Gastrointestinal varices historical perspective
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Historical Perspective
Landmark Events In The Development Of Treatment Strategies
Pre-1970s
- In 1939, Crafoord and Freckner discovered sclerotherapy with the help of quinine for the management of oesophageal varices
- In the 20th century, sclerotherapy became an important treatment option in the management of variceal haemorrhage, especially with the advent of fibre-optic endoscopy
- Prior to the 1970s, surgery was the mainstay of therapy for variceal haemorrhage
- Previously, surgical techniques such as oesophageal stapling or oesophagectomy were used, but with high mortality rates from complications such as sepsis, liver failure and renal failure
- In the 1980s, in patients with portal hypertension, devascularisation procedures were associated with decreased mortality in patients
- In the late 20th century, splenectomy became a famous procedure for management of gastrointestinal varices
- Surgical therapies are employed in patients who have failed endoscopic procedures
- In 1950, The Sengstaken-Blakemore tube’s use was first described by Sengstaken and Blakemore and later used as a treatment option in 1930
- It has been largely replaced by endoscopic therapies
1970s and 1980s
- In the early 1970s, the first reported case series of endoscopic sclerotherapywas published with its use becoming more widespread in the 1980s
- Ethanolamine oleate, sodium tetradecyl sulphate, polidocanol, sodium morrhuate and ethanol have been used as treatment options in sclerotherapy
- In Europe the most commonly used agents were ethanolamine oleate and polidocanol, whereas in the United States sodium morrhuate was employed as a treatment strategy
- Paravariceal injection consisted of injection in the vicinity of the varix causing variceal occlusion by tamponade resulting in submucosal fibrosis of tissue around the varix, on the other hand, intra-variceal injection lead to thrombosis and resultant occlusion of the lumen
- Sclerotherapy when compared to placebo and baloon tamponade has been shown to significantly control bleeding from varices
- In 1988, EVBL was first used for the treatment of esophageal varices, based on the concept of banding haemorrhoids with elastic O-rings. EVBL became a treatment option for the treatment of esophageal varices in 1990s
1990s
- In the 1990s, sclerotherapy became a popular treatment option not only for esophageal varices but gastric varices as well
- EVBL became increasingly popular treatment modality for esophageal varices in the 1990s
- To achieve higher success rates in endoscopic therapies, pharmacological therapies for example, the use of octreotide, telipressin and somatostatin was developed for better control of variceal hemorrhage
- Transjugular intrahpatic portosystemic shunt (TIPSS)- which involves placement of a stent between the portal and hepatic vein to reduce portal pressure, was used as a radiological treatment option for varices for the first time in 1990s
2000-present
- During the 21st century, pharmacological, endoscopic and radiological therapies for variceal haemorrhage became optimized
- Antibiotics were used for the first time during the management of varices. Antibiotics were found to decrease the rate of bacterial infections, recurrent bleeding and improve mortality in patients bleeding from esophageal varices
- Cyanoacrylate glue was shown to have a faster rate of variceal obliteration when compared to ethanol injection in sclerotherapy
- In the early 200s, thrombin was also used for variceal obliteration
- In 2004, the use of a covered TIPSS stent (covered with polytetrafluoroethylene) was approved by the United States Food and Drug Administration
- In the 2000s, interventional radiological procedures for the treatment of gastric varices included the use of BRTO as rescue therapy when endoscopic obturation therapy failed
- Although, liver transplantation is the only curative treatment for liver cirrhosis at this point in time, its role in the management of varices is unknown
- Another new area of interest that has been the development of haemostatic powders/sprays. TC-325 (Hemospray, Cook Technology™) is a granular non absorbable mineral powder used in the management of arterial wounds