Perforation of esophagus after endoscopic variceal sclerotherapy. Incidence and clues to pathogenesis.

To determine the true incidence of endoscopic variceal sclerotherapy (EVS)-related esophageal perforation, a retrospective analysis of 900 EVS procedures using sodium tetradecyl sulfate performed on 170 patients during a five-year period (1980-1985) was carried out. Autopsy data of all patients who received EVS and who died (32 patients, 100%) during this period were available to confirm the diagnosis of perforation. Esophageal perforation was confirmed in 5 (2.9%) and was seen in patients with advanced alcoholic liver disease. Importantly, most patients did not manifest features of an esophageal leak, but presented instead as a deterioration in condition and died after a mean (+/- SD) 14 +/- 5.2 days. Analysis of the clinical and EVS data reveals that the risk of developing perforation is high when EVS is performed during active bleeding. The extravariceal location of sclerosant and microabscesses may be important predisposing factors. In our experience large-dose injection, deep ulceration, and balloon tamponade are less likely predisposing factors of this complication.