Equal Efficacy of Endoscopic Variceal Ligation and Propranolol in Preventing Variceal Bleeding in Patients With Noncirrhotic Portal Hypertension

doi:10.1053/j.gastro.2010.06.017

Gastroenterology

Volume 139, Issue 4, October 2010, Pages 1238-1245.e1

https://doi.org/10.1053/j.gastro.2010.06.017 Get rights and content

Background & Aims

Variceal bleeding increases morbidity and mortality among patients with noncirrhotic portal hypertension (NCPH). Blockers of β-adrenergic receptor signaling and endoscopic variceal ligation (EVL) have been used to prevent recurrence of bleeding, based on data from cirrhotic patients. We compared the efficacy and safety of the β-blocker propranolol with that of EVL in preventing the recurrence of variceal bleeding in patients with NCPH.

Methods

Consecutive patients with NCPH with a history of variceal bleeding in the past 6 weeks were assigned randomly to groups treated every 3 weeks with EVL (n = 51) or propranolol (until they had a resting heart rate of 55 beats per minute or to a maximum of 320 mg/day; n = 50). Primary end points were recurrence of variceal bleeding or death. Secondary end points were complications of EVL in patients given EVL, variceal eradication after EVL, variceal recurrence after EVL, or a decrease in variceal grade in patients given propranolol.

Results

After a median follow-up period of 23 months, rates of recurrence of bleeding were similar between the groups (EVL, 23.5%; propranolol, 18%; P = .625). The actuarial probability of remaining free of bleeding recurrence was similar between the groups. No deaths occurred in either group. Of the patients given propranolol, 47% had a decrease in the grade of varices and none experienced bleeding. Adverse events were minor and comparable between groups (EVL, 12%; propranolol, 18%; P = .635).

Conclusions

EVL was not more effective than the β-blocker propranolol for the secondary prophylaxis of variceal bleeding in patients with NCPH.

Section snippets

Patients

Between January 2005 and April 2009, patients with NCPH presenting to our Liver Clinic with a history of recent hematemesis and/or melena within the past 6 weeks and proven to have esophageal varices as the bleeding source on upper gastrointestinal endoscopy, were included in the study. Exclusion criteria were as follows: (1) patients who were already on a secondary prophylaxis protocol (eg, β-blockers, sclerotherapy, EVL, or glue injection) before presenting to our hospital; (2) a history of

Patients

A total of 2038 new patients with a diagnosis of portal hypertension presented to our liver follow-up clinic between January 2005 and April 2009 (Figure 2). Of these, 246 were of noncirrhotic etiology and were screened. A total of 107 patients never had upper gastrointestinal bleed and were excluded from the study. A total of 139 patients presented with acute variceal bleed (29 patients) or had a history of variceal bleed in the recent past (110 patients). Thirty-eight patients who did not

Discussion

This novel and large prospective randomized controlled trial clearly shows that propranolol is as effective as endoscopic variceal band ligation in preventing variceal rebleed in patients with noncirrhotic portal hypertension. Side effects resulting from either therapy are minor and comparable with each other. There were no major side effects, suggesting that propranolol and EVL are well tolerated in NCPH patients.

The 2 most commonly used treatment modalities for prevention of esophageal

Acknowledgments

The trial is registered with ClinicalTrial.gov vide NCT01000779.

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Citation Excerpt :
Findings of EGD and details of endoscopic sclerotherapy (EST) and/or endoscopic variceal ligation (EVL) at the time (within 3 weeks) of colonoscopy were noted. EVs, PHG, and gastric varices were graded as per the classification of Conn,14 McCormack et al,15 and Sarin et al,16 respectively. The preparation and procedure for colonoscopy were explained to the parents and child.
The medical literature on colonic changes in children with extrahepatic portal venous obstruction (EHPVO) is limited. We evaluated EHPVO children for prevalence, nature, and relation of colonic changes with disease duration, extent of splenoportal axis (SPA) thrombosis, portal hypertensive gastropathy (PHG), and esophageal varices (EVs). The correlation between histologic and endoscopic changes was studied.
Subjects were evaluated by colonoscopy with ileoscopy and biopsy sampling, clinico-laboratory profiles, and SPA imaging. Colonic changes were classified as varices (rectal/colonic) and portal hypertensive colopathy (PHC; colitis-like or vascular lesions). Morphometric analysis of colonic biopsy specimens was performed.
Fifty-four children (median age, 12 years [range, 8-15]; hematochezia in 9 [16.6%]) were evaluated. Rectal and colonic varices were seen in 51 (94%) and 2 (3.7%) cases, respectively. Seventy-five percent of patients had PHC, and colitis-like lesions were more common than vascular lesions (36/40 vs 23/40; P = .001). Colopathy changes were pancolonic in 52.5%, left-sided in 42.5%, and right-sided in 5% of cases. Sixteen percent of patients (8/49) had ileal changes. Children with PHC had PHG more often (90% vs 57%; P = .01), more endotherapy sessions (mean 6 [range, 4-8] vs 2 [range, 1-4]; P = .03), and large EVs less often (12.5% vs 43%; P = .02) than those without colopathy. The extent of SPA thrombosis was similar in patients with and without PHC. The number of capillaries per crypt was higher in EHPVO than in control subjects. Morphometric changes had no correlation with endoscopy.
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: Conflicts of interest The authors disclose no conflicts.

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Clinical—Liver, Pancreas, and Biliary TractEqual Efficacy of Endoscopic Variceal Ligation and Propranolol in Preventing Variceal Bleeding in Patients With Noncirrhotic Portal Hypertension

Background & Aims

Methods

Results

Conclusions

Section snippets

Patients

Patients

Discussion

Acknowledgments

Gastroenterology

J Hepatol

Gastroenterology

J Hepatol

Gastrointest Endosc

J Pediatr

Comparative efficacy of emergency endoscopic sclerotherapy for active variceal bleeding due to cirrhosis of the liver, non-cirrhotic portal fibrosis and extrahepatic portal venous obstruction

J Gastroenterol Hepatol

The aetiology, presentation and natural history of extra-hepatic portal venous obstruction

QJM

Endoscopic sclerotherapy for bleeding oesophagogastric varices secondary to extrahepatic portal vein obstruction in an adult Caucasian population

Eur J Gastroenterol Hepatol

Controlled trial of propranolol to prevent recurrent variceal bleeding in patients with noncirrhotic portal fibrosis

BMJ

Sclerotherapy in noncirrhotic portal fibrosis

Dig Dis Sci

Sclerotherapy in extrahepatic portal venous obstruction

Gut

Endoscopic sclerotherapy for bleeding oesophagogastric varices secondary to extrahepatic portal vein obstruction in an adult Caucasian population

Eur J Gastroenterol Hepatol

Clinical—Liver, Pancreas, and Biliary Tract
Equal Efficacy of Endoscopic Variceal Ligation and Propranolol in Preventing Variceal Bleeding in Patients With Noncirrhotic Portal Hypertension