PROPHYLACTIC TREATMENT OF PATIENTS WITH ESOPHAGEAL-VARICES - IS IT EVER INDICATED

The prognosis of patients who bleed from esophageal varices is dismal. Prophylactic treatment of the varix or the elevated portal venous pre ssure offers a possibility of improving the outlook for these patients . However, as only approximately one-third of patients with varices bl eed during their lifetime, correct identification of high-risk patient s is vital before embarking on prophylaxis. At present, neither Europe an or Japanese selection criteria are perfect in this respect. The doc umented incidence of initial variceal bleeding varies between 27% and 48%, and most bleeding episodes occur within the first year after vari ces are diagnosed. Data from six randomized controlled trials comparin g prophylactic beta-blockers with placebo demonstrated a decreased inc idence of bleeding in propranolol-treated patients, which in large mea sure may depend on patient compliance and did not significantly affect survival in all but one study. Early randomized studies of prophylact ic sclerotherapy have shown significant reductions in both the inciden ce of bleeding and mortality, but this promise has not been sustained by subsequent trials, and indeed sclerotherapy was detrimental in two studies. The impressive results in highly selected patients treated in Japan by prophylactic surgery are unlikely to be repeated in a Wester n setting, involving patient populations that consist predominantly of alcoholic cirrhotics. At present prophylaxis with beta-blockade seems to offer the best therapeutic option, but the future may lie in the d evelopment of new interventional techniques such as transjugular intra hepatic portosystemic stent shunting (TIPS) or variceal banding, and u ltimately with hepatic transplantation.