The cirrhotic patient with no varices and with small varices

  • Carlo Merkel
  • Massimo Bolognesi
  • Angelo Gatta
Conference paper


The history of treatment of portal hypertension is characterized by a progressive tendency to treat patients in earlier stages of the disease. Indeed, in the beginning, treatment of portal hypertension was limited to treatment of acute bleeding and prevention of recurrent variceal bleeding; from the end of the 1980s it was shown that patients with high-risk varices but without previous bleeding are good candidates for a pharmacologic prophylaxis (and in some instances for an endoscopic prophylaxis). Recent research has been devoted to investigating whether prophylaxis of variceal bleeding should be started early, when varices are not yet present (in order to prevent varices formation), or when small varices with low risk of bleeding are seen, in order to decrease the risk of growth of varices and eventually the risk of variceal bleeding 1. This area of research, sometimes called “pre-primary prophylaxis”, is the background on which the clinical decisions on single patients with cirrhosis without varices or with small varices should be made.


Portal Hypertension Cirrhotic Patient Esophageal Varix Variceal Bleeding Portal Pressure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Merkel C, Escorsell A, Sieber CC, Lee FY, Groszmann RJ. Pre-primary prophylaxis: can (and should) we prevent the formation and growth of varices? In: de Franchis R, editor. Portal Hypertension III. Oxford: Blackwell, 2001:97–111.Google Scholar
  2. 2.
    Lebrec D, De Fleury P, Rueff B, Nahum H, Benhamou JP. Portal hypertension, size of esophageal varices, and risk of gastrointestinal bleeding in alcoholic cirrhosis. Gastroenterology. 1980;79:1139–44.PubMedGoogle Scholar
  3. 3.
    Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices, and variceal bleeding. Hepatology. 1985;5:419–24PubMedCrossRefGoogle Scholar
  4. 4.
    Zuin R, Gatta A, Merkel C et al. Evaluation of peritoneoscopic and oesophagoscopic findings as indexes of portal hypertension in patients with liver cirrhosis. Ital J Gastroenterol. 1982;14:214–19.Google Scholar
  5. 5.
    Sarin SK, Groszmann RJ, Mosca PG et al. Propranolol ameliorates the development of portal-systemic shunting in a chronic murine schistosomiasis model of portal hypertension. J Clin Invest. 1991;87:1032–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Colombato LA, Albillos A, Genecin P. Prevention of portal-systemic shunting in propranolol-treated and in sodium-restricted cirrhotic rats. Gastroenterology. 1991;100:A730.Google Scholar
  7. 7.
    Lin HC, Soubrane O, Cailmail S, Lebrec D. Early chronic administration of propranolol reduces the severity of portal hypertension and portal-systemic shunts in conscious portal vein stenosed rats. J Hepatol. 1991;13:213–19.PubMedCrossRefGoogle Scholar
  8. 8.
    Oberti F, Rifflet H, Maiga MY et al. Prevention of portal hypertension by propranolol and spironolactone in rats with bile duct ligation. J Hepatol. 1997;26:167–73.PubMedCrossRefGoogle Scholar
  9. 9.
    Calès P, Desmorat H, Vinel JP et al. Incidence of large esophageal varices in patients with cirrhosis: application to prophylaxis of first bleeding. Gut. 1990;31:1298–302.PubMedCrossRefGoogle Scholar
  10. 10.
    Pagliaro L, D’Amico G, Pasta L et al. Portal hypertension in cirrhosis: natural history. In: Bosch J, Groszmann RJ, editors. Portal Hypertension: Pathophysiology and Treatment. Oxford: Blackwell, 1994:72–92.Google Scholar
  11. 11.
    Merli M, Nicolini G, Angeloni S et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol. 2003;38:361–3.CrossRefGoogle Scholar
  12. 12.
    Groszmann RJ, Garcia-Tsao G, Makuch R et al. Multicenter randomized placebo-controlled trial of non-selective beta-blockers in the prevention of the complications of portal hypertension: final results and identification of a predictive factor. Hepatology. 2003;38 (Suppl. 1):206 (abstract).Google Scholar
  13. 13.
    Le Moine O, Hadengue A, Moreau R et al. Relationship between portal pressure, esophageal varices and variceal bleeding on the basis of the stage and cause of cirrhosis. Scand J Gastroenterol. 1997;32:731–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Gluud C, Henriksen JH, Nielsen G, Copenhagen Study Group for Liver Disease. Prognostic indicators in alcoholic cirrhotic man. Hepatology. 1988;8:222–7.PubMedCrossRefGoogle Scholar
  15. 15.
    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. N Engl J Med. 1988;319:983–9.CrossRefGoogle Scholar
  16. 16.
    Rigo GP, Merighi A, Chahin NJ et al. A prospective study of the ability of three endoscopic classifications to predict hemorrhage from esophageal varices. Gastrointest Endosc. 1992; 38:425–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Prada A, Bortoli A, Minoli G, Carnovali M, Colombo E, Sangiovanni A. Prediction of oesophageal variceal bleeding: evaluation of the Beppu and North Italian Endoscopic Club scores by an independent group. Eur J Gastroenterol Hepatol. 1994;6:1009–13.CrossRefGoogle Scholar
  18. 18.
    Zoli M, Merkel C, Magalotti D, Marchesini G, Gatta A, Pisi E. Evaluation of a new endoscopic index to predict first bleeding from the upper gastrointestinal tract in patients with cirrhosis. Hepatology. 1996;24:1047–52.PubMedCrossRefGoogle Scholar
  19. 19.
    Merkel C, Marin R, Angeli P, Zanella P et al. Beta-blockers in the prevention of aggravation of esophageal varices in patients with cirrhosis and small esophageal varices: a placebocontrolled clinical trial. Hepatology. 2003;38(Suppl. 1):217 (abstract).CrossRefGoogle Scholar
  20. 20.
    Escorsell A, Ferayorni L, Bosch J et al. The portal pressure response to beta-blockade is greater in cirrhotic patients without varices than in those with varices. Gastroenterology. 1997;112:2012–16.PubMedCrossRefGoogle Scholar
  21. 21.
    Calès P, Oberti F, Payen JL et al. Lack of effect of propranolol in the prevention of large esophageal varices in patients with cirrhosis: a randomized trial. French-Speaking Club for the Study of Portal Hypertension. Eur J Gastroenterol Hepatol. 1999;11:741–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Merkel C, Angeli P, Marin R et al. Beta-blockers in the prevention of aggravation of esophageal varices in patients with cirrhosis and small esophageal varices. interim analysis of a controlled clinical trial. Hepatology. 1998;28(Suppl. 1):453A (abstract).Google Scholar
  23. 23.
    Andreani T, Poupon RE, Balkau BJ et al. Preventive therapy of first gastrointestinal bleeding in patients with cirrhosis: results of a controlled trial comparing propranolol, endoscopic sclerotherapy and placebo. Hepatology. 1990;12:1413–19.PubMedCrossRefGoogle Scholar
  24. 24.
    Conn HO, Grace ND, Bosch J et al. Propranolol in the prevention of the first hemorrhage from esophagogastric varices: a multicenter, randomized clinical trial. Hepatology. 1991;13:902–12.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2004

Authors and Affiliations

  • Carlo Merkel
    • 1
  • Massimo Bolognesi
  • Angelo Gatta
  1. 1.Department of Clinical and Experimental MedicineUniversity of PaduaPadovaItaly

Personalised recommendations