Failure of combined efforts: propranolol and sclerotherapy do not add up to the prevention of variceal bleeding

Abstract

Endoscopic sclerotherapy has gained wide acceptance as an effective prevention of recurrent variceal bleeding, thereby prolonging the life expectancy of patients at risk of this complication. A meta-an.alysis of 13 trials has shown that the risk of rebleeding is reduced to about 50% and the risk of dying to about 70% (1). This effect is thought to be due to variceal thrombosis and perivariceal inflammation leading to obliteration of the varices and fibrotic thickening of the submucosal wall between the varices and the oesophageal lumen. Inspired by the success of this therapy in the secondary prevention after the first episode of variceal bleeding, there have been many attempts to test whether it may be beneficial for primary prevention, i.e. treatment of varices that have not yet ruptured. Despite the many trials this indication is still uncertain because of the discrepant results, ranging from clearly beneficial effects to harmful effects for both the risk of bleeding and death (2). A comparison of the trials suggests that the beneficial effects are only obtained in patients who have a particularly high risk of bleeding. It is still uncertain whether sclerotherapy has a positive effect in the acute phase of variceal bleeding. In some patients acute sclerotherapy is thought to stop bleeding by inducing thrombosis or compression due to the perivariceal edema. However, a reduction in shortterm morbidity and mortality following variceal rupture