DIFFERENT ENDOSCOPIC MODALITIES FOR THE MANAGEMENT OF JUNCTIONAL VARICES

Methods: 103 patients with cirrhosis and acute variceal bleeding were considered.The hepatic venous pressure gradient (HVPG) was determined 4-6 days after the initial bleeding and repeated 5-7 days after maximum tolerated doses of drugs were achieved (maximum 160 mg qd and nitrates 40 mg bid).Hemodynamic responders (HVPG ≤ 12 mmHg or ≥20% decrease from baseline) were maintained on drugs and followed-up with additional annual HVPG evaluations.If rebleeding occurred, endoscopic ligation was added.Results: 48 patients were early responders.Median follow-up was 50 months (range 2-97).Etiology of cirrhosis was alcohol in 28 (58%) and viral + others in 20 (42%).Long-term HVPG evaluations could not be performed in 8 patients (4 deaths, 2 rebleedings, 2 follow-up <1 year).Long-term hemodynamic response was maintained in 26 (65%) patients and lost in 14 (35%).There were no baseline differences between long-term responders and non-responders.However, all 15 alcoholic patients who remained abstinent maintained long-term response compared to 36% of 11 non-abstinent alcoholics (p < 0.001) and 50% of 14 patients with viral cirrhosis (p = 0.002).During the study period, 10 (25%) patients rebled, 5 (12.5%) died and 4 (10%) were transplanted.Patients with loss of hemodynamic response rebled more (50% vs 11%, p = 0.018) and had lower survival free of transplantation (64% vs 85%, p = 0.23).All abstinent alcoholics were alive at end of follow-up (2 had rebled, 2 were transplanted).Cox analysis identified loss of hemodynamic response as an independent risk factor for rebleeding (HR 6.0, CI95 1.5-23.8,p = 0.011), and viral etiology (HR 5.4, CI95 1.2-24.4,p = 0.03) and Child-Pugh score at 1 year (HR 1.5, CI95 1.1-2.0,p = 0.02) as independent determinants of less survival free of transplantation.Conclusions: After variceal bleeding, long-term maintenance of hemodynamic response to drug therapy is mainly restricted to patients with alcoholic cirrhosis who remain abstinent.Half of patients with viral cirrhosis loose this response in the long term.The loss of this long-term response carries worse clinical outcomes.