EVL Plus Drug to Prevent Variceal Rebleeding
EVL Plus Drug to Prevent Variceal Rebleeding
Both medications with beta-blockers and isosorbide-5-mononitrate and endoscopic variceal
 ligation have been proven plausible in the prevention of variceal rebleeding. However, the
 relative efficacy and safety of the combined treatment for preventing rebleeding remains
 unresolved.
Bleeding from esophageal varices is a severe complication of portal hypertension. After
 initial control of acute variceal bleeding, patients still carry a high risk of rebleeding.
 Of those do rebleed, there is a 20%-35% mortality (1). Therefore, preventive procedures are
 required in patients surviving an episode of acute variceal bleeding. In recent years,
 endoscopic variceal ligation (EVL) has replaced endoscopic injection sclerotherapy (EIS) as
 the endoscopic treatment of choice in the management of bleeding esophageal varices (2-3). On
 the other hand, nonselective beta blockers have been well documented to be effective in
 reducing variceal rebleeding (4-5). The addition of isosorbide-5-mononitrate (ISMN) has been
 shown to be even more effective than propranolol alone in the reduction of portal pressure
 and in the prevention of variceal rebleeding (6). Some studies showed that the combination of
 nadolol and ISMN is more effective than EIS or EVL in the reduction of variceal rebleeding
 (7-8). It is still unknown whether EVL combined with nadolol and ISMN is superior to nadolol
 and ISMN in the prevention of variceal rebleeding. This study was undertaken to compare the
 effectiveness and complications of ligation plus nadolol and isosorbide mononitrate vs.
 nadolol plus isosorbide mononitrate for the prevention of variceal rebleeding.
Inclusion Criteria:

 1. Acute bleeding from esophageal varices (defined below);

 2. the etiology of portal hypertension was cirrhosis; and

 3. age was between 20 and 75 years old. The diagnosis of cirrhosis was based on
 pathology, clinical, biochemical, and sonographic or computed tomographic findings.
 Acute esophageal variceal bleeding was defined as when blood was directly seen by
 endoscopy to issue from an esophageal varix, or when patients presented with red color
 signs on their esophageal varices with blood in esophagus or stomach and no other
 potential site of bleeding identified.

 Exclusion Criteria:

 1. association with hepatocellular carcinoma or other malignancy,

 2. association with cerebral vascular accident, uremia, sepsis or other debilitating
 disease,

 3. had history of gastric variceal bleeding,

 4. received beta blocker within one month prior to entry,

 5. had history of contraindication to the use of beta blockers, such as asthma, heart
 failure, atrioventricular block, bradycardia (pulse rate <55/min) or arterial
 hypotension (systolic blood pressure<90 mmHg).

 6. had history of prior shunt operation, TIPS (transjugular intrahepatic portosystemic
 stent shunt), EIS or EVL,

 7. deep jaundice (serum bilirubin >10mg/dl),

 8. encephalopathy greater than stage II,

 9. failure in control of index variceal bleeding,

 10. death within 24 hours of admission, or

 11. refused to participate in the trial.