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Cirrhosis patients should be screened for esophageal varices
Last Updated: 2001-04-09 11:15:44 EDT (Reuters Health)
WESTPORT, CT (Reuters Health) - Contrary to practice guidelines, less than half of the patients with cirrhosis or pulmonary hypertension who are referred for orthotopic liver transplantation are not being screened for esophageal varices, according to researchers.
Dr. Miguel R. Arguedas and colleagues, from the University of Alabama at Birmingham, evaluated a random sample of 125 patients with cirrhosis or portal hypertension who were referred for liver transplantation. Data regarding demographics, clinical information, relevant time intervals, screening strategies used, and implementation of primary or secondary prophylaxis were included in the analysis.
According to the report in the March issue of The American Journal of Gastroenterology, 12 of the patients were excluded from the analysis due to presentation of variceal bleeding at the initial manifestation of cirrhosis. Of the remaining 113 subjects, 52 (46%) had screening endoscopy or radiologic studies to detect the presence of varices.
Primary prophylaxis with beta-blocker therapy was initiated in 15 (29%) of the 52 patients who underwent screening and were determined to have large varices, according to the report. Of these, one patient had esophageal variceal bleeding 12 months after screening endoscopy and 14 had not experienced variceal bleeding after a median follow-up of 20 months.
"Thirty-seven patients had a history of variceal bleeding before referral for transplantation," the authors explain. Secondary prophylaxis, including endoscopic obliteration, ß-blocker therapy, or distal splenorenal shunt, was instituted in all of these patients, they add.
"Primary prophylaxis with ß-blockers is not being instituted in a timely manner," Dr. Arguedas told Reuters Health. "This means that patients are at continued risk of developing an episode of variceal hemorrhage."
"While we did not address the reasons why [the recommendations are not being followed]," he said, "questions regarding physician reimbursement for endoscopy performed for screening, lack of awareness of the recommendations, or questions regarding the appropriate timing of the endoscopy may be playing a role."
"Once bleeding occurs, the mortality at 6 weeks may approach 30%," Dr. Arguedas added. "Institution of primary prophylaxis may decrease the risk of bleeding by 40% to 50%," he said. "Therefore, in order to institute prophylaxis in patients with large varices, screening endoscopy should be performed."
In a related editorial, Dr. Naga Chalasani, of Indiana University School of Medicine, Indianapolis, and colleagues agree: "It is essential that all of us who care for patients with cirrhosis adhere to the published guidelines for primary prophylaxis of variceal bleeding, beginning with endoscopic screening for their detection."
Am J Gastroenterol 2001;96:623-624,833-837.
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