Practical Gastrointestinal Endoscopy

THERAPEUTIC UPPER ENDOSCOPY 73
to compress distal varices or on the scope itself to permit tamponade
if bleeding occurs. However, most experts use a simple
‘free-hand’ method, with a standard large-channel endoscope
and a flexible, retractable needle (Fig. 5.14). Injections are given
directly into the varices, starting close to the cardia (and below
any bleeding site) and working spirally upwards for about
5·cm. Each injection consists of 1–2·mL of sclerosant, to a total
of 20–40·mL.
Precise placement of the needle within the varix (as guided
by co-injection of a dye such as methylene blue or by simultaneous
manometric or radiographic techniques) may improve the
results and reduce the complications. However, some experts
believe that paravariceal injections are also effective, and it is
often difficult to tell which has been achieved. If bleeding occurs
on removal of the needle, it is usually helpful to tamponade
the area simply by passing the endoscope into the stomach. The
esophago-gastric junction can be compressed directly if the endoscope
is retroflexed.
Fig. 5.14 –A retractablesclerotherapy
needle.
Sclerosants
Several chemical agents are available as sclerosants. Sodium
morrhuate (5%) and sodium tetradecylsulfate (STD) (1–1.5%) are
popular in the USA. Polidocanol (1%), ethanolamine oleate (5%)
and STD are widely used in Europe. Efficacy, ulcerogenicity and
the risk of complications run together, since it is the process of
damage and healing by fibrosis that eradicates or buries the communicating
veins, but may also cause stricturing. Endoscopic
polymer injection is another alternative. The two cyanoacrylate
agents most commonly used are not available in the USA. These
polymers solidify almost immediately on contact with aqueous
material. The endoscopist and nurse must use them carefully
to provide an effective injection without gluing up the endoscope.
Results are excellent, especially in gastric varices (which
do not respond well to standard sclerotherapy). Many use this
technique also in patients who relapse quickly after banding
or sclerotherapy in the acute situation. Other ‘glues’ are being
evaluated.
Varicealbanding
This has become popular because it causes fewer ulcers and
strictures than sclerotherapy. The device consists of a friction-fit
sleeve on the endoscope tip, an inner cylinder preloaded with
elastic bands and a trip wire that passes up the endoscope channel
(Fig. 5.15). The varix is sucked into the sleeve, and the band
released by pulling on the wire. Multiple bands are applied in an
upwards spiral fashion every 1–2·cm. Banding can be applied also
to gastric varices and to small ulcers (e.g. Dieulafoy lesions).
Fig. 5.15–An esophageal banding
device.