Abstract
Background and study aim: Carvedilol has beneficial effects on splanchnic haemodynamics following acute and chronic administration in cirrhosis. The aim of this study is to evaluate the role of carvedilol in prevention of first variceal bleeding in patients with liver cirrhosis and to compare its effect with that of variceal band ligation (VBL) and propranolol. Patients and methods: Seventy five patients with liver cirrhosis and endoscopically proven esophageal varices (grade II or larger in size with or without variceal red color signs), that have not bled yet were randomized to either VBL performed every 2 weeks until varices were eradicated (25 patients), carvedilol 12.5mg once daily (25 patients) or propranolol titrated to reduce resting pulse by >25% (25 patients) and followed up on the same schedule at 6 and 12 months. Results: Carvedilol had lowest rate of the first variceal bleeding when compared with VBL and propranolol (10%, 12% and 20% respectively). Carvedilol had significantly decreased the percentage of patients with varices grade III or IV over the follow up period (from 40% to 24%). Both carvedilol and propranolol significantly decreased severity of portal hypertensive gastropathy over follow up period. On the other hand, VBL significantly increased severity of portal hypertensive gastropathy. Conclusion: Carvedilol is effective in preventing the first variceal bleeding. Carvedilol is an option for primary prophylaxis in cirrhosis and esophageal varices grade ≥ II in single daily dose of 12.5 mg.
Highlights
A major cause of cirrhosis related morbidity and mortality is the development of variceal hemorrhage.Variceal hemorrhage occurs in 25 to 40 percent of patients with cirrhosis[1]
In the view of relatively high rate of bleeding from esophageal varices, an important goal of management of patients with cirrhosis is the primary prevention of variceal hemorrhage, all patients with cirrhosis should undergo diagnostic screening upper gastrointestinal tract endoscopy when cirrhosis is first diagnosed to document the presence of varices and to determine their risk for variceal bleeding
The portal vein congestion index (CI) significantly decreased over the follow up period in both carvedilol group (0.183 ± 0.09 at randomization time to 0.152 ± 0.01 at 12 months with P = 0.009 ) and propranolol group ( 0.185 ± 0.09 at randomization time to 0.169 ± 0.09 at 12 months with P = 0.01) .there was no significant change in the mean CI in variceal band ligation (VBL) group (0.176 ± 0.08 at 0 time to 0.171 ± 0.02 at 12 months with P = 0.86)
Summary
Variceal hemorrhage occurs in 25 to 40 percent of patients with cirrhosis[1]. In the view of relatively high rate of bleeding from esophageal varices, an important goal of management of patients with cirrhosis is the primary prevention of variceal hemorrhage, all patients with cirrhosis should undergo diagnostic screening upper gastrointestinal tract endoscopy when cirrhosis is first diagnosed to document the presence of varices and to determine their risk for variceal bleeding. In patients with medium/large varices that have not bled either, nonselective Beta blockers (Propranolol or Nadolol) or variceal band ligation (VBL) is recommended for the prevention of first variceal bleeding and VBL should be considered in patients with contraindications, intolerance or noncompliance to beta blockers[2]. The aim of this study is to evaluate the role of carvedilol in prevention of first variceal bleeding in patients with liver cirrhosis and to compare its effect with that of variceal band ligation (VBL) and propranolol
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