Correspondence

Abstract

In a recent study, Mastai et al.(1) present evidence that metoclopramide and domperidone reduce variceal blood flow in cirrhotics with portal hypertension. The authors postulate that these drugs reduce esophageal venous perfusion by increasing lower esophageal sphincter pressure. The authors conclude that agents which increase lower esophageal sphincter pressure may eventually be useful in the treatment of portal hypertension and possibly reduce the incidence of variceal hemorrhage.Caution should be exercised before using metoclopramide for this purpose. Many cirrhotics at risk for variceal hemorrhage also have ascites. Previous studies have shown that metoclopramide may impair diuresis in cirrhotics via further elevation of serum aldosterone levels (2). Fortunately, domperidone has not exhibited a similar effect and therefore would be preferable. It would therefore seem logical to utilize domperidone rather than metoclopramide in clinical trials designed to evaluate the therapeutic efficacy of elevation of lower esophageal sphincter pressure to reduce incidence of variceal hemorrhage. Reply:Drs. Gholson and Freeman are correct in pointing out the risk of worsening the sodium retention in cirrhotics with ascites by giving metoclopramide. We agree with their suggestion that, because of this, it is probably preferable to utilize domperidone rather than metoclopramide in clinical trials in these patients. An additional reason for it could be that, in our study, there was a trend for a more pronounced reduction in azygos blood flow after domperidone (decrease of 15.6%) than after metoclopramide (decrease of 11.5%). Similarly, the number of patients in whom azygos blood flow was reduced by more than 10% was greater following domperidone (8 of 12; mean decrease = 27%) than with metoclopramide (6 of 12; mean decrease = 19%).