Albillos Agustín
Servicio de Gastroenterología, Hospital Universitario Ramón y Cajal, Ciberehd, Unidad I+D Asociada al Centro Nacional de Biotecnología (CSIC), Universidad Alcalá, Madrid, Spain.
J Clin Gastroenterol. 2007 Nov-Dec;41 Suppl 3:S305-11. doi: 10.1097/MCG.0b013e318150d3c6.
Variceal bleeding is still a life-threatening complication of portal hypertension responsible for an appreciable rate of morbidity and mortality. The most appropriate treatment approach, whether drugs (nonselective beta-blockers) or endoscopic (variceal band ligation) therapy, to prevent the initial bleed, or primary prophylaxis, is an issue of controversy. Meta-analysis of randomized controlled trials indicates that banding seems to be somehow slightly more effective than beta-blockers at preventing a first bleeding episode, but this does not translate to improved survival. The firmness of this conclusion is, in addition, diminished by the small sample size and short follow-up of most studies. Moreover, adverse events due to banding are more severe than those associated with beta-blockers. Thus, beta-blockers remain as first-line therapy in patients with cirrhosis and large esophageal varices. Prophylactic therapy with beta-blockers can be considered in patients with small varices, especially in those with red signs or Child class C liver disease. The available evidence does not support the idea that organic nitrates improve the efficacy of beta-blockers in primary prophylaxis. The method used to establish the dose of beta-blockers and check its effect on hepatic venous pressure gradient (HVPG) has also been disputed. An attractive strategy is to measure the HVPG response to beta-blockers as a guide to primary prophylaxis, with the aim of switching to another therapy, that is, band ligation, in HVPG nonresponders. However, no study has yet demonstrated that banding as rescue therapy in nonresponders lowers the risk of first bleeding and improves survival.
静脉曲张破裂出血仍然是门静脉高压症一种危及生命的并发症，导致相当高的发病率和死亡率。预防首次出血，即一级预防，最合适的治疗方法是药物治疗（非选择性β受体阻滞剂）还是内镜治疗（静脉曲张套扎术），这是一个有争议的问题。对随机对照试验的荟萃分析表明，在预防首次出血发作方面，套扎术似乎比β受体阻滞剂略有效，但这并未转化为生存率的提高。此外，由于大多数研究样本量小且随访时间短，这一结论的可靠性有所降低。此外，套扎术引起的不良事件比与β受体阻滞剂相关的不良事件更严重。因此，β受体阻滞剂仍然是肝硬化和大食管静脉曲张患者的一线治疗方法。对于小静脉曲张患者，尤其是有红色征或Child C级肝病的患者，可考虑使用β受体阻滞剂进行预防性治疗。现有证据不支持有机硝酸盐可提高β受体阻滞剂在一级预防中的疗效这一观点。用于确定β受体阻滞剂剂量并检查其对肝静脉压力梯度（HVPG）影响的方法也存在争议。一种有吸引力的策略是测量HVPG对β受体阻滞剂的反应，以此作为一级预防的指导，目的是在HVPG无反应者中改用另一种治疗方法，即套扎术。然而，尚无研究表明，在无反应者中采用套扎术作为挽救治疗可降低首次出血风险并提高生存率。
