A randomized, controlled trial of medical therapy versus endoscopic ligation for the prevention of variceal rebleeding in patients with cirrhosis.
OBJECTIVE
Patients who have had one variceal bleed are at high risk of rebleeding. Since its introduction, endoscopic variceal banding has been shown to be superior to needle sclerotherapy. Banding has not been compared with hepatic venous pressure-guided medical therapy (beta-blockers and nitrates).


METHODS
One hundred two patients with cirrhosis and a recent esophageal variceal bleed were randomized to either endoscopic banding (51 patients) or medical therapy (51 patients). The hepatic venous pressure gradient was measured in all patients at baseline, at 3 months (drug therapy arm), and at yearly intervals (all patients). Primary end points were death or rebleeding.


RESULTS
The 2 groups were well matched. Fifty-one percent were Pughs C, with a median Pughs score of 9.5. Nineteen patients rebled in the drug arm (median time, 24 days) and 27 patients in the banding arm (median time, 24 days). At 1 year, 43.7% of patients had bled in the drug arm compared with 53.8% in the banding arm (P = 0.25). Thirty-two percent of patients on medical therapy had died at 1 year, 22.5% on banding (P = 0.97).


CONCLUSIONS
In the prevention of variceal rebleeding, beta-blockers +/- nitrates are as effective as endoscopic banding.
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000009:adverse effects; D000328:Adult; D000368:Aged; D004724:Endoscopy; D004932:Esophageal and Gastric Varices / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007548:Isosorbide Dinitrate / Q000008:administration & dosage / Q000009:adverse effects / Q000031:analogs & derivatives; D008026:Ligation; D008103:Liver Cirrhosis / Q000150:complications* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D011433:Propranolol / Q000008:administration & dosage / Q000009:adverse effects; D055502:Secondary Prevention; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000009:adverse effects; D014690:Venous Pressure
D000319:Adrenergic beta-Antagonists; D014665:Vasodilator Agents; D011433:Propranolol; D007548:Isosorbide Dinitrate; C030397:isosorbide-5-mononitrate