english.prescrire.org > Spotlight > Archives : 2012 > Bleeding from ruptured oesophageal varices: propranolol for primary prevention

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Bleeding from ruptured oesophageal varices: propranolol for primary prevention

FEATURED REVIEW  Oesophageal varices are a common complication of cirrhosis. Bleeding from ruptured oesophageal varices is fatal in about 20% of cases. Propranolol should be used for both primary and secondary prevention of bleeding from ruptured oesophageal varices, because of its favourable harm-benefit balance, convenience, and low cost. If propranolol has unacceptable adverse effects or is contraindicated, endoscopic ligation is the best alternative.
Full review (5 pages) available for download by subscribers.

Abstract

  • Oesophageal varices are a common complication of cirrhosis. Bleeding from ruptured oesophageal varices is fatal in about 20% of cases.
     
  • Available options to prevent bleeding from oesophageal varices include drugs, endoscopic procedures and venous shunting catheterisation. The following article examines the respective harm-benefit balances of these treatments, based on a review of the literature using the standard Prescrire methodology.
     
  • Propranolol, a beta-blocker, is the best-evaluated option. In primary prevention, a meta-analysis in 811 patients showed that non-cardioselective beta-blockers reduced the risk of bleeding in patients with medium or large varices compared with placebo. Beta-blockers also reduced mortality when used for secondary prevention. However, beta-blockers are contraindicated or have unacceptable adverse effects in about 15% of patients with cirrhosis.
     
  • Other drugs, such as isosorbide mononitrate, have no proven efficacy in the prevention of bleeding from ruptured oesophageal varices.
     
  • Endoscopic ligation of oesophageal varices appears to have similar efficacy to beta-blockers in terms of morbidity and mortality, according to two meta-analyses, one in primary prevention (about 1000 patients) and the other in secondary prevention (700 patients). However, ligation has more serious adverse effects, including oesophageal ulceration that can also lead to bleeding.
     
  • Combination therapy with a beta-blocker and endoscopic ligation has rarely been assessed in primary prevention. In secondary prevention, this combination seems to be more effective than ligation alone in reducing the risk of recurrent bleeding, but it has no proven effect on mortality and is associated with more adverse effects.
     
  • Portocaval shunting by the transjugular route increases the risk of encephalopathy. In secondary prevention, compared with endoscopic treatments, it has been shown to reduce the risk of rebleeding but not to improve survival.
     
  • In practice, propranolol should be used for both primary and secondary prevention of bleeding from ruptured oesophageal varices, because of its favourable harm-benefit balance, convenience, and low cost. If propranolol has unacceptable adverse effects or is contraindicated, endoscopic ligation is the best alternative.

©Prescrire 1 March 2012

"Bleeding from ruptured oesophageal varices. Propranolol for primary prevention " Prescrire Int 2012; 21 (125): 73-77. (Pdf, subscribers only)
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