840 ENDOSCOPIC VARICEAL LIGATION IS HIGHLY EFFECTIVE IN THE PREVENTION OF VARICEAL REBLEEDING IN HEMODYNAMIC NON-RESPONDERS TO PHARMACOLOGICAL THERAPY

Introduction: Non-responder patients to pharmacological therapy in the prevention of variceal rebleeding show high rebleeding rates.It is not known which is the most adequate treatment for these patients.Objective: To evaluate the efficacy of endoscopic variceal ligation in the prevention of variceal rebleeding in non-responders to pharmacological therapy.Methods: Patients with liver cirrhosis admitted to our Bleeding Unit for acute variceal bleeding were considered for the study.In every patient, the hepatic venous pressure gradient (HVPG) was determined 4-6 days after the initial bleeding.Treatment with propranolol/nadolol and isosorbide mononitrate (ISMN) was subsequently started.An HVPG measurement was repeated 5-7 days after maximum tolerated doses of drugs were achieved (up to 160 mg/12-24 hours for propranolol/nadolol and 40 mg bid for ISMN).Responders (HVPG ≤12 mmHg or ≥20% decrease from baseline) were maintained on drugs, while non-responders (HVPG >12 mmHg or decrease <20%) had variceal ligation added at 2-3 week intervals until variceal eradication was achieved.Results: Fifty-one patients (39 male, median age 54 years) with at least 3-month follow-up have been included.Mean time to first hemodynamic study was 5.1±1.1 days (median HVPG: 18.1±4.6mmHg).Child distribution was: 18 Child A, 25 Child B, 8 Child C. Five patients rebled before the second hemodynamic study (group C).The remaining 46 patients underwent a second HVPG measurement 13.2±2.2days after the first study, and were classified as: responders (24 patients, 52% -group A) and nonresponders (22 patients, 48% -group B).Median follow-up was 28 months.Rebleeding and mortality outcomes during follow-up are shown in the Table .All rebleeding episodes were secondary to esophageal variceal bleeding.Conclusion: Variceal ligation is highly effective in the prevention of variceal rebleeding in non-responders to pharmacological treatment, and should be regarded as an adequate therapy in this setting.