Monday, August 16, 2010

Preventing the first variceal bleed

Once a person has been diagnosed with Cirrhosis due to any etiology, then the next question would be if they are compensated or decompensated? Signs of decompensation are ascites, jaundice, encephalopathy, variceal bleeding. The median survival of pts with compensated cirrhosis is about 9 yrs.
So...... after someone has been diagnosed with compensated cirrhosis, they all need a screening for varices and hepatocellular caner. Lets discuss varices and its management,as its present in 50% of cirrhotics. If varices are found on screening endoscopy, there are two options available for managing them.
1. Non selective beta blockers (NSBB)
2. Endoscopic Variceal ligation (EVL)
 For management purpose varices can be divided into small (<6mm) and large (>or = 6mm).

For varices which are small, have any red wale marks on them, or child Pugh class B/C then NSBB are the right options.They reduce the incidence of first bleed by 10% over 2 years.Actually the effect is more evident in pts with large varices than in small varices.(Gastro 2004). NSBB should be titrated to a HR of 55 - 60/min.( but remember there is no correlation between reduction in HR and reduction in portal pressure)
NSBB are not useful if endoscopy does not show varices, as they dont prevent development of varices, but delay the growth of varices. Once you begin treatment with NSBB there is no need to repeat endoscopy.

For those with large varices,red wale marks, idependent of Child Pugh class either EVL or beta blockers can be used, and both are equally effective in preventing the first variceal bleed and reducing mortality. Randomised trials have shown EVL to have a small but significant reduction in variceal bleed than NSBB. But these trials were of very short duration. And recent metaanalysis have shown that both therapies are equally effective. Check this excellent report.Hepatology 2008 . Again if NSBB is started there is no need for a repeat endoscopy, whereas EVL is done every 1-2 weeks until obliteration, and needs surveilance every 6 months.

Well, a combination of EVL and NSBB has also been tested in a few studies with no significant difference between combination and each agent used alone.In fact there were more side effects with combining them.


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