Band ligation versus beta-blockers in the prevention of primary bleeding of oesophageal varices: clinical, biochemical, ultrasongraphic and endoscopic evaluation

ABSTRACT

Most of the published data comparing endoscopic variceal band ligation [EVL] to propranolol for primary prevention of variceal bleeding have reached a conclusion that EVL is the option for patients with contraindications or intolerance to beta-blockers. Whether it is an alternative to beta-blockers that could be used for all cirrhotic patients with varices in case propranolol fails, or it is the prophylactic treatment of choice has not been answered. This study was designed to compare the effectiveness of prophylactic EVL to propranolol in the primary prevention of variceal bleeding from medium and large sized varices among Egyptian patients. The study included 60 patients with chronic liver disease, grade III or IV varices and negative history of variceal bleeding. Patients were randomized to receive either EVL or propranolol and were followed up every 3 months for one year. In the EVL group, successful initial variceal obliteration was achieved in 22 patients [88%]. In 5 of these patients [22.7%], variceal recurrence to grade II occurred. Failure to reduce the size of varices was reported in one patient [4%]. Patients in the propranolol group showed high incidence of hypotension [52.1%]. The mean dose of propranolol was low [43 +/- 7.3mg]. A resting heart rate of 69 beats/mm was 100% sensitive and 100% specific for the development of hypotension. Both groups were comparable as regards bleeding and overall mortality but compliance to therapy was significantly less in the propranolol group. Adverse effects to therapy were significantly higher in the propranolol group as hypotension occurred in 52.1% of patients. Although EVL is an invasive therapy as compared to propranolol, yet patients are more compliant to this short term therapy. Given this fact in addition to the high incidence of drug intolerability seen with propranolol makes EVL the preferred therapeutic option despite the comparable effectiveness of the two modalities in the primary prevention of variceal bleeding