Preventing first variceal hemorrhage in cirrhosis

Variceal bleeding is still a life-threatening complication of portal hypertension responsible for an appreciable rate of morbidity and mortality. The most appropriate treatment approach, whether drugs (nonselective beta-blockers) or endoscopic (variceal band ligation) therapy, to prevent the initial bleed, or primary prophylaxis, is an issue of controversy. Meta-analysis of randomized controlled trials indicates that banding seems to be somehow slightly more effective than beta-blockers at preventing a first bleeding episode, but this does not translate to improved survival. The firmness of this conclusion is, in addition, diminished by the small sample size and short follow-up of most studies. Moreover, adverse events due to banding are more severe than those associated with beta-blockers. Thus, beta-blockers remain as first-line therapy in patients with cirrhosis and large esophageal varices. Prophylactic therapy with beta-blockers can be considered in patients with small varices, especially in those with red signs or Child class C liver disease. The available evidence does not support the idea that organic nitrates improve the efficacy of beta-blockers in primary prophylaxis. The method used to establish the dose of beta-blockers and check its effect on hepatic venous pressure gradient (HVPG) has also been disputed. An attractive strategy is to measure the HVPG response to beta-blockers as a guide to primary prophylaxis, with the aim of switching to another therapy, that is, band ligation, in HVPG nonresponders. However, no study has yet demonstrated that banding as rescue therapy in nonresponders lowers the risk of first bleeding and improves survival.