Pitfalls in studies of prophylactic therapy for variceal bleeding in cirrhotics

Bleeding from esophageal or gastric varices is the major complication of portal hypertension in cirrhotic patients and carries a high mortality. If it could be prevented, one might expect survival to improve. Porta-caval shunts were the first type of prophylactic therapy for variceal bleeding to be evaluated in four controlled randomized clinical trials. Unfortunately, survival was not improved even though bleeding was prevented (1-3). This failure was attributed to a combination of immediate operative mortality and later deaths due to hepatic failure, the shunt contributing to the hepatic failure in these patients. In recent years, sclerotherapy of esophageal varices and pharmacological treatment of portal hypertension (P-blockade

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