High-risk varices in patients with Child-Pugh-Turcotte B and C: consider band ligation with carvedilol for preventing first variceal bleeding, especially in patients with MASLD-associated cirrhosis

International guidelines recommend that primary prophylaxis of varices in patients with cirrhosis be either non-selective beta-blockers (NSBBs) or variceal band ligation (VBL). These recommendations are based on studies that include both compensated and decompensated patients. Notably, the European Association for the Study of the Liver 2018 guidelines recognise a gap in the efficacy of NSBB therapy for patients with decompensated cirrhosis.1 The Baveno guidelines recommend preventing further decompensation in patients with ascites and high-risk varices (large varices >5 mm, or with red spot signs, or Child-Pugh-Turcotte (CPT-C)), with traditional NSBBs or carvedilol preferred over VBL.2 The American Association for the Study of Liver Diseases guidelines support NSBBs or VBL for large high-risk varices.3 However, a recent systematic review with network meta-analysis indicated that VBL is associated with higher risks of complications and mortality compared with NSBBs.4 The supporting evidence for these recommendations is limited, and it remains unclear whether the same treatment options or combination therapies are more effective in decompensated cirrhosis (CPT B or C). In Gut , Tevethia et al report the results of the CAVARLY trial.5 The study compared carvedilol, VBL and a combination of both for preventing the first variceal bleed in patients with CPT- B/C cirrhosis (up to C-13) and high-risk oesophageal varices (>5 mm or <5 mm with red signs). The authors excluded patients with contraindications to carvedilol, hepatocellular carcinoma, portal vein thrombosis, platelet count <30 000 per µL, those on therapeutic anticoagulation, or with previous VBL or transjugular intrahepatic portosystemic shunt (TIPS). They enrolled 330 patients (110 for each arm) …