope). The scope transmits an image of the inside of the colon, so the physician can carefully examine the lining of the colon. The scope bends, so the physician can move it around the curves of your colon. You may be asked to change position occasionally to help the physician move the scope. The scope also blows air into your colon, which inflates the colon and helps the physician see better.

If anything abnormal is seen in your colon, like a polyp or inflamed tissue, the physician can remove all or part of it using tiny instruments passed through the scope. That tissue (biopsy) is then sent to a lab for testing. If there is bleeding in the colon, the physician can pass a laser, heater probe, or electrical probe, or inject special medicines through the scope and use it to stop the bleeding.

Bleeding and puncture of the colon are possible complications of colonoscopy. However, such complications are uncommon.

Colonoscopy takes 30 to 60 minutes. The sedative and pain medicine should keep you from feeling much discomfort during the exam. You will need to remain at the endoscopy facility for 1 to 2 hours until the sedative wears off.

Preparation

Your colon must be completely empty for the colonoscopy to be thorough and safe. To prepare for the procedure you may have to follow a liquid diet for 1 to 3 days beforehand. A liquid diet means fat-free bouillon or broth, strained fruit juice, water, plain coffee, plain tea, or diet soda. Gelatin or popsicles in any color but red may also be eaten. You will also take one of several types of laxatives the night before the procedure. Also, you must arrange for someone to take you home afterward--you will not be allowed to drive because of the sedatives. Your physician may give you other special instructions. Inform your physician of any medical conditions or medications that you take before the colonscopy.

Upper GI Series

The digestive system

The upper gastrointestinal (GI) series uses x rays to diagnose problems in the esophagus, stomach, and duodenum (first part of the small intestine). It may also be used to examine the small intestine. The upper GI series can show a blockage, abnormal growth, ulcer, or a problem with the way an organ is working.

During the procedure, you will drink barium, a thick, white, milkshake-like liquid. Barium coats the inside lining of the esophagus, stomach, and duodenum and makes them show up more clearly on x rays. The radiologist can also see ulcers, scar tissue, abnormal growths, hernias, or areas where something is blocking the normal path of food through the digestive system. Using a machine called a fluoroscope, the radiologist is also able to watch your digestive system work as the barium moves through it. This part of the procedure shows any problems in how the digestive system functions, for example, whether the muscles that control swallowing are working properly. As the barium moves into the small intestine, the radiologist can take x rays of it as well.

An upper GI series takes 1 to 2 hours. X rays of the small intestine may take 3 to 5 hours. It is not uncomfortable. The barium may cause constipation and white-colored stool for a few days after the procedure.

Preparation

Your stomach and small intestine must be empty for the procedure to be accurate, so the night before you will not be able to eat or drink anything after midnight. Your physician may give you other specific instructions.