Management: Cirrhotic Portal Hypertension



Gastroesophageal varices are a direct consequence of portal hypertension, the main complication of cirrhosis. An understanding of the pathophysio­logy of portal hypertension has led to significant improvements in the prevention and treatment of variceal hemorrhage. However, variceal hemorrhage continues to carry a significant mortality. By screening all patients with cirrhosis for varices, applying prophylaxis appropriately, actively managing acute variceal hemorrhage, and aggressively preventing recurrence, survival can be improved. Future directions include better risk stratification for a more individualized care, determining the role of noninvasive markers of varices and portal pressure and the development of novel pharmacotherapeutic agents.


Variceal hemorrhage Esophagogastric varices Cirrhosis Portal hypertension 


  1. 1.
    D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis. A systematic review of 118 studies. J Hepatol 2006; 44:217–231.Google Scholar
  2. 2.
    Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis. N Engl J Med 2010; 362(9):823–832.PubMedCrossRefGoogle Scholar
  3. 3.
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46(3):922–938.PubMedCrossRefGoogle Scholar
  4. 4.
    Garcia-Tsao G, Lim JK. Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program. Am J Gastroenterol 2009; 104(7):1802–1829.PubMedCrossRefGoogle Scholar
  5. 5.
    de Franchis R. Evolving Consensus in Portal Hypertension Report of the Baveno IV Consensus Workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005; 43(1):167–176.PubMedCrossRefGoogle Scholar
  6. 6.
    Garcia-Tsao G, Bosch J, Groszmann RJ. Portal hypertension and variceal bleeding – unresolved issues. Summary of an American Association for the Study of Liver Diseases and European Association for the Study of the Liver Single-Topic Conference. Hepatology 2008; 47(5):1764–1772.Google Scholar
  7. 7.
    Kovalak M, Lake J, Mattek N, Eisen G, Lieberman D, Zaman A. Endoscopic screening for varices in cirrhotic patients: data from a national endoscopic database. Gastrointest Endosc 2007; 65(1):82–88.PubMedCrossRefGoogle Scholar
  8. 8.
    Navasa M, Pares A, Bruguera M, Caballeria J, Bosch J, Rodes J. Portal hypertension in primary biliary cirrhosis. Relationship with histological features. J Hepatol 1987; 5(3):292–298.Google Scholar
  9. 9.
    Sanyal AJ, Fontana RJ, DiBisceglie AM, Everhart JE, Doherty MC, Everson GT et al. The prevalence and risk factors associated with esophageal varices in subjects with hepatitis C and advanced fibrosis. Gastrointest Endosc 2006; 64:855–864.PubMedCrossRefGoogle Scholar
  10. 10.
    Blasco A, Forns X, Carrion JA, Garcia-Pagan JC, Gilabert R, Rimola A et al. Hepatic venous pressure gradient identifies patients at risk of severe hepatitis C recurrence after liver transplantation. Hepatology 2006; 43(3):492–499.PubMedCrossRefGoogle Scholar
  11. 11.
    Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med 2005; 353:2254–2261.PubMedCrossRefGoogle Scholar
  12. 12.
    Merli M, Nicolini G, Angeloni S, Rinaldi V, De Santis A, Merkel C et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003; 38(3):266–272.PubMedCrossRefGoogle Scholar
  13. 13.
    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; 319:983–989.Google Scholar
  14. 14.
    Lecleire S, Di Fiore F, Merle V, Herve S, Duhamel C, Rudelli A et al. Acute upper gastrointestinal bleeding in patients with liver cirrhosis and in noncirrhotic patients: epidemiology and predictive factors of mortality in a prospective multicenter population-based study. J Clin Gastroenterol 2005; 39(4):321–327.PubMedCrossRefGoogle Scholar
  15. 15.
    Abraldes JG, Villanueva C, Banares R, Aracil C, Catalina MV, Garci A-P et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 2008; 48(2):229–236.PubMedCrossRefGoogle Scholar
  16. 16.
    Augustin S, Muntaner L, Altamirano JT, Gonzalez A, Saperas E, Dot J et al. Predicting early mortality after acute variceal hemorrhage based on classification and regression tree analysis. Clin Gastroenterol Hepatol 2009; 7(12):1347–1354.PubMedCrossRefGoogle Scholar
  17. 17.
    Villanueva C, Piqueras M, Aracil C, Gomez C, Lopez-Balaguer JM, Gonzalez B et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol 2006; 45(4):560–567.PubMedCrossRefGoogle Scholar
  18. 18.
    Bosch J, Thabut D, Albillos A, Carbonell N, Spicak J, Massard J et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: A randomized, controlled trial. Hepatology 2008;47(5):1604–1614.PubMedCrossRefGoogle Scholar
  19. 19.
    El-Serag HB, Everhart JE. Improved survival after variceal hemorrhage over an 11-year period in the Department of Veterans Affairs. Am J Gastroenterol 2000; 95:3566–3573.PubMedCrossRefGoogle Scholar
  20. 20.
    Bosch J, Garcia-Pagan JC. Prevention of variceal rebleeding. Lancet 2003; 361(9361):952–954.PubMedCrossRefGoogle Scholar
  21. 21.
    Groszmann RJ, Glickmann MM, Blei A, Storer EH, Conn HO. Wedged and free hepatic venous pressure measured with a balloon catheter. Gastroenterology 1979; 76(2):253–258.PubMedGoogle Scholar
  22. 22.
    Groszmann RJ, Wongcharatrawee S. The hepatic venous pressure gradient: Anything worth doing should be done right. Hepatology 2004; 39(2):280–283.PubMedCrossRefGoogle Scholar
  23. 23.
    Bosch J, Garcia-Pagan JC, Berzigotti A, Abraldes JG. Measurement of portal pressure and its role in the management of chronic liver disease. Semin Liver Dis 2006; 26(4):348–362.PubMedCrossRefGoogle Scholar
  24. 24.
    Villanueva C, Aracil C, Colomo A, Hernandez-Gea V, Lopez-Balaguer JM, Alvarez-Urturi C et al. Acute hemodynamic response to beta-blockers and prediction of long-term outcome in primary prophylaxis of variceal bleeding. Gastroenterology 2009; 137(1):119–128.PubMedCrossRefGoogle Scholar
  25. 25.
    Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology 1985; 5(3):419–424.PubMedCrossRefGoogle Scholar
  26. 26.
    Groszmann RJ, Bosch J, Grace N, Conn HO, Garcia-Tsao G, Navasa M et al. Hemodynamic events in a prospective randomized trial of propranolol vs placebo in the prevention of the first variceal hemorrhage. Gastroenterology 1990; 99(5):1401–1407.PubMedGoogle Scholar
  27. 27.
    Feu F, Garcia-Pagan JC, Bosch J, Luca A, Teres J, Escorsell A et al. Relation between portal pressure response to pharmacotherapy and risk of recurrent variceal haemorrhage in patients with cirrhosis. Lancet 1995; 346:1056–1059.PubMedCrossRefGoogle Scholar
  28. 28.
    D’Amico G, Garcia-Pagan JC, Luca A, Bosch J. HVPG reduction and prevention of variceal bleeding in cirrhosis. A systematic review. Gastroenterology 2006; 131:1611–1624.Google Scholar
  29. 29.
    Moitinho E, Escorsell A, Bandi JC, Salmeron JM, Garcia-Pagan JC, Rodes J et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology 1999; 117:626–631.PubMedCrossRefGoogle Scholar
  30. 30.
    Monescillo A, Martinez-Lagares F, Ruiz-del-Arbol L, Sierra A, Guevara C, Jimenez E et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40(4):793–801.PubMedGoogle Scholar
  31. 31.
    Perello A, Escorsell A, Bru C, Gilabert R, Moitinho E, Garcia-Pagan JC et al. Wedged hepatic venous pressure adequately reflects portal pressure in hepatitis C virus-related cirrhosis. Hepatology 1999; 30:1393–1397.PubMedCrossRefGoogle Scholar
  32. 32.
    de Franchis R, Pascal JP, Burroughs AK, Henderson JM, Fleig W, Groszmann RJ et al. Definitions, methodology and therapeutic strategies in portal hypertension. A Consensus Development Workshop. J Hepatol 1992; 15:256–261.CrossRefGoogle Scholar
  33. 33.
    Giannini E, Botta F, Borro P, Risso D, Romagnoli P, Fasoli A et al. Platelet count/spleen diameter ratio: proposal and validation of a non-invasive parameter to predict the presence of oesophageal varices in patients with liver cirrhosis. Gut 2003; 52(8):1200–1205.PubMedCrossRefGoogle Scholar
  34. 34.
    D’Amico G, Morabito A. Noninvasive markers of esophageal varices: another round, not the last. Hepatology 2004; 39(1):30–34.PubMedCrossRefGoogle Scholar
  35. 35.
    de Franchis R. Non-invasive (and minimally invasive) diagnosis of oesophageal varices. J Hepatol 2008; 49(4):520–527.PubMedCrossRefGoogle Scholar
  36. 36.
    de Franchis R, Eisen GM, Laine L, Fernandez-Urien I, Herrerias JM, Brown RD et al. Esophageal capsule endoscopy for screening and surveillance of esophageal varices in patients with portal hypertension. Hepatology 2008; 47(5):1595–1603.PubMedCrossRefGoogle Scholar
  37. 37.
    Castera L, Le Bail B, Roudot-Thoraval F, Bernard PH, Foucher J, Merrouche W et al. Early detection in routine clinical practice of cirrhosis and oesophageal varices in chronic hepatitis C: comparison of transient elastography (FibroScan) with standard laboratory tests and non-invasive scores. J Hepatol 2009; 50(1):59–68.PubMedCrossRefGoogle Scholar
  38. 38.
    Kim SH, Kim YJ, Lee JM, Choi KD, Chung YJ, Han JK et al. Esophageal varices in patients with cirrhosis: multidetector CT esophagography – comparison with endoscopy. Radiology 2007; 242(3):759–768.PubMedCrossRefGoogle Scholar
  39. 39.
    Lapalus MG, Ben Soussan E, Gaudric M, Saurin JC, D’Halluin PN, Favre O et al. Esophageal capsule endoscopy vs. EGD for the evaluation of portal hypertension: a French prospective multicenter comparative study. Am J Gastroenterol 2009; 104(5):1112–1118.Google Scholar
  40. 40.
    Ladas SD, Triantafyllou K, Spada C, Riccioni ME, Rey JF, Niv Y et al. European Society of Gastrointestinal Endoscopy (ESGE): recommendations (2009) on clinical use of video capsule endoscopy to investigate small-bowel, esophageal and colonic diseases. Endoscopy 2010; 42(3):220–227.PubMedCrossRefGoogle Scholar
  41. 41.
    Blei AT, Garcia-Tsao G, Groszmann RJ, Kahrilas P, Ganger D, Fung HL. Hemodynamic evaluation of isosorbide dinitrate in alcoholic cirrhosis: Pharma­cokinetic-hemodynamic interactions. Gastroenterology 1987; 93:576–583.PubMedGoogle Scholar
  42. 42.
    Gonzalez-Abraldes J, Albillos A, Banares R, Ruiz del Arbol L, Moitinho E, Rodriguez C et al. Randomized comparison of long-term losartan versus propranolol in lowering portal pressure in cirrhosis. Gastroenterology 2001; 121:382–388.Google Scholar
  43. 43.
    Schepke M, Werner E, Biecker E, Schiedermaier P, Heller J, Neef M et al. Hemodynamic effects of the angiotensin II receptor antagonist irbesartan in patients with cirrhosis and portal hypertension. Gastroenterology 2001; 121:389–395.PubMedCrossRefGoogle Scholar
  44. 44.
    Abraldes JG, Albillos A, Banares R, Turnes J, Gonzalez R, Garcia-Pagan JC et al. Simvastatin lowers portal pressure in patients with cirrhosis and portal hypertension: a randomized controlled trial. Gastroenterology 2009; 136(5):1651–1658.PubMedCrossRefGoogle Scholar
  45. 45.
    Groszmann RJ, Kravetz D, Bosch J, Glickman M, Bruix J, Bredfeldt JE et al. Nitroglycerin improves the hemodynamic response to vasopressin in portal hypertension. Hepatology 1982; 2:757–762.PubMedCrossRefGoogle Scholar
  46. 46.
    Garcia-Pagan JC, Feu F, Bosch J, Rodes J. Propranolol compared with propranolol plus isosorbide-5-mononitrate for portal hypertension in cirrhosis. A randomized controlled study. Ann Intern Med 1991; 114:869–873.Google Scholar
  47. 47.
    Banares R, Moitinho E, Matilla A, Garcia-Pagan JC, Lampreave JL, Piera C et al. Randomized comparison of long-term carvedilol and propranolol administration in the treatment of portal hypertension in cirrhosis. Hepatology 2002; 36(6):1367–1373.PubMedGoogle Scholar
  48. 48.
    Sarin SK, Groszmann RJ, Mosca PG, Rojkind M, Stadecker MJ, Reuben A et al. Propranolol ameliorates the development of portal-systemic shunting in a chronic murine schistosomiasis model of portal hypertension. J Clin Invest 1991; 87:1032–1036.PubMedCrossRefGoogle Scholar
  49. 49.
    D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: A meta-analytic review. Hepatology 1995; 22(1):332–354.PubMedGoogle Scholar
  50. 50.
    D’Amico G, Pagliaro L, Bosch J. Pharmacological treatment of portal hypertension: an evidence-based approach. Sem Liv Dis 1999; 19:475–505.CrossRefGoogle Scholar
  51. 51.
    Perez-Ayuso RM, Pique JP, Bosch J, Panes J, Gonzalez A, Perez R et al. Propranolol in prevention of recurrent bleeding from severe portal hypertensive gastropathy in cirrhosis. Lancet 1991; 337:1431–1434.PubMedCrossRefGoogle Scholar
  52. 52.
    Turnes J, Garcia-Pagan JC, Abraldes JG, Hernandez-Guerra M, Dell’era A, Bosch J. Pharmacological reduction of portal pressure and long-term risk of first variceal bleeding in patients with cirrhosis. Am J Gastroenterol 2006; 101(3):506–512.PubMedCrossRefGoogle Scholar
  53. 53.
    Hernandez-Gea V, Colomo A, Aracil C, Concepcion M, Poca MC, Torras X et al. Relationship between changes in portal pressure and development of ascites in cirrhotic patients with severe portal hypertension. Hepatology 50[4 (Suppl)], 313A. 2009.Ref Type: AbstractGoogle Scholar
  54. 54.
    Garcia-Tsao G, Grace N, Groszmann RJ, Conn HO, Bermann MM, Patrick MJ et al. Short term effects of propranolol on portal venous pressure. Hepatology 1986; 6:101–106.PubMedCrossRefGoogle Scholar
  55. 55.
    Abraczinkas DR, Ookubo R, Grace ND, Groszmann RJ, Bosch J, Garcia-Tsao G et al. Propranolol for the prevention of first variceal hemorrhage: A lifetime commitment? Hepatology 2001; 34:1096–1102.CrossRefGoogle Scholar
  56. 56.
    Longacre AV, Imaeda A, Garcia-Tsao G, Fraenkel L. A pilot project examining the predicted preferences of patients and physicians in the primary prophylaxis of variceal hemorrhage. Hepatology 2008; 47:169–176.PubMedCrossRefGoogle Scholar
  57. 57.
    Tripathi D, Ferguson JW, Kochar N, Leithead JA, Therapondos G, McAvoy NC et al. Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed. Hepatology 2009; 50(3):825–833.PubMedCrossRefGoogle Scholar
  58. 58.
    Bosch J, Garcia-Tsao G. Pharmacological versus endoscopic therapy in the prevention of variceal hemorrhage: and the winner is.. Hepatology 2009; 50(3):674–677.PubMedCrossRefGoogle Scholar
  59. 59.
    Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995; 123:280–287.Google Scholar
  60. 60.
    Khuroo MS, Khuroo NS, Farahat KL, Khuroo YS, Sofi AA, Dahab ST. Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding. Aliment Pharmacol Ther 2005; 21(4):347–361.PubMedCrossRefGoogle Scholar
  61. 61.
    Garcia-Pagan JC, Bosch J. Endoscopic band ligation in the treatment of portal hypertension. Nat Clin Pract Gastroenterol Hepatol 2005; 2(11):526–535.PubMedCrossRefGoogle Scholar
  62. 62.
    Gluud LL, Klingenberg S, Nikolova D, Gluud C. Banding ligation versus beta-blockers as primary prophylaxis in esophageal varices: systematic review of randomized trials. Am J Gastroenterol 2007; 102(12):2842–2848.PubMedCrossRefGoogle Scholar
  63. 63.
    Shaheen NJ, Stuart E, Schmitz SM, Mitchell KL, Fried MW, Zacks S et al. Pantoprazole reduces the size of postbanding ulcers after variceal band ligation: a randomized, controlled trial. Hepatology 2005; 41(3):588–594.PubMedCrossRefGoogle Scholar
  64. 64.
    Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E et al. A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology 2004; 127(2):476–484.PubMedCrossRefGoogle Scholar
  65. 65.
    Chalasani N, Kahi C, Francois F, Pinto A, Marathe A, Bini EJ et al. Improved patient survival after acute variceal bleeding: a multicenter, cohort study. Am J Gastroenterol 2003; 98(3):653–659.PubMedCrossRefGoogle Scholar
  66. 66.
    Carbonell N, Pauwels A, Serfaty L, Fourdan O, Levy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 2004; 40(3):652–659.PubMedCrossRefGoogle Scholar
  67. 67.
    Stokkeland K, Brandt L, Ekbom A, Hultcrantz R. Improved prognosis for patients hospitalized with esophageal varices in Sweden 1969-2002. Hepatology 2006; 43(3):500–505.PubMedCrossRefGoogle Scholar
  68. 68.
    Colomo A, Hernandez-Gea V, Muniz-Diaz E, Madoz P, Aracil C, Alvarez-Urturi C et al. Transfusion strategies in patients with cirrhosis and acute gastrointestinal bleeding. Hepatology 48[4 (Suppl)], 413A. 2008.Ref Type: AbstractGoogle Scholar
  69. 69.
    Bernard B, Grange JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999; 29:1655–1661.PubMedCrossRefGoogle Scholar
  70. 70.
    Hou MC, Lin HC, Liu TT, Kuo BI, Lee FY, Chang FY et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology 2004; 39(3):746–753.PubMedCrossRefGoogle Scholar
  71. 71.
    Rimola A, Garcia-Tsao G, Navasa M, Piddock LJV, Planas R, Bernard B et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. J Hepatol 2000; 32:142–153.PubMedCrossRefGoogle Scholar
  72. 72.
    Fernandez J, Ruiz dA, Gomez C, Durandez R, Serradilla R, Guarner C et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006; 131(4):1049–1056.Google Scholar
  73. 73.
    D’Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis. Gastroenterology 2003; 124(5):1277–1291.PubMedCrossRefGoogle Scholar
  74. 74.
    Ioannou GN, Doust J, Rockey DC. Systematic review: terlipressin in acute oesophageal variceal haemorrhage. Aliment Pharmacol Ther 2003; 17(1):53–64.PubMedCrossRefGoogle Scholar
  75. 75.
    Escorsell A, Ruiz del Arbol L, Planas R, Albillos A, Banares R, Cales P et al. Multicenter randomized controlled trial of terlipressin versus sclerotherapy in the treatment of acute variceal bleeding: the TEST study. Hepatology 2000; 32:471–476.Google Scholar
  76. 76.
    Escorsell A, Bandi JC, Andreu V, Moitinho E, Garcia-Pagan JC, Bosch J et al. Desensitization to the effects of intravenous octreotide in cirrhotic patients with portal hypertension. Gastroenterology 2001; 120:161–169.PubMedCrossRefGoogle Scholar
  77. 77.
    Banares R, Albillos A, Rincon D, Alonso S, Gonzalez M, Ruiz-del-Arbol L et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology 2002; 35:609–615.PubMedCrossRefGoogle Scholar
  78. 78.
    Cales P, Masliah C, Bernard B, Garnier PP, Silvain C, Szostak-Talbodec N et al. Early administration of vapreotide for variceal bleeding in patients with cirrhosis. N Engl J Med 2001; 344:23–28.PubMedCrossRefGoogle Scholar
  79. 79.
    Ramirez FC, Colon VJ, Landan D, Grade AJ, Evanich E. The effects of the number of rubber bands placed at each endoscopic session upon variceal outcomes: a prospective, randomized study. Am J Gastroenterol 2007; 102(7):1372–1376.PubMedCrossRefGoogle Scholar
  80. 80.
    Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med. 2010; 362(25):2370–2379.PubMedCrossRefGoogle Scholar
  81. 81.
    Hubmann R, Bodlaj G, Czompo M, Benko L, Pichler P, Al Kathib S et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006; 38(9):896–901.Google Scholar
  82. 82.
    Wright G, Lewis H, Hogan B, Burroughs A, Patch D, O’Beirne J. A self-expanding metal stent for complicated variceal hemorrhage: experience at a single center. Gastrointest Endosc 2010; 71(1):71–78.PubMedCrossRefGoogle Scholar
  83. 83.
    Gournay J, Masliah C, Martin T, Perrin D, Galmiche JP. Isosorbide mononitrate and propranolol compared with propranolol alone for the prevention of variceal rebleeding. Hepatology 2000; 31:1239–1245.PubMedCrossRefGoogle Scholar
  84. 84.
    Lo GH, Chen WC, Lin CK, Tsai WL, Chan HH, Chen TA et al. Improved survival in patients receiving medical therapy as compared with banding ligation for the prevention of esophageal variceal rebleeding. Hepatology 2008; 48(2):580–587.PubMedCrossRefGoogle Scholar
  85. 85.
    Gonzalez R, Zamora J, Gomez-Camarero J, Molinero LM, Banares R, Albillos A. Meta-analysis: Combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med 2008; 149(2):109–122.PubMedGoogle Scholar
  86. 86.
    Lo GH, Lai KH, Cheng JS, Chen MH, Huang HC, Hsu PI et al. Endoscopic variceal ligation plus nadolol and sucralfate compared with ligation alone for the prevention of variceal rebleeding: a prospective, randomized trial. Hepatology 2000; 32:461–465.PubMedCrossRefGoogle Scholar
  87. 87.
    de la PJ, Brullet E, Sanchez-Hernandez E, Rivero M, Vergara M, Martin-Lorente JL et al. Variceal ligation plus nadolol compared with ligation for prophylaxis of variceal rebleeding: a multicenter trial. Hepatology 2005; 41(3):572–578.Google Scholar
  88. 88.
    Villanueva C, Minana J, Ortiz J, Gallego A, Soriano G, Torras X et al. Endoscopic ligation compared with combined treatment with nadolol and isosorbide mononitrate to prevent recurrent variceal bleeding. N Engl J Med 2001; 345:647–655.PubMedCrossRefGoogle Scholar
  89. 89.
    Patch D, Goulis J, Gerunda G, Greenslade L, Merkel C, Burroughs AK. A randomized controlled trial of medical therapy versus endoscopic ligation for the prevention of variceal rebleeding in patients with cirrhosis. Gastroenterology 2002; 123:1013–1019.PubMedCrossRefGoogle Scholar
  90. 90.
    Lo G-H, Chen W-C, Chen M-H, Hsu P-I, Lin C-K, Tsai W-L et al. A prospective, randomized trial of endoscopic variceal ligation versus nadolol and isosorbide mononitrate for the prevention of esophageal variceal rebleeding. Gastroenterology 2002; 123:728–734.PubMedCrossRefGoogle Scholar
  91. 91.
    Romero G, Kravetz D, Argonz J, Vulcano C, Suarez A, Fassio E et al. Comparative study between nadolol and 5-isosorbide mononitrate vs. endoscopic band ligation plus sclerotherapy in the prevention of variceal rebleeding in cirrhotic patients: a randomized controlled trial. Aliment Pharmacol Ther 2006; 24(4):601–611.Google Scholar
  92. 92.
    Garcia-Pagan JC, Villanueva C, Albillos A, Banares R, Morillas R, Abraldes JG et al. Nadolol plus isosorbide mononitrate alone or associated with band ligation in the prevention of variceal rebleeding: A multicenter randomized controlled trial. Gut 2009; 58(8):1144–1150.PubMedCrossRefGoogle Scholar
  93. 93.
    Kumar A, Jha SK, Sharma P, Dubey S, Tyagi P, Sharma BC et al. Addition of propranolol and isosorbide mononitrate to endoscopic variceal ligation does not reduce variceal rebleeding incidence. Gastroenterology 2009; 137(3):892–901, 901.Google Scholar
  94. 94.
    Luca A, D’Amico G, LaGalla R, Midiri M, Morabito A, Pagliaro L. TIPS for prevention of recurrent bleeding in patients with cirrhosis: meta-analysis of randomized clinical trials. Radiology 1999; 212:411–421.PubMedGoogle Scholar
  95. 95.
    Papatheodoridis GV, Goulis J, Leandro G, Patch D, Burroughs AK. Transjugular intrahepatic portsystemic shunt compared with endoscopic treatment for prevention of variceal rebleeding. A meta-analysis. Hepatology 1999; 30:612–622.CrossRefGoogle Scholar
  96. 96.
    Villanueva C, Aracil C, Colomo A, Lopez-Balaguer JM, Piqueras M, Gonzalez B et al. Clinical trial: a randomized controlled study on prevention of variceal rebleeding comparing nadolol + ligation vs. hepatic venous pressure gradient-guided pharmacological therapy. Aliment Pharmacol Ther 2009; 29(4):397–408.Google Scholar
  97. 97.
    La Mura V, Abraldes JG, Raffa S, Retto O, Berzigotti A, Garcia-Pagan JC et al. Prognostic value of acute hemodynamic response to i.v. propranolol in patients with cirrhosis and portal hypertension. J Hepatol 2009; 51(2):279–287.Google Scholar

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© Springer New York 2011

Authors and Affiliations

  1. 1.Section of Digestive DiseasesYale University School of MedicineNew HavenUSA
  2. 2.Section of Digestive DiseasesVA Connecticut Health Care SystemWest HavenUSA

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