RESUMO
Background: Major variceal bleeding is a life threatening complication of portal hypertension
Patients and methods: To compare between partial obliteration and complete eradication of post-bleeding esophageal varices [EV] using injection sclerotherapy as regards effectiveness in preventing rebleeding; development of de novo congestive gastropathy or change of its severity if previously present, development of new gastric varices and hemodynamic changes of the portal circulation and its collaterals. Forty patients with upper gastrointestinal bleeding in whom EV were proved to be the source of bleeding were included and randomly classified into two equal groups [I and II] matched for their variceal grade and Child-Pugh class as far as possible md subjected to injection sclerotherapy; GI [20 cases] [those who were subjected to repeated sessions of injection scierotherapy and the end point was reduction of the size of EV to grade I to II] and GI] [20 cases] to whom repeated sessions of injection sclerotherapy were done till complete eradication of EV. Color Doppler study of portal hemodynamics was done before starting sclerotherapy and repeated 6 and 12 months later afier the end of sessions including portal vein velocity [PVV], congestion index [CI]; and status of intra-abdominal collaterals. After reaching the end of treatment, regular endoscopic follow-up was done every three months and abdominal US and color Doppler follow-up examination every 6 months to compare with the previously mentioned parameters recorded before sclerotherapy
Results: There was a statistically significant difference [P < 0.05] in esophageal varices grade batman both groups after sclerotherapy endpoint by 3 and 6 months with more evident recurrence in group II. Regarding the impact on the hemodynamic parameters, there was no statistically significant differance [P> 0.05] between both groups after sclerotherapy. In each group there was no statistically significant correlation between the grade of esophageal varices, the portal vein diameter [before sclerotherapy] and the number of sessions needed for obliteration or eradication of EV
Conclusion: Recurrence of esophageal varices is early and more evident after complete variceal eradication than partial obliteration. Both partial obliteration and complete eradication can lead to secondary rise in the portal pressure with increase in the rate of new gastric varices development
RESUMO
Portal hypertension is sometimes associated with hypersplenism and pancytopenia. Splenectomy cures the hypersplenism in these circumstances. The presence of critical thrombocytopenia is usually associated with high morbidity and mortality of the splenectomy procedure. To evaluate the effect of preoperative splenic artery embolization on the outcome of splenectomy in these circumstances. From April 2000 to June 2002, 23 patients with pancytopenia associating portal hypertension were selected to be enrolled in the study. All patients had splenic artery embolization as a preoperative measure to improve their thrombocytopenic state. This was followed by a surgical splenectomy after reaching a platelet count above 100,000 /cm3. Post embolization all patients showed a progressive increase in platelet count from a mean of 51000/ cm3 to a mean of 122000/cm3 on day 6. Complications of the embolization procedure were bleeding at the puncture site, portal vein thrombosis, splenic abscess, and systemic sepsis. Complications of the splenectomy procedure were one mortality, post operative Heeding in one case, chest infection in one case and wound infection in 2 cases. Preoperative splenic artery embolization can be used to improve the outcome of splenectomy in the presence of thrombo-cytopenia. The technique should be used selectively and only when platelet counts drop below 50000/cm3 [critical thrombocytopenia]. Splenectomy timing at day 6 post embolization is safe as thrombocytopenia was corrected at that time in all patients