Variceal
hemorrhage still carries a high mortality and a high risk of recurrence.
Esophageal varices bleed rarely with a porto-systemic pressure gradient below 12 mmHg;
pharmacotherapy, thus, aims at lowering the pressure gradient below this critical threshold. Conceptually, this can be achieved by decreasing portal-venous inflow (via lowering cardiac output and/or increasing splanchnic-arteriolar vasoconstriction) or by decreasing portal-venous resistence (via portal vasodilation). In acute variceal
bleeding, easily applicable
pharmacotherapy with
terlipressin plus
nitroglycerin, probably also with
octreotide, can help to stabilize the patient and to buy time until diagnostic endoscopy and treatment by
sclerotherapy or variceal band
ligation. For pharmacotherapeutic secondary prophylaxes of variceal
hemorrhage the combination of
propranolol or
nadolol with isosorbid-5-mononitrate is available. Future studies will tell, whether this
drug combination is superior to the nowadays established endoscopic eradication of
varices, especially by long-term variceal band
ligation. For primary prophylaxis of variceal
hemorrhage non-selective beta-anatagonists remain the
therapy of choice in compliant patients with
esophageal varices and endoscopic signs indicating a high risk of
bleeding. Future studies must clarify the role of the beta-antagonist-
nitrate combination, as well as that of prophylactic variceal band
ligation, in this setting.