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January 2, 1987

The Management of Bleeding Esophageal Varices-Reply

JAMA. 1987;257(1):30. doi:10.1001/jama.1987.03390010033022

In Reply.—  We thank Mr Dasta for his kind comment concerning our article.1 The two reports he cites2,3 describing clinical trials with nitroglycerin in addition to vasopressin are of considerable interest, but appeared after our article was already in press. Not withstanding these two favorable reports, we would still recommend caution in the use of nitroglycerin in addition to vasopressin in the treatment of bleeding varices. The two studies cited differ in a variety of respects, including the dose of vasopressin and the means of administering nitroglycerin (sublingual vs intravenous). In addition, neither study measured hepatic or systemic hemodynamics, including portal pressure, total hepatic blood flow, cardiac output, or peripheral vascular resistance. Although these reports indicate the need for additional, more extensive studies, we regard them as tentative first steps in evaluating the use of nitroglycerin in addition to vasopressin therapy.Dr Palko raises a number of important