Beta-blockers for preventing variceal bleeding

Evolution of endoscopic therapy for esophageal varices

Endoscopic treatment for bleeding esophageal varices was first described 65 years ago, but the technique was not widely adopted until the 1970s. Rapid progress since then has resulted in new, more effective forms of endoscopic treatment. Currently, endoscopic therapy is the primary treatment for patients with bleeding esophageal varices at most centers. This review traces the evolution of endoscopic treatment, summarizes current outcomes data, and speculates on future development.

Prevention of first variceal bleed: an appraisal of current therapies

Primary prophylaxis of esophageal variceal hemorrhage (EVH) is an important issue in the management of patients with portal hypertension. Given the high rates of initial variceal hemorrhage and mortality in patients who have not experienced bleeding from varices, there is an urgent need for some form of primary prophylaxis in all patients with large esophageal varices. The aim of this article is to review the various therapies that have been clinically assessed in randomized controlled trials for their efficacy in prevention of initial EVH. Beta-blockers have been found to be useful in primary prophylaxis of EVH, and the consensus at present is that they should be offered to all patients with portal hypertension who are at high risk for EVH. Nitrates and other newer agents are under evaluation. Surgery is not recommended for primary prophylaxis of EVH. Endoscopic sclerotherapy has not been shown unequivocally to be efficacious, and may even be deleterious, possibly related to an unacceptably high complication rate in this clinical setting. However, it may merit further clinical evaluation in light of recent reports of benefit in certain subgroups of patients with portal hypertension. On the other hand, endoscopic variceal ligation, which has an inherently low complication rate and brings about rapid obliteration of varices, may be a better option for primary prophylaxis of EVH. In the future, preprimary prophylaxis, an attractive concept, may be considered. This would involve intervention with pharmacologic agents even before the development of portal hypertension or esophageal varices.

Utility of endoscopic evaluations in liver transplant candidates

OBJECTIVE

The aim of this study was to determine whether endoscopic evaluation of patients referred for liver transplant evaluation contributes significantly to patient selection or management.

METHODS

Esophagogastroduodenoscopy (EGD) was performed in transplant candidates who had not undergone this examination within a previous 6-month period. Colonoscopy (CSP) was performed if the patient was >50 yr of age or had anemia, a history of colonic pathology such as adenomatous polyps, or a history suggesting gastrointestinal tract abnormalities.

RESULTS

A total of 118 patients were studied. EGD was performed in 74 (63%) patients. Forty-seven patients had esophageal varices identified; in 26, this represented a new diagnosis. Other findings on EGD included portal gastropathy (21 patients), gastric varices (seven patients), peptic ulceration (10 patients), Barrett's esophagus (three patients), and one case each of esophageal and gastric carcinoma. CSP was performed in 56 patients. Findings included adenomatous polyps (24 patients) and one case of colon carcinoma. Overall, gastrointestinal pathology was discovered in 67 (57%) of the patients undergoing endoscopic evaluation as part of our study. Alterations in patient selection or management resulted from 44% of the procedures performed; 42% of the patients were affected by these management changes and 2.5% of patients were removed from further transplant evaluation because of the diagnosis of malignancy.

CONCLUSION

Endoscopic evaluation of liver transplant candidates often identifies important gastrointestinal pathology and frequently impacts patient selection and management before OLT.

Propranolol and sclerotherapy in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis

BACKGROUND/AIMS

A meta-analysis of nine selected randomized trials was performed to compare the effects of propranolol and sclerotherapy in the prevention of rebleeding and on survival in patients with cirrhosis.

METHODS

Five end points were assessed: rebleeding, esophageal rebleeding, death, death due to bleeding, and adverse events. Analyses were performed according to the intention-to-treat method. For each end point, heterogeneity and treatment efficacy were assessed by the Der Simonian and Peto methods. When a significant difference was observed, sensitivity analyses were performed by successive stratification according to treatment duration, type of publication, severity of cirrhosis, and methodological quality.

RESULTS

The mean percentage of patients free of rebleeding, the mean survival rate and the mean percentage of patients free of death from bleeding were not significantly different between patients treated with propranolol and those treated by sclerotherapy. The mean percentage of patients free of variceal rebleeding was 39% in propranolol group and 55% in sclerotherapy group (mean difference: 17%, 95% confidence interval: 9-25%, p < 0.001). The mean percentage of patients free of adverse events was significantly higher in the propranolol group than in the sclerotherapy group (mean difference: 22%, 95% confidence interval: 6-38%, p < 0.007).

CONCLUSION

In patients with cirrhosis and esophageal varices, endoscopic sclerotherapy is more effective than propranolol in preventing variceal rebleeding, but the incidence of adverse events is significantly higher with sclerotherapy. There was no difference in survival between the treatments. Propranolol should be considered as a first choice treatment for preventing rebleeding.

The management of variceal bleeding

Fastidious resuscitation is essential in the initial management of acute variceal bleeding and requires adequate monitoring. Where endoscopic services are available diagnostic endoscopy should be performed ideally within 4-6 hours of admission and endoscopic therapy with injection sclerotherapy or binding ligation performed. Treatment to prevent early rebleeding will require further endoscopic treatment and possibly adjuvant vasoconstrictor therapy (somatostatin/octreotide or glypressin). Where endoscopy is unavailable vasoconstrictor therapy and/or balloon tamponade should be started prior to transfer to a centre with endoscopic facilities. Treatment failures should be considered for TIPSS or surgery. Gastric varices are better treated endoscopically with bovine or human thrombin than sclerotherapy. For prevention of rebleeding, variceal obliteration with endoscopic band ligation or prophylactic beta blockade are the two optimal treatments, although candidates may be identified for TIPPS if rebleeding recurs. Only beta blockers have so far been shown to be of value as primary prophylaxis.

Bleeding oesophageal varices

BACKGROUND

The Danish contribution to evaluation and treatment of bleeding oesophageal varices.

METHODS

Danish papers dealing with portal hypertension and oesophageal varices have been reviewed and set in relation to international publications.

RESULTS

The Danish papers have mainly contributed with controlled clinical trials concerning both primary and secondary prophylaxis. Furthermore, they have dealt with pathophysiologic, clinical and experimental studies concerning portal haemodynamics and the evolution and treatment of variceal bleeding.

CONCLUSION

The Danish studies have been well designed and are frequently cited. Further prospective randomized studies in the new treatment modalities are encouraged.

Prevention of rebleeding from oesophageal varices: two-year follow up of a prospective controlled trial of propranolol in addition to sclerotherapy

A prospective randomised trial comparing propranolol and sclerotherapy to sclerotherapy alone was conducted over a 2-year follow up in a district hospital setting of unselected patients. Rebleeding and survival were analysed. Thirty-nine patients were randomised to propranolol plus sclerotherapy and 34 to sclerotherapy alone. The two groups were clinically comparable. There was no significant difference in the cumulative percent of patients free of rebleeding; 54% of the sclerotherapy group rebled compared to 52% of the group treated with propranolol plus sclerotherapy (Hazard ratio 1.09 (0.54-2.22) and p = 0.81, NS). Two-year actuarial survival was also not significantly different, with 77% of the propanolol plus sclerotherapy group surviving, compared to 74% of sclerotherapy alone (Hazard ratio 1.08 (0.35-2.22) and p = 0.79, NS). The mean time to eradication of varices was not significantly different between the two groups (propranolol plus sclerotherapy 222 days, sclerotherapy alone 243 days), nor did the rate of variceal recurrence differ (72.7 vs 72 days). This study did not show long-term improvement in rebleeding or survival using propranolol in addition to a regular sclerotherapy programme.

Prophylaxis of first hemorrhage from esophageal varices by sclerotherapy, propranolol or both in cirrhotic patients: a randomized multicenter trial. The PROVA Study Group

The objective of this randomized multicenter trial was to assess the prophylactic effect on the incidence and severity of the first variceal hemorrhage of endoscopic sclerotherapy, propranolol and the combination of the two compared with none of these treatments in patients with cirrhosis and esophageal varices. Among 819 cirrhotic patients who never had experienced variceal bleeding, esophagoscopy revealed varices in 379, of whom 286 were enrolled in the trial; 73 were allocated to sclerotherapy (paravenous polidocanol [10 mg/ml] every 1 to 2 wk until eradication), 68 to propranolol (slow-release preparation in one daily dose adjusted to provide about 25% heart rate reduction), 73 to both treatments and 72 to neither of the two treatments. The patients were observed for up to 42 mo, with an average of 15 mo. After variceal bleeding, patients in all groups received sclerotherapy only. The incidences of variceal bleeding (n = 50) were almost identical in the four groups. The relative risk (with 95% confidence limits) with sclerotherapy was 1.06 (0.61 to 1.84), and the relative risk with propranolol was 0.92 (0.53 to 1.60). The mortality rate after variceal bleeding (n = 29) did not differ significantly either. The mortality rate without variceal bleeding (n = 46) was 2.75 (1.45 to 5.22) times higher in the sclerotherapy groups than in the nonsclerotherapy groups (p = 0.002), whereas propranolol showed no effect, the relative risk being 1.17 (0.66 to 2.10). The total mortality rate showed no significant difference between the sclerotherapy, propranolol and control groups, but the combined therapy group had a significantly increased mortality rate.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of variceal bleeding

Variceal bleeding has a high mortality, as the majority of patients have cirrhosis, with hepatic coma, renal failure, ascites and clotting deficiencies as complicating factors. Bleeding varices must therefore be treated as an emergency. Resuscitation, endoscopic diagnosis and haemostasis are the cornerstones of treatment. Once bleeding varices have been identified, attempts to stop the bleeding must be made at once as this will lessen the chances of hepatic failure developing. Endoscopic sclerotherapy at the time of diagnosis is the best available treatment at present, although profusely bleeding varices can be difficult to see and inject. In these circumstances the passage of a Sengstaken tube should stop the bleeding, allowing later sclerotherapy to be successful. If rebleeding recurs and cannot be controlled, oesophageal transection with a stapling gun may be life-saving, although the varices may later recur and long-term endoscopic follow-up will be necessary. Portacaval shunting and the distal splenorenal shunt involve arduous surgery and are followed by a significant incidence of hepatic encephalopathy; they should be reserved for those few cases when simpler measures have failed, although shunts do lead to permanent decompression of the portal system. The acute variceal bleed may also be dealt with pharmacologically. Vasopressin, used in combination with nitroglycerin to lessen the harmful side-effects, is cheaper and as effective as terlipressin or somatostatin and its synthetic analogue octreotide. Several courses of injection sclerotherapy will be required to eliminate oesophageal varices. Thereafter, long-term follow-up will be necessary to deal with any recurrence. The place of non-selective beta-blockers is still contentious, but they do reduce portal pressure and may lessen the chance of rebleeding. There is also a growing role for hepatic transplantation, which not only eliminates the varices but also restores liver function to normal and greatly reduces the risk of subsequent hepatoma development.