To the Editor:

We read with interest the American Association for the Study of Liver Diseases Practice Guidelines “Prevention and Management of Gastroesophageal Varices and Variceal Hemorrhage in Cirrhosis.”1 These practice guidelines are helpful for clinicians managing portal hypertensive gastrointestinal hemorrhage. However, some recommendations reported in this article are not well evidence-based.

According to recommendation 10 (for prophylaxis of first variceal bleeding), if a patient is treated with endoscopic variceal ligation (EVL), it should be repeated every 1-2 weeks until obliteration. According to recommendation 22 (for prevention of variceal rebleeding), EVL should be repeated every 1-2 weeks until obliteration. Both recommendations suggest repeating EVL every 1-2 weeks until obliteration of varices to prevent first variceal bleeding and to prevent variceal rebleeding. Up to now, there are no data to support the idea that EVL at intervals of every 1-2 weeks is appropriate. Our previous study showed that EVL at an interval of 3-4 weeks could achieve an appreciably low incidence of variceal rebleeding.2 In our own personal experience, if EVL is performed at an interval of 1-2 weeks, a lot of esophageal ulcers induced by EVL may hamper the performance of EVL. Yoshida et al.3 showed that EVL performed at an interval of 2 months to prevent first variceal bleeding brought about better results than the same treatment performed at an interval of 2 weeks. Thus, the optimal interval of EVL remains undetermined.

On the other hand, recommendation 15 suggests treating variceal hemorrhage with either EVL or sclerotherapy. Our previous study showed that even during active variceal bleeding, EVL is superior to sclerotherapy in achieving successful hemostasis.4 Villanueva et al.5 also showed that added to somatostatin, EVL is superior to sclerotherapy in the control of acute esophageal variceal bleeding. Baveno IV consensus statements6 suggested that EVL is the recommended form of endoscopic therapy for acute esophageal variceal bleeding and that sclerotherapy may be used in the acute setting if ligation is technically difficult. We believe that this recommendation is more pertinent and evidence-based.


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  • 1
    Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, and the Practice Guidelines Committee of the AASLD, the Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. HEPATOLOGY 2007; 46: 922938.
  • 2
    Lo GH, Lai KH, Cheng JS, Hwu JH, Chang CF, Chen SM, et al. A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices. HEPATOLOGY 1995; 22: 466471.
  • 3
    Yoshida H, Mamada Y, Taniai N, Yamamoto K, Kawano Y, Mizuguchi Y, et al. A randomized control trial of bimonthly versus biweekly endoscopic variceal ligation of esophageal varices. Am J Gastroenterol 2005; 100: 20052009.
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  • 4
    Lo GH, Lai KH, Cheng JS, Lin CK, Huang JS, Hsu PI, et al. Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices. HEPATOLOGY 1997; 25: 11011104.
  • 5
    Villanueva C, Piqueras M, Aracil C, Gómez C, Lopez-Balaguer JM, Gonzalez B, et al. A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding. J Hepatol 2006; 45: 560567.
  • 6
    Bosch J, Laine L, Banares R, Marcon N, Nevens F, Silvain C, et al. Consensus statements: treatment of acute bleeding episode. In: de FranchisR, ed. Portal Hypertension IV. Proceedings of the Fourth Baveno International Consensus Workshop on Methodology of Diagnosis and Treatment. Oxford, England: Blackwell; 2006: 240242.

Gin-Ho Lo*, Kwok-Hung Lai†, * Medical Research & Education, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, † Administration, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.