Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: A meta-analysis

Abstract

Endoscopic therapy, involving either injection sclerosis or band ligation, is considered the intervention of first choice for acute variceal bleeding (AVB). Pharmacologic agents have also been shown to be highly effective in the control of the bleeding episode. The purpose of this meta-analysis was to assess whether vasoactive drugs may improve the efficacy of endoscopic therapy (injection sclerosis or band ligation) in the control of AVB and thus increase survival rates. Computer databases and scientific meeting abstracts from 1994 to 2001 were used to search for randomized trials that compared the combined use of endoscopic and drug therapy with endoscopic therapy alone in the control of AVB. Eight trials involving 939 patients fulfilled the selection criteria and the following evaluated by standard meta-analysis methods: initial hemostasis, 5-day hemostasis, 5-day mortality, and adverse events. Combined treatment improved initial control of bleeding (relative risk [RR], 1.12; 95% confidence interval (CI), 1.02-1.23), and 5-day hemostasis (RR, 1.28; 95% CI, 1.18-1.39), with numbers of patients needed to treat (NNT) of 8 and 5, respectively. The difference in favor of combined treatment remained significant when trials that used drugs other than octreotide or that included a low proportion of alcoholic patients (<40%) or high-risk cirrhotic patients (<35%) were excluded. Mortality was not significantly decreased by combined therapy (RR, 0.73; 95% CI, 0.45-1.18). Severe adverse events were similar in both groups. In conclusion, in patients with AVB, pharmacologic agents improve the efficacy of endoscopic therapy to achieve initial control of bleeding and 5-day hemostasis, yet fail to affect mortality. (HEPATOLOGY 2002;35:609-615.) A cute variceal bleeding (AVB) is the most severe consequence of portal hypertension. The treatment of this entity should involve the initial control of hemorrhage and prevention of early rebleeding. 1-3 Endoscopic sclerotherapy has been shown to be highly effective in the control of both these processes. Sclerotherapy stops bleeding in about 80% to 90% of patients, and band ligation appears to be equally effective. 4,5 Indeed, it was concluded at the Reston conference that endoscopic therapy is the intervention of first choice for AVB. 2 On the other hand, vasoactive drugs, such as somatostatin and terlipressin, are as effective as endoscopic sclerotherapy for the arrest of the acute episode of bleeding and prevention of early rebleeding. 6,7 However, hemodynamic and clinical data are not so consistent when other agents such as octreotide are employed. 8,9 The question arises as to whether drugs may improve the efficacy of endoscopy without enhancing adverse events. The combination of both types of therapy is aimed at adding the portal pressure-lowering effect of drugs to the local hemostatic effects of injection sclerosis or ligation, and different vasoactive agents have been tested to this end in several randomized trials. Whereas drugs improved the efficacy of endoscopic therapy...

Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis

“…A meta-analysis of 8 trials showed that, compared to endoscopic therapy alone (sclerotherapy or EVL), endoscopic plus pharmacological (octreotide, somatostatin, vapreotide) therapy improved the initial control of bleeding and 5-day hemostasis without differences in mortality or severe adverse events. 105 …”

Clinical trial: the effect of somatostatin vs. octreotide in preventing post‐endoscopic increase in hepatic venous pressure gradient in cirrhotics with bleeding varices

“…This consideration supported by a meta-analysis found that the combination of endoscopic therapy and SST or its analogues achieves better haemostasis although without improvement in survival. 34 It has also been demonstrated that the addition of sclerotherapy significantly improves the efficacy of SST alone for the treatment of acute variceal bleeding. 35 The results of our study support the beneficial role of SST in combination with endoscopic therapy but not OCT in the optimal management of BEVs.…”

Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival

“…Sensitivity analysis of methodological quality was performed to control any bias in the estimates of intervention efficacy. [13][14][15][16] …”