Comparison Study to Evaluate the Effect of Propranolol Use Versus Carvidolol to Control Portal Hypertension on the Anorectal Varices Symptomes and Size in Egyptian Cirrhotics

Abstract

Portal hypertension is an almost unavoidable complication of cirrhosis, and provides the driving force for most of its complications, such as Esophageal and gastric varices, variceal bleeding, portal hypertensive gastropathy ano rectal varices …..Etc. Recent studies have shown that for these complications to develop, the portacaval pressure gradient (HVPG) should increase above 10 mm Hg and should be above 12 mm Hg for variceal bleeding. The prevalence of varices is about 40% in asymptomatic compensated patients. Development of varices follows an incidence of approximately 6% per year. The incidence is nearly double in patients with a baseline HVPG >10 mm Hg, who therefore represent a high-risk group. Anorectal varices are common in patient with portal hypertension. Varices occur in mid rectum at connection between portal system and the middle and inferior rectal veins. Treatment is usually directed at the underlying portal hypertension. Because of this, there is a great interest in strategies to revert portal hypertension, since these would prevent portal hypertension-related complications, clinical de compensation, and death. Non-selective beta blockers are very useful drugs in preventing first variceal bleeding and re-bleeding in patients with cirrhosis. These drugs work in two ways: by blocking 1 receptors and reducing cardiac output and 2) by blocking 2 receptors, producing splanchnic vasoconstriction and reducing portal blood flow. Consequently, they reduce portal pressure. When Porto-systemic gradient is reduced to less than 12 mmHg, the patient will not bleed. Carvedilol is a potent nonselective beta-blocker with mild anti-alpha 1 adrenergic activity (one-tenth of its beta-blocker activity). The effects of Carvedilol on portal pressure . Carvedilol is a potent nonselective beta-blocker, and as such, it decreases heart rate and cardiac index (blockade of beta-1 adrenergic receptors) and causes splanchnic vasoconstriction (blockade of beta-2 adrenergic receptors), which result in a reduced portal blood flow, and thereby in decreased portal pressure. This is the same mechanism of the portal pressure–reducing effect of Propranolol. In addition Carvedilol has mild anti-alpha 1 adrenergic activity, which results in decreased hepatic vascular tone and, hence, in a further reduction of portal pressure. However, the anti-alpha 1 adrenergic activity may result in arterial hypotension. Because of its combined effects, as the risk of variceal bleeding are the most dangerous complications so those who are found to have small size varices can be considered for treatment with non-selective BB for primary prevention of variceal bleeding. Patients who are found to have large size varices should also be started on BB as a first line prophylactic therapy as they offer several advantages, including low cost, ease of use and safety. The study included 50 patients withhepatitis C viralinfection induced liver cirrhosis with portal hypertensionwere followedup at endoscopy unit of Ain Shams university hospital and Beni-Suef hospital between March 2014 and May 2015. This study aimed to compare the effect of propranolol versus carvedilol on control of symptoms and size of anorectal varices on top of portal hypertension in cases of hepatitis Cvirus induced liver cirrhosis and to correlate this with the child scorein Egyptian patients. They were divided into two groups, carvedilol group include 25 patients who received carvedilol 12.5 mg per day target dose and propranolol group include 25patients who received maximum tolerated dose and target dose that cause reduction of pulse by one fourth of its base line. Both groups were subjected to full history taking and clinical examination and Laboratory evaluation (C.B.C, liverfunctions, kidney functions, PT,I.N.R, viral markers, abdominal ultra sound, lower gastro intestinal tract endoscopies (ano-scope, procto-scope, sigmoidoscopy …etc.), E.C.G).Patients were followed up for 3 monthsthen re do for re evaluation.