Primary prophylaxis for portal hypertensive bleeding in cirrhosis

Variceal bleeding is a consequence of portal hypertension, which in turn is the major complication of hepatic cirrhosis. Given the high rate of mortal ity of the first bleeding episode, primary prophylaxis to prevent bleeding from varices and portal hypertensive gastropathy is the current optimal the rapeutic approach. The difficulty in identification of patients with varice s who will bleed, before they do so, can justify a strategy of treating all patients with varices prophylactically. We evaluated the various therapies that have been assessed in randomized controlled trials for prevention of first bleeding, using meta-analysis where applicable. The current first cho ice treatment is non-selective beta-blockers; it is cheap, easy to administ er, and is effective in preventing the first variceal haemorrhage and bleed ing from gastric mucosa. Combination drug therapy of beta-blockers and nitr ates looks promising, but needs further evaluation in randomized controlled trials. The conflicting results of the randomized studies of endoscopic ba nding ligation and the small number of patients and clinical events, as wel l as the cost, do not warrant any change in current practice. However, endo scopic banding ligation may be a reasonable alternative for patients who ca nnot tolerate, or have contraindications to beta-blockers or no haemodynami c response to the drug therapy, but this must be proved in randomized trial s.