Prevention of first upper gastrointestinal bleeding in cirrhosis

Variceal bleeding due to portal hypertension, is a major complication of hepatic cirrhosis. There is a high mortality rate after first bleeding 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 meta-analysis where applicable. The current treatment of first choice is non-selective beta-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 beta-blockers and nitrates probably gives little added advantage. Injection sclerotherapy is contraindicated. The conflicting results of the randomized studies of endoscopic banding ligation, as well as its cost, do not warrant its use at present. However, endoscopic banding ligation may be a reasonable alternative for patients who cannot tolerate, or have contraindications to beta-blockers or no haemodynamic response to the drug therapy, but this must be proved in randomized trials.