Primary Prevention Of Variceal Bleeding Research Articles

Analysis of the effectiveness of the method of primary bleeding prevention in the treatment of portal hypertension in children

Objective. To evaluate the role of primary prevention of variceal bleeding in children with prehepatic portal vein obstruction. Materials and methods. The single–centre prospective cohort clinical trial involved 120 patients with extrahepatic obstruction of the hepatic portal vein who underwent primary or secondary prevention of variceal bleeding in 2016–2021. Laboratory, ultrasound, and endoscopic data were collected and evaluated before and after prophylactic treatment. Results. Episodes of variceal bleeding were observed in 3 (5.78%) patients who received primary prophylaxis, and rebleeding occurred in 19 (27.94%) patients who received secondary prophylaxis (p=0.013). Of the 53 (44.17%) patients who underwent endoscopic treatment, variceal bleeding occurred in 3 (5.66%), and 19 (28.36%) of the 67 (55.83%) patients who underwent surgery experienced rebleeding (p=0.001). Esophageal varices eradication was achieved in 83 (69.17%) patients: 44 (53.01%) patients who received primary prevention and 39 (46.99%) patients who received secondary prevention. Bleeding episodes occurred less frequently after eradication (p<0.001). After primary prevention, varicose veins disappeared more often than after secondary prevention (p=0.003). The incidence of varicose veins recurrence after achieving eradication did not differ in the groups (p=0.51). Conclusions. Primary prevention can reduce the high risk of bleeding in prehepatic portal vein obstruction. Prophylactic endoscopic ligation is important in the treatment of portal hypertension in children, which, together with portosystemic shunting, can potentially improve the results of preventive treatment.

For people with esophageal varices due to liver cirrhosis, how do interventions for primary prevention of variceal bleeding compare with no active intervention and with one another?

For people with esophageal varices due to liver cirrhosis, how do interventions for primary prevention of variceal bleeding compare with no active intervention and with one another?

Primary prevention of variceal bleeding in people with oesophageal varices due to liver cirrhosis: a network meta-analysis.

Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years. There are several different treatments to prevent bleeding, including: beta-blockers, endoscopic sclerotherapy, and variceal band ligation. However, there is uncertainty surrounding their individual and relative benefits and harms. To compare the benefits and harms of different treatments for prevention of first variceal bleeding from oesophageal varices in adults with liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for prevention of first variceal bleeding from oesophageal varices according to their safety and efficacy. We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers to December 2019 to identify randomised clinical trials in people with cirrhosis and oesophageal varices with no history of bleeding. We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and oesophageal varices with no history of bleeding. We excluded randomised clinical trials in which participants had previous bleeding from oesophageal varices and those who had previously undergone liver transplantation or previously received prophylactic treatment for oesophageal varices. We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR), and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute for Health and Care Excellence Decision Support Unit guidance. We performed the direct comparisons from randomised clinical trials using the same codes and the same technical details. We included 66 randomised clinical trials (6653 participants) in the review. Sixty trials (6212 participants) provided data for one or more comparisons in the review. The trials that provided the information included people with cirrhosis due to varied aetiologies and those at high risk of bleeding from oesophageal varices. The follow-up in the trials that reported outcomes ranged from 6 months to 60 months. All but one of the trials were at high risk of bias. The interventions compared included beta-blockers, no active intervention, variceal band ligation, sclerotherapy, beta-blockers plus variceal band ligation, beta-blockers plus nitrates, nitrates, beta-blockers plus sclerotherapy, and portocaval shunt. Overall, 21.2% of participants who received non-selective beta-blockers ('beta-blockers') - the reference treatment (chosen because this was the most common treatment compared in the trials) - died during 8-month to 60-month follow-up. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates all had lower mortality versus no active intervention (beta-blockers: HR 0.49, 95% CrI 0.36 to 0.67; direct comparison HR: 0.59, 95% CrI 0.42 to 0.83; 10 trials, 1200 participants; variceal band ligation: HR 0.51, 95% CrI 0.35 to 0.74; direct comparison HR 0.49, 95% CrI 0.12 to 2.14; 3 trials, 355 participants; sclerotherapy: HR 0.66, 95% CrI 0.51 to 0.85; direct comparison HR 0.61, 95% CrI 0.41 to 0.90; 18 trials, 1666 participants; beta-blockers plus nitrates: HR 0.41, 95% CrI 0.20 to 0.85; no direct comparison). No trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation had a higher number of serious adverse events (number of events) than beta-blockers (rate ratio 10.49, 95% CrI 2.83 to 60.64; 1 trial, 168 participants). Based on low-certainty evidence, beta-blockers plus nitrates had a higher number of 'any adverse events (number of participants)' than beta-blockers alone (OR 3.41, 95% CrI 1.11 to 11.28; 1 trial, 57 participants). Based on low-certainty evidence, adverse events (number of events) were higher in sclerotherapy than in beta-blockers (rate ratio 2.49, 95% CrI 1.53 to 4.22; direct comparison rate ratio 2.47, 95% CrI 1.27 to 5.06; 2 trials, 90 participants), and in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison rate ratio 1.72, 95% CrI 1.08 to 2.76; 1 trial, 140 participants). Based on low-certainty evidence, any variceal bleed was lower in beta-blockers plus variceal band ligation than in beta-blockers (direct comparison HR 0.21, 95% CrI 0.04 to 0.71; 1 trial, 173 participants). Based on low-certainty evidence, any variceal bleed was higher in nitrates than beta-blockers (direct comparison HR 6.40, 95% CrI 1.58 to 47.42; 1 trial, 52 participants). The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Based on low-certainty evidence, beta-blockers, variceal band ligation, sclerotherapy, and beta-blockers plus nitrates may decrease mortality compared to no intervention in people with high-risk oesophageal varices in people with cirrhosis and no previous history of bleeding. Based on low-certainty evidence, variceal band ligation may result in a higher number of serious adverse events than beta-blockers. The evidence indicates considerable uncertainty about the effect of beta-blockers versus variceal band ligation on variceal bleeding. The evidence also indicates considerable uncertainty about the effect of the interventions in most of the remaining comparisons.

Carvedilol vs endoscopic variceal ligation for primary and secondary prevention of variceal bleeding: Systematic review and meta-analysis.

BACKGROUNDVariceal hemorrhage is associated with high mortality and is the cause of death for 20–30% of patients with cirrhosis. Nonselective β blockers (NSBBs) or endoscopic variceal ligation (EVL) are recommended for primary prevention of variceal bleeding in patients with medium to large esophageal varices. Meanwhile, combination of EVL and NSBBs is the recommended approach for the secondary prevention. Carvedilol has greater efficacy than other NSBBs as it decreases intrahepatic resistance. We hypothesized that there was no difference between carvedilol and EVL intervention for primary and secondary prevention of variceal bleeding in cirrhosis patients.AIMTo evaluate the efficacy of carvedilol compared to EVL for primary and secondary prevention of variceal bleeding in cirrhotic patientsMETHODSWe searched relevant literatures in major journal databases (CENTRAL, MEDLINE, and EMBASE) from March to August 2018. Patients with cirrhosis and portal hypertension, regardless of aetiology and severity, with or without a history of variceal bleeding, and aged ≥ 18 years old were included in this review. Only randomized controlled trials (RCTs) that compared the efficacy of carvedilol and that of EVL for primary and secondary prevention of variceal bleeding and mortality in patients with cirrhosis and portal hypertension were considered, irrespective of publication status, year of publication, and language.RESULTSSeven RCTs were included. In four trials assessing the primary prevention, no significant difference was found on the events of variceal bleeding (RR: 0.74, 95%CI: 0.37-1.49), all-cause mortality (RR: 1.10, 95%CI: 0.76-1.58), and bleeding-related mortality (RR: 1.02, 95%CI: 0.34-3.10) in patients who were treated with carvedilol compared to EVL. In three trials assessing secondary prevention, there was no difference between two interventions for the incidence of rebleeding (RR: 1.10, 95%CI: 0.75-1.61). The fixed-effect model showed that, compared to EVL, carvedilol decreased all-cause mortality by 49% (RR: 0.51, 95%CI: 0.33-0.79), with little or no evidence of heterogeneity.CONCLUSIONCarvedilol had similar efficacy to EVL in preventing the first variceal bleeding in cirrhosis patients with esophageal varices. It was superior to EVL alone for secondary prevention of variceal bleeding in regard to all-cause mortality reduction.

Study protocol for a randomised controlled trial of carvedilol versus variceal band ligation in primary prevention of variceal bleeding in liver cirrhosis (CALIBRE trial)

IntroductionLiver cirrhosis is the fifth largest cause of adult deaths, and a major complication, variceal bleeding is associated with a 1-year mortality of 40%. There is uncertainty on the first-line...

Carvedilol for prevention of variceal bleeding: a systematic review and meta-analysis.

BackgroundBeta-blockers are used for prophylaxis of variceal bleeding. Our aim was to assess the efficacy and safety of carvedilol for primary or secondary prevention of variceal bleeding in patients with cirrhosis.MethodsWe searched Medline, Embase, CENTRAL and gray literature sources for randomized controlled trials (RCTs) comparing carvedilol with placebo or any active intervention. We synthesized data using random effects models. We summarized the strength of evidence using GRADE criteria.ResultsWe included 13 trials with 1598 patients. Carvedilol was as efficacious as endoscopic variceal ligation (EVL) (4 RCTs, risk ratio [RR] 0.74, 95% confidence interval [CI] 0.37-1.49) or propranolol (3 RCTs, RR 0.76, 95%CI 0.27-2.14) for primary prevention of variceal bleeding. Likewise, carvedilol was as efficacious as EVL (3 RCTs, RR 1.10, 95%CI 0.75-1.61), non-selective beta-blockers (NSBBs) plus isosorbide-5-mononitrate (2 RCTs, RR 1.02, 95%CI 0.70-1.51) or propranolol (2 RCTs, RR 0.39, 95%CI 0.15-1.03) for secondary prevention of variceal bleeding. Carvedilol was associated with lower all-cause mortality compared to EVL (3 RCTs, RR 0.51, 95%CI 0.33-0.79). There was no difference in any other efficacy outcome. Finally, there were no significant differences in the safety profiles compared with EVL and NSBBs. Our confidence in the effect estimates for all outcomes was very low.ConclusionCarvedilol is as efficacious and safe as standard-of-care interventions for the primary and secondary prevention of variceal bleeding.

Specific Factors That Influence Adherence to Beta Blocker Treatment in Primary Prevention of Variceal Bleeding in Cirrhotic Romanian Patients. a Proof of Concept Qualitative Study.

Adherence to medical treatment in chronic patients challenging, especially in primary prevention where the benefit is not directly perceived by the patient. Through the directed interview of this qualitative study we assessed some specific factors that intervene in beta-blockers adherence in cirrhotic patients with oesophageal varices in primary prevention in Romanian. We identified that the most important modifiable extrinsic factor that influences adherence is the confidence in medicine. The intensely negative perception of the disease seemed to be another major driver of adherence.

Efficacy of carvedilol versus propranolol versus variceal band ligation for primary prevention of variceal bleeding.

Band ligation and propranolol are the current therapies for primary prevention of variceal bleeding. Carvedilol is a rising nonselective beta-blocker used for reducing portal pressure with favorable outcome. The aim of this study to assess the efficacy of carvedilol, propranolol, and band ligation for primary prevention of variceal bleeding based on the effect of each regimen on progression of Child score and portal hypertensive gastropathy after 1year. The study included 264 cirrhotic patients with medium/large-sized varices who were candidates for primary prophylaxis of variceal bleeding. Patients were randomly divided into three groups: groupI: band ligation; groupII: propranolol; groupIII: carvedilol. GroupI showed higher success rate of 75%, followed by groupIII with 70.2% and groupII with 65.2%. Risk of bleeding was comparable between the three groups, with groupII carrying the highest rate of complications (34.7%) followed by groupIII (14.2%) and finally groupI (5.7%). After 1year of follow-up, Child score did not improve in any of the studied groups, while portal hypertensive gastropathy significantly increased in groupI but decreased in groupsII and III. Band ligation is the best treatment option for primary prevention of variceal bleeding with minimal complications. Carvedilol is a good pharmaceutical alternative medicine to propranolol with lesser side-effects. Progress of liver disease as represented by Child score is not affected by any of the primary variceal prophylactic regimens, although medical treatment reduces portal hypertensive gastropathy. Choice of treatment depends on patient will, compliance with treatment, and endoscopist competence.

Comparison of endoscopic variceal ligation and beta-blocker (carvedilol) plus nitrate for the primary prevention of variceal bleeding

Background: Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic sclerotherapy and variceal ligation are effective in stopping bleeding in up to 90% of patients. Beta-blocker (Carvedilol) + Isosorbide Mononitrate are promising alternative to other nonselective beta blocker or endoscopic band ligation for the prevention of first variceal bleeding of medium to large varices, which needs to be further explored.Methods: The present study was an observational study in 200 patients at LLR and Associated Hospitals PG Department of Medicine GSVM Medical College, Kanpur. After randomization 120 patients underwent for Endoscopic Variceal ligation and 80 patients were put on beta-blocker (Carvedilol) + Isosorbide Mononitrate therapy for the primary prevention of variceal bleeding.Results: Most common cause of portal hypertension was liver cirrhosis (in carvedilol plus isosorbide mononitrate group 70%, and it was 85%. in EVL group. Bleeding in patients of carvedilol plus isosorbide mononitrate was significantly lower (23.75%) than patients of EVL (60%) group. Reduction in bleeding was statistically highly significant (p value < 0.05). Mortality among patients receiving combination therapy with carvedilol plus isosorbide mononitrate was (12.5%) comparison to EVL (21.66%). Reduction in mortality was statistically not significant. (p value >0.05). Adverse effects were significantly lower among patients receiving combination therapy with carvedilol plus isosorbide mononitrate (38.75%) than patients of EVL (86.66%) group.Conclusions: Both EVL and beta-blockers may be considered first-line treatment to prevent first variceal bleeding, whereas beta-blockers (carvedilol) plus isosorbide mononitrate may be the best choice for the prevention of re-bleeding.

Prediction of Esophageal Variceal Bleeding in Liver Cirrhosis: Is There a Role for Hemostatic Factors?

Variceal bleeding is a frequent and ominous complication of liver cirrhosis. Fortunately, primary prophylaxis with β blockers or esophageal band ligation effectively reduces the risk of variceal bleeding and its associated mortality. Periodic endoscopic surveillance of esophageal varices (EV) is currently recommended in every patient with cirrhosis for early detection of EV and initiation of primary variceal bleeding prophylaxis is indicated for high-risk patients. During the last decades several noninvasive tests have emerged, aiming to facilitate access, reduce cost, and avoid unnecessary risk associated with endoscopic EV surveillance. In addition, several hemostatic abnormalities have been described in cirrhosis, and their role in variceal bleeding pathogenesis is yet to be defined. In this article, we review and critically analyze the accuracy of noninvasive EV predictors and utility of hemostatic factors to predict individual variceal bleeding risk. In addition, we summarize available data regarding the therapeutic role of hemostatic factors in primary prevention of variceal bleeding and early recurrence after an initial episode of variceal hemorrhage.

O021 : Non-invasive screening of large esophageal varices using endoscopic capsule and/or liver fibrosis tests

Background and Aims: The non-invasive screening of large esophageal varices (LEV) might be useful in primary prevention of variceal bleeding in cirrhosis. The main objective was to compare strategies for the diagnosis of LEV by using predictive values and direct costs. Methods: 330 cirrhotic patients were included in a prospective multicenter study. Diagnostic tools were upper gastro-intestinal endoscopy (UGIE, reference), esophageal capsule endoscopy (ECE), liver stiffness measurement (LSM) by Fibroscan and several blood markers and liver fibrosis tests. Results: 287 patients had per protocol analysis defined by UGIE and ECE available. Child–Pugh class distribution was: A: 61%, B: 20%, C: 19%. Etiology was: alcohol: 45%, viral hepatitis: 27%, NASH: 5%, mixed: 11%, others: 6%. Among the 35 diagnostic predictors tested in the per protocol population, 10 had an AUROC >0.7 for LEV: Child–Pugh score (0.72), bilirubin (0.72), AST/ALT (0.74), LSM (0.74), hyaluronate (0.77), QuantiMeter (0.77), FibroMeter (0.77), CirrhoMeter (0.77), Elasto-FibroMeter (0.78), ECE (0.89). The most performant combination by binary logistic regression was either with ECE: ECE + AST/ALT (score 1, AUROC: 0.92) or without ECE: prothrombin index + AST/ALT (score 2, AUROC: 0.77), LSM having no independent role. Then, we defined 5 strategies based on noninvasive tools with high negative predictive value (NPV ≥95%) and/or positive predictive value (PPV ≥90%) for LEV in a first step; then, UGEI was used in the indeterminate zone. The 5 strategies were: S1: ECE for NPV and PPV, S2: LSM for NPV and ECE for PPV, S3: LSM for NPV and score 2 (ECE + blood markers) for PPV, S4: score 1 (blood markers) for NPV and PPV, S5: score 2 (ECE + blood markers) for NPV and PPV. The rank of strategies for decreased request to UGEI was: S5: 12.9%, S1: 28.9%, S2: 41.7%, S3:42.2%, S4: 47.5% (p < 0.001 between all and S5 vs others). But the rank for direct costs per patient was different: S4: 64€, S2: 393€, S3: 399€, S5: 632€, S1: 645€, reference UGEI cost being 114€. Conclusions: This is the first study comparing capsule endoscopy and fibrosis tests in the screening of large esophageal varices. By using capsule and blood markers, one can avoid 87% of endoscopies in cirrhotic patients but this strategy has currently high direct costs (x6). By contrast, simple blood markers can avoid 48% of endoscopies and divide the direct costs by around 50%. These results should be validated in an independent population, compared to spleen stiffness and add indirect costs. O022 THE UK-PBC RISK SCORE: DERIVATION AND VALIDATION OF A RISK SCORE TO PREDICT LIVER EVENTS IN THE UK-PBC RESEARCH COHORT M. Carbone, S.J. Sharp, M.A. Heneghan, J.M. Neuberger, G.M. Hirschfield, A.K. Burroughs, D. Thorburn, A. Bathgate, M. Aldersley, C. Adgey, P. Trembling, K. Williamson, L. Jopson, R.T. Lim, N.J. Wareham, H.J. Cordell, G.J. Alexander, J.E. Jones, R.N. Sandford, G.F. Mells, UK-PBC Consortium. Division of Gastroenterology and Hepatology, Addenbrooke’s Hospital, Academic Department of Medical Genetics, MRC Epidemiology Unit, University of Cambridge, Cambridge, Institute of Liver Studies, King’s College Hospital, London, Liver Unit, Queen Elizabeth Hospital, NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, The Sheila Sherlock Liver Centre, The Royal Free Hospital, London, Liver Unit, Royal Infirmary Hospital, Edinburgh, Liver Unit, St James’s Hospital, Leeds, Liver unit, Royal Victoria Hospital, Belfast, Liver Unit, Barts and The London NHS Trust, London, Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, Institute of Cellular Medicine, Institute of Genetic Medicine, Newcastle university, Newcastle, United Kingdom E-mail: mc767@medschl.cam.ac.uk

Effectiveness of beta-blocker in primary prevention of variceal bleeding in patients with cirrhosis: A prospective evaluation by hepatic venous pressure gradient measurement

Effectiveness of beta-blocker in primary prevention of variceal bleeding in patients with cirrhosis: A prospective evaluation by hepatic venous pressure gradient measurement

Combined therapies versus monotherapies for the first variceal bleeding in patients with high‐risk varices: A meta‐analysis of randomized controlled trials

The effect of combined therapies (among non-selected beta-blockers [NSBB], endoscopic therapy, and other treatments) on the first variceal bleeding has been evaluated in several randomized controlled trials previously, and the results were controversial. We performed this meta-analysis to assess the effect of combined therapies in patients with high-risk varices without previous variceal bleeding. The Cochrane Library, The Cochrane Hepato-Biliary Group Controlled Trials Register, MEDLINE, and EMBASE were searched for eligible trials. Manual searches were also performed for additional studies. Upper gastrointestinal bleeding, variceal bleeding, mortality, and adverse events were evaluated as end-points by meta-analysis. Twelve randomized controlled trials with 1571 patients were included. Compared with the NSBB (propranolol or nadolol) or endoscopic therapy alone, all of the combined therapies did not demonstrate significant improvements in variceal bleeding, total upper gastrointestinal bleeding, and mortality. Only the combinations of isosorbide-mononitrate or spironolactone with NSBB tended to decrease the risk of variceal bleeding when compared with the use of NSBB alone (isosorbide-mononitrate plus NSBB vs NSBB: odds ratio = 0.67, 95% confidence interval 0.40-1.13, P = 0.13; spironolactone plus NSBB vs NSBB: odds ratio = 0.41, 95% confidence interval 0.10-1.69, P = 0.22). Adverse events were more frequently observed in the combined therapy groups. Based on the available evidences, no combined therapy can be recommended as the first-line treatment for the primary prevention of variceal bleeding currently. Further studies with large sample sizes and long-term follow up are warranted.

Role of transjugular intrahepatic portosystemic shunt in prevention and treatment of variceal bleeding in liver cirrhosis

In patients with liver cirrhosis,variceal bleeding is a common fatal complication of portal hypertension. Varices are present in almost half of patients with cirrhosis at the time of diagnosis. Since transjugular intrahepatic portosystemic shunt(TIPS) was first applied clinically in 1988,the relevant information about TIPS has been continually updated and perfected by lots of clinical trials. The role of TIPS in the prevention and treatment of variceal bleeding in cirrhotic patients with portal hypertension,including primary prevention of variceal bleeding,treatment of acute variceal bleeding,and prevention of rebleeding,is reviewed. TIPS is an effective treatment for variceal bleeding in cirrhotic patients with portal hypertension. Along with the technical development,TIPS will be available for more and more patients and will play an increasingly important role in the prevention and treatment of variceal bleeding among cirrhotic patients with portal hypertension.

Primary prevention of bleeding from esophageal varices in patients with liver cirrhosis.

Variceal bleeding is a life threatening situation with mortality rates of at least 20%. Prophylactic treatment with non-selective beta blockers (NSBBs) is recommended for patients with small varices that have not bled but with increased risk for bleeding. The recommended treatment strategies on primary prevention of variceal bleeding in patients with medium and large-sized varices are NSBBs or endoscopic band ligation. Nitrates, shunt surgery and sclerotherapy are not recommended in this setting. In this review, the most recent data on prevention of esophageal variceal bleeding are presented. Available data derived from randomized-controlled trials suggest both treatment strategies, and according to Baveno V consensus in portal hypertension "the choice of treatment should be based on local resources and expertise, patient preference and characteristics, side-effects and contra-indications".

Primary prevention of variceal bleeding: Pharmacological therapy versus endoscopic banding

Variceal bleeding is one of the most feared complications in patients with liver cirrhosis. It continues to be a leading cause of death among patients with liver cirrhosis. Although its prognosis has improved over the last several decades, it still carries substantial mortality. Preventing variceal bleeding has been extensively studied and evaluated in several studies in the recent years and the comparison between the different modalities available to prevent variceal bleeding has been an area of discussion. Currently the two most widely used modalities to prevent variceal bleeding are pharmacologic (non-selective beta-blockers [NSBB]) and endoscopic (variceal band ligation [VBL]) which have replaced sclerotherapy in the recent years. In addition to NSBB and recent carvedilol, different other medications have been evaluated including isosorbide mononitrates, spironolactone and angiotensin blocking agents. Comparing the outcomes and adverse effects of these two modalities has been evaluated in different studies. Some studies have showed superiority of VBL until recently, when carvedilol has been included, however; overall mortality has been similar in most trials. Despite that, NSBB remain the first line treatment, as they are cheaper and relatively effective in preventing both esophageal and gastric bleeding. The following sections discuss the primary prevention of variceal bleeding with a focus on NSBB, carvedilol and VBL.

The initial experience of safety and efficacy of argon plasma coagulation (APC) in the primary prevention of variceal bleeding

Background and study aimsThe well-known complications of variceal bleeding together with the high mortality rate mandate effective prophylaxis. Because of the intolerance, failure of response and lack of compliance related to B blockers and because of the high incidence of variceal recurrence after endoscopic variceal ligation (EVL), other alternatives should be investigated. As APC provides coagulation at a shallow depth, it has been considered an ideal procedure to promote mucosal fibrosis for oesophageal varices. This study aims to investigate the safety and effectiveness of APC application to the oesophagus post-variceal obliteration in an attempt to decrease variceal recurrence and bleeding, as compared to EVL. Patients and methodsThis study included 60 patients with chronic liver disease and portal hypertension referred to the Gastrointestinal Endoscopy Unit, Kasr Al-Aini Hospital, Cairo University, during the period from August 2008 till January 2010. Patients had to have large-sized varices (F3), without history of bleeding, portal hypotensive drugs or intervention.Patients were allocated into either group I that included 30 patients for whom EVL was performed and sequentially followed by one session of APC or group II that included 30 patients for whom EVL alone was done. Patients underwent surveillance endoscopy at 3 and 6months to evaluate variceal recurrence (F1 or more). ResultsBoth groups were comparable in terms of the demographic features, hepatic functional reserve and endoscopic findings. Post-APC, fever was reported in 6.7%, dysphagia in 3.3%, procedure-related bleeding in 0% and stricture in 3.3%. At 3 and 6months follow-up, both groups were comparable in terms of variceal recurrence and none of the patients in both groups developed variceal bleeding. ConclusionAlthough, APC application to the oesophageal mucosa is a safe technique, its additive benefit in terms of variceal recurrence and re-bleeding is comparable to EVL alone. This is encountered when only a single session of APC is applied. A more beneficial effect of multiple sessions of APC awaits further studies.

Komplikationen der Leberzirrhose

The occurrence of complications increases the mortality in patients with cirrhosis of the liver. Therefore, early detection and treatment of complications of cirrhosis is of major importance. Following diagnosis of cirrhosis, a screening gastroscopy detects esophageal varices. Primary prevention of variceal bleeding can be initiated with β-receptor antagonists or variceal band ligation. With the first episode of ascites or the manifestation of other complications of cirrhosis such as hepatic encephalopathy and hepatorenal syndrome, a paracentesis excludes spontaneous bacterial peritonitis. Hepatorenal syndrome can be treated with a combination of vasopressors and albumine. Furthermore, occurrence of complications in patients with cirrhosis of the liver should prompt the evaluation of an indication for liver transplantation.

Primary Prevention of Variceal Hemorrhage

Variceal hemorrhage is one of the leading causes of death in patients with cirrhosis, with the 6-week mortality after each episode ranging from 15% to 20%. The two main strategies for primary prevention of variceal bleeding in patients with cirrhosis and varices are the administration of nonselective β-blockers or the obliteration of varices with use of endoscopic band ligation. In this review, we present and critically review the latest data on primary prevention of variceal hemorrhage. We advocate that nonselective β-blockers should be the first line therapy, and band ligation should be offered only in cases of intolerance or side effects. We also explore potential future therapies based on preliminary experimental and clinical data.

Overview of the methods and therapies for the primary prevention of variceal bleeding

Patients with cirrhosis develop varices at a rate of 5% per year, and a third of patients with high-risk varices will bleed. The mortality associated with variceal haemorrhage is typically 20%, and still exceeds that of myocardial infarction. Current options to prevent the first variceal bleed include noncardioselective β-blockers or variceal band ligation. In patients with medium-to-large esophageal varices, both therapies reduce the risk of bleeding by 50% or more. The choice of therapy should take into account patient choice and local availability; although for most patients drug therapy is the preferred first-line treatment. There has been recent interest in carvedilol, with promising initial data. Further studies are necessary before universal recommendation. There is no role for drug therapy in patients without varices, and the use of β-blockers for patients with small varices is controversial.