Propranolol or endoscopic sclerotherapy in the prevention of recurrence of variceal bleeding. A prospective, randomized controlled trial.

Endoscopic sclerotherapy (ES) and continuous propranolol (P) treatment have both been proposed as useful methods to prevent recurrent esophageal variceal bleeding. We report a prospective randomized trial in 65 patients with a previous history of endoscopically proven esophageal variceal bleeding. Patients were randomized by sealed envelopes stratified for Child's A and B groups to receive either endoscopic sclerotherapy (n = 31) or propranolol (n = 34). The dose of oral propranolol was based on a reduction of the resting pulse rate by 25%. Intravascular ethanolamine oleate was used for the endoscopic sclerotherapy in a 3-week schedule. The follow-up period ranged from 17 to 57 months (median: ES = 31; P = 28 months). There was no difference in the cumulative percentages of patients free of rebleeding from any source: esophageal and gastric varices, acute esophageal and gastric ulcers or erosions (ES = 37%; P = 16%). Also, there was no difference in the cumulative survival (ES = 69%; P = 54%). However, patients in the propranolol group had significantly more variceal rebleeding from the esophagus (n = 21) than did those in the sclerotherapy group (n = 9). The cumulative percentages of patients free of esophageal variceal rebleeding after inclusion were 67% in the endoscopic sclerotherapy group and 25% in the propranolol group (log-rank test, P less than 0.02). These differences indicated that sclerotherapy should be used in 29% of the propranolol patients who rebled. Based on these results we recommend elective sclerotherapy as long-term therapy for preventing rebleeding of esophageal varices.

Controlled trial of vasopressin and balloon tamponade in bleeding esophageal varices.

In a randomized controlled trial, the effect of continuous intravenous administration of vasopressin was compared with Sengstaken-Blakemore balloon tamponade in 37 episodes of bleeding esophageal varices in patients with cirrhosis. The majority were Group A and B of Child's classification. Bleeding was controlled in 11 of 17 (65%) patients on vasopressin and in 14 of 20 (70%) patients on tamponade. The patients who failed to respond initially (6 episodes on vasopressin and 5 on tamponade) were treated successfully with the alternative method. Overall mortality was similar in both groups: 3 patients in the vasopressin group and 4 in the tamponade group died. Only one patient died of uncontrolled bleeding; 4 patients probably died of complications of treatment, 2 of cardiac ischemia after vasopressin and 2 of pulmonary infection after tamponade. The vasopressin group required significantly fewer blood transfusions than did the tamponade group.

Combined approach to the differential diagnosis of cholestatic jaundice with endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography, ultrasonography, and liver biopsy.

A prospective study of 33 patients with cholestatic jaundice was performed with combined use of endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), ultrasonography, and liver biopsy. A higher rate of success with PTC in 25 cases of extrahepatic cholestasis was offset by the better score of ERCP in 8 cases of intrahepatic cholestasis and its wider diagnostic scope. The procedures were complementary in 10 cases. Ultrasonic imaging of intrahepatic bile ducts proved useful for selecting the first cholangiographic technique. Liver biopsy established etiology in intrahepatic cholestasis. Our combined approach allowed us to develop through objective criteria a diagnostic flow chart of cholestasis.