POST ESOPHAGEAL VARICEAL BAND LIGATION PAIN, ANOTHER INSULT TO INJURY.
Objective: To measure and characterize pain in post esophageal variceal band ligation patients.
Study Design: Cross sectional observational study.
Place and Duration of Study: This study was carried out in Combined Military Hospital Kharian which is a tertiary care hospital, from Dec 2014 to Aug 2015.
Material and Methods: All patients of esophageal varices due to any underlying pathology requiring esophageal variceal band ligation (EVBL) were included in this study. Patients unwilling for EVBL were excluded from the study. Their EVBL was done with the help of Upper Gastrointestinal Pentax High definition 90i series Video Endoscope and subsequently they were inquired about the details of pain till next session of banding.
Results: Out of 86 patients 63 (73%) were males and 23 (27%) were females. Their mean age was 54 years with SD +- 12. Pain was present in 47 (54%) patients and 39 (46%) were pain free. It was severe in 3 (7%), moderate in 34 (72%) and mild in 10 (21%) patients. Out of post EVBL pain group 30 (65%) patients experienced pain after first EVBL session, 12 (25%) in subsequent and 5 (10%) after all the sessions.
Conclusion: Post EVBL pain is a common complication. Mostly it is mild to moderate in intensity and needs attention in almost half of the patients to relief the suffering.
Keywords: Decompensated chronic liver disease, Esophageal varices, Post EVBL pain.
Upper gastrointestinal bleeding secondary to esophageal varices is one of major complications of decompensated chronic liver disease (DCLD). Esophageal varices develop when hepatic venous pressure gradient (HVPG) is increased to 10 mm of Hg and may bleed when above 12 mmHg1. With a single episode of bleeding, mortality is increased to 20%2, rebleed in 40% in 6 weeks and 75% at one year. Injection sclerotherapy i.e. sclerosing agents e.g. sodium morrhuate in varices is being practiced since the last decade of previous century. The sclerosing agent leads to necrosis of esophageal tissue and mucosal ulcers. This procedure lost its popularity because of certain complications like rebleeding in case of large ulcers, stricture formations, less common complications like perforation, mediastinitis and more number of sessions required to obliterate varices. Complications are more if sclerotherapy is performed weekly as compared to if done at two or three weeks interval3.
Currently EVBL is considered to be the first-line treatment in bleeding esophageal varices and has good therapeutic effect in esophageal variceal rebleeding4,5. Meta-analysis has found that EVL is better than sclerotherapy in terms of lower rates of rebleeding, complications, and higher rates of variceal eradication6. This procedure is not free of side effects like transient dysphagia, worsening of portal hypertensive gastropathy7, retrosternal burning sensations and at times moderates to severe pain requiring intervention to relieve the pain. Pain is an established side effect but few studies describe the details of the pain as elaborated in this study.
MATERIAL AND METHODS
Patients with esophageal varices due to any underlying pathology like DCLD or portal vein thrombosis requiring EVBL were included in this study. Patients of above mentioned diseases having small varices not requiring EVBL or not willing to be included in the study were excluded from the study. Informed consent was taken from the patients and study was approved from the ethical committee of the hospital. After the demographic data of the patients, information was gathered on the following lines. Mode of presentation e.g. upper gastrointestinal (GI) bleed secondary to esophageal varices, screening for esophageal varices in patients of DCLD or surveillance in case of previous EVBL sessions. Patients were investigated to find out underlying pathology e.g. hepatitis B, C or D serology, Anti mitochondrial antibodies in suspicion of primary biliary cirrhosis or portal vein doppler studies in case of portal vein thrombosis.
Child-Turcotte-Pugh (CTP) criterion was recorded on the basis of serum bilirubin, albumin levels in mg/dl, international normalized ratio (INR), presence and severity of ascites and encephalopathy. Video Upper GI endoscopy was done after the consent, throat spray with lignocaine 4% solution and conscious sedation with injection midazolam. Dose of midazolam was adjusted keeping underlying disease and age of the patient in mind. Multi-band ligators manufactured by the Wilson-Cook medical GI endoscopy company were used. After the procedure they were inquired about the pain as per numeric pain rating scale (N-11)8. It is an 11 point scale to assess the severity. Its severity was classified asnone, mild, moderate and severe for points 0, 1-3, 4-6 and 7-10 respectively. They were also inquired about the duration of pain in hours to further assess the severity. Pain less than 24 hours was graded as mild, 24 to 72 hours moderate and more than 72 hours was severe.
Nature of pain was assessed on pain assessment quality scale (PAQS). For PAQS they were inquired about whether pain was sharp, diffuse retrosternal discomfort, sensitive, tender, shooting, numb, aching, burning and heaviness. Pain relation with banding session was inquired i.e. after first session, in subsequent or every time after the procedure. Patients were followed up till next session. Repeat endoscopy of the patients was done after every two weeks interval till varices completely obliterated. Total numbers of EVBL sessions required in each patient to obliterate varices were recorded. Data like descriptive statistics includingmean, frequency and percentage were calculated on the latest version of SPSS 22.
Table-I: Mode of presentation of patient required esophageal variceal band ligation.
Mode of presentation###Frequency###Valid percentage###Cumulative percentage
Upper G I bleed###57###66.3###66.3
Screening for esophageal varices###16###18.6###84.9
Surveillance of EVBL###13###15.1###100.0
Table-II: Aetiology of diseases leading to esophageal varices.
Aetiology of disease###Frequency###Valid percent###Cumulative percentage
###HCV e HCC###2###2.4###91.8
###Portal Vein Thrombosis###1###1.2###92.9
In 86 patients, 63 (73%) were male and 23 (27%) female. The mean age was 54 years with SD +- 12.47%. Post EVBL male to female pain ratio was 70:30. The main reason for upper GI endoscopy requiring esophageal variceal band ligation was upper gastrointestinal bleed followed by screening for esophageal varices as mentioned in table-I. Amongst the patients of DCLD, hepatitis C was the main cause followed by cryptogenic and hepatitis B as shown in table-II. The percentage of patient's child class was A, B; C was 12, 43 and 31% respectively. Post EVBL chest pain was noted in 46 (54%) while 40(46%) were pain free. Ratio of the severity of the pain i.e. mild, moderate and severe is shown fig-1. Mean duration of pain was 27 hours with SD +- 36. Character of pain was retrosternal chest discomfort, burning, sharp, shooting and aching with frequency as shown in fig-2.
Retrosternal chest discomfort, burning sensation and aching was more common in mild cases and moderate cases, while it was sharp and shooting in severe cases. Mild pain settled on its own in a day without any medication in 10 (11.5%) cases, moderate pain settled easily with sucralfate or lidocaine: antacid solution in 33 (40%) cases within 2 to 3 days. Severe pain was in 3 (3.5%) and lasted for 7 to 10 days requiring pain killer in addition to the sucralfate or lidocain: antacid solution. In 86 patients 207 EVBL sessions were done with minimum 1 and maximum 10 with average 2.4 sessions per patient. A total of 516 bands were applied with average of 6 per patient. In post EVBL pain group 30 (65%) patients experienced pain after first EVBL session, 12 (25%) in subsequent and in 5 (10%) after all the sessions.
Sixty five patients (85%) had pain during the initial post EVBL days likely because of esophageal spasm and 21 (15%) after one week because of ulcer formed at variceal slough off sites.
Upper GI bleed due to portal hypertension is a devastating complication of cirrhosis liver. Pharmacological treatment includes non-selective Beta blockers like nadolol, propranolol and carvedilol. Endoscopic treatments are injection sclerotherapy and esophageal variceal band ligation. EVBL is preferred treatment in esophageal varices2,4. EVBL and b-blockers are more effective in secondary prophylaxis than either treatment alone9,10. EVBL has better efficacy in control of esophageal variceal bleed in Child's class A and B than in C with high model for endstage liver disease (MELD) score11. Argon Plasma Coagulation (APC) followed by EVBL is another emerging concept to eradicate the varices and to reduce the risk of recurrent bleed12. EVBL has lesser (14%) and minor complications including transient dysphagia, chest discomfort and small ulcers formation around the base and less risk of rebleed4,13.
Unusual complications associated with EVBL are perforation, stenosis and mesenteric vein thrombosis14-17. In our observation, retrosternal chest discomfort and heaviness was in 21% followed by aching, burning in 12% and 10% respectively as shown in fig-2. The frequency of pain was 54% including both multiple as well as single band therapy that matches the average frequency observed by Ali et al in which the frequency of pain in multiple versus single band therapy groups was 30% and 82% respectively18. Majority of the patients had pain, mild to moderate in intensity, which used to settle on its own or with sucralfate or lidocaine: antacid solution. However intense sharp shooting severe pain group required painkillers in addition to the medicines mentioned above. Immediate esophageal pain is due to an abnormal process inside, esophageal spasm or esophageal hyper sensitivity.
It is either due to stimulation by chemoreceptors due to acid or hyperosmolar substances, mechano receptors by distension or thermo receptors by hot and cold food19.
In our study, amongst the pain group immediate post EVBL pain was observed in 85% due to esophageal spasm and in 15% after a week due to esophageal ulcer formation. Esophageal ulcers in EVBL are superficial and resolve faster as compared to sclerotherapy induced ulcers 14 versus 21 days13,20. Probably that was the reason pain in ulcer stage was comparatively less common and mild if present at all in the index study. Pain was more on first session in majority of the patients i.e. 65%, in comparison to study by Hyder et al, amongst the two groups i.e. multiband therapy versus single band therapy, pain was severe in later group i.e. 82%. In this study tolerability of single session band ligation group was poor due to post procedural chest pain as compared to multisession band ligation. Mean duration of symptoms was 27 hours with SD +- 36 in comparison to a study by Hou et al in which mean duration was 8.27 +- 5.52 and 9.55 +- 5.82 hours respectively in two groups of patients21.
Pain was more than double in males as compared to females (70:30) likely due to hypersensitivity, differencein patients as described by Hobson et al22. On paired sample t-test analysis there was no statistical significant correlation observed between Child's class, cause of the bleed with severity or occurrence of the pain. A p-value [?]0.05 was considered statistically significant.
Limitation of Study
It was difficult to elaborate the pain especially in old patients because of low threshold for pain and in patients with encephalopathy. Other associated diseases like reflux esophagitis or ischemic heart disease that can be triggered after banding were not included in the protocol. Pitfall of the study is that pain was not assessed separately in multiple versus single band therapy.
Contribution of study
Post EVBL pain is a common problem that has been mentioned in a number of studies but has never been stressed upon regarding its details like frequency, character and severity which are highlighted in this study.
Post EVBL pain is a common complication. Mostly it is mild to moderate in intensity and needs attention in almost half of the patients to relief the suffering.
I want to pay special thanks to my staff, Mr Irfan and Mr Faisal for help during upper GI endoscopy and EVBL. They fully participated in gathering the data as well.
CONFLICT OF INTEREST
This study has no conflict of interest to declare by any author.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Jun 30, 2017|
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