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To the Editor:

Gastroesophageal variceal hemorrhage (GEVH) remains a significant cause of morbidity and mortality in patients with cirrhosis.1 Despite the proliferation of endoscopic and vasoactive therapies, the rebleeding rate in GEVH remains high.2 Prior to the advent of endoscopic therapy, balloon tamponade (BT) was used frequently for control of GEVH, but the current role of BT and comfort of hepatologists and trainees with BT placement has been questioned.3, 4

We set out to determine the attitudes of clinical physician members of the American Association for the Study of Liver Diseases (AASLD) regarding BT use. A web-based survey enquiring about demographic information, practice type (academic, private practice, trainee), BT applications in last 2 years, and attitudes toward BT was e-mailed to 575 members with accessible e-mail addresses. Since we were interested in the members' personal opinions, no specific patient-related information was sought. Because of worldwide differences in GEVH management this survey was restricted to clinical physician members based in the United States.

A total of 234 members (46%) replied, whereas 61 surveys were returned because of inaccurate addresses. Statistical analysis was performed using t test and chi-square test as appropriate. Respondents (n = 234) were divided into academicians (156; 67%), private practitioners (56; 24%), and trainees (22; 9%). Most (59%) of the respondents had >50% hepatology patients in their practice, and 71% had used BT within the last 2 years. Respondents with >50% hepatology patients had used BT at a significantly higher rate than those with <50% hepatology patients (45.7% vs. 25.6%; P = .03). There was no significant difference in BT use over the last 2 years between academicians and private practitioners (75% vs. 62.5% P = .10). BT was used for initial bleeding (21%), rebleeding (14%), or both (65%) from esophageal (34%), gastric (8%), or gastroesophageal (58%) varices. The majority (93%) of respondents regularly used octreotide, and 95% employed BT after at least one prior endoscopic attempt to control GEVH.

The majority (89%) believed that BT should be used for stabilization before transjugular intrahepatic portal systemic shunting (TIPS) (Fig. 1). The 11% who did not believe BT should be used cited complications (23%), low benefit (11%), high success rate of endoscopy alone (29%), or all of the above (37%).

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Figure 1. Perceived role of balloon tamponade in the management of GEVH categorized by practice type.

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Eighty-two percent of non-trainee respondents were comfortable with use of BT, and this was not significantly different between academicians and private practitioners. None of the trainees were comfortable with BT. More than 70% of respondents had not given/received training in BT over the last 2 years; 54% of respondents believed their gastroenterology trainees were not comfortable with BT; and 88% felt that gastroenterology trainees should undergo specialized BT training.

The conclusions of our study were limited by small number of trainees, the predominantly academic nature of AASLD membership, and the lack of specific, patient-related information.

Our study shows that BT continues to have a selected role in current GEVH management. Most practitioners feel comfortable with BT use but also feel that trainees are not comfortable and should undergo specialized BT training. Further evaluation of trainee comfort with BT and implementation of BT training is warranted.

References

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  • 1
    The North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices; a prospective, multicenter study. N Engl J Med 1988; 319: 983989.
  • 2
    Sharara AI, Rockey DC. Gastroesophageal variceal hemorrhage. N Eng J Med 2001; 345: 669681.
  • 3
    Panes J, Teres J, Bosch J, Rodes J. Efficacy of balloon tamponade in the treatment of bleeding gastric and esophageal varices. Dig Dis Sci 1988; 33: 454459.
  • 4
    Sorbi D, Gostout CJ, Peura D, Johnson D, Lanza F, Foutch P, et al. An assessment of management of acute bleeding varices: A multicenter prospective, member-based study. Am J Gastroenterol 2003; 98: 24242434.

Jasmohan Singh Bajaj M.D.*, Ashwin Ananthakrishnan M.D.*, Kia Saeian M.D.*, * Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI.