Gastrointestinal varices historical perspective

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

In 1850s, Sappey for the first time, described esophageal varices. In 1877, well before the role of portal hypertension in the development of variceal disease was understood, Nikolai Eck had already established the role of port-caval shunts to relieve animals from ascites. Popularly known as the ‘Eck fistula’, these shunts were employed in the treatment of eight dogs, seven of which died post-operatively and one escaped the laboratory. In 1906 Gilbert and Villaret coined the term ‘portal hypertension’. In 1928, Wolf first showed esophageal varices on thin barium roentgenograms as small dilated structures with a lumen. In 1931, Schatzki published the first findings of gastric varices on roentgenograms of five patients, followed by 45 further patients with esophageal and gastric varices in 1933. Varices were initially described as “dilated veins that bulge into the lumen, producing uneven worm like surface of the inside of esophagus. In 1939, Crafoord and Freckner discovered sclerotherapy with the help of quinine for the management of esophageal varices. In the 20th century, sclerotherapy became an important treatment option in the management of variceal haemorrhage, especially with the advent of fibre-optic endoscopy. In 1950, The Sengstaken-Blakemore tube’s use was first described by Sengstaken and Blakemore and later used as a treatment option. Ethanolamine oleate, sodium tetradecyl sulphate, polidocanol, sodium morrhuate and ethanol have been used as treatment options in sclerotherapy. In 1988, endoscopic variceal band ligation (EVBL) was first used for the treatment of esophageal varices, based on the concept of banding haemorrhoids with elastic O-rings. EVBL became a treatment option for the treatment of esophageal varices in 1990s. Antibiotics were recently used for the first time during the management of varices . Antibiotics were found to decrease the rate of bacterial infections, recurrent bleeding and improve mortality in patients bleeding from esophageal varices.

Historical Perspective

  • In 1543, Vesalius discovered the mapping of the portal venous system.
  • In the 1700s, Morgagni descried the process of "portal hypertensive bleeding".[1]
  • In 1805, Philip Bozzini created a special tube, naming it the ‘Lichtleiter’ or ‘light-guiding instrument’ for examining the urinary tract. This was later termed as ‘endoscope’ by a French surgeon named Antoine Jean Desormeaux. In 1868, Adolph Kussmaul first used the endoscope to examine the stomach of a patient.[2]
  • In 1841, Raciborski was the first to discover collateral blood circulation between systemic and portal systems, specifically the short gastric and hemorrhoidal veins.[3]
  • In 1850s, Sappey for the first time, described esophageal varices.[4]
  • In 1877, well before the role of portal hypertension in the development of variceal disease was understood, Nikolai Eck had already established the role of port-caval shunts to relieve animals from ascites. Popularly known as the ‘Eck fistula’, these shunts were employed in the treatment of eight dogs, seven of which died post-operatively and one escaped the laboratory.[3]
  • In 1881, Johann von Mikulicz, a Polish-Austrian surgeon, invented and used ‘gastroscope’, for examination of the esophagus, stomach and small intestine.[5]
  • In 1903 Vidal, successfully created an Eck fistula was used a treatment option in a human suffering from ascites.
  • In 1906 Gilbert and Villaret coined the term ‘portal hypertension’.[6]
  • In 1928, Wolf first showed esophageal varices on thin barium roentgenograms as small dilated structures with a lumen.[3]
  • This was further confirmed by case reports and series by Berg (1931), Hjelm (1931), Kirklin (1931), Beutel (1932) and Oppenheimer (1937), demonstrating the presence of esophageal varices on barium studies
  • In 1931, Schatzki published the first findings of gastric varices on roentgenograms of five patients, followed by 45 further patients with esophageal and gastric varices in 1933.[3]
  • Varices were initially described as “dilated veins that bulge into the lumen, producing uneven worm like surface of the inside of esophagus.
  • In 1936, Rousselot on patients with ‘Banti’s syndrome’ shed light on elevated portal pressure.[7]
  • During the same year, Crafoord and Freckner, two Swedish surgeons, first reported their use of rigid gastroscopes to visualize bleeding varices and stop the bleeding process via sclerotherapy with quinine-urethane.[3]
  • In 1937, Thomson and colleagues confirmed these findings by measuring portal pressures during celiotomy procedures, further stressing the importance of portal hypertension in the development of varices.[3]

Landmark Events In The Development Of Treatment Strategies

Pre-1970s

  • In 1939, Crafoord and Freckner discovered sclerotherapy with the help of quinine for the management of esophageal varices.[8]
  • In the 20th century, sclerotherapy became an important treatment option in the management of variceal haemorrhage, especially with the advent of fibre-optic endoscopy.
  • Prior to the 1970s, surgery was the mainstay of therapy for variceal hemorrhage.
  • Esophageal stapling or esophagectomy were previously being used for management of gastrointestinal varices but were associated with high mortality rates from sepsis, hepatic failure and renal failure.[9]
  • In the 1980s, in patients with portal hypertension, devascularisation procedures were associated with decreased mortality in patients.
  • In the late 20th century, splenectomy became a famous procedure for management of gastrointestinal varices.
  • Surgical therapies are employed in patients who have failed endoscopic procedures.
  • In 1950, The Sengstaken-Blakemore tube’s use was first described by Sengstaken and Blakemore and later used as a treatment option.
  • It has been largely replaced by endoscopic therapies.

1970s and 1980s

  • In the early 1970s, the first reported case series of endoscopic sclerotherapy was published with its use becoming more widespread in the 1980s.
  • Ethanolamine oleate, sodium tetradecyl sulphate, polidocanol, sodium morrhuate and ethanol have been used as treatment options in sclerotherapy.
  • In Europe the most commonly used agents were ethanolamine oleate and polidocanol, whereas in the United States sodium morrhuate was employed as a treatment strategy.
  • Para-variceal injection consisted of injection in the vicinity of the varix causing variceal occlusion by tamponade resulting in submucosal fibrosis of tissue around the varix, on the other hand, intra-variceal injection lead to thrombosis and resultant occlusion of the lumen.
  • Sclerotherapy when compared to placebo and baloon tamponade has been shown to significantly control bleeding from varices
  • In 1988, endoscopic variceal band ligation (EVBL) was first used for the treatment of esophageal varices, based on the concept of banding hemorrhoids with elastic O-rings. EVBL became a treatment option for the treatment of esophageal varices in 1990s

1990s

  • In the 1990s, sclerotherapy became a popular treatment option not only for esophageal varices but gastric varices as well.
  • EVBL became increasingly popular treatment modality for esophageal varices in the 1990s.
  • To achieve higher success rates in endoscopic therapies, pharmacological therapies for example, the use of octreotide, telipressin and somatostatin were developed for better control of variceal hemorrhage.
  • Transjugular intrahepatic portosystemic shunt (TIPSS) which involves placement of a stent between the portal vein and hepatic vein to reduce portal pressure, was used as a radiological treatment option for varices for the first time in 1990s.

2000-present

  • During the 21st century, pharmacological, endoscopic and radiological therapies for variceal haemorrhage became optimized.
  • Antibiotics were used for the first time during the management of varices. Antibiotics were found to decrease the rate of bacterial infections, recurrent bleeding and improve mortality in patients bleeding from esophageal varices.
  • Cyanoacrylate glue was shown to have a faster rate of variceal obliteration when compared to ethanol injection in sclerotherapy.
  • In the early 2000s, thrombin was also used for variceal obliteration.
  • In 2004, the use of a covered TIPS stent (covered with polytetrafluoroethylene) was approved by the United States Food and Drug Administration
  • In the 2000s, interventional radiological procedures for the treatment of gastric varices included the use of balloon-occluded retrograde transvenous obliteration (BRTO) as rescue therapy when endoscopic obturation therapy failed.
  • Although, liver transplantation is the only curative treatment for liver cirrhosis at this point in time, its role in the management of varices is unknown.
  • Another new area of interest that has been the development of haemostatic powders/sprays. TC-325 (Hemospray, Cook Technology™) is a granular non absorbable mineral powder used in the management of arterial wounds

References

  1. Randall CW, Vizuete JA, Martinez N, Alvarez JJ, Garapati KV, Malakouti M, Taboada CM (2015). "From historical perspectives to modern therapy: a review of current and future biological treatments for Crohn's disease". Therap Adv Gastroenterol. 8 (3): 143–59. PMC 4416294Freely accessible. PMID 25949527. doi:10.1177/1756283X15576462. 
  2. Spaner SJ, Warnock GL (1997). "A brief history of endoscopy, laparoscopy, and laparoscopic surgery". J Laparoendosc Adv Surg Tech A. 7 (6): 369–73. PMID 9449087. doi:10.1089/lap.1997.7.369. 
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Abby Philips C, Sahney A (2016). "Oesophageal and gastric varices: historical aspects, classification and grading: everything in one place". Gastroenterol Rep (Oxf). 4 (3): 186–95. PMC 4976684Freely accessible. PMID 27324725. doi:10.1093/gastro/gow018. 
  4. Sharma M, Rameshbabu CS (2012). "Collateral pathways in portal hypertension". J Clin Exp Hepatol. 2 (4): 338–52. PMC 3940321Freely accessible. PMID 25755456. doi:10.1016/j.jceh.2012.08.001. 
  5. Zajaczkowski T (2008). "Johann Anton von Mikulicz-Radecki (1850-1905)--a pioneer of gastroscopy and modern surgery: his credit to urology". World J Urol. 26 (1): 75–86. PMID 18074140. doi:10.1007/s00345-007-0227-y. 
  6. "Portal hypertension - Surgical Treatment - NCBI Bookshelf". 
  7. Shillam DS (1947). "CONGESTIVE SPLENOMEGALY (BANTI'S SYNDROME) DUE TO PORTAL STENOSIS". Calif Med. 67 (6): 379–81. PMC 1643092Freely accessible. PMID 18731340. 
  8. Rajoriya N, Tripathi D (2014). "Historical overview and review of current day treatment in the management of acute variceal haemorrhage". World J. Gastroenterol. 20 (21): 6481–94. PMC 4047333Freely accessible. PMID 24914369. doi:10.3748/wjg.v20.i21.6481. 
  9. Cooperman M, Fabri PJ, Martin EW, Carey LC (1980). "EEA esophageal stapling for control of bleeding esophageal varices". Am. J. Surg. 140 (6): 821–4. PMID 6970000. 



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