Primary prevention of portal hypertensive bleeding in cirrhosis

Abstract

SUMMARY
Variceal bleeding due to portal hypertension represents the
major complication that develops in patients with cirrhosis
of the liver. The mortality of the first bleeding episode
is still very high, so that primary prophylaxis to prevent
bleeding from varices and portal hypertensive gastropathy
is the current optimal therapeutic approach. The difficulty
in identifying individual patients with varices who will bleed
before they do so, can justify a strategy of prophylactic treatment
for all patients with varices. We have evaluated the
different therapies that have been assessed in randomized
controlled trials for prevention of first bleeding, using metaanalysis
where applicable. The current treatment of first
choice is non-selective b-blockers; it is cheap, easy to administer,
and is effective in preventing the first variceal
hemorrhage and bleeding from gastric mucosa. Combination
drug therapy of â-blockers and nitrates probably gives
little added advantage. Injection sclerotherapy is contraindicated.
The conflicting results of the randomized studies
of endoscopic banding ligation (EBL), as well as the cost,
do not warrant its use at present. However, EBL may be a
reasonable alternative for patients who cannot tolerate, or
have contraindications to â-blockers or no haemodynamic
response to the drug therapy, but this must be proved in
randomized trials.
Keywords: Cirrhosis, portal hypertension, varices, primary
prophylaxis, â-blockers, endoscopic sclerotherapy, band ligation.