Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial.
OBJECTIVE
Bleeding from gastric varices is often severe and difficult to manage. Endoscopic injection of gastric varices with cyanoacrylate is effective in prevention of rebleeding. The efficacy of beta-blockers in secondary prophylaxis of gastric variceal bleed has not been well studied. A comparison of the efficacy of beta-blocker treatment and cyanoacrylate injection for the prevention of gastric variceal rebleeding was carried out.


METHODS
Patients with gastro-oesophageal varices type 2 (GOV2) with eradicated oesophageal varices or isolated gastric varices type 1 (IGV1) who had bled from gastric varices were randomised to cyanoacrylate injection (n=33) or beta-blocker treatment (n=34). Baseline and follow-up upper gastrointestinal endoscopy and hepatic venous pressure gradient (HVPG) measurements were performed. Primary end points were gastric variceal rebleeding or death.


RESULTS
The probability of gastric variceal rebleeding rate in the cyanoacrylate group was significantly lower than in the beta-blocker group (15% vs 55%, p=0.004) and the mortality rate was lower (3% vs 25%, p=0.026) during a median follow-up of 26 months. The median baseline and follow-up HVPG in the cyanoacrylate group were 15 (10-23) and 17 (11-24) mm Hg (p=0.001) and for the beta-blocker group 14 (11-24) and 13 (8-25) mm Hg (p=0.003). While no patient showed reduction of HVPG in the cyanoacrylate group, in the beta-blocker group 12 of 28 (42%) patients were responders, of which 5 (41% of responders) bled. On multivariate analysis, treatment method, portal hypertensive gastropathy and size of the gastric varix >20 mm independently correlated with gastric variceal rebleeding. Gastric variceal rebleeding independently correlated with mortality.


CONCLUSIONS
Cyanoacrylate injection is more effective than beta-blocker treatment for the prevention of gastric variceal rebleeding and improving survival.
Mishra
Smruti Ranjan
SR
Department of Gastroenterology, G B Pant Hospital, 201 Academic Block, New Delhi 110002, India.
Chander Sharma
Barjesh
B
Kumar
Ashish
A
Sarin
Shiv Kumar
SK
D000293:Adolescent; D000319:Adrenergic beta-Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D002648:Child; D003487:Cyanoacrylates / Q000009:adverse effects / Q000627:therapeutic use*; D004621:Embolization, Therapeutic / Q000009:adverse effects / Q000379:methods*; D016099:Endoscopy, Gastrointestinal / Q000379:methods; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D006503:Hepatic Veins / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011433:Propranolol / Q000009:adverse effects / Q000627:therapeutic use; D012008:Recurrence; D012307:Risk Factors; D016019:Survival Analysis; D014014:Tissue Adhesives / Q000009:adverse effects / Q000627:therapeutic use*; D016896:Treatment Outcome; D014690:Venous Pressure / Q000502:physiology; D055815:Young Adult
D000319:Adrenergic beta-Antagonists; D003487:Cyanoacrylates; D014014:Tissue Adhesives; D011433:Propranolol