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 22 June 2018

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HepatologyCirrhosis and portal hypertension

Variceal hemorrhage

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T Roesch What to do after endoscopic histoacryl injection for acute fundic variceal bleeding?
T Roesch, 22 May 2006

A comment on: Endoscopic histoacryl obilteration vs. propanolol in the prevention of esophagogastric variceal rebleeding: a randomized trial. Evrad S, Dumonceau JM, Delhaye M, Golstein P, Deviere J, LeMoine O Endoscopy 2003; 35: 730-736.

Histoacryl injection was introduced by Nib Soehendra to solve a difficult and hitherto unsatisfatorily solved clinical situation (Endoscopy 1986; 18: 25-26). The patient with acute bleeding from fundic varices, which can be a life-threatening situation, is quite difficult to manage, due to poor visibilty and limited possibilities of endoscopic therapy

This contrasts with the treatment for esophageal varices, where sclerotherapy and banding are firmly incorportated into the therapeutic armamentarium.

Successful hemostasis can be achieved in 80-90% of cases of fundic varices (Endoscopy 2002; 34: 926-32). The crucial question is, whether and how to continue, since the rebleeding rate from other remaining fundic varices may be high (although this has never been syste-matically studied in a large collective).

The Brussels group of Evrad et al. addresses this question in a randomized trail of 41 patients. They, however, did not include a control group without any further therapy, and, in fact, beta-blockers may represent the current standard in these cases.

Continuing Histoacryl obliteration in a mean of 5 further sessions after initial hemostasis (achieved in 97% of cases) was compared to propoanolol administration (80 mg/day). During a follow-up of 32 months (Histoacryl) and 23 months (propanolol), the number of early and late rebleedings was not significantly different, nor was the death rate in any way difference. More complications were encountered in the Histoacryl group (see Table 1).

Table 1. Outcome data of Histoacryl obliteration versus propanolol group

(n = 21)

(n = 20)

Early rebleeding
Early mortality
Late rebleeding
Late mortality
p > 0.02

Early - within 6 weeks.

We can therefore conclude that it is probably not worthwhile to continue Histoacryl injection after initial hemostasis for any remaining varices, but to put patients on propanolol.

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Although this study is small, it comes from an experienced endoscopy center (so that nobody can accuse them of lacking experience with Histoacryl) and the trend in rebleeding and early mortality rates was numerically in favour of propanolol. A larger study may have given stronger support to the use of beta-blockers. Randomized studies in endoscopy have to be supported and Ervad et al. are to be congratulated for clarifying this clinically important question.

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