title: Early primary prophylaxis with beta-blockers does not prevent the growth of small esophageal varices in cirrhosis: a randomized controlled trial.
abstract: BACKGROUND
  The efficacy of portal pressure reduction by beta-blockers and the utility of serial hepatic venous pressure gradient (HVPG) measurements for the management of small (≤5 mm) esophageal varices in patients of cirrhosis are not clear.
  
  
  OBJECTIVE
  The study had the following aims: to study (1) the effect of propranolol on the growth of small varices and (2) whether single or serial HVPG measurements result in a better outcome compared to no measurement in patients with small varices.
  
  
  METHODS
  Consecutive cirrhosis patients with small varices, without any history of variceal bleed, were randomized to receive propranolol or placebo and to undergo no HVPG, only baseline HVPG, or serial HVPG measurements.
  
  
  RESULTS
  A total of 150 cirrhotics (cirrhosis predominantly viral or alcohol induced) were included (77 in the beta-blocker and 73 in the placebo group). Baseline characteristics were similar. The actuarial 2-year risk of growth of varices (primary endpoint) was 11 and 16% in the propranolol and placebo group, respectively (P = 0.786). Variceal bleeding and mortality were also comparable in the two groups. Similarly, the outcome was not influenced by HVPG measurements (whether serial, only baseline, or no HVPG). A bilirubin level of ≥1.5 mg/dl was found to be an independent predictor of variceal progression.
  
  
  CONCLUSIONS
  In cirrhotics with small esophageal varices, nonselective beta-blockers are unable to prevent the growth of varices, variceal bleed, or mortality. HVPG monitoring of these patients did not change the outcome; however, the role of HVPG-guided therapy modification needs to be studied.
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi, 110070, India. shivsarin@gmail.com.|Department of Gastroenterology, GB Pant Hospital, University of Delhi, New Delhi, India. shivsarin@gmail.com.|Special Centre for Molecular Medicine (SCMM), Jawaharlal Nehru University (JNU), New Delhi, India. shivsarin@gmail.com.
authors.forename: Shiv Kumar
authors.initials: SK
authors.lastname: Sarin
authors.affiliation: Department of Gastroenterology, GB Pant Hospital, University of Delhi, New Delhi, India.
authors.forename: Smruti Ranjan
authors.initials: SR
authors.lastname: Mishra
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi, 110070, India.
authors.forename: Praveen
authors.initials: P
authors.lastname: Sharma
authors.affiliation: Department of Gastroenterology, GB Pant Hospital, University of Delhi, New Delhi, India.
authors.forename: Barjesh Chander
authors.initials: BC
authors.lastname: Sharma
authors.affiliation: Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), D-1, Vasant Kunj, New Delhi, 110070, India.|Special Centre for Molecular Medicine (SCMM), Jawaharlal Nehru University (JNU), New Delhi, India.
authors.forename: Ashish
authors.initials: A
authors.lastname: Kumar
keywords: Beta-blockers; Chronic liver disease; Cirrhosis; HVPG; Portal hypertension; Portal pressure; Small varices; Variceal bleeding