Endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleed: Preliminary report of a randomized controlled trial

Background: Prevention of variceal bleeding, a major cause of morbidity and mortality, is an important goal in the management of patients with portal hypertension (PHT). Although propranolol has been found useful in preventin g the first episode of variceal bleeding (primary prophylaxis) in cirrhotic PI-IT, it has limitations which include side effects, contraindications, n on-compliance and failure in some patients. Endoscopic variceal ligation (E VL) has not been used for primary prophylaxis. Methods: Thirty cirrhotic patients with PI-IT grade III to IV oesophageal v arices, hepatic venous pressure gradient greater than or equal to 12 mmHg a nd no prior history of upper gastrointestinal bleeding were randomized to r eceive propranolol (to reduce their pulse rate by 25% from baseline, n = 15 ) and EVL (weekly to fortnightly until variceal eradication, n = 15). The t wo groups were comparable. All the patients in EVL group had variceal eradi cation during 3.8+/-2.2 sessions. Results: There was no major complication or interval bleeding. During a fol low-up period of 17.6+/-4.7 months, varices recurred in three, two of which bled (successfully treated by EVL). In contrast, during this period of fol low up one patient in the propranolol group had variceal bleeding (P=NS). S ide effects of propranolol included symptomatic bradycardia requiring reduc tion of dose in one of 15 patients. Conclusions: Although sample size in this study is small, it seems that EVL may be a good option for primary prophylaxis for variceal bleeding in pati ents with cirrhotic PHT; further studies on a larger number of patients and longer follow up are required.