Primary prevention of variceal bleeding: Pharmacological therapy versus endoscopic banding

Abstract

Variceal bleeding is one of the most feared complications in patients with liver cirrhosis. It continues to be a leading cause of death among patients with liver cirrhosis. Although its prognosis has improved over the last several decades, it still carries substantial mortality. Preventing variceal bleeding has been extensively studied and evaluated in several studies in the recent years and the comparison between the different modalities available to prevent variceal bleeding has been an area of discussion. Currently the two most widely used modalities to prevent variceal bleeding are pharmacologic (non-selective beta-blockers [NSBB]) and endoscopic (variceal band ligation [VBL]) which have replaced sclerotherapy in the recent years. In addition to NSBB and recent carvedilol, different other medications have been evaluated including isosorbide mononitrates, spironolactone and angiotensin blocking agents. Comparing the outcomes and adverse effects of these two modalities has been evaluated in different studies. Some studies have showed superiority of VBL until recently, when carvedilol has been included, however; overall mortality has been similar in most trials. Despite that, NSBB remain the first line treatment, as they are cheaper and relatively effective in preventing both esophageal and gastric bleeding. The following sections discuss the primary prevention of variceal bleeding with a focus on NSBB, carvedilol and VBL.

Recurrence and prognosis of patients emergently hospitalized for acute esophageal variceal bleeding: A long‐term cohort study

“…Our study has several limitations. First, although proton pump inhibitors were prescribed for half of the patients in our study, very few β‐blockers or nitrates, which affect esophageal bleeding, were prescribed . This might be a situation more typical to Japan than to Europe and North America.…”

“…First, although proton pump inhibitors were prescribed for half of the patients in our study, very few β-blockers or nitrates, which affect esophageal bleeding, were prescribed. 20,21 This might be a situation more typical to Japan than to Europe and North America. Second, we systematically assessed various factors but could not collect data on antibiotics, which might affect infection rates after EVL.…”

Primary prophylaxis of variceal bleeding

“…Patients receiving NSBBs were also noted to have a lower mortality rate (23.9 vs. 28.4%). NSBBs may also impact the progression of portal hypertension in patients with small varices, with studies suggesting a reduction in progression to large varices, although no survival benefit was observed [12].…”

“…Disadvantages include: the need for operator experience in EVL; procedure-related complications (sedation risks, post-procedural pain and/or dysphagia, esophageal ulcers, strictures and bleeding); the high costs associated with multiple procedures, and; significant time commitments from patients [6]. Although rare, there is a potential risk of serious adverse outcomes from EVL, including deaths from bleeding ulcers secondary to EVL [12].…”

β2‑adrenergic receptor functionality and genotype in two different models of chronic inflammatory disease: Liver cirrhosis and osteoarthritis

“…Currently the most widely used modalities to prevent variceal bleeding in LC patients are drugs as propranolol, a non-selective beta-blocker (26)(27)(28). However, the prevalence of patients 'non-responders' ranges between 30 and 60%, suggesting changes in the functional state of βAR receptors (29).…”