Prophylactic Sclerotherapy of Large Esophageal Varices

Santangelo, William C.; Dueno, Maria I.; Estes, Boyce L.; Krejs, Guenter J.

doi:10.1056/nejm198803313181304

Cited by 112 publications

(26 citation statements)

References 20 publications

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“…Indeed,'first promising results of prophylactic sclerotherapy have been published by Paquet" 12 [6] 13 [13] Primary biliary cirrhosis 6 [5] 3 [2] Cryptogenetic cirrhosis 4 [4] 7 [7] Bleeding free interval (days) Fig. 1 …”

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confidence: 99%

Prophylactic endoscopic sclerotherapy of oesophageal varices in liver cirrhosis. A multicentre prospective controlled randomised trial in Vienna.

Pötzi

Bauer

Reichel

et al. 1989

Gut

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SUMMARYThe effect of prophylactic treatment of oesophageal varices by endoscopic injection sclerotherapy before the first episode of variceal haemorrhage was studied in patients with cirrhosis in a prospective, randomised and controlled multicentre trial. From February 1984 to March 1987 patients with liver cirrhosis and large varices (stage III-IV according to Paquet) were treated and followed up. The sample comprised 87 patients: 45 in the prophylactic treatment and 42 in the control group. After excluding drop outs, 41 patients were treated in each group. Twenty nine per cent of patients in the sclerotherapy group and 34% in the control group had a variceal haemorrhage during the period of observation. There was no significant difference in the distributions of the bleeding free intervals between the sclerotherapy and the control groups. During the follow up period 24% of patients in the sclerotherapy group and 46% in the control group died. The distribution of survival times indicates a tendency towards longer survival of patients with prophylactic sclerotherapy, particularly in those with alcoholic cirrhosis.Severe haemorrhages from oesophageal varices belong to the most serious complications in patients with liver cirrhosis and portal hypertension. About 30 to 70% of patients with liver cirrhosis develop oesophageal varices' and some 20-40% of these will eventually bleed.2 The mortality of the first haemorrhage has been reported to be between 30 and 80% .3 Although many studies from all over the world show that sclerotherapy during the acute bleeding phase will efficiently stop variceal bleeding-9 and repeated sclerotherapy after terminating the initial bleeding episode can increase the longterm survival of such patients,"' the first massive variceal haemorrhage is nevertheless fatal for many patients. It therefore

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confidence: 99%

Prophylactic endoscopic sclerotherapy of oesophageal varices in liver cirrhosis. A multicentre prospective controlled randomised trial in Vienna.

Pötzi

Bauer

Reichel

et al. 1989

Gut

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“…The rates of variceal bleeding-related deaths ranged from 0% to 18% (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23). In three studies (14,20,21), the bleedingrelated mortality rate was even higher in the treated group than the control (Table 1). It is likely that sclerotherapyinduced ulcers were partly responsible for the higher bleeding rates.…”

Section: Sclerotherapymentioning

confidence: 96%

Asymptomatic Esophageal Varices Should Be Endoscopically Treated

Soehendra

1998

Canadian Journal of Gastroenterology and Hepatology

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Endoscopic treatment has generally been accepted in the management of bleeding esophageal varices. Both the control of acute variceal bleeding and elective variceal eradication to prevent recurrent bleeding can be achieved via endoscopic methods. In contrast to acute and elective treatment, the role of endoscopic therapy in asymptomatic patients who have never had variceal bleeding remains controversial because of the rather disappointing results obtained from prophylactic sclerotherapy. Most published randomized controlled trials showed that prophylactic sclerotherapy had no effect on survival. In some studies, neither survival rate nor bleeding risk was improved. In this article, the author champions the view that asymptomatic esophageal varices should be endoscopically treated.

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“…Prophylactic endoscopic sclerotherapy (EST) has been reported in peer-reviewed RCTs to reduce hemorrhage and mortality in some RCTs , to show no significant improvement in others (12)(13)(14)(15) and to increase the risk of bleeding in another (16). Preliminary communications by other investigators have also noted improved, unchanged or detrimental effects after EST in individual investigations (17)(18)(19)(20)(21).…”

Section: Steven C Wright' Daniel S Matloff' Guadalupe Garcia-tsaomentioning

confidence: 99%

Propranolol in the prevention of the first hemorrhage from esophagogastric varices: A multicenter, randomized clinical trial

et al. 1991

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To assess the effectiveness of propranolol in the prevention of initial variceal hemorrhage, a double-blind, randomized trial was carried out in three centers. Patients with cirrhosis (78% alcoholic), hepatic venous pressure gradients greater than 12 mm Hg and endoscopically proven esophageal varices were randomly assigned to propranolol (51 patients) or placebo (51 patients). Of the 102 patients, 58% were Child's class A, 34% were Child's class B and 8% were Child's class C. Daily dosage was determined by the administration of progressively increasing doses of propranolol with the hepatic vein catheter in place to achieve a 25% decrease in hepatic venous pressure gradient, a decrease in hepatic venous pressure gradient to less than 12 mm Hg or a decrease in resting heart rate to less than 55 beats/min. During a mean follow-up period of 16.3 mo, 11 patients in the placebo group (22%) bled from esophageal varices compared with 2 in the propranolol group (4%) during a mean period of 17.1 mo (p less than 0.01). Three additional patients (6%) in the placebo group bled from portal hypertensive gastropathy compared with none in the propranolol group. Propranolol appeared effective in preventing bleeding from large varices. Eleven deaths (22%) occurred in the placebo group compared with eight deaths (16%) in the propranolol group (NS). The mean dose of propranolol was 132 mg/day, and the median dose was 80 mg/day. Using a compliance index (pill count, clinic attendance, alcohol and propranolol levels and alcohol history), 81% of the propranolol patients and 77% of the placebo patients were considered compliant. Complications severe enough to require cessation of therapy occurred in eight patients (16%) in the propranolol group and four in the placebo group (8%) (NS). We conclude that propranolol effectively prevents the first variceal hemorrhage in patients with alcoholic cirrhosis and large esophageal varices but does not improve survival.

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Prophylactic Sclerotherapy of Large Esophageal Varices

Cited by 112 publications

References 20 publications

Prophylactic endoscopic sclerotherapy of oesophageal varices in liver cirrhosis. A multicentre prospective controlled randomised trial in Vienna.

Prophylactic endoscopic sclerotherapy of oesophageal varices in liver cirrhosis. A multicentre prospective controlled randomised trial in Vienna.

Asymptomatic Esophageal Varices Should Be Endoscopically Treated

Propranolol in the prevention of the first hemorrhage from esophagogastric varices: A multicenter, randomized clinical trial

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