Comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding

Background and Methods We compared propranolol therapy and endoscopic ligat ion for the primary prevention of bleeding from esophageal varices. This pr ospective, controlled trial included consecutive eligible patients who had large varices (>5 mm in diameter) that were at high risk for bleeding. The patients were assigned to either propranolol therapy, at a dose sufficient to decrease the base-line heart rate by 25 percent, or variceal ligation, t o be performed weekly until the varices were obliterated or so reduced in s ize that it was not possible to continue treatment. Results Of the 89 patients, 82 of whom had cirrhosis of the liver, 44 recei ved propranolol and 45 underwent variceal ligation. The mean (+/-SD) durati on of follow-up in each group was 14+/-9 and 13+/-10 months, respectively. The mean time required to achieve an adequate reduction in the heart rate w as 2.5+/-1.7 days; the mean number of sessions needed to complete variceal ligation was 3.2+/-1.1. After 18 months, the actuarial probability of bleed ing was 43 percent in the propranolol group and 15 percent in the ligation group (P = 0.04). Twelve patients in the propranolol group and four in the ligation group had bleeding. Three of the four in the ligation group had bl eeding before their varices had been obliterated. Nine patients in the liga tion group had recurrent varices, a mean of 3.7 months after the initial tr eatment. Five patients in each group died; bleeding from the varices was th e cause of death of four patients in the propranolol group and of three in the ligation group. There were no serious complications of variceal ligatio n; in the propranolol group, treatment was stopped in two patients because of side effects. Conclusions In patients with high-risk esophageal varices, endoscopic ligat ion of the varices is safe and more effective than propranolol for the prim ary prevention of variceal bleeding. (N Engl J Med 1999;340: 988-93.) (C)19 99, Massachusetts Medical Society.