THE TREATMENT OF ESOPHAGEAL-VARICES - A DEBATE AND A DISCUSSION

At the Biennial Meeting of the International Association for the Study of the Liver, in Cape Town, South Africa, 20-24 February 1996, the tr eatment of oesophageal varices was selected as a subject for the discu ssion of controversies in portal hypertension. This review gives a sum mary of that discussion. Dr Didier LeBrec gave a broad overview of the medical management of oesophageal varices by presenting a list of 52 pharmacological agents that reduce portal venous pressure and presente d the advantages and disadvantages of each. He emphasized that recent randomized clinical trials (RCT) have demonstrated that propranolol de lays and decreases the occurrence of haemorrhage from varices in patie nts who have not previously suffered such complications. He also repor ted that isosorbide-mononitrate is equally effective and further enhan ces the effect of propranolol. He also reported that the effects of pr opranolol plus endoscopic sclerotherapy (EST) were more effective than EST alone in preventing haemorrhage, but not in improving survival. F inally he noted that propranolol in high dosage did not prevent the de velopment of large varices in cirrhotic patients with small or undetec table varices. Dr John Terblanche compared the efficacy of EST and end oscopic ligation of varices (ELV) and reported that all four RCTs foun d ELV to be superior. He discussed portacaval anastomosis (PCA) and co ncluded that only emergency PCA as reported by Orloff, is thought to b e truly beneficial, and suggested that EST, plus ELV may be the treatm ent of choice. Dr Harold O. Conn, who served as the moderator of this session summarized the presentations and pointed out that liver transp lantation is the most effective form of therapy of all, albeit extreme ly complex and expensive. He discussed transjugular intrahepatic porto systemic shunts (TIPS), the newest form of therapy, and emphasized its virtues (immediate reduction of portal venous pressure) and its limit ations (frequent portosystemic encephalopathy and frequent spontaneous stenoses). He presented a brief discussion of the prevention of the d evelopment of the varices themselves, currently termed 'preprimary pro phylaxis', a hope for the future. He ended with 'Predictions' which if proven correct will give a preview of portal hypertension in the 21st century.