Sclerotherapy: Sclerosing agents like sodium tetradocyl sulphate and 3 percent phenol in water are injected through upper GI endoscopy, around the varices. They obliterate the blood vessels and prevent future bleeds.
It stops variceal bleed in 80 percent of patients and can be repeated if bleeding recurs. However, if there is active bleeding, sclerotherapy is hazardous and first the bleeding should be controlled by balloon tamponade.
Banding: Here, the varices are sucked into an endoscope accessory, allowing them to be occluded with a tight rubber band. The occluded varice subsequently sloughs with variceal obliteration.
Balloon tamponade: This is done with Sengstaken-Blakemore tube which possesses two balloons and exerts pressure in lower esophagus and fundus of the stomach. The tube is passed through the mouth and its presence in the stomach is checked by auscultating over the upper abdomen while injecting air into the stomach. The gentle traction is used to maintain pressure on the varices. Initially gastric balloon only is inflated, which would control the bleeding. If esophageal balloon also required to be inflated, it is important to deflate it for 10 mins every three hours to prevent esophageal mucosal damage. This usually stops the variceal bleed, but only allows for time for more definite therapy.
Transaction: Transaction of the varices can be done easily with a stapling gun. This is used when bleeding cannot be controlled by other measures. It carriers a small risk of subsequent esophageal stenosis.
Shunt surgery: Portocaval shunts also give excellent results with low morbidity and mortality and is a one time procedure unlike sclerotherapy which may have to be repeated. However, the incidence of hepatic encephalopathy is high and death could result from liver failure. Hence it is only used when other measures fail and offered only to patients with good liver functions.
