The bleeding rate was also 14%. Even if the seven patients were compliant to

receive EVL and without episodes of variceal bleed, the variceal bleeding rate would become 13%, a figure still similar to that in the Nadolol group. Some of our patients bled after variceal obliteration was achieved. This may mandate that the interval of follow-up endoscopy after variceal obliteration should be shorter than 6 months. However, this would constitute another drawback of combination with EVL. If EVL is anticipated to be synergistic to beta blockers in the decrease of first variceal bleed, the patients should be very compliant to achieve variceal obliteration as soon as possible and variceal bleeds induced by EVL should not occur. Actually, FK506 concentration this kind of perfect situation would only be encountered by chance.30 Regarding

adverse events, significantly more patients treated with combination therapy than nadolol alone had adverse events. The majority of these adverse events were modest in severity. Serious complications were noted only in two patients (3%) of the Combined group with esophageal ulcer bleed and variceal bleed directly induced by EVL, similar to our previous trials.10, 29 This implies that the potential benefit of EVL in prevention of variceal rupture is Selleckchem BGJ398 offset by the associated serious complications. Previous meta-analysis of trials regarding primary prophylaxis revealed that adverse events were associated with EVL in 42.7% and with beta blockers in 56.1%.20 Moreover, serious 上海皓元 complications were noted in 0-6.7% in patients

treated with EVL and 6.7-30.3% in patients receiving beta blockers. Thus, the meta-analysis drew the conclusion that severe adverse events were significantly less in EVL compared with beta blockers. Based on our observation, nadolol alone did not cause severe adverse events if nadolol was reduced or discontinued in patients who reported side effects. A recent report from Tripathi et al.31 suggested that carvedilol is more effective than EVL in the prevention of first esophageal variceal bleed. The variceal bleeding rate was 10% and 23%, respectively. This study demonstrated that drug therapy alone could achieve a rather low incidence of first bleed in patients with high-risk varices without evoking serious adverse events. Given that drug therapy could be highly effective in primary prophylaxis, the necessity of combination beta blockers with EVL would be doubtful. However, the role of carvedilol in primary prophylaxis warrants further confirmation. On the other hand, Villaneuva et al.32 demonstrated that the acute hemodynamic response to beta blockers can be used to predict the long-term risk of first bleeding. Our study did not measure portal pressure. Based on this observation, possibly, EVL is required only in those with a reduction of hepatic venous pressure gradient less than 10% from baseline measurement.