Prevention of recurrent variceal bleeding: non-surgical procedures

Patients with cirrhosis, who have survived an episode of variceal bleeding, often have far-advanced liver disease and therefore, on average, a severely restricted life expectancy. Still, the prognosis for the individual patient varies greatly depending on the presence or absence of large varices and the Child classification. Centres evaluating treatment of variceal bleeding often attract different patient populations. Comparison of the outcome of the complete series of patients is usually meaningless since results reflect the composition of the patient population rather than the applied therapy. The natural history of patients with variceal bleeding should be defined by Child category, allowing more precise definition of the therapeutic aims and subsequently assessment of the results. Persistent lowering of the portal pressure by pharmacological modulation of the portal haemodynamic system is now feasible due to the availability of long-acting oral medication. Propranolol is still the leading drug and, in one centre, its use in predominantly Child A patients was associated with a marked reduction in recurrent gastrointestinal bleeding and subsequently mortality rate. These results could not be reproduced in another centre. Both the restricted indication as well as the uncertain efficacy limit the current use of propranolol, but further pharmacological developments are bound to appear. Endoscopic sclerotherapy has become the treatment of choice in the prevention of recurrent variceal haemorrhage. The proponents of paravasal injection report excellent efficacy in combination with a low incidence of side-effects, whereas mainly theoretical reasons are advanced by users of intravariceal injections. Still, variceal haemorrhage remains an important clinical problem in the period between the start of sclerotherapy and the eradication of varices. Combination of sclerotherapy with portal antihypertensive medication might become the treatment of choice until eradication of varices has been achieved; thereafter either continued medication or repeated endoscopy will maintain an avariceal state and effective prevention of recurrent variceal bleeding.