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Risk factors for complications after injection sclerotherapy were studied in 163 patients undergoing 667 treatments for bleeding oesophageal varices. The overall mortality rate was 7 per cent per injection sclerotherapy session; 16 per cent per acute session and 2.4 per cent per elective session. Acute variceal bleeding was controlled by injection sclerotherapy in 91 per cent of patients. Complications occurred after 16 per cent of injection sclerotherapy sessions. Deaths and complications were significantly associated with poor modified Child's grading (P less than 0.001), the first variceal bleed (P less than 0.001), acute injection sclerotherapy (P less than 0.001) and the use of the rigid oesophagoscope (P less than 0.001).

The results of injection sclerotherapy for oesophageal varices which recurred after portal non-decompressive surgery were analysed retrospectively to evaluate its efficacy. We treated 60 consecutive patients with portal hypertension; 19 were treated on an emergency basis, seven electively and 34 on a prophylactic basis. All acute bleeding was controlled with one session of sclerotherapy using a transparent overtube. After eradication by sclerotherapy, no bleeding episodes occurred and there was no recurrence of the varices, except in three uncompliant patients, during a mean follow-up period of 33.1 months. Bleeding from a gastric ulcer and gastritis occurred in one patient each. Oesophageal stenosis occurred in nine (15 per cent) patients and gastric varices developed in two (3 per cent) patients. Twelve patients died, five from liver failure and six with hepatoma, but there was no bleeding from the gastrointestinal tract. The overall 4-year survival rate was 80 per cent. We recommend the use of sclerotherapy as the primary treatment for recurrent oesophageal varices.

A total of 152 consecutive children with oesophageal varices have been endoscopically reviewed since 1979. In all, 108 of these children presented with variceal bleeding which was managed by injection sclerotherapy. Variceal obliteration was achieved in 33 (92 per cent) children with extrahepatic portal hypertension and 54 (75 per cent) with intrahepatic portal hypertension. Prophylactic injection sclerotherapy was used to obliterate large varices in 11 children with no history of haemorrhage. Bleeding episodes occurred in 38 (39 per cent) children before variceal obliteration was complete. However, the mortality rate from variceal bleeding was only 1 per cent. Complications were oesophageal ulceration (29 per cent) and stricture (16 per cent) which both resolved with conservative management. During a mean follow-up period of 2.9 years after sclerotherapy, recurrent oesophageal or gastric varices developed in 12 (12 per cent) cases, with rebleeding in 9 (9 per cent), but all responded successfully to a second course of treatment. These results are superior to contemporary surgical management and injection sclerotherapy should therefore currently be the primary treatment of choice for bleeding oesophageal varices in children.

Thirty-nine adult and teenage patients with extrahepatic portal venous obstruction (EHPVO) were treated with injection sclerotherapy. There were 22 males and 17 females with a mean age of 27 years (range 12-69). Oesophageal varices were eradicated in 33 patients after seven injections (range 1-17) over a mean of 14.5 months (range 1-48). Fewer injections were needed to eradicate varices in older patients. Variceal bleeding occurred on 13 occasions in 9 patients before eradication of varices and on 4 occasions in 4 of the 33 patients in whom varices had been eradicated, with a mean follow-up of 44 months (range 3-105). There were no deaths during the study period. Complications, mostly of a minor nature, occurred in 25 patients and included injection site leak in 5, stenosis in 7 and mucosal ulceration in 23. We conclude that injection sclerotherapy is the treatment of choice in patients with EHPVO.

Injection sclerotherapy for acutely bleeding oesophageal varices has been used in Belfast since 1958. However, a chronic injection sclerotherapy programme with rigid oesophagoscopy under general anaesthesia commenced only in 1979. So far, 82 patients have entered the programme; 57 patients had already received 73 acute injections before commencing chronic sclerotherapy. Subsequently, the 82 patients received 221 chronic injections plus a further 29 acute injections for rebleeding episodes which occurred during the programme. There were 24 Child's grade A patients, 23 B and 35 C; 48 per cent had alcoholic cirrhosis. Forty-eight patients achieved variceal obliteration with a mean of four injections. During the programme 24 patients experienced 42 acute bleeds. There were only two bleeding episodes within 1 week of a chronic injection and eight within 4 weeks. In the 8-year period there have been four early deaths. One occurred 17 days after a chronic injection and three followed acute injections required for rebleeding during the programme. There were 21 late deaths, mostly due to progressive liver failure, and none from rebleeding. We conclude that chronic injection sclerotherapy using rigid oesophagoscopy under general anaesthesia is both safe and effective.

Of 309 patients with portal hypertension, gastric varices were found in 48 (16 per cent). While the majority (88 per cent) of the patients had gastric varices in association with oesophageal varices, 6 (12 per cent) patients had 'isolated' gastric varices. Gastric varices were seen significantly (P less than 0.01) more often with grade 4 than with grade 3 varices. In 11 (28 per cent) of the 40 patients who completed sclerotherapy for oesophageal varices, gastric varices disappeared concurrently on eradication of oesophageal varices or during the following 6 months. Of the initial five patients with gastric varices who received direct intravariceal injections, four rebled; this technique was therefore replaced by combination (paravariceal + intravariceal) gastric variceal sclerotherapy. Emergency combination sclerotherapy successfully controlled bleeding from gastric varices in six of the eight treated patients. Thirty-two patients entered a programme of elective combination gastric variceal sclerotherapy. Variceal obliteration was achieved in 12 cases (38 per cent) and reduction in size was noted in another 7 patients (22 per cent) after a minimum of four courses. There were 11 (23 per cent) deaths, 8 due to uncontrolled bleeding from gastric varices and 3 due to hepatic coma. The other complications of gastric variceal sclerotherapy were minor and included retrosternal pain, fever and dysphagia. It is concluded that gastric varices often coexist with large oesophageal varices. If they persist for 6 months after eradication of oesophageal varices, a combination of paravariceal and intravariceal sclerotherapy should be attempted for their obliteration.

Oesophageal varices in 21 children with portal hypertension (intrahepatic 13, extrahepatic 8) were treated with sclerotherapy using ethanolamine oleate injected via a fibreoptic endoscope. Repeat endoscopy confirmed variceal obliteration in 18 children with a mean of 3.5 (range 1-8) injections. No patient has bled since obliteration of varices. Complications were oesophageal stricture (2 patients), oesophageal ulcer (5 patients) and haemorrhage within 3 days of injection (5 patients). The early results suggest that this is a satisfactory method for the treatment of oesophageal varices in children.

The complications of injection sclerotherapy were retrospectively studied in 122 patients with acute variceal bleeding. Initial control of bleeding was achieved in 72.5 per cent of patients and the final success rate of sclerotherapy was 86.1 per cent. The overall morbidity rate was 30.3 per cent. Minor complications occurred in 13.9 per cent of patients and major complications were recorded in 16.4 per cent. Twenty patients developed complications directly attributable to sclerotherapy: 14 minor and 6 major. The overall mortality rate was 21.3 per cent, and 7.4 per cent of the patients died due to complications. Pulmonary complications occurred in 15 patients and resulted in 3 deaths. Retrosternal pain developed in 8 patients, but dysphagia and oesophageal ulceration were rare. No stricture was recorded. The incidence of liver failure in 17 Child's grade C cases was almost certainly a complication of the underlying disease rather than the injection therapy. It is suggested that injection sclerotherapy is an effective and relatively safe treatment for variceal bleeding.

Forty-five cirrhotic patients with oesophageal varices underwent endoscopic injection sclerotherapy in a prospective randomized trial carried out to compare two sclerosing agents (5 per cent ethanolamine oleate and 2 per cent sodium tetradecyl sulphate (STD] with respect to safety, efficacy and complications. Twenty-three patients were allocated to the ethanolamine group and twenty-two to the STD group. The rate of control of acute bleeding was 100 per cent (6/6) in the ethanolamine group and 75 per cent (3/4) in the STD group. There was a significantly lower rate of postinjection bleeding after the over-tube was removed at the initial session of sclerotherapy when ethanolamine was injected 0/23 versus 7/22, 32 per cent; P less than 0.01) and at the second session there was a significantly (P less than 0.01) higher rate of jet-like bleeding from injection sites in the STD group (6/21, 29 per cent) than in the ethanolamine group (0/22). The disappearance rate of red colour signs 1 week after the initial session of sclerotherapy in the ethanolamine group was 100 per cent and 62 per cent in the STD group. Early oesophageal ulcers developed less frequently in the ethanolamine group (0 and 9 per cent) than in the STD group (24 per cent and 43 per cent both after the initial (P less than 0.05) and the second session of sclerotherapy (P less than 0.01]. Early bleeding from an oesophageal ulcer occurred only in the STD group (5/21, 24 per cent) before the third session of sclerotherapy (P less than 0.05). The rate of early mortality did not differ between the two groups. We conclude that ethanolamine seems to be safer and more efficacious than STD for sclerosing oesophageal varices.

Fifty cirrhotic Japanese patients with oesophageal varices underwent sclerotherapy in a prospective randomized trial carried out to examine the effects of human thrombin given concomitantly with the sclerosant 5 per cent ethanolamine oleate. The two groups (25 patients each) were comparable with regard to size of the oesophageal varices, and the aetiology and severity of the liver disease. Twenty-five patients, 13 and 12 in the thrombin + and - groups, respectively, had at least one episode of variceal bleeding. The remaining 25 were given prophylactic injections. There was a significantly lower rate of occurrence of bleeding from injection sites when the injection needle was removed at the initial session of sclerotherapy in the thrombin + group, where human thrombin was injected (0.2-0.3 ml, 100-150 units per injection) just before removal of the injection needle. Endoscopy at 1 week after the initial session showed a significantly (P less than 0.05) higher rate of disappearance of red colour signs on varices in the thrombin + group (96 per cent) than in the thrombin - group (72 per cent). Fibrin degradation product E-fraction (FDP-E) values increased 1 h, 1 day and 6 days after the initial session of sclerotherapy in the two groups. The rate of increase in FDP-E values 1 h after sclerotherapy was significantly larger (P less than 0.001) in the thrombin + than in the thrombin - group. There was no clinical sign of disseminated intravascular coagulation. Administration of human thrombin plus a sclerosant seems to be useful and efficacious, especially for patients with huge oesophageal varices.

Acute injection sclerotherapy has been used in Belfast for 25 years and the results are reviewed. During this period 264 patients had injection sclerotherapy for acute bleeding from oesophageal varices during 396 admissions; a rigid oesophagoscope was used and 447 injections were performed. The series includes 19 children who received 69 injections. Thirty-eight had extrahepatic portal venous hypertension and the remainder had intrahepatic disease. Overall, 81 were Child's grade A (including the 38 extrahepatics), 82 were grade B and 101 were grade C. Of the 396 admissions, acute injection sclerotherapy controlled bleeding in 362 instances (control rate 91.4 per cent); control rate in the children's group was 97.1 per cent and in the adults 90.2 per cent. The hospital mortality was 14.9 per cent (57 adults and 2 children). Nineteen deaths were due directly to bleeding oesophageal varices, two from bleeding gastric varices and seven directly or indirectly from oesophageal leaks. Most of the remaining deaths were due to liver failure. We consider that sclerotherapy is valuable in the control of variceal haemorrhage where bleeding is uncontrolled or recurs after vasopressin or tamponade in any admission.

Combined therapy consisting of sclerotherapy, embolization and splenopneumopexy was established for the treatment of oesophageal varices. These procedures were safely performed in 16 patients. No serious complications and no recurrent bleeding have been observed. The varices disappeared or were significantly improved as determined by periodic endoscopic evaluations. Portopulmonary shunt by splenopneumopexy is an alternative technique in the eradication of varices following sclerotherapy.