Discussion and Round Table Presentation

Chairman Terblanche: Most of the discussion time will be spent reviewing the long-term management of patients after a variceal bleed. In the last 10 minutes we will attempt to place the role of prophylactic therapy in perspective. In my view there are some end-stage patients who should not be subjected to either emergency or definitive treatment. Unfortunately they are frequently difficult to identify as even apparently poor risk patients may well improve their liver status if they recover from the bleeding episode. There is also evidence to suggest that the risk of recurrent bleeding and death rapidly diminishes as time passes after a bleeding episode, with this risk returning to baseline within two to three months. I believe that continued non-specific medical management alone is an option that should be considered in some otherwise fit patients who survive a single episode of variceal bleeding. This would allow one to determine whether they fall into the 30% of so of patients who will not have a further bleed. However, I concede that the majority of patients who have had a variceal bleed do require further therapy to prevent the next variceal bleed. All of the panelists have agreed that repeated injection sclerotherapy is the most widely used form of therapy and emphasised the "need to identify those patients who should be considered as failures of sclerotherapy. Such patients should be subjected to a surgical salvage procedure, either a shunt or a devascularisation and transection operation. The views of the panel differ on the exact criteria to be used and which patients should be subjected to operation. Bornman first drew attention to the fact that two sclerotherapy failures during a single hospital admission for an acute variceal bleed was associated with a prohibitive mortality in Child's category B and C patients and that such patients should be subjected to early surgical therapy2. Will the panel please define the current role of sclerotherapy and how they would identify sclerotherapy failures. Panelist Paquet: Concerning the chairman's first statement that there are some patients who should not be subjected to either emergency or definitive treatment, I propose that emergency and definitive treatment should be separated. From my point of view, every patient with uncontrollable variceal haemorrhage needs emergency treatment as early as possible. This immediate endoscopic sclerosis should preferably be performed in centers with expertise. Otherwise, the patients should be transferred to such a center …