Clinical

Ligation may outperform beta blockade for esophageal varices

Last Updated: 2005-04-18 16:19:43 -0400 (Reuters Health)

NEW YORK (Reuters Health) - In patients with hepatic cirrhosis and high-risk esophageal varices, endoscopic variceal band ligation may be more effective than treatment with the beta-blocker propranolol in preventing variceal hemorrhage, the results of a small study suggest. Overall costs appear to be similar for the two treatment modalities.

There are no randomized controlled trials comparing beta-blockade with banding using a multishot-banding device with translucent tips, Dr. Dennis M. Jensen of the David Geffen School of Medicine at UCLA and colleagues note in the April issue of Gastroenterology.

Beta-blockers reduce the risk of variceal bleeding by decreasing portal pressure and variceal blood flow, the authors explain, and are considered the standard of care for preventing a first esophageal variceal hemorrhage. The researchers suggest that recent improvements to banding devices may make them a better alternative.

For their prospective study, Dr. Jensen's group enrolled subjects with cirrhosis of the liver who were candidates for liver transplant and had large or high-risk nonbleeding esophageal varices. Thirty-one patients were randomly assigned to propranolol 80 mg to 160 mg b.i.d. to achieve heart rate reduction of 25% while maintaining a heart rate greater than 50 beats/minute and systolic blood pressure of 90 mm Hg.

The remaining 31 patients were randomly assigned to variceal ligation performed monthly with a multishot-banding device with translucent tips until varices were eradicated.

Enrollment was stopped early because an interim analysis showed a significant difference in treatment failure rates, the authors report.

During mean follow-up of 15 months, there were four cases of variceal bleeding and two other severe adverse events, and four deaths in the propranolol group, compared with no adverse events or deaths in the banding group (p = 0.0098 and 0.0443, respectively).

Overall costs were not significantly different when including treatment costs and costs of hospitalization ($3300 in the propranolol group and $2228 in the banding group, p = 0.44).

"Prophylactic banding seems to be a more promising treatment than propranolol for preventing initial variceal bleeding for compliant patients who are at high risk of initial variceal hemorrhage and who are candidates for liver transplantation," Dr. Jensen's group concludes.

However, Dr. Thomas D. Boyer, at the University of Arizona in Tucson, disagrees with this conclusion. He notes in an editorial that the study by Dr. Jensen's group was too small and follow-up too short to conclusively state that banding is preferable to treatment with propranolol. He believes that the two treatments are equivalent.

"Nonselective beta-blockers remain the treatment of choice for the primary prevention of variceal bleeding," he writes. "Variceal band ligation should be considered in patients who are intolerant of beta-blockers or in whom beta-blocker therapy is contraindicated."

Gastroenterology 2005;128:870-881,1120-1122.