Escleroterapia endoscópica asistida mediante balón oclusivo como tratamiento de varices gástricas cardiofúndicas de alto riesgo: reporte de dos casos y revisión de la literatura / Fundal variceal bleeding treated with balloon occluded endoscopic inyection sclerotherapy: report of two cases

Management of gastrointestinal bleeding caused by fundal varices is particularly difficult to manage. The options are: transjugular intrahepatic portosystemic shunt (TIPS), endoscopic injection of cyanoacrylate or balloon-occluded retrograde transvenous obliteration (BRTO). We report a 63 year-old male with a cirrhosis caused by hepatitis C and a 66 year-old female with a cirrhosis caused by a non-alcoholic steatohepatitis. Both patients had a gastrointestinal bleeding caused by fundal varices and were treated with sclerotherapy with cyanoacrylate assisted with BRTO. Flow was interrupted in the gastro-renal shunt by a femoral access in both patients. The male patient had a new bleeding two months later and died. In the female patient an endosonography performed nine months after the procedure showed absence of remaining varices.

Frecuencia y mortalidad de resangrado en pacientes cirróticos tratados por hemorragia de várices esofágicas en dos hospitales de Lima-Perú durante los años 2009-2011 / Frequency and mortality by rebleeding in cirrhotic patients treated for bleeding esophagic varices in two hospitals in Lima Peru during years 2009 to 2011

Durante las primeras 6 semanas después de una hemorragia variceal hay un 30-40% de probabilidad de recurrencia y de aquellos que resangran mueren del 20-35%. Pasado este periodo, el riesgo de resangrado se presenta en un 60% de pacientes alcanzando una mortalidad de 60-70% en dos años sin tratamiento. Objetivo: Describir la frecuencia de resangrado y mortalidad por resangrado en pacientes cirróticos tratados por hemorragia variceal en los Centros Endoscópicos del Hospital Nacional Cayetano Heredia (HNCH) y del Hospital Nacional Arzobispo Loayza (HNAL) , ambos en Lima, Perú, durante los años 2009-2011. Materiales y Métodos: El estudio es transversal de periodo y retrospectivo donde participaron en total 176 pacientes cirróticos mayores de 14 años de edad que hayan sangrado por varices esofágicas y que hayan recibido tratamiento endoscópico por hemorragia variceal. Los instrumentos fueron la ficha de datos donde se consignó la información obtenida de las historias clínicas de cada paciente, la escala de CHILD para medir la severidad de la enfermedad hepática, informes endoscópicos y llamadas telefónicas. Resultados: En total se halló una tasa de frecuencia de 32,20% (56 pacientes) con resangrado temprano menor de 6 semanas. Asimismo, se obtuvo un 22,56% (37 pacientes) con resangrado tardío en los controles posteriores. Se halló una mortalidad de 5,70% (10 pacientes) en el total de los pacientes. Y una tasa de mortalidad por resangrado de 13,33% (6 pacientes). Conclusión: La hemorragia variceal es una causa importante de morbimortalidad en la población peruana, la frecuencia y mortalidad por resangrado resultaron ligeramente menores a la reportada en la bibliografía mundial.

During the first 6 weeks after a variceal hemorrhage there is a 30-40% of probability of recurrence and those who rebleed 20-30% die. Passed this period, the risk of rebleeding is of 60% and reaches a mortality of 60-70% in two years without treatment. Objective: Describe the frequency of rebleeding and mortality due to rebleeding in cirrhotic patients treated for variceal hemorrhage at Endoscopic Centers of Hospital Nacional Cayetano Heredia, Lima, Peru and Hospital Nacional Arzobispo Loayza, Lima, Peru during the years 2009-2011. Materials and methods: The study type is a transversal, periodic and retrospective one in which were included 176 cirrhotic patients older than 14 years who have bleed for esophageal varices and that have received endoscopic therapy. The instruments used were a data sheet with all the information obtained from the clinical chart of each patient, the CHILD score to assess severity of hepatic disease, endoscopic informs and phone calls. Results: The frequency of rebleeding before 6 weeks was 32.20% (56 patients). Also, the frequency of rebleeding after that time was 22.56% (37 patients). There was a mortality rate of 5.70% (10 patients) and a mortality rate due to rebleeding of 13.33% (6 patients). Conclusions: Variceal hemorrhage is an important cause of mobimortality in peruvian people. The frequency of rebleeding and mortality due to rebleeding resulted slightly lower than in other countries.

Comparación de la efectividad de la ligadura vs esclerosis endoscópica en pacientes con sangrado de várices esofágicas en el Hospital Hernán Henríquez de Temuco: estudio de cohortes comparativas / Comparison of band ligation with sclerotherapy for the treatment of bleeding esophageal varices

Background: Endoscopic band ligation is the treatment of choice for bleeding esophageal varices. However it is not clear if this procedure is associated with less early and late mortality than sclerotherapy. Aim: To assess rates of re-bleeding and mortality in cohorts of patients with bleeding esophageal varices treated with endos-copic injection or band ligation. Patients and Methods: Analysis of medical records and endoscopy reports of two cohorts of patients with bleeding esophageal varices, treated between 1990 and 2010. Of these, 54 patients were treated with sclerotherapy and 90 patients with band ligation. A third cohort of 116patients that did not require endoscopic treatment, was included. The mean analyzed follow up period was 2.5 years (range 1-16). Collection of data was retrospective for patients treated with sclerotherapy and prospective for patients treated with band ligation. Rates of re-bleeding and medium term mortality were assessed. Results: During the month ensuing the first endoscopic treatment, re-bleeding was recorded in 39 and 72% of patients treated with band ligation and sclerotherapy, respectively (p < 0.01). The relative risk of bleeding after band ligation was 0.53 (95% confidence limits 0.390.73). Death rates until the end of follow up were 20 and 48% among patients with treated with band ligation and sclerotherapy, respectively (p < 0.01), with a relative risk of dying for patients subjected to band ligation of 0.41 (95% confidence limits 0.25-0.68). Conclusions: Band ligation was associated with lower rates of re-bleeding and mortality in these cohorts of patients.

Contribuição do TIPS para o controle das complicações da hipertensão portal / TIPS contribution towards the control of portal hypertension complications

Objetivo: O propósito deste estudo foi avaliar a eficácia do procedimento denominado TIPS (transjugular intrahepatic portosystemic shunt) para diminuir a pressão do sistema portal e resolver a complicação clínicade pacientes com hepatopatia crônica e hipertensão portal. Adicionalmente, procurou-se estabelecer a segurança do procedimento, verificando-se a incidência de complicações diretamente decorrentes dele. Também se procurou verificar a existência de fatores prognósticos da evolução clínica pós-operatória. Casuística e método: Foram revistos todos os casos de pacientes submetidos a TIPS numa única instituição por um único operador no período de oito anos. Quarenta e quatro pacientes, sendo 30 do sexo masculino e 14 do feminino e com idade média de 52 anos, todos brancos, foram submetidos a TIPS. Todos os pacientes tinham hepatopatia crônica e hipertensão portal e, como sintoma principal, recidiva hemorragica por ruptura de varizes esofagogástricas ou gastropatia em 28 e ascite refratária em 16. Foram verificados os níveis séricos de bilirrubina, albumina, tempo de protrombina e creatinina. Os pacientes foram caracterizados clinicamente pela classificação de Child-Pugh, resultando que nove eram Child-Pugh A, 24 erm Child-Pugh B e 11 eram Child-Pugh C. Resultados: O TIPS foi completado com sucesso em todos os pacientes (100por cento), verificando-se queda do grandiente pressórico P/S médio de 49,69por cento( de 18,98mmHg para 9,55mmHg), o que foi estatisticamente significativo. Adicionalmente, se observou melhora clínica em 35 pacientes(79,55por cento) sendo 24/28 com HDA, 8/11 com ascite refratária e 3/5 com SHR. A mortalidade geral PO foi de 13,64por cento, sendo mais incidente nos pacientes caracterizados como Child-Pugh C (83,4por cento). Através da análise das variáveis clínicas que caracterizam os pacientes foi observado que os fatores mais relevantes de mau prognóstico foram o aumento do nível de creatinina, da bilirrubina e prolongamento do tempo de protrombina. Verificou-se que 75por cento dos pacientes sobreviveram durante o período de observação de um ano. A sobrevida média de pacientes Child-Pugh A foi de 11,5 meses, nos Child-Pugh B foi de 10,97 meses e nos ChildPugh C foi de apenas 5,9 meses, evidenciando uma diferença estatisticamente significativa na sobrevida de acordo com a classificação de Child-Pugh

Escleroterapia versus somatostatina na hemorragia digestiva alta por ruptura de varizes esofágicas / Sclerotherapy versus somatostatin in the treatment of upper digestive hemorrhage caused by rupture of esophageal varices

The aim of this study was to compare the efficacy of somatostatin versus endoscopic sclerotherapy in the management of digestive bleeding caused by rupture of esophageal varices. Forty patients were evaluated; 21 were randomly assigned to receive somatostatin (initial 250 micrograms followed by a 48-hour continuous infusion of 250 micrograms/h and 250 micrograms 6/6 h bolus in the first 24 hours) and 19 to receive endoscopic sclerotherapy with ethanolamine oleate 5 per cent. The patients were evaluated after 48 hours and after 7 days of treatment. Both groups of patients were similar in sex, age, gravity of the hemorrhage and liver dysfunction. Therapeutic failure occurred in 26.3 per cent and 35.7 per cent in the group of endoscopic sclerotherapy (48 h and 7 days respectively), and in 23.8 per cent and 21.4 per cent in the group of somatostatin. The need of blood transfusion (3.38 U in the group of endoscopic sclerotherapy and 2.42 U in the group of somatostatin) and the mortality rate (31.6 per cent in the group of endoscopic sclerotherapy and 28.6 per cent in the group of somatostatin) were also similar (P > 0.05). The authors conclude that somatostatin is as effective as endoscopic sclerotherapy and that it should be considered in the treatment of acute esophageal variceal bleeding

Utilizacion del shunt portosistemico intrahepatico transyugular (TIPS) en un paciente de 84 años durante un episodio de hemorragia aguda por varices esofagicas / Use of transjugular intrahepatic portosystemic shunt (TIPS) in an 84 year-old patient during acute variceal bleeding

El shunt portosistémico intrahepático transygular (TIPS) es un procedimiento no quirúrgico que consiste en crear una comunicación porto-cava a través del parénquima hepático. La mortalidad asociada al procedimiento es baja y no interfiere en el transplante hepático. Se presenta un paciente añoso con hepatopatía crónica e hipertensión portal que se internó por un episodio de hemorragia por várices esofágicas. Debido al fallo del tratamiento médico y escleroterápico, se le embolizó la vena coronaria estomáquica con un coil y se colocó un TIPS durante el episodio agudo de hemorragia por várices esofágicas. Evolucionó favorablemente y a un año del procedimiento se encuentra asintomático.