Prophylactic treatment of esophageal varices before bleeding.

After years of effort, the treatment of an episode of bleeding from a ruptured varix remains unsatisfactory, as does prophylaxis of rebleeding. As a consequence it was logical to try to prevent bleeding before the first hemorrhage has occurred (primary prophylaxis). Shunt surgery proved to be useful in terms of bleeding rate, but side effects and operative risk made this method inapplicable for prophylaxis. Endoscopic sclerotherapy was efficient in terms of bleeding rate, but doubts about its efficacy in improving survival, together with difficulties in performing repeated endoscopies over the long term, have limited its use in primary prophylaxis. Beta-blockers have proved useful for preventing bleeding and, in some studies, for improving survival. Further studies are still necessary to accurately identify the suitable target population, the method of follow-up and the duration of treatment. Although some groups have started using beta-blockers for prophylaxis before bleeding on a routine basis, others consider this treatment only for prospective randomized trials.