Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage: a multicentre randomized controlled trial.

BACKGROUND & AIMS: Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective ß blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed. METHODS: Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant. RESULTS: Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48 ± 12.2 years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3 ± 1.6 and mean follow up was 13.3 ± 12.1 months (range 1-50 months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment. CONCLUSIONS: Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.

Corelation of serum alpha fetoprotein and tumor size in hepatocellular carcinoma.

OBJECTIVE: To determine the correlation of elevated serum Alpha feto-protein with tumour size in hepatocellular carcinoma. METHODS: A cross-sectional analytical study was done at Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from January 2009 to June 2010. Patients enrolled in study were known cases of chronic liver disease and were complicated by development of hepatocellular carcinoma; those having metastasis in liver from any where were excluded. Demographic data such as age, gender, residence, were recorded. Detailed clinical history and examination were carried out and recorded in a preformed Performa. Complete blood count, liver function test, total protein, Albumin/Globulin (A/G) ratio, serum Albumin, HBsAg, anti HCV, alpha fetoprotein, ultrasound guided liver biopsy, ultrasound whole abdomen and/or CTscan Abdomen for size and number of tumour were also done. On the basis of alfa fetoprotein level patients were divided in to 3 groups; Group I with normal AFP (< or = 20IU/ml), Group II with moderately elevated AFP (20-399IU/ml), and Group III with markedly elevated AFP (> or =400 iu/ml). On the basis of tumour size patients were also divided in to 3 groups; group A <3 cm, group B 3-5 cm and group C >5 cm. Correlation of serum AFP levels with tumor size was analyzed by applying Spearman's rank correlation with r-values of 0.01 being considered significant. RESULTS: Review of the clinical data of 98 patients male 69 (70.4%) and female were 29 (29.6%) with mean age of 53.89 +/- 12.511 ranging from 32 to 82 years was done. Of these there were 22 (22.4%), 25 (25.5%), 51(52%) cases in group 1, 2, 3 respectively. While in tumour size groups, 17 (17.3%) were in group A, 35 (35.7%) in group B and 46 (46.9%) in group C. There was a significant correlation of serum AFP level with tumour size in hepatocellular carcinoma. (r=0.472, 0.0001). CONCLUSION: Our study suggests that serum AFP has significant correlation with the size of tumour. AFP level may serve as a useful marker for detection of Hepatocellular carcinoma and to differentiate between early and advance stage. On the basis of this proper treatment strategy can be planned.