Management of Bleeding Œsophageal Varices when Portal Systemic Shunt is Inadvisable, with Particular Reference to the Use of Balloon Tamponade and Sclerosing Injections

HAEMORRHAGE from cesophageal varices is a dreaded and frequently fatal complication of portal hypertension. In patients with cirrhosis the mortality within one year of the first hxmorrhage is from 25-75 per cent. The most effective way of preventing recurrent bleeding is reduction of the portal pressure by some form of portal-systemic shunt, but unfortunately there are patients where this is impractical. The large variety of other recommended procedures in this situation is a sure indication that no one method is entirely satisfactory. Indeed Mikkelson and Pattison (1959) considered that if a venous shunt could not be constructed, no satisfactory alternative operative procedure was available for the treatment of bleeding from cesophageal varices. There are a large number of patients in whom a portacaval shunt is impossible or inadvisable. (1) A situation where shunt is contra-indicated is in the cirrhotic patient where advanced age, significant jaundice, resistant ascites, hypo-albuminaemia or a previous history of liver failure are present. Although these contra-indications to shunting are widely recognised, the treatment of those "surgical rejects" is less well documented so that methods helpful in the management of these cases are of some importance. (2) When varices are secondary to an extrahepatic block the portal vein is rarely available for the construction of a shunt. As many as 70 per cent. of the patients with portal vein thrombosis have their first haemorrhage before the age of 7 years (Aracari and Lynn, 1961), but unfortunately the conventional lieno-renal shunts are unsatisfactory before the age of 10 years, 80 per cent. becoming thrombosed (Clatworthy et al., 1964). It is in this extrahepatic group that Shaldon and Sherlock (1962) advocate medical management when portacaval shunt is impractical. (3) In the cirrhotic patient, surgery as an emergency procedure carries a mortality of more than 50 per cent. Both emergency portacaval shunt carry this prohibition mortality in most centres. Indeed Crile, one of the surgeons who introduced the operation of trans-cesophageal ligation in the emergency treatment of bleeding varices, recently 110