Sudan Med J 2013 April;49(1) 1 Review Article An overview of the treatment of oesophageal varices: recommendations for the best approach in our patients Shakir Z Ibrahim-Elimam, FRCS * , Suliman H Suliman, FRCS * , Mohammed A El-Tahir, MRCP ** Units of Gastrointestinal Surgery * and Gastroenterology ** , Soba University Hospital, University of Khartoum, Sudan ﺷ ﻧﻈﺮة اﻟﻤﺮئ دواﻟﻰ ﻋﻼج ﻷﺳﺎﻟﻴﺐ ﻤﻮﻟﻴﺔ: اﻟﺴﻮداﻧﻴﻴﻦ اﻟﻤﺮﺿﻰ ﻓﻰ اﻟﻄﺮق ﻷﺻﻠﺢ ﺗﻮﺻﻴﺎت اﻻﻣﺎم اﺑﺮاهﻴﻢ اﻟﻌﺎﺑﺪﻳﻦ زﻳﻦ ﺷﺎآﺮ) ﻟﻠﺠﺮاﺣﻴﻦ اﻟﻤﻠﻜﻴﺔ اﻟﻜﻠﻴﺔ زﻣﺎﻟﺔ( , اﻟﻄﺎهﺮ ﻋﻠﻰ ﻣﺤﻤﺪ) أﻟﺒﺎﻃﻨﻴﺔ ﻷﺧﺘﺼﺎﺻﻰ اﻟﻤﻠﻜﻴﺔ اﻟﻜﻠﻴﺔ ﻋﻀﻮﻳﺔ( , ﺳﻠﻴﻤﺎن ﺣﺴﻴﻦ ﺳﻠﻴﻤﺎن ) ﻟﻠﺠﺮاﺣﻴﻦ اﻟﻤﻠﻜﻴﺔ اﻟﻜﻠﻴﺔ زﻣﺎﻟﺔ.( ﻳﻌﺘﺒﺮ اﻟﺴﻮدان وﺳﻂ ﻓﻰ اﻟﻌﻠﻮى اﻟﻤﻌﻮى اﻟﻨﺰﻳﻒ أﺳﺒﺎب أآﺜﺮ ﻣﻦ اﻟﻤﺮئ دواﻟﻰ اﻧﻔﺠﺎر. ﻓﻰ% 90 ﻣﺮض ﻋﻦ اﻟﻨﺎﺗﺠﺔ اﻟﻤﺮئ ﻟﺪواﻟﻰ اﻟﺴﺒﺐ ﻳﻌﺰى اﻟﻤﺮﺿﻰ ﻣﻦ اﻟﺒﻠﻬﺎرﺳﻴﺎ. اﻟﻜﺒﺪى اﻟﺘﻠﻴﻒ ﺑﻤﺮﺿﻰ ﻣﻘﺎرﻧﺔ ﺣﻤﻴﺪا ﻣﺴﺎرا ﻣﺮﺿﻬﻢ وﻳﺘﺒﻊ اﻟﺼﻐﻴﺮة اﻷﻋﻤﺎر ذوى ﻣﻦ اﻟﻤﺮﺿﻰ هﺆﻻء ﻣﻌﻈﻢ. ا اﻟﺴﺒﺐ ﻓﺎن ذﻟﻚ ﻣﻦ ﺑﺎﻟﺮﻏﻢ ﻷﺳﺎﺳﻰ اﻟﺪواﻟﻰ ﻣﻦ اﻟﻤﻌﻮى اﻟﻨﺰﻳﻒ هﻮ اﻟﻤﺮﺿﻰ هﺆﻻء ﻓﻰ ﻟﻠﻤﻮت. ﻟﻬﺆﻻء اﻷﺳﺎﺳﻰ اﻟﻌﻼج هﻮ اﻟﺒﺮوﺑﺮاﻧﻮﻟﻮل ﻋﻘﺎر وﺗﻨﺎول ﺑﺎﻟﻤﻨﻈﺎر اﻟﺪواﻟﻰ ﺣﻘﻦ اﻟﺮاهﻦ اﻟﻮﻗﺖ ﻓﻰ اﻟﻤﺮﺿﻰ. ﻓﺸﻠﻬﻤﺎ ﻟﺤﺎﻻت اﻟﺠﺮاﺣﺔ ﺧﺼﺼﺖ وﻗﺪ هﺬا. اﻟﻤﺮﺿﻰ ﻟﻤﻌﻈﻢ ﻣﺘﺎﺣﺔ ﻏﻴﺮ اﻟﻨﺰﻳﻒ اﻳﻘﺎف وﻋﻘﺎرات اﻟﻤﻨﺎﻇﻴﺮ ﻣﺮاآﺰ ان اﻟﻤﻮﺑﻮءة اﻟﺮﻳﻔﻴﺔ اﻟﻤﻨﺎﻃﻖ ﻓﻰ ﺑﺎﻟﺒﻠﻬﺎرﺳﻴﺎ. اﻟﻮاﻗﻊ هﺬا ﺗﻨﺎﺳﺐ أﺟﺪى وﺳﻴﻠﺔ اﻳﺠﺎد ﻣﻦ ﺑﺪ ﻻ ﻋﻠﻴﻪ. ﺗﺘﻘﺪم أن وﺗﺤﺎول اﺻﺪد هﺬا ﻓﻰ أﺟﺮﻳﺖ اﻟﺘﻰ اﻟﺒﺤﻮث ﺷﻤﻮﻟﻴﺔ ﺑﺼﻮرة ﺗﺘﻨﺎول اﻻﻃﺮوﺣﺔ هﺬﻩ ان اﻟﻤﺮئ دواﻟﻰ ﻧﺰﻳﻒ ﻣﻦ اﻷوﻟﻴﺔ اﻟﻮﻗﺎﻳﺔ ﻣﺠﺎل ﻓﻰ اﻟﺴﺒﻞ ﻷﻧﺠﻊ اﻟﺪﻟﻴﻞ ﻳﺪﻋﻤﻬﺎ ﺑﺘﻮﺻﻴﺎت, وﻋﻼج اﻟﺤﺎد اﻟﻨﺰﻳﻒ, ﻣﺮﺿﻰ ﻓﻰ وﺧﺎﺻﺔ ﻣﺴﺘﻘﺒﻠﻴﺎ اﻟﻨﺰﻳﻒ ﺗﻜﺮار وﻣﻨﻊ اﻟﺒﻠﻬﺎرﺳﻴﺎ. Abstract Oesophageal variceal rupture is the commonest cause of upper gastrointestinal bleeding in central Sudan. In 90% of patients, it is secondary to schistosomal portal hypertension. The majority of these patients are young and their disease is characterized by a benign course compared to cirrhosis. However, a major cause of death in these patients is acute variceal bleeding. The current treatment for oesophageal varices in our patients is endoscopic therapy and the beta blocker propranolol. Surgery is reserved for failures of this therapy. Endoscopic centers and vasoactive drug therapy are not readily available in the endemic areas. A more ________________________________ Corresponding author Shakir Z Ibrahim-Elimam Department of Surgery, University of Khartoum Email: shakirelimam@yahoo.co.uk Tel: 00249912390539 appropriate and cost-effective approach is required. This communication is a literature overview that attempts as much as possible to provide evidence based recommendations for the most suitable approach in our patients in the areas of primary prophylaxis against a first variceal bleed, treatment of acute variceal bleeding, and secondary prophylaxis against variceal rebleeding, especially for those with schistosomal portal hypertension. Keywords: oesophageal varices, treatment, schistosomiasis, cirrhosis Introduction Over the last two decades endoscopic therapy and beta blockade have emerged as the treatment of choice for oesophageal varices in the Sudan (1,2,3) . This, in part, was due to the marked decline in the prevalence of schistosomiasis following the extensive mass treatment campaign and preventive measures implemented by the Blue Nile Health project by the WHO from1980 to 1990 (4) . “Primary prophylaxis” to prevent a first variceal bleed in our patients includes beta blockade, in the