Bleeding esophageal varices: treatment by sclerotherapy and liver transplantation

Variceal hemorrhage is frequently a lethal event. Mortality among patients who have bled is high, with survival over the short term of only 25% to 50%. We retrospectively reviewed the records of 177 patients in whom variceal bleeding was treated with variceal sclerosis during a 5-year period from 1981 to 1986. All patients were treated by freehand injection of 25% sodium morrhuate with 35% dextrose, 4 ml per injection, through a fiberoptic endoscope. Of this group, 46 patients were treated with sclerosis followed by liver transplantation (group 1). These were compared to 36 nonalcoholic Child's class B and C patients treated with sclerosis alone (group 2). Survival at 4 years was poor in group 2 (17%). Liver failure and continued gastrointestinal bleeding were the most frequent causes of death. Survival among the liver-transplant group was significantly better (73%, p less than 0.001). Causes of death in this group were primarily due to sepsis, often in the setting of acute graft rejection. Group 1 patients were younger (39.8 +/- 10.8 vs 49.8 +/- 16.5 years, p less than 0.01); this difference is influenced by the deliberate selection of younger patients for liver transplantation. We conclude that sclerotherapy followed by liver transplantation significantly improves survival compared to conventional therapy in selected patients with advanced liver disease and portal hypertension. Donor organ availability will seriously limit the applicability of this approach to patients with bleeding esophageal varices.