Portal Hypertension & Esophageal Varices. Controversy

July 8, 2009 · Posted in ABDOMINAL SURGERY 

CONTROVERSY

32. How should a patient with known esophageal varices be treated to prevent an initial variceal bleed?

Show answer
The combination of beta blocker and nitrate is used for primary prophylaxis, but endoscopic band ligation is at least equivalent to pharmacotherapy without the side effects (one third of patients cannot tolerate beta-blockers because of fatigue or bronchospasm, and 20% cannot tolerate nitrates secondary to pounding headaches). These treatments reduce the incidence of an initial bleed from 30% to < 10% and the mortality from 30% to 20%. Endoscopic band ligation was previously suggested for prophylaxis only in class C disease, but mounting evidence suggests that EBL is more effective than pharmacotherapy in all patients. The effect of combined EBL and beta blockade in primary prophylaxis remains to be established but makes great intuitive sense.

References
WEB SITE
http://www.emedicine.com/med/topic1889.htm
BIBLIOGRAPHY
1. Hayes PC: Primary prophylaxis of variceal hemorrhage: A randomized controlled trial comparing band ligation, propranolol, and isosorbide mononitrate. Gastroenterology 123:735-744, 2002. Medline Similar articles
2. Hegab AM, Luketic VA: Bleeding esophageal varices: How to treat this dreaded complication of portal hypertension. Postgrad Med 109:75-86, 2001. Medline Similar articles
3. Jensen DM: Endoscopic screening for varices in cirrhosis: Findings, implications, and outcomes; Gastroenterology 122:1620-1630, 2002.
4. Lo GH, Chen WC, Chen MH, et al: Banding ligation versus nadolol and isosorbide mononitrate for the prevention of esophageal variceal rebleeding. Gastroenterology 123:728-734, 2002. Medline Similar articles
5. Lui HF, Stanley AJ, Forrest EH, et al: Gastroesophageal variceal hemorrhage. N Engl J Med 345:669-681, 2001.
6. Tait KS, Krige J, Terblanche J: Endoscopic band ligation of oesophageal varices. Br J Surg 86:437-446, 1999. Full article
7. Tierney LM, McPhee SJ, Papadakis MA (eds): Current Medical Diagnosis and Treatment, 41st ed. New York, McGraw-Hill, 2002, pp 606-609. Full article

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