Open Journal of Gastroenterology, 2013, 3, 281-287 OJGas Published Online September 2013 (
Management of ac ute esophageal variceal b le ed i ng by
endoscopic sclerotherapy in technically difficult endoscopic
band ligation cases—A population based cohort study
Gamal E. Esmat1, Iman M. Hamza1*, Bahaa E. Abbas2, Ahmed M. Hashem1, Hossam S. Ghoneim3
1Endemic Medicine Department, Division of Endoscopy, Cairo University, Giza, Egypt
2Division of Endoscopy, Air Force Hospital, Cairo, Egypt
3Tropical Medicine Department, Beni Sweif University, Cairo, Egypt
Email: *
Received 14 June 2013; revised 15 July 2013; accepted 29 July 2013
Copyright © 2013 Gamal E. Esmat et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Endoscopic band ligation is regarded as the main
therapeutic option for acute esophageal variceal bleed-
ing, while sclerotherapy may be used in the acute set-
ting if ligation is technically difficult. The incidence of
difficult-to-perform band ligation in acute esophageal
variceal bleeding, as well as the outcome of patients
subjected to injection sclerotherapy as an alternative
treatment, has not been clearly investigated. Our aim
is to study the outcome of patients subjected to injec-
tion sclerotherapy in the acute setting of esophageal
variceal bleeding when endoscopic band ligation is
technically difficult to perform. We included 151 pa-
tients with acute esophageal variceal bleeding origin-
nating from medium or large sized varices. All pa-
tients were planned for EBL as the 1st treatment op-
tion (EBL group 61.6%), meanwhile, EIS using 5%
ethanolamine oleate was reserved as the 2nd treat-
ment option when EBL was technically difficult (EIS
group 38.4%). The mean time to restore hemody-
namic stability was significantly prolonged in the EIS
group (11.5 ± 6.5 hrs versus 9.5 ± 5.0 hrs, p 0.05). Ini-
tial control of bleeding was significantly higher in the
EBL group versus the EIS group (96.7% vs 84.5%, p
0.021). Re-bleeding was more among the EIS group
(42.9% vs 24.2%, p 0.04). There were no significant
differences as regarding mortality and duration of
hospital stay. So, a considerable proportion of cases
presenting with acute variceal bleeding will have dif-
ficulty in performing EBL. In these patients, sclero-
therapy is not a waning procedure with an accepted
success rate, without much additional complications
and without dera nging mortality.
Keywords: Esophageal Varices; Band Ligation;
Injection Sclerotherapy
The management of acute variceal bleeding remains a
clinical challenge. Regarding the best endoscopic thera-
peutic option, a meta-analysis of 10 randomized con-
trolled trials including 404 patients showed an almost
significant benefit of endoscopic band ligation in the
initial control of bleeding compared to sclerotherapy [1].
At the same time, Baveno IV and V consensuses had re-
peatedly confirmed that ligation is the recommended me-
thod of endoscopic therapy for acute esophageal variceal
bleeding although sclerotherapy may be used in the acute
setting if ligation is technically difficult [2,3].
The incidence of difficulty to perform band ligation in
acute esophageal variceal bleeding, as well as the out-
come of patients subjected to injection sclerotherapy as
an alternative treatment, has not been clearly investi-
Our aim is to study the outcome of patients subjected to
injection sclerotherapy in the setting of acute esophageal
variceal bleeding in case of technical difficulty to per-
form band ligation.
This study was approved by the Hepatogastroenterology
Department and the Research Board of Cairo University.
It included 151 patients with acute bleeding from eso-
phageal varices originating from medium and large sized
varices. They were admitted to Gastroenterology unit of
*Corresponding author.
G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287
Air force Hospital, Cairo; during the period from 15
January 2010 till 15 July same year. Patients with bleed-
ing gastric varices, bleeding small sized oesophageal
varices, bleeding portal hypertensive gastropathy, hepatic
coma or hepatocellular carcinoma were not included in
the study.
Patients were resuscitated after relevant history taking
and clinical examination. Stabilization of hemodynamics
was firstly performed. Blood transfusion was initiated
depending upon the severity of bleeding and hemo-dy-
namic status with a transfusion target hematocrit of 24%
and/or hemoglobin of 8 g/dl. I.V antibiotics were rou-
tinely given. Octreotide was started whenever indicated
in a dose of 50 μg IV bolus, followed by continuous in-
fusion 50 μg/hr for 2 - 5 days. Further assessment was
done including laboratory investigations and abdominal
ultrasonography. The severity of bleeding was consid-
ered as: mild when pulse rate <100/min, orthostatic hy-
potension or cold extremities, moderate when pulse rate
100 - 120 beats/min with restlessness or severe when
pulse rate >120 beats/min, systolic blood pressure <60
mmHg, severe pallor or oliguria [4]. Endoscopy session
was scheduled once the patient’s hemodynamics permit-
ted after an informed and written consent. Emergency
endotherapy was performed by a single endoscopist, all
patients were planned for endoscopic band ligation (EBL)
using the Saeed multi-band ligators manufactured by the
Wilson-Cook Medical GI endoscopy company as the 1st
treatment option to control the acute bleeding episode
(EBL group) (Figure 1), meanwhile, endoscopic injec-
tion sclerotherapy (EIS) using ethanolamine oleate was
reserved as a 2nd treatment option when EBL was tech-
nically difficult (only when the view of the bleeding
source was obscured) (sclerotherapy group) (Figure 2).
Varices were assigned grades according to their shape
and size: grade F1, small straight veins; grade F2,
Figure 1. EVL to bleeding varices.
Figure 2. Sclerotherapy for bleeding varices.
slightly enlarged tortuous veins occupying less than one-
third of the esophageal lumen; and grade F3, large coil-
shaped varices that occupied more than one-third of the
esophageal lumen [5].
The assessment for treatment side-effects was per-
formed during hospital stay and included monitoring of
symptoms, physical examination and laboratory data.
Complications were defined as untoward events related
to treatment and require active therapy or prolonged hos-
pitalization. All available patients in both groups were
followed up for 42 days for clinical assessment, variceal
re-bleeding, and hepatic de-compensation. Failure to
control active bleeding was considered according to the
UK guidelines [6] as transfusion requirement of 4 units
or more and inability to achieve an increase in systolic
blood pressure by 20 mm Hg or to 70 mm Hg or more,
and/or inability to achieve a pulse rate reduction to less
than 100 beat/min or a reduction of 20 beat/min from
baseline pulse rate (within the first six hours). Or the
occurrence of haematemesis from the six hour point,
reduction in blood pressure of more than 20 mm Hg from
the six hour point and/or increase in pulse rate of more
than 20 beat/min from the six hour point on two con-
secutive readings an hour apart, transfusion of 2 units of
blood or more (over and above the previous transfusions)
required to increase the haematocrit to above 27%, or
haemoglobin to above 9 g/l. Re-bleeding: was considered
as the occurrence of new hematemesis or melena after a
period of 24 hours or more of stable vital signs and he-
matocrit/hemoglobin following an episode of acute bleed-
ing up to 42 days from the acute bleeding episode. Stop-
page of bleeding: is considered when there is no he-
matemesis, stable hemoglobin concentration without blood
transfusions, stable hemodynamic conditions at the be-
ginning of the first 24-hour interval from time zero [2].
Copyright © 2013 SciRes. OPEN ACCESS
G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287
Copyright © 2013 SciRes.
Patients’ data were tabulated and processed using
SPSS (10.0) statistical package. Quantitative variables
were expressed by means and standard deviation. While
qualitative data were expressed by frequency and percent.
Qualitative variables were analyzed using Chi-square or
Ficher’s exact test when appropriate. Quantitative vari-
ables were analyzed using student’s T-test or Fried-
mann’s test when appropriate. In all tests p value was
significant when <0.05.
This study included 151 patients with acute esophageal
variceal bleeding. They were sub-grouped based on the
type of endoscopic intervention into EBL (band ligation)
group (93 patients 61.6%) and EIS (sclerotherapy group)
(58 patients 38.4%).
The majority of patients in the EBL group had a mild
bleeding episode (64.5%) versus none in the sclerother-
apy group. While the majority of those in the scerother-
apy group had a moderate bleeding episode (67.2%, p
0.38). Time from admission to patient stabilization was
significantly prolonged in the EIS group 11.5 ± 6.5 hrs
versus 9.5 ± 5.0 hrs (p 0.05) (Tab le 1). The post endo-
scopy outcome is demonstrated in (Table 2).
Bleeding from esophageal varices is a life-threatening
complication of portal hypertension which accounts for
most of cirrhosis-related mortalities [7,8]. Endoscopic
therapy is an integral component of the management of
acute variceal bleeding as well as prevention of recurrent
bleeding [8,9]. Since it first evolved as a new therapeutic
option, EBL has been regarded as a more effective mo-
dality than endoscopic injection sclerotherapy in the con-
trol of acute hemorrhage with less reported adverse
events [10-12]. On the other hand, some studies still ad-
vocate the use of sclerotherapy as a better treatment op-
tion up to regarding it as the gold-standard treatment
Despite the routine standard of care given to patients
presenting with hematemesis such as pharmacotherapy
and gastric lavage, still up to one third of cases are ac-
tively bleeding during endoscopy, and it is this group of
patients that poses a challenge to endoscopists and en-
Table 1. Base-line characteristics of EIS and EVL groups.
EVL group
N: 93 (61.6%)
EIS Group
N: 58 (38.4%)
No/% Mean/SD No/% Mean/SD
Age (years) 52 ±3 53 ±3 0.89
Male 52 56% 42 72.5%
Female 41 44% 16 27.5%
Previous bleeding attacks 48 51.6% 33 56.9% 0.63
Child Pugh class:
A 9 9.7% 4 6.9%
B 37 39.8% 25 43.1%
C 47 50.5% 29 50%
Grade of varices
Grade F2 48 51.6% 28 48.2%
Grade F3 45 48% 30 51.7%%
Hemodynamic instability 81 87.1% 53 91.4% 0.53
Severity of bleeding
Mild 60 64.5% 0 0%
Moderate 24 25.8% 39 67.2%
Severe 9 9.7% 19 32.8%
Time from admission to endoscopy (hrs) 9.5 ±5 11.5 ±6.5 0.05
G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287
Table 2. Post-endoscopy outcome in both groups.
EVL group
N: 93 (61.6%)
EIS Group
N: 58 (38.4%)
No/% Mean/SD No/% Mean/SD
Control of acute bleeding 90 96.7% 49 84.5% 0.021
Re-bleeding 22 24.2% 21 42.9% 0.04
Control of re-bleeding 17/22 77.35 11/19 57.9% 0.23
Incidence of complications among
different child-Pugh cases
Child A 1 1.1% 2 3.4%
Child B 8 8.6% 14 24.1%
Child C 6 6.4% 13 22.4%
Bacterial peritonitis 6 6.4% 11 19% 0.01
Aspiration pneumonia 0 0% 1 1.7% 0.41
Sepsis 1 1.1% 2 3.4% 0.065
Bleeding esophageal ulcer 1 1.1% 2 3.4% 0.065
Chest pain 2 2.2% 5 8.6% 0.01
Fever 1 1.1% 2 3.4% 0.065
Transient arrhythmias 1 1.1% 1 1.7% 0.1
Nausea 1 1.1% 2 3.4% 0.068
Transient dysphagia 2 2.2% 3 5.2% 0.012
Mean hemoglobin (gm/dl)
Day 1 8.6 ±0.34 8.1 ±0.36 0.18
Day 5 8.8 ±0.34 8.4 ±0.31 0.45
Units of packed RBCs 3.1 ±1.07 4.1 ±1.2 0.01
Hospital stay in days 8.3 ±1.9 9.1 ±2.6 0.27
Total Mortality 19 20.4% 21 36.2% 0.19
dangers the life of the patient as it has been found to
have a negative impact on survival [7,15,16]. In this
situation banding may be technically difficult to perform
in the presence of continued bleeding, and sclerotherapy
may then be necessary [2,3,9,17]. So this means that,
whether endoscopists fall for band ligation or sclero-
therapy as the preferred treatment, the set up of an emer-
gency endoscopic unit should be equipped with both and
the endoscopists should be ready to switch between the 2
How frequent is this situation encountered, what is the
outcome and what are the sequaele, remained to be in-
vestigated. This was the rational to conduct this study. It
was carried in the Air Force hospital on 151 patients with
acute variceal bleeding. All included patients had acute
esophageal variceal bleeding from medium or large sized
varices, while other portal hypertensive bleeding sources
were not included. To ensure homogeneity among these
patients, they were all given the same standards of care
such as gastric lavage and pharmacotherapy with oc-
terotide and judicious volume expanders. All of them
underwent endoscopy whenever they reached hemodya-
mic stability irrespective of time and all were endo-
scoped by a single operator. The plan at the time of en-
doscopy was to perform band ligation as a primary treat-
ment option unless profuse bleeding was encountered to
the extent of posing technical difficulty in visualizing
and banding the bleeding varix, in the latter condition,
switch to sclerotherapy was done.
The studied cases in both groups were comparable in
terms of their demographic features. All patients had
received pharmacotherapy by octerotide and yet, 38.4%
of the studied cases were actively bleeding at endoscopy,
profusely enough, to change the decision of treatment
Copyright © 2013 SciRes. OPEN ACCESS
G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287 285
from band ligation to sclerotherapy. Terblanche et al.
[16], stated that one third of cases are actively bleeding
at the time of endoscopy, this finding was made before
the advent of octreotide as a recommended treatment. In
our study although octreotide was given, still a subset of
patients similar to those reported by Terblanche were
bleeding profusely at the time of endoscopy (38%). Ac-
tually the therapeutic effects of octreotide on the portal
and systemic hemmodynamics in patients with liver cir-
rhosis have yielded conflicting results, while some au-
thors showed beneficial effects on the portal hemody-
namics, others failed to show any beneficial effects. In an
interesting study, Baik et al. [18] demonstrated that in
patients with acute variceal bleeding, the main effect of
octreotide on the HVPG was during the first minute after
therapy, whereas thereafter the effect is not sustained and
soon the HVPG reverts to base line after 5 mins of ther-
apy. This might explain why patients were still bleeding
during endoscopy.
The profuse bleeding at the time of endoscopy (as
represented in the sclerotherapy group) was not influ-
enced by the severity of liver disease (as both groups
were comparable regarding Child-Pugh class), nor by the
grade of varices at the time of endoscopy probably be-
cause bleeding might have temporarily reduced variceal
size during endoscopy.
All patients underwent endoscopy after attaining he-
modynamic stability, and yet the majority of these pa-
tients were hemodynamically unstable at the time of pre-
sentation (87.1% in the EBL group and 91.4% in the
scerotherapy group), this emphasizes the role of the pre-
endoscopic standards of care given to the patients like
volume restitution and maintaining the aerobic metabo-
lism by restoring an appropriate delivery of oxygen to
the tissues (which depends on oxygen saturation, cardiac
output, and hemoglobin concentration) [19]. This also
explains why the scerotherapy group underwent endo-
scopy after a significantly longer time than the EBL
group (9.5 ± 5 hrs in the EBL group versus 11.5 ± 6.5 hrs
in the sclerotherapy group) and had a significantly more
amount of transfused packed RBCs as compared to the
EBL group (4.1 ± 1.2, versus 3.1 ± 1.07; p 0.01).
The next point to highlight in this study is the outcome
of patients following the emergency endoscopy, it is
clear that rapid switching from conventional EBL to
sclerotherapy in our patients saved the time that could
have been spent over getting a clear view so as to per-
form EBL, which of course could have endangered the
patients' lives. That is why there were no reported dif-
ferences in the mortalities between the 2 groups nor the
duration of hospital stay. However, some of the unfavor-
able outcomes were significantly reported among the
sclerotherapy than the EBL groups. The initial success to
control bleeding for both techniques is compatible with
the universally reported figures (around 90%) [20]. How-
ever, it was significantly higher in the EBL versus EIS
groups (96.7% versus 84.5%; p 0.02). Also, bleeding re-
currence was significantly less in the EBL versus the EIS
groups (24.2% versus 42.9%; p 0.04). Lo et al. [7], re-
ported 17% rate of re-bleeding with EBL vs. 33% with
EIS, Villanueva et al. [11], reported 12% incidence rate
for re-bleeding for EBL versus 21% for EIS. Krige et al.
[14], reported that even under optimal conditions, cur-
rently available treatment options fail to control initial
variceal bleeding or prevent early re-bleeding in up to
20% of patients. The overall analysis of these figures
reveals that they match those reported by other authors.
However, it is important to emphasize that these studies
were randomized and it is supposed that patients with
severe bleeding were homogenously distributed among
both the EBL and EIS groups. This was not the case in
this study, where the EIS group was a special grouping
for those who were actively bleeding and difficult to
perform EBL as explained by the significantly higher in-
cidence of moderate and severe bleeding attacks among
the EIS group. So the less success rates we encountered
in this situation, where the technique might have been
deranged due to the severe bleeding, is rather accepted.
On the other hand, since the severity of the initial re-
bleed has been one of the contributing factors to recur-
rent bleeding [21], this again explains why the sclero-
therapy group had a higher incidence of variceal re-
The other reported adverse events like chest pain, dys-
phagia and bacterial peritonitis were significantly higher
in the EIS than the EBL group. These can be attributed
mainly to the type of the technique and to a less extent to
the severity of bleeding. Randomized trials that com-
pared EBL to scerotherapy have yielded similar findings,
without essentially having difference in the severity of
bleeding between both arms. Most of these studies have
reported that EBL is generally a safer technique than EIS
because it involves a mechanical, less invasive method of
variceal obliteration with less systemic and local com-
plications involving the esophageal wall [7,11,22-29].
For example our data of peritonitis were 19% with EIS
versus 6.4% with EBL (p 0.01). This matches with Laine
et al. [24], who reported 18% incidence rate of peritonitis
in EIS vs. 15.8% in EBL.
About one third of cases presenting with acute variceal
bleeding will have difficult-to-perform EBL due to the
severity of active bleeding at the time of endoscopy. In
these patients, sclerotherapy is not a waning procedure
and is still a technique that can be resorted to with an
accepted success rate, without additional complications
and without deranging mortality.
Copyright © 2013 SciRes. OPEN ACCESS
G. E. Esmat et al. / Open Journal of Gastroenterology 3 (2013) 281-287
The authors appreciate the contribution made by Dr Mohamed El-
Gouhary in the execution of this work
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