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Prevention of variceal rebleeding
Jaume Bosch1, Juan Carlos García-Pagán
1Hepatic Haemodynamic Laboratory, Liver Unit, Institut de Malalties Digestives, Hospital Clínic, IDIBAPS, University of Barcelona, 08036, Barcelona, Spain. jbosch@medicina.ub.es
Lancet (London, England)
|March 22, 2003
Summary
Preventing variceal rebleeding in cirrhosis patients can be improved by adding isosorbide-5-mononitrate (ISMN) to beta-blockers for those with inadequate portal pressure reduction. This targeted drug therapy enhances outcomes for high-risk individuals.
Area of Science:
- Hepatology and Gastroenterology
- Clinical Trials and Therapeutics
Background:
- Variceal bleeding is a severe complication of portal hypertension in cirrhosis patients, leading to high rebleeding rates and mortality.
- Current prevention strategies include endoscopic band ligation (EBL), TIPS, and drug therapy with beta-blockers, each with limitations.
- Identifying patients who will benefit from specific drug regimens is crucial for effective rebleeding prevention.
Purpose of the Study:
- To evaluate the efficacy of adding isosorbide-5-mononitrate (ISMN) to beta-blocker therapy in patients with cirrhosis and portal hypertension.
- To determine if monitoring hepatic venous pressure-gradient (HVPG) can guide treatment adjustments for preventing variceal rebleeding.
- To compare the effectiveness of optimized drug therapy with endoscopic band ligation (EBL).
Main Methods:
- Randomized controlled trials comparing EBL with drug therapy (propranolol +/- ISMN) for variceal bleeding survivors.
- Measurement of hepatic venous pressure-gradient (HVPG) to assess portal pressure reduction in response to drug therapy.
- Addition of ISMN to beta-blockers for patients not achieving target HVPG reduction.
Main Results:
- Drug therapy showed similar overall rebleeding rates to EBL (44% vs 54% at 1 year).
- Adding ISMN to beta-blockers improved HVPG reduction in non-responders, significantly lowering rebleeding rates (10% vs 64%).
- No significant differences in survival or non-bleeding complications were observed between treatment groups.
Conclusions:
- Long-term drug therapy, particularly when guided by HVPG monitoring and adjusted with ISMN, is an effective strategy for preventing variceal rebleeding.
- HVPG monitoring is essential for identifying patients who require intensified drug therapy.
- Further trials are needed to establish optimal treatments for non-responders to current drug therapies.
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