ENDOSCOPIC ASSESSMENT OF VARICEAL VOLUME AND WALL TENSION IN CIRRHOTIC-PATIENTS - EFFECTS OF PHARMACOLOGICAL THERAPY

Background & Aims: Variceal rupture is believed to occur when variceal wall tension is excessive. The combined use of endosonography, allowi ng the objective measurement of variceal radius, and endoscopic measur ement of transmural variceal pressure may enable assessment of this im portant parameter. The aim of this study was to assess the effects on variceal hemodynamics of drugs acting through different mechanisms: de creasing portocollateral blood flow (propranolol) or resistance (isoso rbide-5-mononitrate [ISMN]). Methods: Repeated measurements of varicea l radius, volume (by endosonography), and transmural pressure (using e ndoscopic gauge) were performed in 27 cirrhotic patients at baseline a nd 40 minutes after double-blind administration of placebo (n = 9), pr opranolol (n = 9), or ISMN (n = 9). Results: Placebo had no effect. Pr opranolol significantly reduced variceal volume (-32% +/- 26%; P = 0.0 1), radius (-12% +/- 9%; P < 0.005), and pressure (-26% +/- 10%; P < 0 .0001). The resulting decrease in wall tension (-34% +/- 13%; P < 0.00 05) exceeded that in transmural pressure (P < 0.01). ISMN reduced tran smural variceal pressure (-26% +/- 21%; P < 0.005), but not radius (-3 % +/- 14%; NS) and volume (-9% +/- 31%; NS). Conclusions: The combinat ion of endosonography and endoscopic measurement of transmural varicea l pressure allows quantitative estimation of variceal wall tension. Pr opranolol and ISMN reduce similarly transmural variceal pressure. Prop ranolol, but not ISMN, reduces variceal volume and radius. Therefore, despite similar decreases in variceal wall tension, propranolol may of fer a greater therapeutic effect than ISMN in portal hypertension.