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Endoscopic cyanoacrylate injection versus β-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial
  1. Smruti Ranjan Mishra1,
  2. Barjesh Chander Sharma1,
  3. Ashish Kumar2,
  4. Shiv Kumar Sarin1,2
  1. 1Department of Gastroenterology, G B Pant Hospital, New Delhi, India
  2. 2Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
  1. Correspondence to Dr S K Sarin, Department of Gastroenterology, G B Pant Hospital, 201 Academic Block, New Delhi 110002, India; shivsarin{at}gmail.com

Abstract

Background and aims Bleeding from gastric varices is often severe and difficult to manage. Endoscopic injection of gastric varices with cyanoacrylate is effective in prevention of rebleeding. The efficacy of β-blockers in secondary prophylaxis of gastric variceal bleed has not been well studied. A comparison of the efficacy of β-blocker treatment and cyanoacrylate injection for the prevention of gastric variceal rebleeding was carried out.

Methods Patients with gastro-oesophageal varices type 2 (GOV2) with eradicated oesophageal varices or isolated gastric varices type 1 (IGV1) who had bled from gastric varices were randomised to cyanoacrylate injection (n=33) or β-blocker treatment (n=34). Baseline and follow-up upper gastrointestinal endoscopy and hepatic venous pressure gradient (HVPG) measurements were performed. Primary end points were gastric variceal rebleeding or death.

Results The probability of gastric variceal rebleeding rate in the cyanoacrylate group was significantly lower than in the β-blocker group (15% vs 55%, p=0.004) and the mortality rate was lower (3% vs 25%, p=0.026) during a median follow-up of 26 months. The median baseline and follow-up HVPG in the cyanoacrylate group were 15 (10–23) and 17 (11–24) mm Hg (p=0.001) and for the β-blocker group 14 (11–24) and 13 (8–25) mm Hg (p=0.003). While no patient showed reduction of HVPG in the cyanoacrylate group, in the β-blocker group 12 of 28 (42%) patients were responders, of which 5 (41% of responders) bled. On multivariate analysis, treatment method, portal hypertensive gastropathy and size of the gastric varix >20 mm independently correlated with gastric variceal rebleeding. Gastric variceal rebleeding independently correlated with mortality.

Conclusions Cyanoacrylate injection is more effective than β-blocker treatment for the prevention of gastric variceal rebleeding and improving survival.

Clinical trial number NCT00888784.

  • Cirrhosis
  • endoscopy

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Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the MAMC Ethical Committee, New Delhi.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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