Prophylactic treatment of patients with esophageal varices: Is it ever indicated?

Abstract

The prognosis of patients who bleed from esophageal varices is dismal. Prophylactic treatment of the varix or the elevated portal venous pressure offers a possibility of improving the outlook for these patients. However, as only approximately one-third of patients with varices bleed during their lifetime, correct identification of high-risk patients is vital before embarking on prophylaxis. At present, neither European or Japanese selection criteria are perfect in this respect. The documented incidence of initial variceal bleeding varies between 27% and 48%, and most bleeding episodes occur within the first year after varices are diagnosed. Data from six randomized controlled trials comparing prophylactic beta-blockers with placebo demonstrated a decreased incidence of bleeding in propranolol-treated patients, which in large measure may depend on patient compliance and did not significantly affect survival in all but one study. Early randomized studies of prophylactic sclerotherapy have shown significant reductions in both the incidence of bleeding and mortality, but this promise has not been sustained by subsequent trials, and indeed sclerotherapy was detrimental in two studies. The impressive results in highly selected patients treated in Japan by prophylactic surgery are unlikely to be repeated in a Western setting, involving patient populations that consist predominantly of alcoholic cirrhotics. At present prophylaxis with beta-blockade seems to offer the best therapeutic option, but the future may lie in the development of new interventional techniques such as transjugular intrahepatic portosystemic stent shunting (TIPS) or variceal banding, and ultimately with hepatic transplantation.

Autosomal recessive polycystic kidney disease: long-term outcome of neonatal survivors

“…The prophylaxis and long-term management of these complications are the subject of much debate, and early liver transplantation may be indicated in patients with severe hepatic fibrosis [28,29].…”

Color Doppler velocity profile assessment of portal hemodynamics in cirrhotic patients with portal hypertension: Correlation with esophageal variceal bleeding

“…Keywords: esophageal variceal bleeding; portal hypertension; portal hemodynamics; color Doppler velocity profile E sophageal variceal bleeding (EVB) is a lifethreatening complication of liver cirrhosis and portal hypertension. Approximately a third of patients with esophageal varices experience variceal bleeding, [1][2][3] and up to 70% of the survivors have 1 or more additional episodes of bleeding. 1 The identification of patients at high risk for EVB enables prophylactic management.…”