Annals of the Royal College of Surgeons of England (I976) vol 58
Anaesthesia for injection of bleeding oesophageal varices Michael E Ward FFARCS T D W Davies FFARCS Leo Strunin MD FFARCS Anaesthetic Department, King's College Hospital, London
Summary Patients with haemorrhage from oesophageal varices associated with portal hypertension are poor risks for anaesthesia and surgery. One method of controlling such haemorrhage is injection of the oesophageal varices (sclerotherapy) via an oesophagoscope. Careful preoperative preparation and use of the Sengstaken-Blakemore tube in combination with the anaesthetic techniqute of intermittent Althesin and suxamethonium with artificial ventilation with nitrous oxide and oxygen enables sclerotherapy to be carried out successfully.
Introduction Patients with oesophageal varices secondary to cirrhosis frequently bleed to death. Haemorrhage may further embarrass poor liver function, increasing the risk of future bleeding. Mlanagement consists in replacing blood loss, preventing the onset of hepatic coma, and taking physical measures to stop bleeding. For the latter many methods have been described including iced gastric lavage, vasopressin infuision, emergency portosystemic shunt1, or a direct surgical approach to the varices such as transection of the oesophagus or even gastrectomy2. In many instances, however, these measures are either ineffective or, in the case of surgery, may not be possible owing to the poor liver function of the patient. Therefore a 'holding' operation is desirable and injection of a sclerosing agent around the varices via an oesophagoscope may be helpful. This form of sclerotherapy was first performed in Sweden in I936', was introduced into Britain in I9494, but has only recently been widely used5. Sclerotherapy is normally carried out after haemorrhage has been controlled and resuscitation achieved, the object being to prevent
further bleeding before shunt surgery or as definitive treatment in order to avoid the necessity of other surgery. In those cases in which haemorrhage is not controlled by conservative measures sclerotherapy may be performed as an emergency procedure.
Preanaesthetic management Patients should ideally be referred to a hospital where the staff are experienced in the care of patients with liver disease and bleeding varices6. Management is best carried out by a combined medical and surgical team. Adequate blood replacement is essential and should be monitored by reference to heart rate, systemic arterial pressure, and central venous pressure (CVP). The Sengstaken-Blakemore tube7 as modified by Boyce' is usefully employed to provide tamponade and limit blood loss9. Neomycin and lactulose are introduced into the stomach via the Sengstaken tube to reduce portal-systemic encephalopathy. Endoscopy with a fibreoptic endoscope is carried out to confirm the site of haemorrhage, since even in a patient with known portal hypertension and oesophageal varices bleeding from a peptic ulcer is not uncommon.69'10. Since patients with liver disease may carry hepatitis B virus, all cases are treated as potentially infectious until a definite negative result for the presence of HBsAg (hepatitis B antigen, Australia antigen) is received.
Premedication Endoscopy is generally performed under diazepam sedation, and the effect of this drug should be carefully noted since many patients with liver disease exhibit an enhanced response to sedatives. If injection is carried out in the presence of
3I6
Micha-el E Ward, T D W Davies, and Leo Strunin
bleeding, premedication is omitted and atro- and catheter mount. The surgical procedure has been described pine o.6 mg alone is given intravenously immediately before induction of anaesthesia. by Johnston and Rodgers' and, in adults, inWhen injection is carried out electively the pa- volves oesophagoscopy using a 5o-mm Negus tient is premedicated with intramuscular dia- rigid oesophagoscope with proximal lighting. zepam I0-20 mg and atropine o.6 mg one In children the largest instrument that can be passed with safety is used. A wide-bore inhour before operation. strument produces obstruction of the veins and thus distension. MIodification of the oesophagoAnaesthesia and surgery We generally manage the patient preoperative- scope by cutting a slot in its lower end has ly with a CVP line and an intravenous infu- made visualization and injection of the varices sion, which should be checked for free run- easier". An intravascular injection of 2-5 ml ning immediately the patient arrives in theatre of sclerosant (ethanolamine oleate) is made and again after transfer on to the operating into each varix up to a maximum total of 20 ml around the oesophagus. Bleeding from the intable. If a Sengstaken tube is in situ both gastric jection site is controlled by advancing the oe-oand accessory nasogastric tubes are aspirated phagoscope over the puncture wounds. If there before induction. Preoxygenation is performed is residual bleeding after injection is completed and induction carried out with a slow injec- a modified Sengstaken-Blakemore tube is tion of Althesin (alphaxalone and alpha- passed. The patient is then turned on his side dalone acetate) until consciousness is and ventilated with ioo% oxygen until muscle relaxation is achieved power and adequate ventilation have been Muscle lost. with suxamethonium 1-2 mg/kg, and recovered, the cndotracheal tube not being rea cuffed endotracheal tube is introduced moved until the patient is fully awake. into the trachea; ideally a latex-reinforced tube should be used. Visualization of the vocal cords Postanaesthetic management may be difficult owing to the presence of the No oral intake is allowed until a chest radioSengstaken tube or blood and mucus in the graph, taken at least 8 hours after injection, pharynx. It has been our practice not to, fix the has excltuded an oesophageal leak. Many paendotracheal tube in situ as this may obstruct tients complain of retrostemal pain or soreness surgical access. We therefore hold the tube in which in the absence of a leak from the oesoplace at the left side of the mouth by hand. phagus is presumed to be due to oesophagitis Anaesthesia is maintained with 70%/0 nitrous or perioesophagitis produced by the sclerosant. oxide and oxygen, together with increments of Althesin and s;uxamethonium as required. Discussion When it is anticipated that the procedure may The patient with oesophageal varices as a be unduly long a non-depolarizing muscle restult of portal hypertension due to intraheparelaxant is used in place of intermittent sux- tic block presents a high sunrical and anaesamethonium. Ventilation can be carried out thetic risk. Pugh et al." described a preoperawith any suitable ventilator, but we have tive grading scheme based on Child's" found that the standard double hose and T- three groups (A, B, and C) for the piece are unacceptably heavy to connect di- severity of liver disease which is based rectly to the catheter mount and endotracheal on a points system for the five factors tuibe, considering the amount of movement encephalopathv. ascites, serum bilirubin and of the head that takes place during oesophago- albumin levels, and prothrombin time. scopy. We therefore interpose a single metre This gives a total points score from r- to Ir. length of elephant tubing betwveen T-piece and Only patients in the first two grotips (category catheter mount. In order to prevent rebreath- A with 5 or 6 points or category B with 7ing and, more important, to minimize possible points) are deemed suitable for shunt surgery" bacterial or viral contamination of the ventila- whereas there was an 88% mortality among tor a Rubens-type non-rebreathing valve is patients in the worst group (category C, inserted into the circuit between elephant tube 10-I5 points) wvho were subjected to oesopha-
Anaesthesia for injection of bleeding oesophageal varices
geal transection13. It is, however, primarily patients in categories B and C who present for sclerotherapy, but with careful resuscitation and preoperative preparation the procedure may be performed in safety. The place of sclerotherapy in the treatment of portal hypertension is still a matter for dispute. Although immediate control of haemorrhage may be satisfactory, the long-term results in respect of an improvement in patient survival have yet to be established. In practice sclerotherapy is currently used either to 'buy time' for patients so that elective shunt surgery may be carried out subsequently or for those patients in whom liver disease is so extensive that no other form of therapy is possible. The choice of anaesthetic drugs is important in patients with serious liver disease. Drug metabolism and central nervous system (CNS) effects are most relevant. We have preferred Althesin to thiopentone since the former is readily metabolized even in the presence of impaired liver function'5. Furthermore, although a single small dose of thiopentone is as satisfactory as Althesin in patients with liver disease16, repeated dosage leads to cumulation, which may cause undesirable CNS depression. Althesin is less cumulative with repeated dosage because of its rapid metabolism. Analgesics have been avoided as they may produce disproportionate CNS depression even though their metabolism is relatively normal. Suxamethonium is the muscle relaxant of choice since rapid intubation may be necessary. Plasma cholinesterase, produced by the liver, is responsible for the metabolism of suxamethonium. Although plasma cholinesterase levels may be low in patients with liver disease, it is not our experience that the action of suxamethonium is prolonged in such patients. If the surgical procedure is unduly long non-depolarizing muscle relaxants may be used; however, increased doses will be required"6 and
317
there may be difficulties in reversing their effects. The anaesthetic sequence described above has now been in use for some I8 months (55 patients) and has proved satisfactory, no complications having occurred which could be ascribed to anaesthesia. We should like to record our grateful thanks to Mr J L Dawson, consultant surgeon, for help and advice and also to Miss Kay Le-Surf, our departmental secretary, for seemingly unending patience.
References IJohnston, G W, and Rodgers, H W (I973) British Journal of Surgery, 6o, 797. 2 Macbeth, R (I955) British Medical journal, 2, 877. 3 Crafoord, C, and Frenckner, P (I939) Acta otolaryngologica, 27, 422. 4 Macbeth, R G (1951) Proceedings of the Fourth International Congress of Otolaryngology, I949, I, 294. 5 Hunt, P S, Johnston, G W, and Rodgers, H W (I969) British Journal of Surgery, 56, 305.
6 Terblanche, J, Saunders, S J, and Louw, J H 7
8
9 io ii
I2 I3 I4
I5 i6
(1974) Surgical Forum-The Liver, ed. Rodney Smith, p. 7. London, Butterworths. Sengstaken, R W, and Blakemore, A H (1950) Annals of Surgery, I31, 78I. Boyce, H WV (i962) New England Journal of Medicine, 267, 195. Pitcher, J L (I97I) Gastroenterology, 6i, 29I. Williams, R, and Dawson, J L (I968) British Medical Journal, I, 35. Bailey, M E, and Dawson, J L (I975) British Medical Journal, 2, 540. Pugh, R N H, Murray-Lyon, I M, Dawson, J L, Pietroni, M C, and Williams, R (I973) British Journal of Surgery, 6o, 646. Child, C G (I964) The Liver and Portal Hypertension, p. 50. Philadelphia, Saunders. Smith, M, Tuft, R J, Davidson, A R, Laws, J W, Dawson, J L, and Williams, R (I974) British Medical Journal, 3, 705. Strunin, L, Ward, M E, Strunin, J, and Knights, K (1974) British Journal of Anaesthesia, 46, 3Iq. Ward, M E, Adu-Gyamfi, Y, and Strunin, L (975) British Journal of Anaesthesia, 47, II99.
Anaesthesia for injection of bleeding oesophageal varices Michael E Ward FFARCS T D W Davies FFARCS Leo Strunin MD FFARCS Anaesthetic Department, King's College Hospital, London
Summary Patients with haemorrhage from oesophageal varices associated with portal hypertension are poor risks for anaesthesia and surgery. One method of controlling such haemorrhage is injection of the oesophageal varices (sclerotherapy) via an oesophagoscope. Careful preoperative preparation and use of the Sengstaken-Blakemore tube in combination with the anaesthetic techniqute of intermittent Althesin and suxamethonium with artificial ventilation with nitrous oxide and oxygen enables sclerotherapy to be carried out successfully.
Introduction Patients with oesophageal varices secondary to cirrhosis frequently bleed to death. Haemorrhage may further embarrass poor liver function, increasing the risk of future bleeding. Mlanagement consists in replacing blood loss, preventing the onset of hepatic coma, and taking physical measures to stop bleeding. For the latter many methods have been described including iced gastric lavage, vasopressin infuision, emergency portosystemic shunt1, or a direct surgical approach to the varices such as transection of the oesophagus or even gastrectomy2. In many instances, however, these measures are either ineffective or, in the case of surgery, may not be possible owing to the poor liver function of the patient. Therefore a 'holding' operation is desirable and injection of a sclerosing agent around the varices via an oesophagoscope may be helpful. This form of sclerotherapy was first performed in Sweden in I936', was introduced into Britain in I9494, but has only recently been widely used5. Sclerotherapy is normally carried out after haemorrhage has been controlled and resuscitation achieved, the object being to prevent
further bleeding before shunt surgery or as definitive treatment in order to avoid the necessity of other surgery. In those cases in which haemorrhage is not controlled by conservative measures sclerotherapy may be performed as an emergency procedure.
Preanaesthetic management Patients should ideally be referred to a hospital where the staff are experienced in the care of patients with liver disease and bleeding varices6. Management is best carried out by a combined medical and surgical team. Adequate blood replacement is essential and should be monitored by reference to heart rate, systemic arterial pressure, and central venous pressure (CVP). The Sengstaken-Blakemore tube7 as modified by Boyce' is usefully employed to provide tamponade and limit blood loss9. Neomycin and lactulose are introduced into the stomach via the Sengstaken tube to reduce portal-systemic encephalopathy. Endoscopy with a fibreoptic endoscope is carried out to confirm the site of haemorrhage, since even in a patient with known portal hypertension and oesophageal varices bleeding from a peptic ulcer is not uncommon.69'10. Since patients with liver disease may carry hepatitis B virus, all cases are treated as potentially infectious until a definite negative result for the presence of HBsAg (hepatitis B antigen, Australia antigen) is received.
Premedication Endoscopy is generally performed under diazepam sedation, and the effect of this drug should be carefully noted since many patients with liver disease exhibit an enhanced response to sedatives. If injection is carried out in the presence of
3I6
Micha-el E Ward, T D W Davies, and Leo Strunin
bleeding, premedication is omitted and atro- and catheter mount. The surgical procedure has been described pine o.6 mg alone is given intravenously immediately before induction of anaesthesia. by Johnston and Rodgers' and, in adults, inWhen injection is carried out electively the pa- volves oesophagoscopy using a 5o-mm Negus tient is premedicated with intramuscular dia- rigid oesophagoscope with proximal lighting. zepam I0-20 mg and atropine o.6 mg one In children the largest instrument that can be passed with safety is used. A wide-bore inhour before operation. strument produces obstruction of the veins and thus distension. MIodification of the oesophagoAnaesthesia and surgery We generally manage the patient preoperative- scope by cutting a slot in its lower end has ly with a CVP line and an intravenous infu- made visualization and injection of the varices sion, which should be checked for free run- easier". An intravascular injection of 2-5 ml ning immediately the patient arrives in theatre of sclerosant (ethanolamine oleate) is made and again after transfer on to the operating into each varix up to a maximum total of 20 ml around the oesophagus. Bleeding from the intable. If a Sengstaken tube is in situ both gastric jection site is controlled by advancing the oe-oand accessory nasogastric tubes are aspirated phagoscope over the puncture wounds. If there before induction. Preoxygenation is performed is residual bleeding after injection is completed and induction carried out with a slow injec- a modified Sengstaken-Blakemore tube is tion of Althesin (alphaxalone and alpha- passed. The patient is then turned on his side dalone acetate) until consciousness is and ventilated with ioo% oxygen until muscle relaxation is achieved power and adequate ventilation have been Muscle lost. with suxamethonium 1-2 mg/kg, and recovered, the cndotracheal tube not being rea cuffed endotracheal tube is introduced moved until the patient is fully awake. into the trachea; ideally a latex-reinforced tube should be used. Visualization of the vocal cords Postanaesthetic management may be difficult owing to the presence of the No oral intake is allowed until a chest radioSengstaken tube or blood and mucus in the graph, taken at least 8 hours after injection, pharynx. It has been our practice not to, fix the has excltuded an oesophageal leak. Many paendotracheal tube in situ as this may obstruct tients complain of retrostemal pain or soreness surgical access. We therefore hold the tube in which in the absence of a leak from the oesoplace at the left side of the mouth by hand. phagus is presumed to be due to oesophagitis Anaesthesia is maintained with 70%/0 nitrous or perioesophagitis produced by the sclerosant. oxide and oxygen, together with increments of Althesin and s;uxamethonium as required. Discussion When it is anticipated that the procedure may The patient with oesophageal varices as a be unduly long a non-depolarizing muscle restult of portal hypertension due to intraheparelaxant is used in place of intermittent sux- tic block presents a high sunrical and anaesamethonium. Ventilation can be carried out thetic risk. Pugh et al." described a preoperawith any suitable ventilator, but we have tive grading scheme based on Child's" found that the standard double hose and T- three groups (A, B, and C) for the piece are unacceptably heavy to connect di- severity of liver disease which is based rectly to the catheter mount and endotracheal on a points system for the five factors tuibe, considering the amount of movement encephalopathv. ascites, serum bilirubin and of the head that takes place during oesophago- albumin levels, and prothrombin time. scopy. We therefore interpose a single metre This gives a total points score from r- to Ir. length of elephant tubing betwveen T-piece and Only patients in the first two grotips (category catheter mount. In order to prevent rebreath- A with 5 or 6 points or category B with 7ing and, more important, to minimize possible points) are deemed suitable for shunt surgery" bacterial or viral contamination of the ventila- whereas there was an 88% mortality among tor a Rubens-type non-rebreathing valve is patients in the worst group (category C, inserted into the circuit between elephant tube 10-I5 points) wvho were subjected to oesopha-
Anaesthesia for injection of bleeding oesophageal varices
geal transection13. It is, however, primarily patients in categories B and C who present for sclerotherapy, but with careful resuscitation and preoperative preparation the procedure may be performed in safety. The place of sclerotherapy in the treatment of portal hypertension is still a matter for dispute. Although immediate control of haemorrhage may be satisfactory, the long-term results in respect of an improvement in patient survival have yet to be established. In practice sclerotherapy is currently used either to 'buy time' for patients so that elective shunt surgery may be carried out subsequently or for those patients in whom liver disease is so extensive that no other form of therapy is possible. The choice of anaesthetic drugs is important in patients with serious liver disease. Drug metabolism and central nervous system (CNS) effects are most relevant. We have preferred Althesin to thiopentone since the former is readily metabolized even in the presence of impaired liver function'5. Furthermore, although a single small dose of thiopentone is as satisfactory as Althesin in patients with liver disease16, repeated dosage leads to cumulation, which may cause undesirable CNS depression. Althesin is less cumulative with repeated dosage because of its rapid metabolism. Analgesics have been avoided as they may produce disproportionate CNS depression even though their metabolism is relatively normal. Suxamethonium is the muscle relaxant of choice since rapid intubation may be necessary. Plasma cholinesterase, produced by the liver, is responsible for the metabolism of suxamethonium. Although plasma cholinesterase levels may be low in patients with liver disease, it is not our experience that the action of suxamethonium is prolonged in such patients. If the surgical procedure is unduly long non-depolarizing muscle relaxants may be used; however, increased doses will be required"6 and
317
there may be difficulties in reversing their effects. The anaesthetic sequence described above has now been in use for some I8 months (55 patients) and has proved satisfactory, no complications having occurred which could be ascribed to anaesthesia. We should like to record our grateful thanks to Mr J L Dawson, consultant surgeon, for help and advice and also to Miss Kay Le-Surf, our departmental secretary, for seemingly unending patience.
References IJohnston, G W, and Rodgers, H W (I973) British Journal of Surgery, 6o, 797. 2 Macbeth, R (I955) British Medical journal, 2, 877. 3 Crafoord, C, and Frenckner, P (I939) Acta otolaryngologica, 27, 422. 4 Macbeth, R G (1951) Proceedings of the Fourth International Congress of Otolaryngology, I949, I, 294. 5 Hunt, P S, Johnston, G W, and Rodgers, H W (I969) British Journal of Surgery, 56, 305.
6 Terblanche, J, Saunders, S J, and Louw, J H 7
8
9 io ii
I2 I3 I4
I5 i6
(1974) Surgical Forum-The Liver, ed. Rodney Smith, p. 7. London, Butterworths. Sengstaken, R W, and Blakemore, A H (1950) Annals of Surgery, I31, 78I. Boyce, H WV (i962) New England Journal of Medicine, 267, 195. Pitcher, J L (I97I) Gastroenterology, 6i, 29I. Williams, R, and Dawson, J L (I968) British Medical Journal, I, 35. Bailey, M E, and Dawson, J L (I975) British Medical Journal, 2, 540. Pugh, R N H, Murray-Lyon, I M, Dawson, J L, Pietroni, M C, and Williams, R (I973) British Journal of Surgery, 6o, 646. Child, C G (I964) The Liver and Portal Hypertension, p. 50. Philadelphia, Saunders. Smith, M, Tuft, R J, Davidson, A R, Laws, J W, Dawson, J L, and Williams, R (I974) British Medical Journal, 3, 705. Strunin, L, Ward, M E, Strunin, J, and Knights, K (1974) British Journal of Anaesthesia, 46, 3Iq. Ward, M E, Adu-Gyamfi, Y, and Strunin, L (975) British Journal of Anaesthesia, 47, II99.
