Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial.

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 beta-blockers in secondary prophylaxis of gastric variceal bleed has not been well studied. A comparison of the efficacy of beta-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 beta-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 beta-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 beta-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 beta-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 beta-blocker treatment for the prevention of gastric variceal rebleeding and improving survival.