The sources of recurrent hemorrhage during long-term sclerotherapy

The sources of recurrent hemorrhage during long-term sclerotherapy undertaken by a single surgeon were studied prospectively in a consecutive series of 53 patients for a period of 2 to 6 years. Recurrent hemorrhage, defined as upper gastrointestinal bleeding requiring transfusion or hospitalization or both, in the course of chronic sclerotherapy was investigated aggressively by means of endoscopy and the findings archived with videotape recording. In 24 patients 51 episodes of recurrent hemorrhage developed in the entire series. On the basis of endoscopic findings and serial comparison of videotape recordings, the most common source of recurrent hemorrhage was the original varices, which accounted for rebleeding in 18 patients. The risk of such bleeding was highest in the first month, diminishing thereafter until total variceal eradication. Rebleeding after eradication of varices was always from sources other than varices, as regenerated vessels were small and infrequent and never the source of bleeding. Continued sclerotherapy ultimately achieved total variceal eradication in 15 of 18 patients with variceal rebleeding. Sclerotherapy alone was successful in eradicating all varices in a total of 38 patients in this series, the mean time required being 13 +/- 4.1 months. Rebleeding from sources not amenable to sclerotherapy was treated with porto-azygos disconnection (6 patients) or distal splenorenal shunts (3 patients). There were 12 deaths: four attributed to hemorrhage (3 after surgery), five from liver failure, and three late deaths from causes not due to liver disease. Recurrent hemorrhage per se during the course of sclerotherapy may not be taken as a sign of treatment failure but must be vigorously investigated, since findings profoundly affect management and outcome.