Is endoscopic therapy the best choice for primary prevention of variceal hemorrhage in patients with liver cirrhosis?

Esophageal varices are present in 50% of cirrhotic patients. Th eir presence is correlated with the severity of the liver disease. While only 40 % of Child A cirrhosis patients have varices, 85% of patients with Child C cirrhosis have esophageal varices at the time of diagnosis (1). Prospective studies show that cirrhotic patients without esophageal varices develop them at an 8% annual rate and patients with small esophageal varices develop large ones at the same annual rate. Variceal hemorrhage occurs at a 12% to 15% annual rate. Th e mortality rate is 20% for each episode of variceal bleeding (2). Diagnosis of esophageal varices is done through esophagogastroduodenoscopies. Th ere are two classifi cations. Th e American AASLD/ACG guidelines recommend that the size of esophageal varices should be classifi ed into two groups: small and large (diameter greater than 5 mm). Another type of classifi cation, which is more widely used, places varices into three groups: small, medium and large. Small esophageal varices are defi ned as varices that are minimally elevated above the esophageal mucosa and disappear with insuffl ation. Medium esophageal varices are tortuous varices that occupy less than a third of the esophageal lumen, and large esophageal varices occupy more than a third of the esophageal cavity. In studies, medium and large esophageal varices are placed within the same group and share similar recommendations (3). One of the main preventive measures for patients with compensated cirrhosis is prevention of the fi rst variceal bleeding (primary prophylaxis).