Zoller W G, Gross M
Ludwig-Maximilians-Universität München, Klinikum Innenstadt, Germany.
Eur J Med Res. 1996 Jun 25;1(9):407-16.
Hemorrhage from esophageal varices is a life-threatening event in patients with liver cirrhosis. About 40% to 80% of the patients surviving the first bleeding suffer from a recurrence of variceal bleeding within one year. This high recurrence rate substantially contributes to the mortality in patients with liver cirrhosis. Therefore, various treatment regimens both in primary and secondary prophylaxis were studied. Most experience in medical primary prophylaxis was collected with beta-blockers, mainly propranolol. Treating patients with esophageal varices with propranolol significantly reduces the incidence of first variceal bleeding. However, the effect on mortality is marginal, and primary prophylaxis is generally not recommended in these patients. Several studies support the hypothesis, that medical prophylaxis with beta-blockers is more effective in reducing the rate of first esophageal bleeding in patients with a high risk of hemorrhage, such as the presence of very large varices with red spots. A score to assess the individual risk of a given patient to suffer a variceal bleeding would be helpful. As long as such a score is not validated, no general rule for this treatment decision can be given. In secondary prophylaxis, both administration of beta-blockers and endoscopic therapy (sclerotherapy or ligation of the varices) are effective in significantly lowering the rate of re-bleeding. However, the effect on mortality was not significant in most studies. Several studies comparing the efficacy of medical prophylaxis and endoscopic treatment showed advantages of the endoscopic therapy with a greater reduction in recurrent bleeding episodes. However, medical prophylaxis with beta-blockers has the important advantage of being immediately effective whereas endoscopic procedures provide the best protection against recurrent bleeding after complete obliteration of the varices. Therefore, in the first weeks and months of endoscopic therapy, the additional treatment with beta-blockers may further reduce the risk of re-bleeding. Only half of all studies on this topic reported a significant advantage of such a combined therapy. Therefore, it seems reasonable to restrict this approach to patients with a high risk of re-bleeding such as patients with large sclerotherapy-derived esophageal ulcers.
食管静脉曲张出血是肝硬化患者危及生命的事件。首次出血存活的患者中约40%至80%会在一年内再次发生静脉曲张出血。这种高复发率在很大程度上导致了肝硬化患者的死亡率。因此，对一级和二级预防的各种治疗方案进行了研究。医学一级预防的大部分经验是使用β受体阻滞剂，主要是普萘洛尔。用普萘洛尔治疗食管静脉曲张患者可显著降低首次静脉曲张出血的发生率。然而，对死亡率的影响很小，一般不建议对这些患者进行一级预防。几项研究支持这样的假设，即对于出血风险高的患者，如存在伴有红色斑点的非常大的静脉曲张，使用β受体阻滞剂进行医学预防在降低首次食管出血率方面更有效。评估特定患者发生静脉曲张出血个体风险的评分会很有帮助。只要这种评分未得到验证，就无法给出这种治疗决策的一般规则。在二级预防中，使用β受体阻滞剂和内镜治疗（硬化疗法或静脉曲张结扎术）均能有效显著降低再出血率。然而，在大多数研究中，对死亡率的影响并不显著。几项比较医学预防和内镜治疗疗效的研究显示内镜治疗具有优势，可更大程度地减少复发出血事件。然而，使用β受体阻滞剂进行医学预防的重要优势是立即有效，而内镜手术在静脉曲张完全闭塞后能提供针对复发出血的最佳保护。因此，在内镜治疗的最初几周和几个月内，联合使用β受体阻滞剂可能会进一步降低再出血风险。关于这个主题的所有研究中只有一半报告了这种联合治疗的显著优势。因此，将这种方法限制在再出血风险高的患者，如患有大型硬化疗法引起的食管溃疡的患者，似乎是合理的。
