A controlled trial conducted by researchers at the E-DA Hospital in Kaohsiung, Taiwan, suggests that a combination of band ligation and nadolol may not be the most effective prophylaxis for first variceal bleeding resulting from cirrhosis. Results of this study appear in the July issue of Hepatology, a journal published by Wiley-Blackwell on behalf of the American Association for the Study of Liver Diseases (AASLD).
Esophageal varices (EV) are abnormally enlarged veins in the esophagus that occur when portal hypertension obstructs normal blood flow to the liver and causes the blood to back up into the esophageal vessels. Variceal rupture is a life-threatening condition. Approximately one third of cirrhotic patients with esophageal varices bleed, and the mortality rate associated with first bleed may be as high as 50%.
The World Gastroenterology Organization practice guideline for esophageal varices in patients with cirrhosis and medium or large varices, but no hemorrhage, recommends nonselective beta blockers (propranolol or nadolol) or endoscopic variceal ligation (EVL) for prevention of first variceal hemorrhage for patients at highest risk, and propranolol or nadolol for those who are not high risk or in whom EVL is not tolerated.
Beta blockers are generally considered the treatment of choice for prophylaxis of first variceal bleeding. A noninvasive method, beta blockers are able to reduce portal pressure, thus reducing the risk of variceal bleeding. While some studies suggest that EVL is superior to beta blockers, it is also associated with serious complications. The Taiwan study was conducted to evaluate the effectiveness of both treatments administered in combination.
Study leader Gin-Ho Lo, M.D. explained the rational behind testing these treatment approaches together. "The strength of EVL lies in its ability to obliterate varices, but portal pressure may be elevated after repeated procedures. Moreover, varices frequently recur after variceal obliteration achieved by EVL and beta blockers were documented to be able to reduce variceal recurrence. A combination of nadolol and EVL has been well established in preventing secondary variceal bleeding, but the effectiveness of this approach is unknown in preventing the first variceal bleeding."