At the Biennial Meeting of the International Association for the Study of the Liver, in Cape Town, South Africa, 20-24 February 1996, the treatment of oesophageal
varices was selected as a subject for the discussion of controversies in
portal hypertension. This review gives a summary of that discussion. Dr Didier LeBrec gave a broad overview of the medical management of oesophageal
varices by presenting a list of 52 pharmacological agents that reduce portal venous pressure and presented the advantages and disadvantages of each. He emphasized that recent randomized clinical trials (RCT) have demonstrated that
propranolol delays and decreases the occurrence of haemorrhage from
varices in patients who have not previously suffered such complications. He also reported that isosorbidemononitrate is equally effective and further enhances the effect of
propranolol. He also reported that the effects of
propranolol plus endoscopic
sclerotherapy (EST) were more effective than EST alone in preventing haemorrhage, but not in improving survival. Finally he noted that
propranolol in high dosage did not prevent the development of large
varices in cirrhotic patients with small or undetectable
varices. Dr John Terblanche compared the efficacy of EST and endoscopic
ligation of
varices (ELV) and reported that all four RCTs found ELV to be superior. He discussed
portacaval anastomosis (PCA) and concluded that only emergency PCA as reported by Orloff, is thought to be truly beneficial, and suggested that EST, plus ELV may be the treatment of choice. Dr Harold O. Conn, who served as the moderator of this session summarized the presentations and pointed out that
liver transplantation is the most effective form of
therapy of all, albeit extremely complex and expensive. He discussed transjugular intrahepatic
portosystemic shunts (
TIPS), the newest form of
therapy, and emphasized its virtues (immediate reduction of portal venous pressure) and its limitations (frequent
portosystemic encephalopathy and frequent spontaneous
stenoses). He presented a brief discussion of the prevention of the development of the
varices themselves, currently termed "pre-primary prophylaxis', a hope for the future. He ended with "Predictions' which if proven correct will give a preview of
portal hypertension in the 21st century.