Pharmacological therapy for the treatment of esophageal varices

Portal hypertension is a common complication of hepatic cirrhosis, and is responsible for much of the mortality and morbidity associated with advanced liver disease. Esophageal varices are a common occurrence, and esophageal variceal hemorrhage carries a high mortality. Endoscopic therapies have proven effective in treating active bleeding and preventing recurrence, but several pharmacological agents are useful adjuncts to endoscopy in both acute bleeding and in the primary and secondary prophylaxis of variceal hemorrhage. In acute hemorrhage, vasoconstricting agents such as vasopressin, terlipressin, somatostatin, and octreotide have been demonstrated to add benefit to endoscopic therapy. Secondary prophylaxis includes endoscopic therapy to eradicate varices, usually combined with oral beta-blockers. Primary prophylaxis is typically used in patients with medium or large varices, and consists of oral beta-blockers, at times combined with oral nitrates. This paper the reviews the pharmacological principles behind these therapies, and the clinical trial data that has led to their widespread use.