Prevention of progression from small to large varices: are we there yet? An updated meta-analysis

We read the article by Bhardwaj and coworkers1 with great interest. With their elegantly designed, randomised, single-blind, placebo-controlled study, Dr. Sarin and his research group have turned over a new leaf in the controversy on the effectiveness of non-selective beta blockers (NSBBs) in preventing the progression from small to large varices in patients who have not bled (table 1). View this table: Table 1 Randomised controlled trials investigating the effect of NSBB treatment on the development of large varices Carvedilol has been shown to be more potent in decreasing portal pressure due to its additional anti-α1-adrenergic activity,2 and thus, achieves hemodynamic response even in non-responders to propranolol.3 Based on the stage-dependent pathophysiology of portal hypertension (PH), the anti-α1-mediated decrease in intrahepatic resistance might be particularly beneficial in patients with less pronounced clinically significant PH, when intrahepatic resistance is still a major determinant of portal …