In the primary prevention of variceal hemorrhage, beta-blockers continue to be the
first-line treatment. Newer nonselective beta-blockers with anti-alpha1-adrenergic activity, such as carvedilol, appear to have a better impact on reducing
the hepatic venous pressure gradient than propranolol. The addition of isosorbide
mononitrate appears to improve the effectiveness of beta-blockers in primary prophylaxis,
but not that of somatostatin in the treatment of acute variceal hemorrhage. The use
of vasoactive drugs alone in acute variceal bleeding has not proved to be more effective
than endoscopic treatment. The advent of endoscopic variceal ligation (EVL) has strengthened
the role of endoscopy in the management of bleeding esophageal varices. EVL has improved
the results, particularly in terms of lowering the treatment-related morbidity, compared
with endoscopic variceal sclerotherapy (EVS). However, the variceal recurrence rate
after initial eradication with EVL is relatively high. In contrast to synchronous
combined therapy with EVL plus EVS, metachronous combination of EVL and low-dose EVS
may improve the results of EVL alone. For bleeding fundic varices, obliteration using
cyanoacrylate is currently the treatment of choice. Endosonography (EUS) is coming
into more widespread use in the assessment of variceal eradication and in further
attempts to improve the results of endoscopic injection therapy. According to two
meta-analysis studies, transjugular intrahepatic portosystemic shunt (TIPS) is not
yet capable of replacing endoscopic treatment in the secondary prevention of variceal
bleeding.
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N. Soehendra,M.D.
Dept. of Interdisciplinary Endoscopy
University Hospital, Hamburg-Eppendorf
Martinistrasse 52
20246 Hamburg
Germany
Fax: Fax:+ 49-40-42-803-4420
Email: E-mail:soehendr@uke.uni-hamburg.de
