Anastasios Armonis

Endoscopic sclerotherapy versus variceal ligation in the long-term management of patients with cirrhosis after variceal bleeding: A prospective randomized study

BACKGROUND/AIMS Long-term endoscopic injection sclerotherapy of oesophageal varices prevents rebleeding in patients with cirrhosis surviving an acute variceal bleeding episode. However, this treatment is associated with a substantial complication rate. Endoscopic band ligation is a newly developed technique in an attempt to provide a safer alternative. The aim of this study was to compare the efficacy and safety of injection sclerotherapy versus variceal ligation in the management of patients with cirrhosis after variceal haemorrhage. METHODS Seventy-seven patients with cirrhosis who proved to have oesophageal variceal bleeding were studied. After initial control of haemorrhage by sclerotherapy, 40 of the patients were randomly assigned to sclerotherapy and 37 to ligation. Both procedures were performed under midazolam sedation at intervals of 7-14 days until all varices in the distal oesophagus were eradicated or were too small to receive further treatment. RESULTS The eradication of varices required a lower mean number of sessions with ligation (3.7 +/- 1.9) than with sclerotherapy (5.8 +/- 2.7, p = 0.002). The mean duration of follow-up was similar in both groups (15.6 months +/- 7.3 and 15 +/- 7.4, respectively). The proportion of patients remaining free from recurrent bleeding against time was significantly higher in the ligation group as compared to the sclerotherapy group (chi 2 = 3.86, p = 0.05). Only 13 patients (35%) developed complications in the ligation group as compared to 24 (60%, p = 0.05) in the sclerotherapy group. The mortality rate was similar in both groups (20% and 21%, respectively). CONCLUSIONS Variceal ligation is better than sclerotherapy in the long-term management of patients with cirrhosis after variceal haemorrhage which was initially controlled with sclerotherapy.

Effects of endoscopic variceal treatment on oesophageal function: a prospective, randomized study.

Aim Endoscopic methods are currently the most widely used techniques for the treatment of bleeding oesophageal varices (BOV). However, a number of complications may limit their usefulness. We conducted a prospective, randomized comparison of variceal ligation versus sclerotherapy in cirrhotics after the control of variceal haemorrhage to study the relative short-term risks of these two procedures with respect to oesophageal motility and gastro-oesophageal reflux. Methods Seventy-three patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to treatment with sclerotherapy or ligation until variceal eradication. In 60 of these patients, oesophageal manometry and 24-h intra-oesophageal pH monitoring were performed at inclusion and 1 month after variceal eradication. Results After variceal eradication with sclerotherapy, peristaltic wave amplitude decreased from 76.2 ± 14.7 mmHg to 61.6 ± 17.7 mmHg (P = 0.0001), simultaneous contractions increased from 0% to 37.9% (P = 0.0008), and the percentage of time with pH < 4 increased from 1.60 ± 0.25 to 4.91 ± 1.16% in channel 1 (P = 0.0002) and from 1.82 ± 0.27 to 5.69 ± 1.37% in channel 2 (P = 0.0006). In contrast, the above parameters were not disturbed with ligation. Conclusion Our data define the advantages of ligation over sclerotherapy with respect to post-treatment oesophageal dysmotility and associated gastro-oesophageal reflux.

CASE REPORT: Toxic Hepatitis After Sequential Administration of Flutamide and Cyproterone Acetate

Flutamide and cyproterone acetate are representatives of the two different classes of androgen receptor antagonists which are commonly used in the treatment of prostatic cancer. Flutamide belongs to the so–called pure, nonsteroidal antiandrogens and cyproterone acetate is classified as a steroidal antiandrogens. A variety of hepatotoxic reactions has been reported with flutamide and also with cyproterone acetate (5–16). Clinical pictures range from weakness and anorexia to the symptoms and signs of fulminant hepatic failure and death. Therefore, close monitoring is recommended during treatment periods, and in cases of hepatic toxicity it is usually the practice to turn to the drug of the other class. Herein we report the observation of toxic hepatitis with severe hepatocellular dysfunction after the sequential administration of a nonsteroidal and a steroidal antiandrogen in a patient taking flutamide and, after a few months, cyproterone acetate. The risk for toxic hepatitis development after sequential administration of two different androgen receptor antagonists is not well known. Our observation raises arguments against the practice of starting treatment with one agent when the other has to be discontinued due to hepatoxicity

Early increase of lower oesophageal sphincter pressure after band ligation of oesophageal varices in cirrhotics: an intriguing phenomenon

Aim We conducted a prospective, randomized comparison of endoscopic variceal ligation, sclerotherapy and metoclopramide injection in order to evaluate their early effect on lower oesophageal sphincter pressure. Methods Twenty-six patients with established cirrhosis and an episode of variceal bleeding controlled by one session of endoscopic therapy were randomized to undergo an oesophageal manometry. The patients’ lower oesophageal sphincter pressure was evaluated, prior to and immediately after a single session of ligation (n = 10), a single session of sclerotherapy (n = 8) or a bolus injection of 20 mg metoclopramide hydrochloride (n = 8). Results Ligation produced a higher early increase in lower oesophageal sphincter pressure (from 12.3 ± 2.3 to 27.8 ± 3.0 mmHg) as compared with sclerotherapy (from 13.6 ± 2.5 to 22.4 ± 4.5 mmHg) or metoclopramide injection (from 14.6 ± 3.2 to 22.5 ± 2.9 mmHg); (P = 0.0001). Conclusion Our data indicate that ligation of oesophageal varices produces an early increase in lower oesophageal sphincter pressure in cirrhotic patients.