Huma Qureshi  ( PMRC Research Centre, Jinnah Postgraduate Medical Centre, Karachi. )

Injection sclerotherapy for oesopliageal varices was first reported from Sweden in 1939 using intravariceal quinine¹. No recurrence of varices or rebleeding occurred till 3 years. Next year at Mayo Clinic, 2.5% sodium morrhuate was used for sclerotherapy resulting in reduction in the size of varices². Longer follow up on a larger series of patients revealed that rebleeding was more fre­quent in those who had associated gastric varices³ and therefore their presence was taken as a con­traindication to the use of sclerotherapy.
The first experience of sclerotherapy from Great Britain was reported in 1949⁴;further follow up on these patients showed a better result of scierotherapy if splenectomy was done prior to the procedure. The need to do follow up endoscopies to recognize the recurrence of varices was also brought to notice⁵. In 1959 sciero­therapy experience in 15 children below the age of 16 years was reported from Toronto⁶. A follow up till 4 years showed success in 9 cases. It was also experienced that bleeding episodes increased during upper respiratory tract infection in children and it was therefore recommended that children with varices should have adenotonsillectomy.
In 1960 instead of intravariceal injection, paravariceal injection was thought to be more effective because of the creation of submucosal fibrosis over the varix thereby protecting them from bleeding⁷. The technique was later picked up by others^8,9 who have collected enough data on its use in both elective and emergency scier­otherapy.
By 1973, surgeons at Kings College showed dissatisfaction with shunt and non-shunt proce­dures, especially in those with severe liver dis­ease¹⁰ while workers from Belfast¹¹  had published 93% success rate with scierotherapy. Therefore, sclerotherapy was taken up by the Kings College too. Further modification in the ridged Negus oesophagoscope was made in 1975¹² allowing the varices to prolapse into the lumen of the scope, making the injection easier. High frequency of deaths due to oesophageal perfora­tion (20%) reported from Kings College in 1977¹³ prompted the development of a flexible outer sheath and endoscope plus needle¹⁴. By 1980, graduated flexible sheath was made commercially available.
Till almost 40 years after the first use of sclerotherapy no controlled data for the efficacy and improvement in the survival time following sclerotherapy was available. First few controlled trials were reported between 1979-1981^15-17  along with significant improvement in the survival time in one.
Blood flow patterns in the oesophageal collaterals were demonstrated using endoscopic doppler¹⁸ Variations in the flow pattern were found tO occur especially during respiration. Perforating veins connecting the varices to the paraoesophageal vessels were also seen throughout the whole length of the oesophagus and it was suggested that perhaps the turbulant blood flow in the perforating vessels was the cause for the vanceal rupture.
For sclerotherapy, the sclerosant can be either injected directly into the varices to obli­terate the lumen, or into the lamina propria and submucosa to produce a fibrous layer over the varix. Intravariceal technique requires a larger volume of sclerosant (3-Sm!) in each varix at two or three sites at the lower oesophageal junction, while paravariceal injection requires smaller volume of sclerosant (0.5ml) at multiple sites. Histologic changes^19,20 and the efficacy in the management of active, and prevention of recurrent bleeding are similar in both the techniques.^9,11,21,22
Some workers^23,24  use baloon temponade during sclerötherapy to achieve a bloodless field, while others use it after scier­otherapy. Various types and combinations of scierosants have been used, including quinine, sodium morrhuate, ^3,5,25 ethanolamine oleate, sotradecal, ⁶ 50% dextrose, absolute alcohol²⁶ and sodium tetradecyl sulphate²⁷. The choice, dosage and combination mostly depends upon the availability, cost and choice of the operator. Time interval between the two courses vary from 1-3 weeks but injections are often initially given weekly for 3 weeks and later every 3-4 weeks until all varices disappear. ²⁸
Multiple controlled trials have been done to see the efficacy of scierotherapy in reducing the number of rebleeds and improving the survival time^21,27,29,30.A trend towards reduction in number of rebleeds was observed and such episodes were seldom life threating. Improvement in the long term survival has been reported from Kings College. ³¹
In some trials, the efficacy of scierotherapy was compared with balloon temponade in the management of acute bleeding. ^32,33 In both the studies bleeding was controlled in a larger group of patients and fewer deaths occurred in the sclerotherapy group.
Some workers have done prophylactic scierotherapy in patients who have never bled. ^34,35 Selection criteria were large varices, prolonged prothrombin time and the presence of stigmata on varices³⁶ in one group while it was unselected in another. Both the studies showed a significant reduction in the bleeding episodes while improvement in the survival time was noted in one study. Regular. endoscopic examinations at 3 months, 6 months and then yçarly are required to check the formation of new varices and inject them as and when needed. Usually few injections (median 2 courses) are required to obliterate new varices and complications of sclerotherapy are rare²⁸.
At the international symposium on the prophylaxis of variceal bleeding³⁷ the pitfalls in the prophylactic treatment were reviewed. It was suggested that apart from geographical variations in the underlying liver disease, patient population and the degree of hepatic decompensation, other risk factors like state of varices, liver status and alcohol abuse should be taken into consideration. Unfortunately neither all these criteria nor the treatment of acute bleeds were matched in most of the cøntrolled trials and, therefore, the results are not absolute.
Early complications of sclerotherapy (within 24hrs) include perforation, aspiration, chest pain and transient fever. Of later compli­cations, oesophageal ulceration is very frequent, but a minor percentage bleeds from this²⁸. Full thickness necrosis along with rnediastinitis though rare, is often fatal. About 10% cases develop stric­ture often after 3-4 courses; dysphagia in these cases resolves spontaneously and only a small number requires dilatation. Abnormal oesophageal motility is reported after sclerotherapy^38-40. Overall mortality with sclerotherapy is about l-2%⁴¹.

1. Crafoord, C. and Frenckner, P. New surgical treatment of varicose veins of the oesophagus. Acta Otolaryngol.  (Stockh), 1939; 27:422.
2. Moersch, H.J. The treatment of esophageal varices by injection of a scierosing solution. J. Thorac. Surg., 1940; 27:4 22.
3. Moersch, HJ. Treatment of esophageal varices by injection of a scierosing solution. JAMA.,1947; 135:754.
4. Macbeth, R.G. Treatment of oesophageal varices by means of scierosing injections, in Proceedings of the Fourth International Congress of Oto­laryngology 1949. London, 1951, p. 294.
5. Macbeth, R. Treatment of oesophageal varices in portal hypertension by means of scierosing injections. Br. Med.J., 1955;2:877.
6. Fearon, B. and Sass-Kortsak, A. The manage­ment of esophageal varices in children by injection of scierosing  agents. Ann. Otol. Rhinol. Laryngol., 1959; 68:906.
7. Wodak, E. Eosophageal varices hemorrhage in portal hypertension; therapy and prevention. Wien. Med. Wochenschr., 1960; 110:5 81.
8. Denck, H. Endoesophageal sclero.therapy of bleeding esophageal varices. J. Cardiovasc. Surg., 1971; 12:146.
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10. Pugh, R.N.H., Murray-Lyon, I.M., Dawson, J.L., Pietroni, M.C. and Williams, R. Transection of the oesophagus for bleeding oesophageal varices. Br. J. Surg., 1973; 60: 646.
11. Johnston, G.W. and Rodgers, H.W. A review of
15 years experience in the use of scierotherapy in the control of acute gastric haemorrhage from oesophageal varices. Br. J. Surg., 1973; 60: 797.
12. Bailey, M.E. and Dawson, J.L. Modified eso­phagoscope for injecting esophageal varices. Br. Med. J., 1975; 2:  540.
13. Williams, R., Mitchell, KJ., Clarke, A. and Silk, D.B.A. Esophageal scierotherapy, in Recenti Progressi in Epatologia. R Williams, L Cantoni (cdi). 1979, pp 45-49.
14. Williams, K.G.D. and Dawson, J.L. Fibreoptic injection of oesophageal varices. Br. Med. J., 1979; 2:766.
15. Terbianché, J., Northover, J.M.A., Bornman P., Khan, D., Barbezat, G.O., Sellars, SI., and Saunders, S.J. A prospective evaluation of injection sclerotherapy in the treatment of acute bleeding from esophageal varices. Surgery, 1979; 85:239.
16. Clark, A.W., Macdougall, B.R.D., Westaby, D., Mitchell, KJ., Silk, D.B.A., Strunin, L., Dawson, J.L. and  Williams, R. Prospective controlled trial of injection scierotherapy in patients with cirrhosis and recent variceal  haemorrhage. Lancet, 1980; 2:552.
17. Macdougall, B.R.D., Westaby, D., Theodossi, A., Dawson, J.L. and Williams, R. Increased long—term survival in variceal haemorrhage using injection sclerotherapy; results of a controlled trial. Lancet, 1982;1: 124.
18. McCormack, T.T., Rose, J.D., Smith, P.M. and Johnson, A.G. Perforating veins and blood flow in oesophageal varices. Lancet, 1983; 2:1442.
19. Evans, DM, Jones, D.B., Cleary, B.K. and Smith, P.M. Oesophageal varices treated by scier­otherapy; a  histological study. Gut, 1982; 23:615.
20. Helpap, B. and Bollweg. L. Morphological changes in the terminal oesophagus with varices, following sclerosis of the wall. Endoscopy, 1981;13:229.
21. The Copenhagen Esophageal Varices Scierother­apy Project Scierotherapy after first variceal hemorrhage in cirrhosis. A randomized multi-center trial. N. Engl. J. Med., 1984; 311:1594.
22. Westaby, D., Macdougall, B.R. and Williams, R. Improved survival following injection sciero­therapy for esophageal varices; final analysis of a controlled trial. Hepatology, 1985; 5: 827.
23. Kirkhaxn, J.S. and Qualye, J.B. Oesophageal varices; evaluation of injection scierotherapy without general  anaesthesia using the flexible fiberoptic gastroscope. Ann. R. CoIl. Surg. Engi., 1982;64:401.
24. Johnson, A.G., Shams, J.M. and Stoddard, C.J. Is there a role for injection scierotherapy in the presence of active bleeding, in variceal bleeding. Edited by D. Westaby, BRD,Macdou­gall, R. Williams. London, Pitman, 1982, p. 159.
25. Patterson, C.O. and Rouse., MO. Scierosing therapy of esophageal varices. Gastroenterology, 1947; 9:391.
26. Sarin, S.K., Sachdeva, G.K., Nanda, R., Vij, J.C. and Anand, BS. Endoscopic scierotherapy using absolute alcohol. Gut, 1985; 26:120.
27. Jensen, D.M. Evaluation of scierosing agents in animal models. Proceedings of the Third Inter­national Endoscopy Symposium. Cleveland, 1983, p. 446.
28. Williams, R. and Westaby, D. Endoscopic scler­otherapy for oesophageal varices. Dig. Dis. SeL, 1986;31: 1085.
29. Terblanche, J., Bornman, P.C., Kahn, D., Jonker, M.T., Campbell, J.H., Wright, J. and Kirsch, R. Failure of  repeated injection scier­otherapy to improve long-term survival after oesophageal variceal bleeding. Lancet, 1983; 2:1328.
30. Komla, J., Balart, L.A., Radvan, G., et al. A pro­spective, randomized controlled trial of chronic esophageal  variceal sclerotherapy. Hepatology, 1984; 5:584.
31. Westaby, D., Melia, W., Gegarty, J. et al. Use of proranolol to reduce the rebleeding rate during injection sclerotherapy prior to variceal oblitera­tion. Hepatology, 1986; (in press).
32. Barsoum, MS., Bolous, F.I El-Rooby, A.A., Rizk-Aflah, M.A. and Ibrahim, A.S. Tainponade and injection  sclerotherapy in the management of bleeding oesophageal varices. Br. J. Surg., 1982; 69:76.
33. Paquet, K.H. and Feussner, H. Endoscopic sclerosis and esophageal temponade in acute hemorrhage from  esophagogastric varices. A prospective controlled randomized trial. Hepato­logy, 1985; 5:580.
34. Paquet, KJ. Prophylactic endoscopic sclerosing treatment of esophageal wall in varices — a prospective controlled randomized trial. Endos­copy, 1982; 14:4.
35. Witzel, L., Wolbergs, E. and Merki, H. Prophy­lactic endoscopic sclerotherapy of oesophageal varices. Lancet,  1985; 1: 773.
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37. Ogle, SJ., Kirk, CJ.C., Bailey, RJ., Johnson, A.G., Williams, R. and Murray—Lyon, I.M. Esophageal function in cirrhotic patients under­going injection selerotherapy for oesophageal varices. Digestion, 1978; 18:178.
38. Sauerbruch, T., Wirsching, R., Leisner, B., Weinzierl, M., Pfahler, M. and Paumgartner, G. Esophageal function after scierotherapy of bleeding varices. Scand. J. Gastroenterol., 1982;17:745.
39. Soderlund, C. and Thor, K. Esophageal function. after sclerotherapy for bleeding varices. Acta Chir. Scand.SuppL,1985;524: 63.
40. Reilly, J.J., Schade, R.R. and Van Thiel, D.S. Esophageal function after injection sclerotherapy. Pathogenesis of esophageal stricture. Am. J.Surg., 1984; 147: 85.
41. Conn, H.O. A plethora of therapies, in variceal bleeding. Edited by D. Westaby, BRD Macdougall, R. Williams. London, Pitman Medical, 1982,P.221.