The presence of esophageal varices (EV), but not treatment with beta-blockers, is associated with a poorer survival in patients with cirrhosis and ascites

EV are predictors of survival in patients with compensated cirrhosis. Beta-blockers (BB) are used in the prevention of variceal hemorrhage. Recent retrospective evidence suggests that BB may be associated with a poorer survival in patients with refractory ascites (Serste et al., Hepatology 2010). However, this may be due to the indication for BB use (i.e. presence of EV) rather than to BB use itself. The aim of the study was to investigate the prognostic relevance of EV in patients with decompensated cirrhosis, with ascites but without variceal hemorrhage. Methods: Retrospective cohort study of 729 consecutive patients with cirrhosis who underwent gastroscopic and hemodynamic evaluation, including hepatic venous pressure gradient (HVPG) measurement, in the period between 11/1995 and 11/2004 and who were followed until death or 11/2006. Results: 194 patients with decompensated cirrhosis (Child-Pugh score [mean±SD] 9.4±1.8; MELD 17.1±7.2; HVPG 16.9±5.3 mmHg) with ascites but without variceal hemorrhage were included in the study and followed for a mean of 37.3±36.2 months. Sixty-two patients had no EV and 132 had EV (63 small, 46 medium and 23 large). Patients with EV had a significantly poorer survival compared to those without EV (Figure). Multivariate analysis including Child-Pugh and MELD scores, HVPG, and EV revealed Child-Pugh score (HR [95%CI]: 1.18 [1.07–1.29]; p=0.001) and EV (1.18 [1.03–1.34]) as independent predictors of survival. Survival curves according to treatment with BB were not significantly different (p=0.7). Conclusion: Esophageal varices are independent predictors of survival in decompensated patients with ascites even in the absence of variceal hemorrhage. These results suggest that EV should be used to further stratify patients with decompensated cirrhosis. Treatment with BB in patients with ascites does not increase mortality.

Figure 1: Kaplan-Meier survival curves of decompensated cirrhotic patients with ascites and without variceal hemorrhage according to the absence and presence of varices.