Prophylactic Sclerotherapy before the First Episode of Variceal Hemorrhage in Patients with Cirrhosis

Abstract

The value of sclerotherapy as prophylaxis against the first episode of variceal hemorrhage has not been established. Therefore, we randomly assigned 133 patients with cirrhosis of the liver (of alcoholic origin in 66 percent), esophageal varices, and no previous intestinal bleeding to either prophylactic sclerotherapy (n = 68) or no prophylaxis (n = 65). The groups were comparable in hepatic function, endoscopic findings, and the pathogenesis of cirrhosis. All patients who subsequently had a first episode of variceal hemorrhage received sclerotherapy whenever possible. During a median follow-up of 22 months, variceal hemorrhage occurred in 28 percent of the patients receiving sclerotherapy and 37 percent of the controls (P = 0.3). Thirty-five percent of the sclerotherapy group and 46 percent of the control group died. The survival curves (Kaplan-Meier) of both groups were similar (P = 0.2). However, among patients with alcoholic and moderately decompensated cirrhosis (Child-Pugh group B), survival was significantly higher in those receiving sclerotherapy, although the risk of bleeding was only marginally reduced by this procedure. We conclude that prophylactic sclerotherapy does not significantly reduce the risk of bleeding from esophageal varices, but that a subgroup of patients with esophageal varices and moderately decompensated alcoholic cirrhosis may benefit from prophylactic sclerotherapy because of factors not solely attributable to prevention of an initial episode of variceal bleeding.

Coexisting Gastric Varices Should Not Preclude Prophylactic Ligation of Large Esophageal Varices in Cirrhosis

“…By contrast, it has been shown that endoscopic obliteration of esophageal varices by sclerotherapy may increase intravariceal pressure of gastric varices and may therefore even increase the risk of bleeding in the stomach [6]. Furthermore, it has been shown that repeated ligation may increase portal pressure [7] and that new gastric varices may develop after obliteration of esophageal varices [5, 8]. Therefore, compared to sclerotherapy, beta-blocker treatment is definitely the preferable bleeding prophylaxis in patients with large esophageal varices and concomitant gastric varices.…”

Transjugular Intrahepatic Portosystemic Stent Shunt: A 2-Year Follow-Up

“…A direct comparison between sclero therapy and shunt surgery in 5 randomized studies [1] revealed a significantly reduced risk of rebleeding in the shunted patients but failed to show a significant differ ence in mortality. Moreover, sclerotherapy has been found to be ineffective in the prevention of variceal rebleeding in patients with Child C cirrhosis [2,22]. Fre quent rebleeding affects the patient's life quality more than any other complication of portal hypertension.…”

The Role of Endoscopy in Portal Hypertension

“…During the last 25 years, a nonselective ␤ -blocker, propranolol, has become the standard in prevention of fi rst bleeding [2] , while injection sclerotherapy, which had been evaluated in many controlled trials, is no longer a primary option [7] . The results of this latter approach were too heterogeneous and the method was burdened with too many complications.…”