Prophylactic therapy for variceal hemorrhage revisited.

The high mortality of a first variceal bleed in cirrhotic patients even in very recent studies makes some effective form of primary prophylaxis desirable. Controlled studies of shunt and nonshunting surgery have shown that these operations can prevent variceal hemorrhage only at the expense of increased morbidity and mortality. Therefore, this type of surgery has no place in the primary prophylaxis of variceal bleeding. Liver transplantation, however, is becoming a real therapeutic alternative for many patients with chronic liver disease. Obviously, it will prevent bleeding in many patients, but primary prophylaxis of bleeding itself is not an indication for a transplant. The radically different results of randomized controlled trials of prophylactic sclerotherapy indicate that it is either very helpful and will save many lives or very harmful and will lead to death in patients who would otherwise survive. The cumulative evidence from the trials that took appropriate care of effective treatment for the acute bleed and that had no major problems with complications of the procedure itself suggests that prophylactic sclerotherapy is neither helpful nor very harmful. Thus, there is also no indication for prophylactic sclerotherapy in clinical routine. Personally, I even doubt that it should be used in future controlled trials in the light of the positive results of the prophylactic trials of beta-blockers. If there is an indication for prophylactic treatment, it should be the last invasive treatment available. In the near future, work should focus on the confirmation and further development of endoscopic or other simple and safe means to predict the risk of first bleeding; on the development and characterization of effective drugs; and on development of methods to identify at an early stage responders and nonresponders. If I presently had large varices that had not yet bled, I would like to join one of my senior colleagues and look for admission to the Control group of an ongoing randomized beta-blocker trial.