Primary Prophylaxis of Variceal Haemorrhage in Patients with Cirrhosis: An Integrated Pharmacological and Endoscopic Approach.

Background: At the present time, in patients with liver cirrhosis and gastroesophageal varices, primary prophylaxis of variceal bleeding made with combination therapy with non-selective b-blockers (NSBBs) and endoscopic band ligation (EBL) is not recommended. The aim of this study was to evaluate if patients who develop an increased bleeding risk from varices while on NSBBs regimen benefit, in terms of bleeding and survival, from adding treatment with EBL. Methods: Patients with endoscopic finding of gastroesophageal varices with increased risk of bleeding (increased variceal size and/or development of red signs) during primary prophylaxis with NSBBs, followed at the Unit of Internal Medicine and Hepatology, University and General Hospital of Padova, Italy, from 2012 to 2019, were retrospectively evaluated. When an increased bleeding risk of the varices was confirmed, patients maintained the pharmacological therapy alone or underwent also EBL. The primary endpoint of the study was the rate of variceal bleeding, the secondary endpoint was mortality at 30 months. Results: Compared to patients treated only with NSBBs (n=56), in patients treated also with EBL (n=45), the 30‐month probability of variceal bleeding (29.1% vs 5.1%; P =0.036) was significantly reduced, while the probability of survival was similar (59.6% vs. 65.7%; P=0.61). On multivariate analysis, treatment with EBL was found to be a weak protective factor for mortality (HR 0.47, P=0.044). Conclusion: In patients with liver cirrhosis, when varices show endoscopic feature of increased haemorrhagic risk, adding EBL to NSBBs is effective in reducing the probability of first bleeding.