Skip to main content

Endoscopic ultrasonography assessment of para-esophageal varices predicts efficacy of propranolol in preventing recurrence of esophageal varices

Journal of Gastroenterology volume 50, pages 342–349 (2015)Cite this article

Abstract

Background

Volume of para-esophageal varices (PEV) correlates with esophageal varices recurrence. The effect of propranolol on volumetric change of PEV has not been studied. The relation between EV recurrence and volumetric change of PEV in patients undergoing endoscopic variceal ligation (EVL) with and without propranolol are studied.

Methods

Sixty-six patients who achieved EV eradication by primary EVL were randomly allocated to a propranolol group (n = 33) or control group (n = 33). The endpoints of the study were EV recurrence and volumetric change of PEV assessed by using endoscopic ultrasonography (EUS) at 3-month intervals for 2 years.

Results

The cumulative probability of recurrence at two years was 28 % in the propranolol group (n = 9) and 68 % in the control group (n = 20) (p = 0.005, log-rank test). Difference of the volumetric change of PEV became significant as early as at the third month [−0.12 (−0.38–0.34) vs. 0.14 (−0.06–0.57), p < 0.001] between the two groups. Regression of PEV was achieved in 20 patients of the propranolol group at a median time of three months (range 3–12 months), and no EV recurrence was found at the end of follow-up for two years. On multivariate analysis, the volumetric change of PEV at the third month and use of propranolol were determinants of EV recurrence.

Conclusions

Propranolol may reduce both EV recurrence rate and volume of PEV in patients achieving endoscopic eradication. Regression of PEV is a predictor of durable eradication of EV without recurrence in patients using propranolol. EUS is an objective and useful tool to measure PEV and predict recurrence of EV.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

References

  1. Bernard B, Lebrec D, Mathurin P, et al. Propranolol and sclerotherapy in the prevention of gastrointestinal rebleeding in patients with cirrhosis: a meta-analysis. J Hepatol. 1997;26:312–24.

    Article  CAS  PubMed  Google Scholar 

  2. Khuroo MS, Khuroo NS, Farahat KLC, et al. Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding. Aliment Pharmacol Ther. 2005;21:347–61.

    Article  CAS  PubMed  Google Scholar 

  3. Gluud LL, Klingenberg S, Nikolova D, et al. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol. 2007;102:2842–8.

    Article  PubMed  Google Scholar 

  4. Hou MC, Lin HC, Lee FY, Chang FY, Lee SD. Recurrence of esophageal varices following endoscopic treatment and its impact on rebleeding: comparison of sclerotherapy and ligation. J Hepatol. 2000;32:202–8.

    Article  CAS  PubMed  Google Scholar 

  5. Lo GH, Liang HL, Lai KH, et al. The impact of endoscopic variceal ligation on the pressure of the portal venous system. J Hepatol. 1996;1:74–80.

    Article  Google Scholar 

  6. Sarin SK, Wadhawan M, Agarwal SR, et al. Endoscopic variceal ligation plus propranolol versus endoscopic variceal ligation alone in primary prophylaxis of variceal bleeding. Am J Gastroenterol. 2005;100:797–804.

    Article  PubMed  Google Scholar 

  7. Irisawa A, Saito A, Obara K, et al. Endoscopic recurrence of esophageal varices is associate with the specific EUS abnormalities: severe periesophageal collateral veins and large perforating veins. Gastrointest Endosc. 2001;53:77–84.

    Article  CAS  PubMed  Google Scholar 

  8. Lo GH, Lai KH, Cheng JS, et al. Prevalence of paraesophageal varices and gastric varices in patients achieving variceal obliteration by banding ligation and by injection sclerotherapy. Gastrointest Endosc. 1999;49:428–36.

    Article  CAS  PubMed  Google Scholar 

  9. Leung VK, Sung JJ, Ahuja AT, et al. Large paraesophageal varices on endosonography predict recurrence of esophageal varices and rebleeding. Gastroenterology. 1997;112:1811–6.

    Article  CAS  PubMed  Google Scholar 

  10. Bosch J, Masti R, Kravetz D, et al. Effects of propranolol on azygos venous blood flow and hepatic and systemic hemodynamics in cirrhosis. Hepatology. 1984;4:1200–5.

    Article  CAS  PubMed  Google Scholar 

  11. El-Saadany M, Jalil S, Irisawa A, et al. EUS for portal hypertension: a comprehensive and critical appraisal of clinical and experimental indications. Endoscopy. 2008;40:690–6.

    Article  CAS  PubMed  Google Scholar 

  12. De Lisi S, Buscarini E. Endoscopic ultrasonography and portal hypertension: where are we in 2009? Eur J Gastroenterol Hepatol. 2009;21:1327–32.

    Article  PubMed  Google Scholar 

  13. Hou MC, Lin HC, Kuo BI, et al. Comparison of endoscopic variceal injection sclerotherapy and ligation for the treatment of esophageal variceal hemorrhage: a prospective randomized trial. Hepatology. 1995;21:1517–22.

    CAS  PubMed  Google Scholar 

  14. Irisawa A, Obara K, Sato Y, et al. EUS analysis of collateral veins inside and outside the esophageal wall in portal hypertension. Gastrointest Endosc. 1999;50:374–80.

    Article  CAS  PubMed  Google Scholar 

  15. Escorsell A, Bordas JM, Feu F, et al. Endoscopic assessment of variceal volume and wall tension in cirrhotic patients: effects of pharmacological therapy. Gastroenterology. 1997;113:1640–6.

    Article  CAS  PubMed  Google Scholar 

  16. Chen WC, Hou MC, Lin HC, et al. Feasibility and potential benefit of maintenance endoscopic variceal ligation in patients with unresectable hepatocellular carcinoma and acute esophageal variceal hemorrhage: a controlled trial. Gastrointest Endosc. 2001;54:18–23.

    Article  CAS  PubMed  Google Scholar 

  17. Bambha K, Kim WR, Pedersen R, et al. Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis. Gut. 2008;57:814–20.

    Article  CAS  PubMed  Google Scholar 

  18. North-Italian Endoscopic Club for the study and treatment of esophageal varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study. N Engl J Med. 1988;319:983–9.

    Article  Google Scholar 

  19. Miller LS, Schiano TD, Adrain A, et al. Comparison of high-resolution endoluminal sonography to video endoscopy in the detection and evaluation of esophageal varices. Hepatology. 1996;24:552–5.

    Article  CAS  PubMed  Google Scholar 

  20. Konishi Y, Nakamura T, Kida H, et al. Catheter US probe EUS evaluation of gastric cardia and perigastric vascular structures to predict esophageal variceal recurrence. Gastrointest Endosc. 2002;55:197–203.

    Article  PubMed  Google Scholar 

  21. Matsumoto A, Hamamoto N, Ohnishi A, et al. Left gastric vein hemodynamics and variceal recurrence in patients undergoing prophylactic endoscopic ligation of high-risk esophageal varices. Gastrointest Endosc. 1999;50:768–74.

    Article  CAS  PubMed  Google Scholar 

  22. Braillon A, Cales P, Valla D, et al. Influence of the degree of liver failure on systemic and splanchnic haemodynamics and on response to propranolol in patients with cirrhosis. Gut. 1986;27:1204–9.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  23. Merkel C, Bolognesi M, Berzigotti A, et al. Clinical significance of worsening portal hypertension during long-term medical treatment in patients with cirrhosis who had been classified as early good-responders on haemodynamic criteria. J Hepatol. 2010;52:45–53.

    Article  PubMed  Google Scholar 

  24. Groszmann RJ, Garcia-Tsao G, Bosch J, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005;353:2254–61.

    Article  CAS  PubMed  Google Scholar 

  25. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infection in the intensive care unit. Crit Care Med. 2004;32:2014–20.

    Article  PubMed  Google Scholar 

  26. de Franchis R, Baveno Faculty V. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53:762–8.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This work was supported in part by grants V97C1-023 and V98C1-034 from the Veterans General Hospital-Taipei, and in part by a grant NSC99-2314-B-010-MY3 from the National Science Council, Taiwan.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Affiliations

  1. School of Medicine, National Yang Ming University, No. 155, Sec. 2, Linong Street, Taipei, 112, Taiwan (ROC)

    Wei-Chih Liao, Ping-Hsien Chen, Ming-Chih Hou, Chen-Jung Chang, Chien-Wei Su, Han-Chieh Lin & Fa-Yauh Lee

  2. Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan

    Wei-Chih Liao

  3. Endoscopy Center for Diagnosis and Treatment, Taipei Veterans General Hospital, Taipei, Taiwan

    Ping-Hsien Chen & Ming-Chih Hou

  4. Division of Gastroenterology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan

    Ming-Chih Hou, Chien-Wei Su, Han-Chieh Lin & Fa-Yauh Lee

  5. Taipei Medical University Hospital, Taipei, Taiwan

    Chen-Jung Chang

Authors
  1. Wei-Chih Liao
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ping-Hsien Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ming-Chih Hou
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Chen-Jung Chang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Chien-Wei Su
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Han-Chieh Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Fa-Yauh Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ming-Chih Hou.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Liao, WC., Chen, PH., Hou, MC. et al. Endoscopic ultrasonography assessment of para-esophageal varices predicts efficacy of propranolol in preventing recurrence of esophageal varices. J Gastroenterol 50, 342–349 (2015). https://doi.org/10.1007/s00535-014-0970-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00535-014-0970-y

Keywords

  • Endoscopic ultrasonography
  • Endoscopic variceal ligation
  • Esophageal varices
  • Para-esophageal varices (PEV)
  • Propranolol