FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Previous Volume 340:988-993 April 1, 1999 Number 13 Next

	Full Text PDF Editorial by Burroughs, A. K. Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background and Methods We compared propranolol therapy and endoscopic ligation for the primary prevention of bleeding from esophageal varices. This prospective, controlled trial included consecutive eligible patients who had large varices (>5 mm in diameter) that were at high risk for bleeding. The patients were assigned to either propranolol therapy, at a dose sufficient to decrease the base-line heart rate by 25 percent, or variceal ligation, to be performed weekly until the varices were obliterated or so reduced in size that it was not possible to continue treatment.

Results Of the 89 patients, 82 of whom had cirrhosis of the liver, 44 received propranolol and 45 underwent variceal ligation. The mean (±SD) duration of follow-up in each group was 14±9 and 13±10 months, respectively. The mean time required to achieve an adequate reduction in the heart rate was 2.5±1.7 days; the mean number of sessions needed to complete variceal ligation was 3.2±1.1. After 18 months, the actuarial probability of bleeding was 43 percent in the propranolol group and 15 percent in the ligation group (P=0.04). Twelve patients in the propranolol group and four in the ligation group had bleeding. Three of the four in the ligation group had bleeding before their varices had been obliterated. Nine patients in the ligation group had recurrent varices, a mean of 3.7 months after the initial treatment. Five patients in each group died; bleeding from the varices was the cause of death of four patients in the propranolol group and of three in the ligation group. There were no serious complications of variceal ligation; in the propranolol group, treatment was stopped in two patients because of side effects.

Conclusions In patients with high-risk esophageal varices, endoscopic ligation of the varices is safe and more effective than propranolol for the primary prevention of variceal bleeding.

Source Information

From the Department of Gastroenterology, G.B. Pant Hospital (S.K.S., G.S.L., M.K., A.M.), and the Department of Biostatistics, Institute of Cytology and Preventive Oncology (N.S.M.) — both in New Delhi, India. Part of this work has appeared in abstract form (Hepatology 1997;26:360A).

Address reprint requests to Dr. Sarin at the Department of Gastroenterology, G.B. Pant Hospital, New Delhi 110 002, India, or at sksarin{at}nda.vsnl.net.in.

Full Text of this Article

This article has been cited by other articles:

• Kodama, H., Aikata, H., Takaki, S., Takahashi, S., Toyota, N., Ito, K., Chayama, K. (2009). Evaluation of Patients with Esophageal Varices After Endoscopic Injection Sclerotherapy Using Multiplanar Reconstruction MDCT Images. Am. J. Roentgenol. 192: 122-130 [Abstract] [Full Text]  
• Liu, C.-H., Hsu, S.-J., Liang, C.-C., Tsai, F.-C., Lin, J.-W., Liu, C.-J., Yang, P.-M., Lai, M.-Y., Chen, P.-J., Chen, J.-H., Kao, J.-H., Chen, D.-S. (2008). Esophageal Varices: Noninvasive Diagnosis with Duplex Doppler US in Patients with Compensated Cirrhosis. Radiology 248: 132-139 [Abstract] [Full Text]  
• Kim, S. H., Kim, Y. J., Lee, J. M., Choi, K. D., Chung, Y. J., Han, J. K., Lee, J. Y., Lee, M. W., Han, C. J., Choi, J. I., Shin, K.-S., Choi, B. I. (2007). Esophageal Varices in Patients with Cirrhosis: Multidetector CT Esophagography--Comparison with Endoscopy. Radiology 242: 759-768 [Abstract] [Full Text]  
• Kim, Y. J., Raman, S. S., Yu, N. C., To'o, K. J., Jutabha, R., Lu, D. S. K. (2007). Esophageal Varices in Cirrhotic Patients: Evaluation with Liver CT. Am. J. Roentgenol. 188: 139-144 [Abstract] [Full Text]  
• Mukherjee, S., Sorrell, M. F. (2005). Beta-Blockers to Prevent Esophageal Varices -- An Unfulfilled Promise.. NEJM 353: 2288-2290 [Full Text]  
• Samonakis, D N, Triantos, C K, Thalheimer, U, Patch, D W, Burroughs, A K (2004). Management of portal hypertension. Postgrad. Med. J. 80: 634-641 [Abstract] [Full Text]  
• Mellinger, J. D. (2003). Upper Gastrointestinal Endoscopy: Current Status. SURG INNOV 10: 3-12 [Abstract]  
• Wiesner, R. H., Rakela, J., Ishitani, M. B., Mulligan, D. C., Spivey, J. R., Steers, J. L., Krom, R. A. F. (2003). Recent Advances in Liver Transplantation. Mayo Clin Proc. 78: 197-210 [Abstract]  
• Sharara, A. I., Rockey, D. C. (2001). Gastroesophageal Variceal Hemorrhage. NEJM 345: 669-681 [Full Text]  
• Jalan, R, Hayes, P C (2000). UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 46: iii1-15 [Full Text]  
• JALAN, R, LUI, H F, REDHEAD, D N, HAYES, P C (2000). TIPSS 10 years on. Gut 46: 578-581 [Full Text]  
• (2000). Additional Articles Abstracted in ACP Journal Club. Evid. Based Med. 5: 3-3 [Full Text]  
• Dam, J. V., Brugge, W. R. (1999). Endoscopy of the Upper Gastrointestinal Tract. NEJM 341: 1738-1748 [Full Text]  
• (1999). Propranolol vs. Ligation to Prevent Variceal Bleeding. JWatch General 1999: 4-4 [Full Text]  
• Burroughs, A. K., Patch, D. (1999). Primary Prevention of Bleeding from Esophageal Varices. NEJM 340: 1033-1035 [Full Text]