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World J Gastrointest Endosc. Dec 16, 2021; 13(12): 628-637
Published online Dec 16, 2021. doi: 10.4253/wjge.v13.i12.628
Primary prophylaxis of variceal bleeding in patients with cirrhosis: A comparison of different strategies
Ângelo Zambam de Mattos, Carlos Terra, Alberto Queiroz Farias, Paulo Lisboa Bittencourt, Alliance of Brazilian Centers for Cirrhosis Care–the ABC Group
Ângelo Zambam de Mattos, Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, Brazil
Carlos Terra, Department of Internal Medicine, Universidade do Estado do Rio de Janeiro, Rio de Janeiro 20950000, Brazil
Alberto Queiroz Farias, Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo 05403-000, Brazil
Paulo Lisboa Bittencourt, Gastroenterology and Hepatology Unit, Hospital Português, Salvador 40140-901, Brazil
Author contributions: All authors contributed to this paper with conception of the manuscript, literature review and analysis, drafting and critical revision of the manuscript, and approval of the final version of the paper.
Conflict-of-interest statement: There are no conflicts of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ângelo Zambam de Mattos, MD, MSc, PhD, Professor, Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, 245 Sarmento Leite Street, Porto Alegre 90050-170, Brazil. angmattos@hotmail.com
Received: June 19, 2021
Peer-review started: June 19, 2021
First decision: July 29, 2021
Revised: August 7, 2021
Accepted: November 22, 2021
Article in press: November 22, 2021
Published online: December 16, 2021
Abstract

Patients with cirrhosis and esophageal varices bleed at a yearly rate of 5%-15%, and, when variceal hemorrhage develops, mortality reaches 20%. Patients are deemed at high risk of bleeding when they present with medium or large-sized varices, when they have red signs on varices of any size and when they are classified as Child-Pugh C and have varices of any size. In order to avoid variceal bleeding and death, individuals with cirrhosis at high risk of bleeding must undergo primary prophylaxis, for which currently recommended strategies are the use of traditional non-selective beta-blockers (NSBBs) (i.e., propranolol or nadolol), carvedilol (a NSBB with additional alpha-adrenergic blocking effect) or endoscopic variceal ligation (EVL). The superiority of one of these alternatives over the others is controversial. While EVL might be superior to pharmacological therapy regarding the prevention of the first bleeding episode, either traditional NSBBs or carvedilol seem to play a more prominent role in mortality reduction, probably due to their capacity of preventing other complications of cirrhosis through the decrease in portal hypertension. A sequential strategy, in which patients unresponsive to pharmacological therapy would be submitted to endoscopic treatment, or the combination of pharmacological and endoscopic strategies might be beneficial and deserve further investigation.

Keywords: Cirrhosis, Esophageal varices, Primary prophylaxis, Non-selective beta-blockers, Carvedilol, Endoscopic variceal ligation

Core Tip: Variceal hemorrhage still is an important cause of death among patients with cirrhosis, and primary prophylaxis against variceal bleeding is of the utmost importance. Traditional non-selective beta-blockers, carvedilol or endoscopic variceal ligation are currently recommended for primary prophylaxis, and the superiority of one alternative over the others is controversial. This review will provide a comparison of the strengths and weaknesses of the different strategies for primary prophylaxis against variceal bleeding, so that practitioners make an informed decision when choosing among them.