In a prospective, randomized clinical trial, immediate injection sclerotherapy was compared with treatment by a combined infusion of vasopressin (0.4 unit per min) and nitroglycerin (40 to 400 pg per min) in 50 consecutive patients with 64 episodes of endoscopy-proven active variceal hemorrhage. Control of bleeding was assessed over a 12-hr period following entry into the trial. Patients in the vasopressin + nitroglycerin group were then treated by sclerotherapy, as were those in the sclerotherapy group who continued to bleed. At 12 hr, bleeding was controlled in 29 (88%) of the 33 episodes treated by sclerotherapy compared with 20 (65%) of 3' episodes treated by vasopressin + nitroglycerin (p c 0.05). Recurrence of variceal bleeding occurred at the same frequency (31%). Although admission mortality was less in those initially treated by sclerotherapy compared to those managed by vasopressin + nitroglycerin, this did not reach statistical significance (27 and 39%, respectively, p > 0.20). Sclerotherapy carried out as the first treatment of the active variceal hemorrhage proved both safe and effective, even in the presence of major hemorrhage, and as compared to combined vasopressin and nitroglycerin it proved superior.
A series of uncontrolled studies have evaluated the use of injection sclerotherapy as treatment for active variceal bleeding either as the first measure or after failure of balloon tamponade or vasoconstrictor therapy (1-3). There have also been two controlled trials in which sclerotherapy as the first measure was compared to balloon tamponade alone (4, 5). Both trials confirmed the efficacy of injection sclerotherapy with control of bleeding over the period of admission in 75 and 90% of the cases, respectively, which was significantly better than that observed with balloon tamponade alone. In both studies, there was a clear but nonsignificant trend toward improved survival for the sclerotherapy-treated patients. However, in none of the trials to date has the important question been addressed of whether injection sclerotherapy is better when used as the first measure during active variceal bleeding than when started after temporary control of the hemorrhage by vasoconstrictor therapy or balloon tamponade, which has the major advantage of a