Volume 67 - 2004 - Fasc.4 - Symposium
Discussion on medical treatment of portal hypertension
The administration of beta-blockers in the early phase of cirrhosis does probably not prevent the formation of varices (1-3). Whether beta-blockers can prevent the growth from small to large varices remains to be deter- mined. At this moment two studies gave opposite results (1,4).
Independent prognostic factors for first variceal bleeding are Child Pugh class, size of varices and red wale markings (5). All patients with medium or large- sized varices should receive primary prophylaxis.
Beta-blockers are still the first choice for primary prophylaxis of oesophageal variceal bleeding. If the patients have contraindications or intolerance to beta- blockers, variceal band ligation can be an option for medium to large varices as primary prophylaxis. Isosorbide 5-mononitrate in monotherapy or in combi- nation with beta-blockers are not indicated for the pre- vention of first variceal bleeding.
Medical treatment of portal hypertension
Prevention of the first variceal haemorrhage should start when the patients have developed medium sized to large varices. Non- selective beta-blockers are the first-line treatment ; band ligation is roughly equivalent to beta-blockers and is the first choice for patients with contraindications or intolerance to beta-blockers.
Treatment of acute bleeding should aim at controlling bleeding and preventing early rebleeding and complications, especially infections. Combined endoscopic and pharmacological treatment with vasoactive drugs can control bleeding in up to 90% of patients.
All patients who survive a variceal bleed should be treated with beta-blockers or band ligation to prevent rebleeding. All patients in whom bleeding cannot be controlled or who continue to rebleed can be treated with salvage TIPS or, in selected cases, with surgi- cal shunts. Liver transplantation should be considered for patients with severe liver insufficiency in which first-line treatments fail. (Acta gastroenterol. belg., 2004, 67, 334-343).
