Prevention of initial variceal hemorrhage.

Results from prospective controlled trials do not justify the use of either prophylactic shunt surgery or sclerotherapy for the prevention of initial variceal bleeding. Use of nonselective beta-adrenergic blockers has been shown to reduce significantly the risk of first variceal hemorrhage, but their effect on survival is marginal. Because only 25% to 40% of patients with cirrhosis and varices experience variceal bleeding, is it justified to place all patients with varices on beta-blocker therapy? The answer lies in the identification of a high-risk population (i.e., patients with large varices and endoscopic red color signs) and patients who can tolerate and will be compliant with therapy. The duration of therapy required is unknown and perhaps requires a lifetime commitment. Future research will involve the use of combinations of pharmacologic agents to reduce further portal pressure and perhaps the use of pharmacologic agents and sclerotherapy. The goal of a significant improvement in survival is yet to be obtained.