Endoscopic sclerotherapy is a test which allows the doctor to look directly at the esophageal varices and inject sclerosing agents to prevent bleeding. Diagnostic endoscopic sclerotherapy is recommended for esophageal varices in cirrhotic patients, history of variceal bleeding and as a preventive test for high-risk patients. In order to do the test, an endoscope is carefully passed through the mouth into the esophagus. The endoscope is a long flexible tube, about the thickness of your index finger, with a bright light at its tip. The video camera on the endoscope transmits images of the esophageal lining to a monitor allowing the physician to examine the esophagus checking for varices or abnormalities. If necessary, sclerosing agents can be injected through the scope during endoscopic sclerotherapy to prevent bleeding. Tissue samples (biopsies) can be taken during the procedure as well.

Diagnosis

Endoscopic sclerotherapy can help doctors diagnose the reasons for

• Portal hypertension from cirrhosis

• Esophageal varices on imaging

• History of variceal bleeding

• Hematemesis or vomiting blood

• Melena or black tarry stools

• To evaluate abnormalities in the esophagus in other imaging like ultrasound and CT scan

• Unexplained anemia and blood loss

• Diagnosis and surveillance of variceal recurrence

Endoscopic sclerotherapy can also detect the size, location and bleeding status of varices. The procedure is used to look for early signs of variceal disease in cirrhotic patients. The doctor can also take samples from abnormal-looking tissues during the procedure. The procedure, called a biopsy, allows the doctor to later look at the tissue with a microscope for signs of disease.

Endoscopic ultrasound: High frequency ultrasound is applied with endoscopy that will help to assess variceal size, blood flow and predict bleeding risk especially in high-risk patients with large varices.

Doppler endosonography: is a modality when applied with endoscopic sclerotherapy can help to assess portal vein flow and differentiate true varices from other esophageal lesions so that therapeutic yield is high.

Treatment

Endoscopic sclerotherapy can help doctors with the following issues

• Prevention of first variceal bleed in high-risk patients

• Treatment of active variceal bleeding (emergency)

• Prevention of variceal rebleeding after initial bleeding episode

• Eradication of esophageal varices completely

• Control of bleeding from ruptured varices

• Reduction of portal pressure gradient

• Palliative treatment for bleeding varices (alternative to surgery or transjugular intrahepatic portosystemic shunt)

• Prevention of recurrent hemorrhage and mortality in cirrhotic patients

Interventions

Intravariceal injection: sclerosing agent injected directly into variceal lumen to cause thrombosis

Paravariceal injection: sclerosing agent injected around varices to cause inflammation and closure

Endoscopic sclerotherapy: injection therapy performed for the eradication of esophageal varices

Repeat sclerotherapy: multiple sessions performed to achieve complete variceal eradication

Hemostatic injection: high concentration sclerosant injected for hemostasis if active bleeding present

Combined therapy: sclerotherapy combined with variceal ligation for difficult varices

Prophylactic sclerotherapy: preventive injection performed in high-risk patients without prior bleeding

Post-sclerotherapy ulcer management: ulcers developing at injection sites are monitored and treated if bleeding occurs

Preventive

Variceal bleeding surveillance: esophageal varices in cirrhotic patients are on the rise in Asian countries. Surveillance is recommended in average and high-risk patients to detect varices in the early stage which may help in endoscopic prevention avoiding surgery.

Surveillance of patients with decompensated cirrhosis: Patients with advanced cirrhosis and portal hypertension are prone to develop variceal bleeding which can be prevented by endoscopic sclerotherapy combined with repeat sessions.

Early detection and sclerotherapy of large varices followed by monitoring: Early detection and sclerotherapy of large or high-risk varices prevents initial variceal bleeding and reduces mortality significantly.

Primary prophylaxis in high-risk patients: Patients with newly diagnosed varices at high risk for bleeding can undergo primary prophylactic sclerotherapy to prevent first variceal hemorrhage.