Review article: primary prophylaxis for portal hypertensive bleeding in cirrhosis

Abstract

Variceal bleeding is a consequence of portal hypertension, which in turn is the major complication of hepatic cirrhosis. Given the high rate of mortality of the first bleeding episode, primary prophylaxis to prevent bleeding from varices and portal hypertensive gastropathy is the current optimal therapeutic approach. The difficulty in identification of patients with varices who will bleed, before they do so, can justify a strategy of treating all patients with varices prophylactically. We evaluated the various therapies that have been assessed in randomized controlled trials for prevention of first bleeding, using meta-analysis where applicable. The current first choice treatment is non-selective beta-blockers; it is cheap, easy to administer, and is effective in preventing the first variceal haemorrhage and bleeding from gastric mucosa. Combination drug therapy of beta-blockers and nitrates looks promising, but needs further evaluation in randomized controlled trials. The conflicting results of the randomized studies of endoscopic banding ligation and the small number of patients and clinical events, as well as the cost, do not warrant any change in current practice. However, endoscopic banding ligation may be a reasonable alternative for patients who cannot tolerate, or have contraindications to beta-blockers or no haemodynamic response to the drug therapy, but this must be proved in randomized trials.

Screening esophagus during routine ultrasound

“…For example, in the USA an estimated 18 170 cases of esophageal cancer were diagnosed in 2013, and 15 450 deaths are expected from the disease [8]. The guidelines also recommend that patients with medium or large varices (grades III, IV) be treated with a combination therapy of β-blockers and endoscopic variceal band ligation [13][14][15][16][17]. In the same context, almost half of the patients with hepatic cirrhosis have esophageal varices, and one-third of all patients with varices will develop variceal hemorrhage, a major cause of morbidity and mortality in patients with liver cirrhosis.…”

Angiotensin converting enzyme inhibitors and angiotensin II antagonists as therapy in chronic liver disease

“…Non-selective β-blockers have proved effective in reducing portal pressure by lowering splanchnic blood inflow3 and are used in primary and secondary prevention of variceal bleeding 45 However, the mean decrease in portal pressure in response to propranolol is only approximately 15%6 and one third of cirrhotic patients do not respond despite adequate blockade 7…”

Tratamento endoscópico das varizes esofágicas utilizando alças pré-atadas confeccionadas com fio de poliamida

“…A profi laxia ao primeiro sangramento por meio de procedimentos endoscópicos é tema controverso, não sendo aceita por todos os pesquisadores, pois algumas vezes os efeitos adversos são maiores do que os seus benefícios (4,8,17) .…”

“…As ligaduras com bandas elásticas, embora efetivas e com menores taxas de complicações do que a esclerose, estão indicadas nos pacientes que não toleram o tratamento medicamentoso com o uso dos betas bloqueadores e/ou nitratos, nos que apresentam contra-indicação ao seu uso ou não respondem a este método terapêutico (17) .…”