A better mousetrap

✍ Scribed by Adrian Reuben

• Publisher: John Wiley and Sons
• Year: 2004
• Tongue: English
• Weight: 592 KB
• Volume: 40
• Category: Article
• ISSN: 0270-9139
• DOI: 10.1002/hep.1840400437

✦ Synopsis

LANDWAIlKS I1 HEPATOLOGY

A Better Mousetrap lood spurts as from a geyser, and prompt action is required. With its familiar hiss, suction is applied, and an expanding redness comes into view, like a vermilion Carolina moon waxing in accelerated time. The knob is turned, and a satisfying muffled click is felt more than heard. Warily, the vacuum is released and the knuckle of once gushing mucosa, now ensnared with a shiny black rubber ring, recedes slowly from sight like the jettisoned stage of a spacecraft. Another bleeding varix, temporarily staunched only weeks ago with a styptic injection, has finally been successfully obliterated (Fig. 1) l .

It seems a little surprising now that the occurrence of esophagogastric varices in cirrhosis and their propensity to bleed became widely appreciated only late in the history of hepatology, after the turn of the 20th century.2 Although modern estimates do range widely, we know that the prevalence of varices in cirrhosis, their risk of bleeding and rebleeding and the consequent mortality, are all in the 20% to 80% range, depending upon the variables in the study and the particular stratification used.3 Nonetheless, William Osler, who recognized the existence of esophageal varices4 and had himselfwitnessed a fatality therefrom,5 had personal experience of only two cases by the time he published his famous textbook in 1892, in which, forsooth, he also wrote that hemorrhage from gastric varices was seldom f a d 6 The existence of esophageal varices had actually been clearly established 50 years earlier, in 1840, by William Power of Maryland, who reported on the autopsy of a 50-year-old man of robust frame, intemperate habits, and deficient intelligence.7 The patient, who died of gastrointestinal hemorrhage, was found to have "Varicose veins of the oesophagus" that Power had never met with before, nor had he found a similar case recorded. Power wondered, ". . .whether the presence ofvarices to such an extent, and death caused by their rupture, be not-something as yet unheard of in pathological anatomy."7 Power's discovery was later confirmed in a report from France,8 but even so this was still the only experience of that entity for Friedrich Theodor von Frerichs, the founder of modern hepatology, by the time his own textbook was written.' Admittedly it was well nigh impossible then to diagnose in life the presence of varices-silent or otherwise-in the years before Adolf Kussmaul performed the first really practical esophagoscopy in Freiburg in 1868, using an ~ ~~~~ ~ ~~ Copyright 0 2004 by the American Association fir the S d y of Liver Diseases.