Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: A multicenter trial

Abstract

and the EVL Study Group ␤-Blockers and endoscopic variceal ligation (EVL) have proven to be valuable methods in the prevention of variceal rebleeding. The aim of this study was to compare the efficacy of EVL combined with nadolol versus EVL alone as secondary prophylaxis for variceal bleeding. Patients admitted for acute variceal bleeding were treated during emergency endoscopy with EVL or sclerotherapy and received somatostatin for 5 days. At that point, patients were randomized to receive EVL plus nadolol or EVL alone. EVL sessions were repeated every 10 to 12 days until the varices were eradicated. Eighty patients with cirrhosis (alcoholic origin in 66%) were included (Child-Turcotte-Pugh A, 15%; B, 56%; C, 29%). The median follow-up period was 16 months (range, 1-24 months). The variceal bleeding recurrence rate was 14% in the EVL plus nadolol group and 38% in the EVL group (P ‫؍‬ .006). Mortality was similar in both groups: five patients (11.6%) died in the combined therapy group and four patients (10.8%) died in the EVL group. There were no significant differences in the number of EVL sessions to eradicate varices: 3.2 ؎ 1.3 in the combined therapy group versus 3.5 ؎ 1.3 in the EVL alone group. The actuarial probability of variceal recurrence at 1 year was lower in the EVL plus nadolol group (54%) than in the EVL group (77%; P ‫؍‬ .06). Adverse effects resulting from nadolol were observed in 11% of the patients. In conclusion, nadolol plus EVL reduces the incidence of variceal rebleeding compared with EVL alone. A combined treatment could lower the probability of variceal recurrence after eradication. V ariceal bleeding is a serious complication of portal hypertension and a leading cause of death in patients with liver cirrhosis. The patients who survive an initial episode have a risk of rebleeding approaching 80% at 2 years. 1 After the first episode of hemorrhage from esophageal varices, ␤-blockers and endoscopic treatment are effective therapies in the secondary prevention of variceal bleeding. 2 Unfortunately, nonselective ␤-blockers achieve target reductions in hepatic venous pressure gradient in only approximately one third of patients. [3][4][5] Moreover, endoscopic injection sclerotherapy (EIS) has been replaced almost universally by endoscopic variceal ligation (EVL), because variceal eradication is faster and provides a lower variceal rebleeding rate with fewer secondary effects than in EIS. [6][7][8][9][10][11][12][13] In addition, a meta-analysis has shown a lower mortality in EVL than in EIS. 14 Some studies comparing band ligation with ␤-blockers plus isosorbide mononitrate show contradictory results regarding the effectiveness of both treatments in the prevention of variceal rebleeding. [15][16][17] The rationale behind the use of a combination therapy is that agents acting through different mechanisms may have additive or even synergistic benefits. 5 There are few studies analyzing the efficacy of associating both therapeutic methods, ␤-blockers and EVL, in the prevention of recurrent hemor...

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…Two randomized trials demonstrate the superiority of combined therapy versus EVL alone. 123,124 Rebleeding rates in these 2 trials were 23% and 14%, respectively, for EVL plus nadolol compared to 47% and 38% for EVL alone. These results support the use of combination therapy to prevent rebleeding, even though a recent consensus conference recommended EVL or ␤-blocker ϩ nitrates as first-line therapy in treatmentnaïve patients.…”

Controlled trial of ligation plus nadolol versus nadolol alone for the prevention of first variceal bleeding

“…Enhanced efficacy by use of beta blockers combined with EVL has been well established in the secondary prophylaxis of variceal bleeding. 16,25 It is still unknown whether a combination of EVL and beta blockers in the primary prophylaxis of variceal bleeding can be similarly effective.…”

Cerebral embolism following N-butyl-2-cyanoacrylate injection for esophageal postbanding ulcer bleed: a case report

“…There is a paucity of data on the incidence of bleeding from such ulcers. Results from secondary prophylaxis trials for esophageal variceal bleed showed that bleeding from postbanding ulcers is relatively uncommon [11,12]. A study by de la Peña et al (n = 80) [11] showed that four of the 20 rebleeding cases were due to bleeding esophageal ulcers.…”

“…Results from secondary prophylaxis trials for esophageal variceal bleed showed that bleeding from postbanding ulcers is relatively uncommon [11,12]. A study by de la Peña et al (n = 80) [11] showed that four of the 20 rebleeding cases were due to bleeding esophageal ulcers. Similarly, a study by Lo et al (n = 122) [12] showed that seven of the 71 rebleeding episodes were due to esophageal ulcers.…”