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Absolute alcohol in variceal sclerosis

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Absolute alcohol in variceal sclerosis
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  constructiveinfluenceon the substanceofthislegislation.We must dealfirstwith the issueofoverutilization. Re- cently, the greateruse of clinicalguidelineshasbeenrecommendedby the AmericanMedicalAssociation(AMA) andthe Joint Commissionon the AccreditationofHealthCareOrganizations(JCAHO)asonesteptowardasolution to thisproblem.Infact, the societyhasformanyyears had aleadingroleinestablishingstandards of practice, and thisisrecognizedas to ourcredit.We must emphasize that this typeofactionby and forphysicianshasapotentialforimprovedhealthcaredelivery that farexceeds the economicimperatives of thePPRC, while at the sametimeaddressing the issueofoverutilization.Whereverpossible, the societymustparticipate inthe process of Medicarereform to point out itsdeficiencies and tomakerecommendations that willcorrectthesefaults. In this respect, theA/S/G/E, alongwith the AGA and ACG,continuestobe an activeparticipant inthe secondphaseof the HarvardRBRVSproject. The societymustalsoopposethoseaspectsof the proposedlegislation that willdamage the deliveryofhealthcare, and we havevoiced our strongopposition to expendituretargets.Finally,Ibelieve the society must alsobeconcernedwith the allegation that manyendoscopicproceduresareovervalued.Wemustdevisemethodsofaddressing the issueofeffectiveness and to study the outcomeofendoscopicproceduresinterms of benefit to patients.Although we oftenregard the valueofendoscopicproceduresasself-evident,thereis an unfortunatelack ofdata to prove the point. ThePPRC hasrecommendedincreasesinfederalsupportforstudies of effectiveness and appropriateness, and it regardssuchknowledgeasessential  if we are to reduceunnecessary and inappropriateservices. Iwouldsuggest that this type of informationwill in greatermeasureconfirmourstandardsofpractice.Accordingly,Ihaveasked the ResearchCommitte to consider this issue andto suggestways in which the societymayobtainoutcomeinformation that hasscientificmerit. R F R N S 1. Lee PR, GinsburgPB, LeRoy LB, Hammons GT. ThePhysicianPayment Review Commission report to Congress.JAMA 1989,261:2382-5. 2. Hsiao WC, Braun P, Becker E, et al. Physician's reference to RBVS. Resource-based relative value scale. Chestnut Hill:Cambridge Health EconomicsGroup, Inc., 1988. Letters to the itor  bsolutealcohol in variceal sclerosis Tothe Editor:Inarecentissue,Paoluzi et aL'compared the efficacy and safetyofalcoholwithpolidocanol.After the inclusionof the first 11 patients  6 in polidocanolgroup and 5in the alcoholgroup), the trialwasinterruptedbecauseofseriouscomplicationsinpatients treated withalcohol. In asimilarstudyby us,2 31 patients withportalhyper- 466 tension and varicealhemorrhageduetocirrhosisofliverornoncirrhoticportalfibrosiswererandomized to receiveeitherabsolutealcoholor 1% polidocanol. Thirteen (76.4%) of the 17 patients inthe alcoholgroupdevelopedlargeesophagealulcers(>3cmindiameter).Theyweresolitaryineight and multiple in fivepatients.Thereweresixepisodesofmajorrebleedingduring the period of trial.Infourpatientsthiswasfoundtooriginatefrom the base of the ulcer.Subsequently,oneof them diedduetomassivebleeding. In 10 patients retrosternal pain persisted and requiredanalgesicsforrelief.Dysphagiaoccurred in 7 of the 13 patients in whomulcerswerepresent. Four of them developedastricturerequiringdilation.Two patients withulcersalsodevelopedmediastinitis.Laterone of themhadan esophagopleuralfistula and died. In contrast nomajorcomplicationsoccurredinpatientsreceivingpolidocanol.Threeof 14 patients had minorcomplications in the formoffever,transientchestpain, and ulcer  1 each). The efficacyofalcoholcould not beassessedas the trialwasterminateddueto the complications.Thus, it seems that both of thesetrialssup portthe experimental data indicating that absolutealcoholhassignificantulcerogeniceffects.  • The resultsoftworecentlypublishedcontrolledtrials 5•6 reportedfrom the samehospital in NewDelhiusingalcohol in differentconcentrationscontradicteachother,whichconfuses the wholeissueofalcoholasasclerosant.Sarin et al. 5 found that absolutealcoholcoulderadicateesophagealvaricesfaster (12.9 ± 5.2 weeksvs. 22.3 ± 8.2 weeks),requiringalesseramount of sclerosant (22.7 ± 9.3 mlvs. 37.3 ± 14.4 ml)injectedoverfewersessions (4.8 ± 1.4 vs. 7.8 ± 2.9) incomparison to 5% ethanolamineoleate. The interestingfeatureof this studyis that the incidenceofulcerationwasonly 16% comparedwith 69% in an earlierstudy.7 In contrast, Vij et al. 6 observed that 50% alcoholwasinferiorto 5% ethanolamineoleate in eradicatingvarices (16 of 24 vs. 20 of 21) and wasaccompaniedbyamuchhighercomplicationrate,includingretrosternalpain (20 vs.8) and esophagealulcers (19 vs.10).Rebleedingepisodeswerealsohigher inthe alcohol-treatedgroup  16 vs.8).Four patients died. The complicationratesencounteredwith 50% alcoholin the trialby Vij et a1. 6 weremuchhigher than thosereportedbySarin et al.7usingabsolutealcohol.However, patients receiving 5% ethanolamineoleate inboth trialsbehavedsimilarly in terms of eradicationofvarices,rebleeding, and complicationrate. ShivaP AtmakuriMD DMDinesh K BhargavaMD PhDMaheshP Sharma MD DM Department o GastroenterologyAI IndiaInstitute o MedicalSciencesAnsariNagarNewDelhi India R F R N S 1. Paoluzi P, Pietroiusti,Ferrari S, Cappa M, Pagnanelli A. Ab solute alcoholin esophageal vein sclerosis. Gastrointest Endosc 1988;34:400-2. 2. AtmakuriSP,Bhargava DK, Sharma MP. Endoscopic sclero therapy for esophagealvarices: aprospectiverandomisedtrial of absolute alcohol versuspolidocanol. IndianJGastroenterol 1988;7:87-9. GASTROINTESTINAL ENDOSCOPY  3. Jensen DM,Machicado GA, SilpaM.Esophagealvarixhaemorrhage and sclerotherapy-animalstudies.Endoscopy1986;18:18-22. 4. Mathur SK,SupeAN, Parulkar BG,Vora 1M, NaikSR,BhaleraoRA.Evaluationof 3 phenolasavenoussclerosant.Anexperimentalstudy.IndianJGastroenteroI1987;6:211-3. 5. Sarin SK,Mishra SP, SachdevGK, Thorat V, DalalL,BroorSL.Ethanolamineoleateversusabsolutealcoholasavaricealsclerosant:aprospective,randomisedcontrolledtrial.AmJGastroenterol1988;83:526-30. 6. Vij JC, Kumar A, AnandBS,BroorSL.Acomparativestudy of 50%alcohol and ethanolamineoleateforesophagealsclerotherapy.IndianJGastroenteroI1988;7:211-3. 7. Sarin SK, Nanda R,Sachdev G,Vij JC,AnandBS.Endoscopicsclerotherapyusingabsolutealcohol.Gut1985;26:120-4. Response The resultsreportedbyAtmakuri et al.aresimilartoours and confirm that ahigh rateof majorcomplications,mainlydue to esophagealulcers,follows the use of absolutealcoholforsclerotherapy of esophagealvarices.Anotherstudycitedseems to suggest that evendilutedalcoholisexceedinglyulcerogenicdespiteareducedefficacycomparedwith 5 ethanolamineoleate. Bycontrast,Sarin et al.,2,3 intwodifferentstudies,reportedonlyminorcomplicationswith the useofabsolutealcohol. Inthe firststudy, this resultwasobtained in spiteofahighrate(69%)ofesophagealulcers.Sincemostsclerotherapy/associatedesophagealulcerscausenosignificantsideeffects, it ispossible that the lack of majorcomplicationswasduemerely to chance. The verylowrate(16%)ofesophagealulcersreported inthe otherstudyismoredifficult to explain.Adifferentstudydesignmaywellhavecontributed tothis result. In fact the amount of alcoholinjectedwaslower  2 to4mlvs.3 to 18ml) andthe intervalbetweensclerotherapysessionslonger  3 weeksvs.1week).Furthermore,aspeciallydesignedsclerotherapyneedlewasused,designedtoreduceparavaricealinjectionsassociatedwithulcers.Afurtherimportantfactormaybe patient selection.Wehave in factrecentlyreported that patients withalcoholiccirrhosisaremorepronetodevelopsclerotherapyassociatedesophagealulcers than patients withnonalcoholiccirrhosis.'·5OnlyasmallfractionofpatientsstudiedbySarin et al. 2.3 had alcoholiccirrhosis.On the basis of currentevidence, we feel that widespreaduseofabsolutealcoholasasclerosingagent cannot berecommended. Further studiesmaydefineabeneficialapplicationofthisagent in selectedsubgroups of patients;forexample,thosewithnonalcoholiccirrhosis. PaoloPaoluzi MDAntonioPietroiusti MD ICattedra  i GastroenterologiaIIClinicaMedicaVialedelPoliclinicoRome Italy REFERENCES 1. Ref. 6, above. 2. Ref. 7, above. 3. Ref. 5, above. 4. PaoluziP,Pietroiusti A. Prophylacticsclerotherapyoflargeesophagealvarices.NEnglJMed1988;319:1015-7. 5. Paoluzi P, Pietroiusti A, FerrariS, et al.Alcoholiccirrhosis:ariskfactorfor the development of sclerotherapy-associatedoesophagealulcers?ItalJGastroenterol(inpress). VOLUME 35, NO 5 9 9 Sclerotherapyforesophagealvaricesandpregnancy To the Editor:Wereadwithinterest the letterbySalenaandSivak reportingacaseofsuccessfulgestation and pregnancyoccurringafterendoscopicsclerotherapyofesophagealvaricesinawomanwithextrahepaticportalveinobstruction.Wewouldlike to addourexperiencewiththreecasesofsuccessfulpregnancyinwomenwithextrahepaticportalveinobstructionwho had undergoneendoscopicsclerotherapy of esophagealvarices. Inthe southernIndianstateofKerala,alargenumber of casesofportalhypertensionoccurasaresultofidiopathicportalveinthrombosis in childhood.Sixty-nine(30%)ofour230casesofportalhypertension in whichendoscopicsclerotherapywascompletedover thepast 5years had extrahepaticportalveinobstruction. The threecasesreportedbelowbelong to thisgroup.A30-year-oldwoman(case 1) had splenomegaly and recurrentuppergastrointestinalhemorrhagefrom the ageof10.Atage16,sheunderwentsurgeryforapossibleportosystemicshunt, but due to extensivecavernousmalformationof the portosplenicaxisnoanastomosiswasfeasible.Asplenectomywasperformed.Sheremainedsymptomfreefor6years.Fromage 22 sheagainhadrecurrentbleedingfromvarices.Atage 29, herfirstchildwasdeliveredbycesareansectionwithoutcomplication.Afteranotherhemorrhage,endoscopyshowedlargeesophagealvarices and sclerotherapywasdoneusing1%polidocanolbyacombinedpara- and intravaricealtechnique.During the courseoftreatment,sheconceived and hersecondchildwasdeliveredbycesareansectionwhenshewas 32 yearsold.Shehasremainedsymptomfreewithnoresidualvarices2yearsafter the secondchildbirth.A22-year-oldwoman(case 2) hadsplenomegaly and amassiveuppergastrointestinalbleed.Shewasfound to havelargeesophagealvarices at endoscopy and extensivesplenoportalthrombosisonultrasonography and percutaneoussplenoportovenography.Sheunderwentsclerotherapyusing1%polidocanolpara- and intravariceally.At the 36thweekofpregnancy,shewasreferredbacktoourhospitalforconfinement.Surveillanceendoscopyrevealedrecurrenceofmajorgradevarices and althoughshe had nofurtherbleeding, it wasdecided to repeatsclerotherapy.Shewasdeliveredbycesareansectionwithoutcomplication at fullterm.Shehasremainedsymptomfreefollowingdeliveryfor 28 months.A22-year-oldwoman(case 3) underwentemergencysurgeryformassiveuppergastrointestinalbleeding in anotherhospital at age 20, whentransgastricligationofesophagealvarices and gastricdevascularizationwereperformed.Shewasreexplored1yearlaterforpossibleportosystemic shunt surgery but noanastomosiscouldbedonedue to extensivesplenoportalthrombosis.Shewasseen in ourcenterbeforeoursclerotherapyprogramwasavailable, and was put onpropranolol.Shecontinued to haverecurrentmelena,needingbloodtransfusions, and sclerotherapywasperformedusing1%polidocanolpara- and intravariceally.Asurveillanceendoscopy3monthslatershowedresidualvaricesconfined tothe gastroesophagealjunction.Nosclerotherapywasdone.Sheconceived1yearlater and at the467
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