The role of nonselective beta-blockers in the prevention of gastric variceal rebleeding

We read with great interest the study of Lo et al. [1] comparing the transjugular intrahepatic portosystemic shunt with cyanoacrylate injection in the prevention of gastric variceal rebleeding. No mention is made in the article about medical treatment using beta-blockers, which remains part of the secondary prophylaxis of variceal bleeding. This certainly deserves further study before any statement that the transjugular intrahepatic portosystemic shunt might be the treatment of choice for prevention of gastric variceal rebleeding. We agree that controlled studies concerning the management of gastric variceal rebleeding are very poor, but currently beta-blockers cannot be ruled out.

We reported a few years ago, in Endoscopy, the results of a prospective randomized controlled study that compared cyanoacrylate injection with nonselective beta-blockers [2]. The study compared the effectiveness, in the prevention of variceal rebleeding, of nonselective beta-blockers (i. e. propranolol, median 160 mg/day), with repeated cyanoacrylate glue injection until there was complete obliteration of varices (esophageal and/or gastric). Among 41 cirrhotic patients enrolled in the study, 10 patients (25 %) presented gastric varices as the acute source of bleeding. Granted that the number of patients with gastric varices was low in this study, we did not observe any differences in the cumulative probabilities of rebleeding (P = 0.91) or death (P = 0.36). However, side effects were more frequent (47 %) with cyanoacrylate than with propranolol (10 %) (P < 0.02).

Also, at the Baveno IV consensus workshop on portal hypertension it was agreed that beta-blockers are recommended, with a level of evidence 2b;B, for the prevention of rebleeding from gastric varices [3].

With these points in mind, we think that the secondary prophylaxis of gastric variceal rebleeding by means of nonselective beta-blockers should be considered in the discussion of the paper of Lo et al.

Competing interests: None

References

• 1 Lo G H, Liang H L, Chen W C. et al . A prospective, randomized controlled trial of transjugular intrahepatic portosystemic shunt versus cyanoacrylate injection in the prevention of gastric variceal rebleeding.  Endoscopy. 2007;  39 679-685
• 2 Evrard S, Dumonceau J M, Delhaye M. et al . Endoscopic Histoacryl obliteration versus propranolol in the prevention of esophagogastric variceal rebleeding: a randomized trial.  Endoscopy. 2003;  35 729-735
• 3 De Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension.  J Hepatol. 2005;  43 167-176