Endoscopic Band Ligation Versus Pharmacological Therapy for Variceal Bleeding in Cirrhosis: A Meta-Analysis

OBJECTIVE: To conduct a meta-analysis of published, full-length, randomized controlled trials evaluating the efficacy of endoscopic band ligation (EBL) versus pharmacological therapy for the primary and secondary prophylaxis of variceal hemorrhage in patients with cirrhosis.METHODS: Literature searches were conducted using the PubMed, EMBASE and Cochrane Library databases. Eighteen randomized clinical trials that fulfilled the inclusion criteria were further pooled into a meta-analysis.RESULTS: Among 1023 patients in 12 trials comparing EBL with beta-blockers for primary prevention, there was no significant difference in gastrointestinal bleeding (RR 0.79 [95% CI 0.61 to 1.02]), all-cause deaths (RR 1.06 [95% CI 0.86 to 1.30]) or bleeding-related deaths (RR 0.66 [95% CI 0.38 to 1.16]). There was a reduced trend toward significance in variceal bleeding with EBL compared with beta-blockers (RR 0.72 [95% CI 0.54 to 0.96]). However, variceal bleeding was not significantly different between the two groups in high-quality trials (RR 0.84 [95% CI 0.60 to 1.17]). Among 687 patients from six trials comparing EBL with beta-blockers plus isosorbide mononitrate for secondary prevention, there was no effect on either gastrointestinal bleeding (RR 0.95 [95% CI 0.65 to 1.40]) or variceal bleeding (RR 0.89 [95% CI 0.53 to 1.49]). The risk for all-cause deaths in the EBL group was significantly higher than in the medical group (RR 1.25 [95% CI 1.01 to 1.55]); however, the rate of bleeding-related deaths was unaffected (RR 1.16 [95% CI 0.68 to 1.97]).CONCLUSIONS: Both EBL and beta-blockers may be considered first-line treatments to prevent first variceal bleeding, whereas beta-blockers plus isosorbide mononitrate may be the best choice for the prevention of rebleeding.

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Favorable Effects of Endoscopic Ligation Combined with Drugs on Rebleeding and Mortality in Cirrhotic Patients: A Network Meta-Analysis

Digestive Diseases ◽

10.1159/000484082 ◽

2017 ◽

Vol 36 (2) ◽

pp. 136-149 ◽

Cited By ~ 2

Author(s):

Liang Shi ◽

Xueping Zhang ◽

Jianye Li ◽

Xibo Bai

Keyword(s):

Beta Blockers ◽

Meta Analysis ◽

Cochrane Library ◽

Isosorbide Mononitrate ◽

Endoscopic Variceal Ligation ◽

Variceal Hemorrhage ◽

Combination Therapies ◽

Previous Episode ◽

Cirrhotic Patients ◽

Endoscopic Ligation

Background: To assess the effects of combination therapies (endoscopic plus drug[s], drug combinations) on variceal/any-cause rebleeding and mortality among cirrhotic patients with one previous episode of variceal hemorrhage. Summary: We searched PubMed, Embase, Cochrane Library, and Web of Science for eligible studies. We included 26 randomized controlled trials involving 2,536 adults using OR to measure the effects. Endoscopic variceal ligation (EVL) plus nadolol ranked first for reducing recurrent bleeds. Both EVL + nadolol and EVL + drugs (nadolol, sucralfate) decreased the risk of any-cause rebleeding than EVL alone (OR 0.34, 95% CI 0.12–0.97; OR 0.40, 95% CI 0.18–0.88, respectively). Meanwhile, EVL + drugs ranked first lowering mortality rates (P-score >0.85) with a marginal superiority over EVL alone (OR 0.52, 95% CI 0.26–1.01). Beta-blockers with isosorbide mononitrate (ISMN) also reached a marginal superiority (OR 0.78, 95% CI 0.56–1.09) for improving mortality. Key Messages: Our findings indicated that EVL + nadolol might be the preferred choice to cirrhotic patients with one previous episode of variceal hemorrhage for preventing rebleeding. EVL + nadolol + sucralfate and beta-blockers + ISMN may be potential alternatives to improve mortality. Further, well-controlled studies are warranted to compare the promising combination therapies.

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Motion – Prophylactic Banding of Esophageal Varices Is Useful: Arguments against the Motion

Canadian Journal of Gastroenterology ◽

10.1155/2002/976072 ◽

2002 ◽

Vol 16 (10) ◽

pp. 693-695 ◽

Cited By ~ 4

Author(s):

Kris V Kowdley

Keyword(s):

Esophageal Varices ◽

Variceal Bleeding ◽

Beta Blockers ◽

Low Cost ◽

Cost Effective ◽

Primary Prophylaxis ◽

Ease Of Use ◽

Endoscopic Sclerotherapy ◽

Variceal Hemorrhage ◽

Band Ligation

Bleeding from esophageal varices leads to substantial morbidity and mortality. Despite advances in pharmacological and endoscopic therapy, as well as general supportive care, the mortality rate associated with acute variceal hemorrhage has not improved significantly over the past two decades. Prophylactic therapy with nonselective beta-blockers or long acting nitrates reduces the incidence of variceal bleeding in patients with cirrhosis, is cost effective and may improve survival. Surgical portosystemic shunting reduces the risk of bleeding but is associated with significant operative mortality and a high risk of portosystemic encephalopathy. Endoscopic sclerotherapy causes adverse effects in a large proportion of patients and is, therefore, not suitable for primary prophylaxis of bleeding. Although variceal band ligation is effective in reducing the rate of bleeding and is safer than sclerotherapy, it has not been shown to provide a survival advantage compared with beta-blockers. A significant reduction in the rate of variceal bleeding with band ligation, compared with beta-blockers, was shown in only one study. Beta-blockers offer several advantages, including low cost, ease of use and safety. The available data do not yet support the prophylactic use of variceal band ligation, and this procedure should be reserved for patients who are either unwilling or unable to take beta-blockers. It is hoped that additional large, multicentre trials of band ligation versus beta-blockers will examine the efficacy, cost effectiveness and impact on quality of life among patients with cirrhosis.

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Band ligation versus propanolol and isosorbide mononitrate for primary prophylaxis of variceal bleeding Lui HF, Stanley AJ, Forrest EH, et al., Primary Prophylaxis of Variceal Hemorrhage: A Randomized Controlled Trial Comparing Band Ligation, Propanolol, and Isosorbide Mononitrate.Gastroenterology 2002;123:735–44

The American Journal of Gastroenterology ◽

10.1016/s0002-9270(03)00520-3 ◽

2003 ◽

Vol 98 (8) ◽

pp. 1887-1889

Author(s):

D Sussman

Keyword(s):

Randomized Controlled Trial ◽

Variceal Bleeding ◽

Controlled Trial ◽

Primary Prophylaxis ◽

Isosorbide Mononitrate ◽

Variceal Hemorrhage ◽

Band Ligation ◽

Randomized Controlled

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Endoscopic band ligation (EBL) vs. non-selective β-blockers in the prevention of first variceal bleeding in cirrhosis: A meta-analysis

Gastrointestinal Endoscopy ◽

10.1016/s0016-5107(01)80488-0 ◽

2001 ◽

Vol 53 (5) ◽

pp. AB195 ◽

Cited By ~ 1

Keyword(s):

Variceal Bleeding ◽

Meta Analysis ◽

Band Ligation ◽

Endoscopic Band Ligation ◽

Β Blockers

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Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding: A meta-analysis

World Journal of Gastroenterology ◽

10.3748/wjg.15.2151 ◽

2009 ◽

Vol 15 (17) ◽

pp. 2151 ◽

Cited By ~ 14

Author(s):

Shi-Hua Ding ◽

Jun Liu ◽

Jian-Ping Wang

Keyword(s):

Meta Analysis ◽

Isosorbide Mononitrate ◽

Esophageal Variceal ◽

Band Ligation ◽

Adrenergic Blocker ◽

Endoscopic Band Ligation

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Band ligation versus propanolol and isosorbide mononitrate for primary prophylaxis of variceal bleeding. Lui HF, Stanley AJ, Forrest EH, et al., Primary Prophylaxis of Variceal Hemorrhage: A Randomized Controlled Trial Comparing Band Ligation, Propanolol, and Isosorbide Mononitrate.Gastroenterology 2002;123:735-44

The American Journal of Gastroenterology ◽

10.1111/j.1572-0241.2003.07623.x ◽

2003 ◽

Vol 98 (8) ◽

pp. 1887-1889

Author(s):

Daniel Sussman ◽

Jamie S. Barkin

Keyword(s):

Randomized Controlled Trial ◽

Variceal Bleeding ◽

Controlled Trial ◽

Primary Prophylaxis ◽

Isosorbide Mononitrate ◽

Variceal Hemorrhage ◽

Band Ligation ◽

Randomized Controlled

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Therapies: Drugs, Scopes and Transjugular Intrahepatic Portosystemic Shunt - When and How?

Digestive Diseases ◽

10.1159/000374101 ◽

2015 ◽

Vol 33 (4) ◽

pp. 524-533 ◽

Cited By ~ 4

Author(s):

Juan G. Abraldes ◽

Puneeta Tandon

Keyword(s):

High Risk ◽

Transjugular Intrahepatic Portosystemic Shunt ◽

Variceal Bleeding ◽

Portosystemic Shunt ◽

Variceal Hemorrhage ◽

Band Ligation ◽

First Choice ◽

Intrahepatic Portosystemic Shunt ◽

Endoscopic Band Ligation ◽

Β Blockers

Variceal bleeding is the most serious complication of portal hypertension. All cirrhotic patients should be screened endoscopically for varices which are present in about 30% of compensated and 60% of decompensated patients at diagnosis. In patients without varices, endoscopy surveillance should be continued every 2 years. Patients with high-risk varices (moderate or large in size, or with red color signs, or in Child-Pugh C patients) should be treated with a nonselective β-blocker to prevent bleeding (propranolol, nadolol or carvedilol). Endoscopic banding ligation is also effective for the prevention of first bleeding, and it is the first choice in patients with contraindications or intolerance to β-blockers. Acute variceal hemorrhage still has a high mortality rate (around 15%) and requires intensive care management and conservative blood transfusion policy. Treatment is based on the combined use of vasoactive drugs, endoscopic band ligation and prophylactic antibiotics. Failures are best managed by transjugular intrahepatic portosystemic shunt (TIPS). Balloon tamponade or specifically designed covered esophageal stents can be used as a bridge to definitive therapy in unstable patients. Early, preemptive TIPS might be the first choice in patients at high risk of failure (Child-Pugh B with active bleeding or Child-Pugh C up to 13 points). Patients surviving a variceal bleeding are at high risk of rebleeding. A combination of β-blockers and endoscopic band ligation is the most effective therapeutic approach. Preliminary data suggest that the addition of simvastatin increases survival in these patients.

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