Medical Versus Endoscopic Treatment of Oesophageal Varices in Liver Cirrhosis

Introduction: Portal hypertension is the most common complication of liver cirrhosis. It may be complicated by gastrointestinal bleeding from oesophageal or gastric varices. Treatment of varices can be medical by using non-selective beta blockers (as propranolol or cavedilol), or endoscopic (endoscopic variceal ligation EVL, endoscopic injection sclerotherapy EIS), or both. Aims & Methods: This study was conducted on 80 patients with liver cirrhosis and oesophageal varices (O.V.) grade III and IV, who were classified into five groups. Group I, 20 patients were subjected to EVL alone, group II, 20 patients received carvedilol alone(6.25 mg once daily, then increased to 6.25 mg twice daily after 1 week), group III received propranolol alone (20 mg three times daily), group IV, 20 patients who were subjected to EVL combined with carvidolol (6.25 mg once daily, then increased to 6.25 mg twice daily after 1 week)and group V, 20 patients who were subjected to EVL combined with propranolol(20 mg three times daily). All patients were followed up by doppler study of portal vein and upper G.I. endoscopy. Results: Upper G.I. endoscopy was done for all patients every 3 months up to 12 months. In the 1st visit, 95% of group I patients had O.V. grade IV and 5% had grade III O.V. , by the 4th visit 80% had O.V. grade I and 20% had no O.V. in the same group. In group II, in the 1st visit 90% of patients had O.V. grade IV and 10% had O.V. grade III, in the 4th visit 60% had O.V. grade I and 40% had no O.V. , In group III, in the 1st visit 95% of patients had O.V. grade IV and 5% had O.V. grade III, in the 4th visit 50% had O.V. grade I and 30% had no O.V. , In group IV, in the 1st visit 20% of patients had O.V. grade IV and 80% had O.V. grade III, in the 4th visit 40% had O.V. grade I and 60% had no O.V. , regarding group V, in the 1st visit, 75% had grade IV O.V. and 5% had O.V. grade III, while in the 4th visit 60% had O.V. grade I and 40% had no varices. Conclusion: The combination of carvedilol and EVL is more effective in treating medium and large sized O.V. than EVL alone or EVL combined to propranolol. Introduction Portal hypertension is responsible for the majority of complications of patients with liver cirrhosis, such as, development of oesophageal varices (OV), ascites, hepatorenal syndrome and hepatic encephalopathy. (1) OV are found in between 39 and 50% of cirrhotic patients; approximately half of them bleed at some point, and rebleeding occurs in up to two-thirds of the patients [1,2] . Almost 25% of patients with variceal bleeding (VB) die, with the associated mortality rate depending on several factors, including the severity of the underlying liver disease, the treatment received during the acute episode [3], the size of the varices and the presence of red spot signs. [2] Up to 30% of these patients also develop gastric varices, which on bleeding result in an even higher mortality [4,5]. Non-selective beta blockers (NSBB) and endoscopic variceal ligation (EVL) has been the mainstay of primary prophylaxis and reduce the risk of bleeding from 50 to 15 % for large varices. [6,7] NSBB are a class of drugs with effects on the sympathetic nervous system [8]. NSBB have beta-1 Correspondence to: Abdelrahman MI, Department of Tropical Medicine, Faculty of Medicine, Alexandria University, Alexandria, Egypt, Tel: +203 5410338, E-mail: marwaibrahim90@yahoo.com Received: July 15, 2018; Accepted: July 18, 2018; Published: July 20, 2018 receptor blocking effects that reduce cardiac output and portal venous inflow and beta-2 receptor blocking effects that lead to splanchnic vasoconstriction. Both the reduced cardiac output and the reduced portal venous inflow will reduce portal pressure [8,9]. NSBB are cost-effective [10], and may be also used in the prevention of other complications of cirrhosis and portal hypertension, including bleeding from portal hypertensive gastropathy [11]. However, other studies do not recommend the use of NSBB in patients with decompensated cirrhosis [12,13] ,in addition, they have some side effects that lead to treatment discontinuation in approximately in 15% of patients [14] such as depression, fatigue, sexual dysfunction, bradycardia and even heart block [15,16]. Therefore further Abdelrahman MI (2018) Medical Versus Endoscopic Treatment of Oesophageal Varices in Liver Cirrhosis Gut Gastroenterol Volume 1(2): 2018 2 researches are needed regarding the appropriate use of NSBB in patients with cirrhosis. NSBB used in clinical practice are propranolol, nadolol, and timolol [17], and recently, carvedilol that represents a promising drug that needs to be explored further [18]. Carvedilol is a racemic mixture that possesses both nonselective β2-antagonist and α1-receptor antagonist activity. Given its combined mechanism of action, carvedilol may have a greater potential for lowering portal pressure than propranolol [19]. The concept of EVL was based upon the treatment of varices with rubber band ligation. EVL obliterates varices by capturing all or part of a varix with rubber bands, resulting in mechanical strangulation and occlusion from thrombosis. The tissue then necrotizes and sloughs off in a few days to weeks, leaving a superficial mucosal ulceration, which rapidly heals [5]. It was documented that there was no difference in survival between EVL and NSBB for treating patients with high-risk OV, EVL showed the same efficacy or even better than the NSBB in preventing a first bleed[20] . But the recurrence of esophageal varices after EVL was more than 50% within 2 years[21]. This is because persistence of high portal pressure after EVL results in reformation of OV [22]. So the addition of NSBB to reduce portal pressure has been proved to decrease OV recurrence [23]. Patients and Methods This study was conducted on 100 patients with liver cirrhosis and esophageal varices (O.V.) Liver cirrhosis was diagnosed on clinical, biochemical and radiological basis then patients were selected after upper GIT endoscopy screening for esophageal varices of grade III and IV. Patients were classified into five groups. Group I, 20 patients were subjected to EBL alone, group II, 20 patients received carvedilol alone(6.25 mg once daily, then increased to 6.25 mg twice daily after 1 week), Group III received propranolol alone (20 mg three times daily), group IV, 20 patients who were subjected to EBL combined with carvedilol (6.25 mg once daily, then increased to 6.25 mg twice daily after 1 week) and group V, 20 patients who were subjected to EBL combined with propranolol(20 mg three times daily). All patients were followed up by doppler study of portal vein and upper G.I. endoscopy.