Manejo de un sangrado por úlcera posligadura de várices esofágicas mediante prótesis metálica autoexpandible: reporte de un caso y revisión de la literatura / Management of a Bleeding Ulcer by Post-esophageal Ligation of Varices with Self Expanding metal Stents: Case Report and Literature Review

Los inicios del manejo del sangrado variceal con compresión directa datan de 1930 por Westphal y colaboradores. Después, en 1950, se desarrolló el balón de Sengstaken-Blakemore, definido por Panes y colaboradores como la primera línea de terapia; en 1980, a nivel de várices esofágicas y en várices gástricas, se empleaba el balón de Linton-Nachlass (1, 2). Se presenta el caso clínico de un paciente con cirrosis hepática por hepatitis C, Child B, con várices esofágicas, a las cuales se les realizó ligadura en dos ocasiones por sangrado y en la segunda ocasión por inminencia de ruptura, esta última llevada a cabo dos semanas antes del evento. El paciente muestra un cuadro clínico compatible con hemorragia de vías digestivas altas masiva, con evidencia endoscópica de úlcera esofágica sangrante que no mejora con terlipresina, ni escleroterapia con adrenalina, ni compresión local con balón de acalasia. En consecuencia, como terapia de rescate se decide colocar un stent esofágico metálico autoexpandible parcialmente recubierto (por no contar con totalmente recubierto en el momento), con control parcial del sangrado. Es recomendable el uso del stent como terapia de rescate para el sangrado por várices esofágicas refractarias. Debe emplearse el diseñado especialmente para esta indicación (SX-Ella Danis), como un puente para poder estabilizar al paciente y realizar una terapia definitiva como la TIPS, tal cual como se procedió en un nuestro paciente.

Early treatment of bleeding varices with direct compression dates from the work by Westphal et al. in 1930. Later in 1950, Sengstaken-Blakemore developed their balloon which Panes and collaborators defined as the first line of therapy for esophageal varices in 1980 while they used the Linton-Nachlass balloon for gastric varices (1, 2). This study presents the clinical case of a patient with liver cirrhosis due to hepatitis C, (Child B) with esophageal varices which were ligated on two different occasions because of bleeding. On the second occasion a rupture was imminent and ligation occurred two weeks prior to the event. The patient presented a clinical picture compatible with massive upper gastrointestinal bleeding with endoscopic evidence of a bleeding esophageal ulcer that did not improve with terlipressin, sclerotherapy with adrenaline, or balloon dilatation. Consequently, it was to use a partially covered self-expanding metal esophageal stent for salvage therapy since a completely covered stent was not available at that time. Stenting achieved partial control of bleeding. We recommend the use of stenting with a stent specifically designed for this indication (SX-Ella Danis) as salvage therapy for refractory bleeding from esophageal varices. The stent can be used as a bridge to stabilize the patient in order to perform TIPS as the definitive treatment, as in the case of our patient.

Bleeding esophageal varices due to liver cirrhosis: surgical aspects and experiences

1. Bleeding esophageal varices due to liver cirrhosis are serious and difficult but not hopeless problems. Although the mortality from the disease is high, patients who survive bleeding should undergo porto-caval surgery because their life expectancy can be reasonably good2. The diagnosis is not difficult, except in a few cases. The emergency diagnostic procedures and non-operative measures undertaken in these patients are discussed3. Emergency surgical intervention is indicated in patients with massive and continuous hemorrhage, either by direct ligation of the bleeding varices, or, in selected cases by direct porto-caval shunts4. Elective porto-caval surgery is discussed, including preoperative evaluation, the operative procedures utilized, and postoperative management5. Of 19 patients who have undergone porto-caval surgery, the author reviews his results in 12 cases in which the main indication for operation was bleeding from esophageal varices due to liver cirrhosis. (Summary)

The sugiura operation for bleeding esophageal varices at Chonburi Hospital.

Seventeen patients with portal hypertension and bleeding esophageal varices were treated by the Sugiura operation (non shunt operation) between 1988 and 1994. The youngest patient was 21, the oldest 64 years. Fourteen patients were male, and 3 were female. The primary diagnosis was postnecrotic cirrhosis in 12 patients, chronic active hepatitis in 2, alcohosis cirrhosis in 2 and non cirrhosis in 1 patient, so according to the child classification, one patient was class A, 12 were class B and 4 were class C. The procedure was elective in 16 cases, and emergency in 1. Patients were followed up for 1 to 6 years. There was one operative death (5.8%), caused by liver failure in a class C patient. The rates for rebleeding, encephlopathic damage and disappeared variceal bleeding because it is effective in controlling of bleeding, has low operative mortality, low relapse rate, and no encephalopathic results.

Follow-up Results after Endoscopic Variceal Ligation for Treatment of Acute Bleeding Esophageal Varices in Liver Cirrhosis) / 대한소화기내시경학회지

Endoscopic injection sclerotherapy(EIS) is currently the most widely practiced method for treating and eradicating bleeding esophageal varices in repeated sessions, but may be associated with some undesirable local and systemic complications. (continue...)