Assessment of different modalities for prevention of esophageal variceal recurrence

Esophageal varices are present in 30% of patients with compensated cirrhosis and up to 60% of those with decompensated cirrhosis, the risk of variceal hemorrhage is related to the size, appearance of varices and degree of liver dysfunction. Endoscopic therapy is currently the definitive treatment of choice for active variceal hemorrhage. Band ligation is the method of choice although injection therapy still has a role in acute bleeding.Endoscopic band ligation has greater efficacy and fewer side effects than endoscopic injection sclerotherapy. Band ligation sessions are carried out every 2 weeks until eradication of varices, which is obtained in around 90% of the patients after 2-4 sessions. However varices frequently recur after endoscopic variceal ligation.In view of the unacceptable high rate of recurrence associated with this technique, the availability of other supplemental consolidation therapies is desired.The aim of our study was to evaluate and compare different consolidation therapies including argon plasma coagulator, paravariceal injection sclerotherapy and B-blockade for their efficacy in prevention of variceal recurrence (after eradication by band ligation ), recurrent bleeding and complications.The study included 60 patients presented with 1st attack of upper GIT bleeding who fulfilled the inclusion criteria (after full examination and investigations) they were subjected to the following:• Full medical history taking &through physical examination.• Routine investigation as: --Liver function tests.- Complete blood picture.- HCV antibody& HBVs antigen & anti-bilharzial antibody.• Abdominal ultrasonography.• Upper GIT endoscopy: for diagnosis of esophageal varices and band ligation (emergency and follow up) until variceal eradication.Patients were classified randomly into three groups following variceal eradication with band ligation and B.B therapy, the 1st group (20 patients) received argon plasma coagulation, the 2nd group (20 patients) received paravariceal sclerotherapy with ethanolamine oleate and the 3rd one (20 patients) continued on B.B therapy.It was found that argon plasma coagulation group had a significant less recurrence rate as compared to paravariceal sclerotherpay or B.B group. B.B group had the highest rate of recurrent bleeding than argon plasma and paravariceal sclerotherapy. The recurrence rate was not related to Child’s class or specific aietiology of cirrhosis but P.V diameter showed a significant relation to variceal recurrence.The argon plasma group showed a more recurrence free time than paravariceal group and B.B group despite that didn’t reach a statistical significance (7± 1.7 vs 6.25±3.6 vs 6.3± 3.57 months respectively).In our study we found that in argon plasma group, no significant increase in gastropathy occurred in comparison to paravariceal sclerotherapy, however no increase or even improvement in gastropathy was found in B.B group in (63.1%).We found also that retrosternal pain and dysphagia are the most common complication in argon plasma group and sclerotheray but higher rates of pyrexia was noticed in argon plasma group. Despite that these complications were absent in B.B group , exersional dypsnea and fatigue occurred in some patients with the use of B.B therapy and 10% mortality rate was found .Lastly we found that esophageal band ligation is an effective method in rapid variceal eradication, no increase in PHG and that P.V diameter may have a positive correlation to number of bands used, treatment sessions and eradication duration. Also O.V grade had a positive correlation to number of bands used. This method was found to have transient local complications inform of retrosternal pain , dysphagia and superficial ulceration.We can conclude that argon plasma coagulation is a safe and effective consolidation therapy following band ligation (which is safe and had a rapid rate of variceal eradication) in prevention of variceal recurrence, recurrent bleeding and the risk of death in comparison with paravariceal sclerotherapy with ethanolamine oleate and use of B.B therapy, but is expensive method.