It is known that patients that have recently suffered an episode of acute bleeding from esophageal varices are at high risk for recurrent bleeding and death. Treatments that can reduce this risk are therefore highly sought.
A research team from the Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, have compared 2 such treatments for prevention of recurrent bleeding - endoscopic ligation and combined medical therapy with nadolol and isosorbide mononitrate.
| Combined medication - safer than endoscopic ligation |
|The New England Journal of Medicine |
A randomly assigned group of 144 patients with cirrhosis, who were hospitalized with esophageal variceal bleeding, received treatment with either endoscopic ligation (72 patients) or the combined therapy (72 patients).
Sessions of ligation were repeated every 2 to 3 weeks until the varices were eradicated. The mean dose of nadolol was 96 mg per day, and the mean dose of isosorbide was 66 mg per day.
The primary end points of the study were recurrent bleeding, complications, and death. The median follow-up period was 21 months.
A total of 35 patients in the ligation group and the 24 in the medication group had recurrent bleeding.
The probability of recurrence was lower in the medication group, both for all episodes related to portal hypertension and for recurrent variceal bleeding.
Major complications occurred in 9 patients treated with ligation (7 suffered from bleeding esophageal ulcers and 2 from contracted aspiration pneumonia).
In the medication group, 2 subjects suffered complications, both experiencing bradycardia and dyspnea.
A total of 30 patients died in the ligation group, compared to 23 in the medication group.
The probability of recurrent bleeding was lower for patients with a hemodynamic response to therapy (18%, versus 54% in patients with no hemodynamic response at 1 year).
A hemodynamic response was defined as an increase in the hepatic venous pressure gradient of more than 20% from the base-line value, or to less than 12 mmHg.
The likelihood of survival however, was higher (94% compared to only 78% in the non-hemodynamically-responsive group).
Dr Candid Villanueva, one of the co-authors of the report, which is published in The New England Journal of Medicine, with an accompanying review article, said that the research showed combined therapy with nadolol and isosorbide mononitrate to be more effective for prevention of recurrent bleeding than endoscopic ligation.
Dr Villanueva added that the therapy was also associated with fewer major complications.