| [ Summary ] |
Gastrointestinal bleeding from ruptured esophageal and gastric varices is the main complication in portal hypertensive cirrhotics. Therefore, the goal of pharmacological therapy for cirrhotics should be to prevent and arrest variceal bleeding by reducing portal pressure. Vasopressin infusion has been used in the management of bleeding esophageal varices for forty years. Adding nitroglycerin may lessen adverse effects. Nonselective beta-blockers such as propranolol are recommended for primary prophylaxis or the prevention of esophageal variceal bleeding in those who have never experienced bleeding. Adding nitrates to beta-blockers may be more effective than the use of one single drug. The role of spironolactone is also under evaluation. Epidemiological studies have shown that acute esophageal variceal bleeding occurs more often at night. This may be explained by recent studies of cirrhotics, which found that upright posture during daytime hours decreases variceal flow velocity, whereas azygos and portal blood flow increases during the night hours. Therefore, prophylaxis drug therapy is aimed at reducing nocturnal azygos and portal blood flow. It is not clear what the role of drugs is in the control of acute bleeding or in the prophylaxis of bleeding from gastric fundal varices. In the future, pharmacological therapy may be considered as a pre-primary prophylaxis to prevent the development of esophageal varices. |