Transcript Management of esophageal varices


HBV carrier, child’s B cirrhosis
Admitted x Upper GI Bleeding
OGD: bleeding esophageal varices, banding performed
Rebleeding few hours later failed to stop bleeding with
endoscopic method (banding and sclerotherapy)
Put in Sengstaken tube  complicated with esophageal tear

We put in a metal stent for rupture esophagus




– Patient has no more bleeding
? Metal stent can stop variceal bleeding?
[4]
Haemetemesis/Melena
Resuscitation
Endoscopy (OGD)
Confirm esophageal variceal bleeding
Variceal ligation (Banding) / Sclerotherapy
Success
Prevent rebleeding:
-Vasoconstrictor
Failure
Balloon Temponade:
- Sengstaken-Blakemore
tube
Haemetemesis/Melena
Resuscitation
Endoscopy (OGD)
Confirm esophageal variceal bleeding
Variceal ligation (Banding) / Sclerotherapy
Success
Prevent rebleeding:
-Vasoconstrictor
Failure
Balloon Temponade:
- Sengstaken-Blakemore
tube
SEMS
•
SX-Ella DANIS stent
[10]
– Removable, covered, selfexpanding
– Control variceal bleeding by
tamponade effect
– Placed at most 2 weeks
– Gold markers: loops at both
end (for repositioning and
stent removal)
– Radiopaque markers: at both
ends and midpoint
•
Stent insertion
– Mean duration of procedure: 10 (+/- 6 minutes)
[7]
Balloon port
Gastric balloon
Guidewire
Stent
White lock
Blue lock
Wire port
[14]
[14]
Stent Removal
[5]
– Can be left in situ as long
as 2 weeks
– Cannot be removed by an
agitated patient
– Allow detailed and repeated
endoscopic examination
– Less risk of pulmonary
aspiration

Limitation
– Gastric varices cannot be controlled
– Do not exert a lasting effect

Complication
– Stent migration into stomach
– Esophageal ulcer
– Esophageal tear
SEMS
[9]

Control of acute bleeding (Time frame: 120 hours (5 days)),
failed if [12]
–
–
–
–
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
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

Death
Fresh hematemesis / >=100ml fresh blood aspirated
Hypovolaemic shock
Hb drop >3g/dL within any 24 hour
Success of stent placement
Duration of placement
Stent migration
Complication
Mortality
Definition according to Baveno criteria
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
6.7%
esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
100%
97%
5 days
(1-14)
18%
2.9%
esophageal
tear
29% (60
days)
Wright et
al. 2010
10
90%
70%
9 days
(6-14)
N/A
10%
esophageal
ulcer
50% (42
days)
Dechene
et al.
2012 [6]
8
100%
88%
11 days
(7-14)
0%
12.5%
compression
of left main
bronchus
75% (60
Days)
Zakaria et 16
al 2013 [7]
93.75%
87.5%
2-4 days
37.5%
6.25%
esophageal
ulcer
25% (42
days)
Febienne
et al
2013 [8]
89%
89%
1-5 days
22%
0%
77% (42
days)
[5]
9
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
1 esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
100%
– Case
controlled
trial
97% series,
5 daysnot18%
1 esophageal
(1-14)
tear
– Small sample
size
29% (60
days)
Wright et
al. 2010
10
90%
70%
9 days
(6-14)
N/A
1 esophageal
ulcer
50% (42
days)
Dechene
et al.
2012 [6]
8
100%
88%
11 days
(7-14)
0%
1
compression
of left main
bronchus
75% (60
Days)
Zakaria et 16
al 2013 [7]
93.75%
87.5%
2-4 days
37.5%
1 esophageal
ulcer
25% (42
days)
Febienne
et al
2013 [8]
89%
89%
1-5 days
22%
0%
77% (42
days)
[5]
9
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
1 esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
100%
97%
Wright et
al. 2010
10
90%
70%
Dechene
et al.
2012 [6]
8
100%
88%
11 days
(7-14)
Zakaria et 16
al 2013 [7]
93.75%
87.5%
Febienne
et al
2013 [8]
89%
89%
[5]
9
5 days
18%
esophageal error)
29% (60
– Failure
(delivery1 system
(1-14)
tear
days)
 gastric balloon rupture
9
days
N/A
failed
inflation1 esophageal 50% (42
(6-14)
ulcer
days)
0%
1
compression
of left main
bronchus
75% (60
Days)
2-4 days
37.5%
1 esophageal
ulcer
25% (42
days)
1-5 days
22%
0%
77% (42
days)
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
1 esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
100%
97%
5 days
(1-14)
Wright et
al. 2010
10
90%
70%
9 days
(6-14)
Dechene
et al.
2012 [6]
8
100%
88%
11 days
(7-14)
0%
1
compression
of left main
bronchus
75% (60
Days)
Zakaria et 16
al 2013 [7]
93.75%
87.5%
2-4 days
37.5%
1 esophageal
ulcer
25% (42
days)
Febienne
et al
2013 [8]
89%
89%
1-5 days
22%
0%
77% (42
days)
[5]
9
18%
1 esophageal 29%
(60
c.f. Balloon
tamponade:
80%
tear
days)
– Failure:
N/A
1 esophageal 50% (42
ulcer
days)
 GV bleeding
 failed stent deployment
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
1 esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
100%
97%
5 days
(1-14)
18%
1 esophageal
tear
29% (60
days)
Wright et
al. 2010
10
90%
70%
9 days
(6-14)
N/A
1 esophageal
ulcer
50% (42
days)
Dechene
et al.
2012 [6]
8
100%
88%
11 days
(7-14)
0%
1
compression
of left main
bronchus
75% (60
Days)
Zakaria et 16
al 2013 [7]
93.75%
87.5%
2-4 days
37.5%
1 esophageal
ulcer
25% (42
days)
Febienne
et al
2013 [8]
89%
89%
1-5 days
22%
0%
77% (42
days)
[5]
9
How to decide??
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
1 esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
100%
97%
5 days
(1-14)
18%
1 esophageal
tear
29% (60
days)
Wright et
al. 2010
10
Dechene
et al.
2012 [6]
8
Immediate repositioning
90%
70%
9 days
(6-14)
N/A
1 esophageal
ulcer
50% (42
days)
100%
88%
11 days
(7-14)
0%
1
compression
of left main
bronchus
75% (60
Days)
Zakaria et 16
al 2013 [7]
93.75%
87.5%
2-4 days
37.5%
1 esophageal
ulcer
25% (42
days)
Febienne
et al
2013 [8]
89%
89%
1-5 days
22%
0%
77% (42
days)
[5]
9
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
6.7%
esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
100%
18%
2.9%
esophageal
tear
29% (60
days)
Wright et
al. 2010
10
90%
70%
9 days
(6-14)
N/A
10%
esophageal
ulcer
50% (42
days)
Dechene
et al.
2012 [6]
8
100%
88%
11 days
(7-14)
0%
12.5%
compression
of left main
bronchus
75% (60
Days)
97%
5 days
Esophageal
tear
(1-14)
[5]
Esophageal ulcer
Zakaria et 16
al 2013 [7]
93.75%
87.5%
2-4 days
37.5%
6.25%
esophageal
ulcer
25% (42
days)
Febienne
et al
2013 [8]
89%
89%
1-5 days
22%
0%
77% (42
days)
9
No. of
patient
Success in
stent
placement
Control
of
bleeding
duration
Stent
migration
Local
complication
mortality
Hubmann
et al.
2006 [3]
15
100%
100%
5 days
(1-14)
25%
1 esophageal
tear
20% (60
days)
Zehetner
et al.
2008 [4]
34
Wright et
al. 2010
10
[5]
Dechene
et al.
2012 [6]
8
100%
97%
5 days
(1-14)
18%
1 esophageal
tear
– Reason of death
 liver failure, multi-organ failure, uncontrolled
90%
70%
9 days
N/A
1 esophageal
bleeding
(6-14)
ulcer
– High mortality rate
100%
88%bias (more
11 dayssevere
0% underlying
1
 Selection
liver
(7-14)
compression
disease)
of left main
29% (60
days)
50% (42
days)
75% (60
Days)
bronchus
Zakaria et 16
al 2013 [7]
Febienne
et al
2013 [8]
c.f. Usual 6 week mortality rate: 15-20%
9
– Further
to rule 2-4
outdays 37.5%
93.75% study
87.5%
1 esophageal
ulcer
 ? Related to stent
 Delayed / Unrecognized complication
89%
89%
1-5 days
22%
0%
25% (42
days)
77% (42
days)

How to monitor any re-bleeding/complication after stent
insertion
– ? Daily OGD/CXR

? One single size of stent fit for every patient

Need expertise for stent placement

Limitation of study
–
–
–
–

Limited number of study available
Not a controlled study
Small sample size
Only short term follow up (up to 60 days)
Future study
– Need randomized trial
– Larger sample size
– Long term follow up

SEMS is a recent advance in management of
refractory esophageal variceal bleeding
– Considered as a alternative to balloon temponade
– safe and effective treatment in limited data
 low complication rate
 Satisfactory rate of bleeding control & stent deployment
– need further study
– Practical aspect: duration, monitoring, expertise
1.
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5.
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11.
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13.
Garcia-Tsao G, Sanyal AJ, Grace ND, et al. Prevention and management of gastroesophageal varices and
variceal hemorrhage in cirrhosis. Hepatology 2007; 46: 922-38.
Gin-Ho Lo. Management of acute esophageal variceal hemorrhage. Kaohsiung J Med Sci 2010; 26: 55-67.
Hubmann R, Bodlaj G, Czompo M, et al. The use of self-expanding metal stents to treat acute esophageal
variceal bleeding. Endoscopy 2006; 38: 896–901.
Zehetner J, Shamiyeh A, Wayand W, et al. Results of a new method to stop acute bleeding from esophageal
varices: implantation of a self-expanding stent. Surg Endosc 2008; 22:2149–2152.
Wright G, Lewis H, Hogan B, et al. Self-expanding metal stent for complicated variceal hemorrhage:
experience at a single center. Gastrointest Endosc 2010;71:71–78.
Dechene A, El Fouly AH, Bechmann LP, et al. Acute management of refractory variceal bleeding in liver
cirrhosis by self-expanding metal stents. Digestion 2012;85:185–191.
Zakaria MS, Hamza IM, Mohey MA, et al. The fist Egyptian experience using new self-expandable metal
stents in acute esophageal variceal bleeding: Pilot study. Saudi J Gastroenterol 2013; 45: 485-8.
Fabienne C. Fierz, Walter Kistler, Volker Stenz, et al. Treatment of esophageal variceal hemorrhage with selfexpanding metal stents as a rescue maneuver in a swiss multicentric cohort. Case Rep Gastroenterol 2013; 7:
97-105.
Fuad Maufa and Firas H. Al-Kawas. Role of Self-Expandable Metal Stents in Acute Variceal Bleeding.
Internalional Journal of Hepatology 2012; 418369.
Angels Escorsell and Jaime Bosch. Self-Expandable Metal Stents in the Treatment of Acute Esophageal
Variceal Bleeding. Gastroenterology Research and Practice 2011; 910986.
Vivek Kumbhari, Payal Saxena, Mouen A, et al. Self-Expandable Metallic Stents for Bleeding Esophageal
Varices. The Saudi J of Gastroenterology 2013; 1434
Roberto de Franchis, on behalf of the Baveno V Faculty, Revising consensus in portal hypertension: Report of
the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension, Journal
of Hepatology 2010; 53: 762-768
National Institute for Health and Clinical Excellence. Stent insertion for bleeding oesophageal varices. 2011;
April
László Benk M.D. New minimal invasive therapeutic options in the management of acute and recurrent
esophageal bleeding, 2007
[13]

Weak evidence
1st stage
2nd stage
SEMS
Failure
SEMS
The Danis stent is larger in diameter and the expansion force has
been adjusted to work efficiently against bleeding varices, but not to
harm the esophageal tissue.
The larger diameter is sufficient to fit every patient.
The pressure exerted by the stent has been evaluated in animal
model and later with clinical experience to be sufficient and safe
[9]

Pre-primary prophylaxis (Prevention of formation of varices)
– Non-selective beta-blockers: no evidence to prevent formation of
varices
– OGD: Should be screened for varices at diagnosis

Primary prophylaxis (prevention of first variceal hemorrhage)
– Non-selective beta blocker: Recommended
– OGD: Esophageal variceal ligation (EVL) recommended
 Repeated every 1-2 weeks till complete obliteration

Secondary prophylaxis (prevention of rebleeding)
– Combination of nonselective beta blockers + EVL
– TIPS: recurrent variceal haemorrhage
– Transplant

When remove stent
– Bind time to let pharmcological therapy to work
– When elective procedure a/v or expertise a/v
– Convert emergency procedure to elective

Contraindication of stent
–
–
–
–

Stricture
Esophageal tumor
Previous radiation
Body weight <40kg
Risk of stent complication like esophageal rupture
– Protective pressure valve  does not allow gastric balloon to
inflate against resistance
– if gastric balloon inflate wrongly in esophagus  safety balloon at
tip of delivery system is inflated

Migration
– Covered stent
 Wait for 3 minutes for full expansion
 Optimal integration with esophageal wall
– Uncovered stent
 Metal wire to dense: impringe on varices with pin point pressure
 Metal wire not close: varices may squeeze out between wire and can’t
exert temponade effect

Pressure it exert
– Not specific mentioned
– Radial pressure
– Evaluate in animal model and clinical experience to be sufficient
and safe

Monitoring
– CXR daily
– OGD alt day

Treat the symptom, not underlying cause (liver failure)
– Treat esophageal varices
 Physical: banding, sengstaken, SEMS
 Chemical: sclerosant, superglue (cyanoarcylate monomer)
– Treat underlying disease
 Best medical treatment

Further treatment
– Late stage
– Further treatment has its own risk and complication, e.g. TIPS (seldom
do)
– Best medical treatment
 Nutrition, lactulose, antibiotic, avoid hepatotoxic drug, medication, etc
– In our study: EVL, TIPS, shunt surgery, transplant