Vol. 16, No. 1 January/February 1992


follow-up after termination of sclerotherapy, the mortality rate in both groups was almost identical. Although sclerotherapy did reduce new episodes of variceal bleeding, There have been a number of conflicting reports on the the procedure was associated with a significant increase in efficacy of prophylactic sclerotherapy and beta-blocker esophageal ulcers ( p < 0.001) with or without bleeding treatment for the prevention of first-episode and recurrent and almost double the mortality rate. Considering the bleeding and subsequent improved survival time in paavailable data in the literature on prophylactic therapy for tients with esophageal varices.1-4 These diverse treatment large esophageal varices and for recurrent bleeding from outcomes may have been the result of differences in severe portal hypertensive gastropathy in men with severity of disease as well as etiologies. With propanolol chronic liver disease, propanolol therapy appears to be the prophylactic therapy, significant variations in density of safest and most effective treatment at this time.6,7 beta-2-adrenoreceptors have been proposed as a major Donald M. Gallant, MD reason for the differences in response to treatment.5 To settle the controversy of the value of prophylactic Jose M. Pkna, MD Department of Psychiatry and Neurology sclerotherapy for esophageal varices in patients with alcoTulane University School of Medicine holic liver disease without a history of variceal bleeding, Veterans Administration Medical Center the Veterans Affairs cooperative project studied 28 1 males, randomly distributing 143 to receive sclerotherapy and a New Orleans, LA control group of 131 for endoscopy and sham sclerotherREFERENCES a ~ yUnfortunately, .~ this random distribution resulted in 1. Lebrec D, Poynard T, Hillon P, Benhamour J P Propanolol for the sclerotherapy group having a significantly higher inprevention of gastrointestinal bleeding in patients with cirrhosis: A cidence ( p = 0.001) of major medical illnesses than the controlled study. New Engl J Med 305: 137 1 - 1374, 198 1 sham group. Major criteria for inclusion in this study 2. Burroughs AK, Jenkins WJ, Sherlock S: Controlled trial of prowere: consumption of more than 48 g of ethanol daily for panolol for the prevention of recurrent variceal hemorrhage in patients longer than 1 year, alcoholic liver disease by biopsy or with cirrhosis. New Engl J Med 309:1539-1542, 1983 3. Lebrec D, Braillon A, Cales P, Valla D, Gaudy D, Geoffroy P clinical diagnosis, no history of upper gastrointestinal (GI) Influence of the stage of liver disease on systemic and splanchnic hemobleeding during the prior 4 years, and “endoscopic evi- dynamics and on response to propanolol in patients with cirrhosis. dence of at least 3 esophageal variceal channels.” For Hepatology 4: 1026, 1984 patients assigned to sham therapy, the placebo solution 4. The Veterans Affairs Cooperative Variceal Sclerotherapy Group: was released through the injector into the upper stomach Prophylactic sclerotherapy for esophageal varices in men with alcoholic six to eight times during the first session and with decreas- liver disease. New Engl J Med 324: 1779-1 784, 199 1 5. Gerbes AL, Remien J, Jungst D, Sauerbruch T, Paumgartner G: ing frequency at the follow-up sessions to mimic the Evidence for down-regulation of beta-2-adrenoreceptorsin cirrhotic pasclerotherapy regimen. All patients were scheduled to re- tients with severe ascites. The Lancet 1:1409-141 l , 1986 ceive sclerotherapy or sham therapy for 2 years, and the 6. Hayes PC, Davis JM, Lewis JA, Bouchier IAD Meta-analysis of duration of the study was projected to last 5 years. Upper value of propanolol in prevention of variceal hemorrhage. The Lancet GI bleeding and death were the two major “end points in 336:153-156, 1990 7. Perez-Ayuso RMP, Pique JM, Bosch J, Panes J, Gonzalez A, et the study.” Patients who required more than six units of al: Propanolol in prevention of recurrent bleeding from severe portal blood for one episode of upper GI bleeding or who had hypertensive gastropathy in cirrhosis. The Lancet 337: 143 1-1434, 199 I three episodes of GI bleeding were considered treatment failures. PLASMA CORTISOL CONCENTRATIONS This study had to be terminated after 22.5 months, as DURING ETHANOL WITHDRAWAL the 32% mortality rate in the sclerotherapy group was significantly higher ( p< 0.004) than the sham group ( 17%) Alcoholic patients who have made multiple attempts at alcohol withdrawal may be prone to develop long-term at this point in the study. At baseline, the sclerotherapy group did have a shorter neurologic and psychiatric disabilities and to experience period of abstinence; twice as many cases of chronic seizures.’ As noted by Adinoff et a1,2changes in the stressobstructive pulmonary disease, malignant disease, and response system of the hypothalamic-pituitary-adrenal cardiovascular disease; and 13 (36%)more cases of Child’s axis (HPAA) may contribute to these pathophysiologic grade C cirrhosis. However, both multivariate logistic- abnormalities in alcoholic patients. As part of an investiregression and Cox-regression analyses showed only the gation of the HPAA following ethanol withdrawal, Adinoff Child’s score and the assigned treatment to be independent examined diurnal changes in plasma cortisol in six alcopredictors of mortality. In addition, during the 37-month holic-dependent men, quantifying plasma cortisol levels AIcoholClin Exp Res, Vol 16, No I , 1992: pp 139-140


Prophylactic therapy of first-episode bleeding in esophageal varices.

0145-6OO8/92/ I60 1-0139$3.00/0 ALCOHOLISM:CLtNlCAL AND EXPERMENTAL RESEARCH Vol. 16, No. 1 January/February 1992 CURRENT LITERATURE REVIEWED AND CR...
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