Department of Gastroenterology, Hepatology & Nutrition, 2823 Fresno Street, Fresno, CA 93721, USAUnited States
VA Central California Health systems, 2615 E Clinton Ave, Fresno, CA 93703, USAUnited States
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A 70-year-old man with history of end-stage liver disease due to alcohol misuse disorder was admitted to the hospital with hematemesis. He had at least 5 episodes of bright red hematemesis and was feeling dizzy. He complained of epigastric pain for 3 days prior to presentation. He had noticed progressive development of dark urine, pale stools and yellow sclera. He had not consumed any non-steroidal anti-inflammatory drugs recently.
Cirrhosis of liver can be complicated by esophageal varices. A bleeding esophageal varices can cause significant mortality and morbidity. The risk of recurrent GI bleed is very high if not treated. Endoscopic management along with pharmacotherapy is the current standard of care for management of esophageal varices. Bands placed through endoscopy can cause scarring of these varices and ligate it thereby preventing GI bleed. Bands can be placed either as a primary prophylaxis in large varices that have never bled before or as secondary prophylaxis in patients with history of bleed or who have high-risk features for bleeding such as nipple sign or red wale sign of varices. Banding of varices is highly successful in most cases. In minority of cases with repeated prior banding, scar formation will prevent successful band ligation. If this happens in the setting of acute GI bleed, the mortality is very high. The society practice guidelines suggest using a Minnesota tube, which is an esophageal balloon for immediate tamponade to control bleeding in refractory variceal bleed. This can be in place for 24 hours and subsequently patients undergo TIPS.
Placement of a Minnesota tube is a complex procedure and can be cumbersome when needed acutely. It has a success rate of only 50% in controlling GI bleed and can have certain risks like mal-deployment and esophageal perforation especially if the gastric balloon is inflated in esophagus. A multicenter randomized control trial of esophageal balloon tamponade vs stent in control of refractory variceal GI bleed showed that success was higher the hemorrhage which otherwise can be life-threatening. Other risks of esophageal stent are acid reflux, which can cause aspira- 1 tion and this can be minimized by high doses of twice a day proton pump inhibitors. Stent-related esophageal perforation is very rare in expert hands, especially if caution is taken to ensure that guidewire is placed in the stomach. A recent meta-analysis of 155 patients from 12 studies showed success rate of achieving hemostasis within 24 hours in acute variceal bleed was 96%. The adverse events included rebleeding, ulceration and stent migration in 36% of patients. The 60 day survival rate was 64% in those undergoing the procedure.6 Another meta-analysis of 80 patients from five studies showed success rate of 94% with no stent-related mortality. Number of patients with uncontrolled bleeding despite the stent placement was 12%, 21% of patients had stent migration and 34% died due to liver disease related cases.7 We have described the technique of placement of Self-expanding fully covered metal esophageal stents under endoscopic guidance for treatment of refractory variceal bleed. However, some of the other kinds of stents like De- 2 nis Ella stent used in Europe for treatment of refractory variceal bleed does not need endoscopic visualization for placement of it.
There is a growing body of evidence suggesting that esophageal stents are safe and effective in treatment of refractory variceal bleeding and it should be the standard of care. This method is safer and more effective compared to Minnesota tube 1 in controlling acute hemorrhage from refractory variceal bleed and can be used as either a bridge to TIPS or better as an alternate to TIPS.
Gastro Open J. 2019; 4(1): 1-3. doi: 10.17140/GOJ-4-128
The authors declare that they have no conflicts of interest.