The patient who cannot receive beta-blockers
During the past 15–20 years management of patients with varices and portal hypertensive gastropathy has been made much easier by the finding that non-selective beta-blockers reduce portal pressure1. Subsequent controlled trials have shown that non-selective beta-blockers are effective in the primary and secondary prevention of variceal bleeding, and they are the standard form of treatment for these complications of portal hypertension2, 3, 4, 5. In addition, bleeding from portal hypertensive gastropathy is reduced following treatment with beta-blockers6. Unfortunately, many patients are intolerant of beta-blockers and thus must be treated with alternative therapies. In this chapter the alternatives to beta-blocker therapy for the treatment of the above conditions are discussed. Controlled trials examining different therapies in this subgroup of patients would allow for determination of the best approach. However, we lack these controlled trials and the conclusions in this chapter are based on data extracted from trials in which beta-blockers were compared to other therapies. I have assumed that the patient intolerant of beta-blockers will respond to alternative therapies in the same manner as patients who can tolerate beta-blockers.
KeywordsPortal Hypertension Transjugular Intrahepatic Portosystemic Shunt Esophageal Varix Primary Prophylaxis Isosorbide Mononitrate
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