Primary prevention of portal hypertensive bleeding in cirrhosis

SUMMARY Variceal bleeding due to portal hypertension represents the major complication that develops in patients with cirrhosis of the liver. The mortality of the first bleeding episode is still very high, so that primary prophylaxis to prevent bleeding from varices and portal hypertensive gastropathy is the current optimal therapeutic approach. The difficulty in identifying individual patients with varices who will bleed before they do so, can justify a strategy of prophylactic treatment for all patients with varices. We have evaluated the different therapies that have been assessed in randomized controlled trials for prevention of first bleeding, using metaanalysis where applicable. The current treatment of first choice is non-selective b-blockers; it is cheap, easy to administer, and is effective in preventing the first variceal hemorrhage and bleeding from gastric mucosa. Combination drug therapy of�-blockers and nitrates probably gives little added advantage. Injection sclerotherapy is contraindicated. The conflicting results of the randomized studies of endoscopic banding ligation (EBL), as well as the cost, do not warrant its use at present. However, EBL may be a reasonable alternative for patients who cannot tolerate, or have contraindications to �-blockers or no haemodynamic response to the drug therapy, but this must be proved in randomized trials. Keywords: Cirrhosis, portal hypertension, varices, primary prophylaxis, �-blockers, endoscopic sclerotherapy, band ligation.