Primary prophylaxis of esophageal variceal bleeding: An endoscopic approach

Abstract

Recent guidelines recommend that patients diagnosed with cirrhosis have endoscopy to screen for varices. Beta-blocker therapy or endoscopic variceal ligation is recommended for those with moderate-large varices that have not bled. This paper reviews the evidence supporting the use of endoscopic ligation rather than beta-blockers for primary prophylaxis in these patients.Ligation is an effective treatment for the prevention of bleeding among patients with esophageal varices that have never bled. A metaanalysis of 5 randomized trials with mean follow-up of 23 months revealed a significant decrease in first variceal bleeding (RR = 0.36, 95% CI, 0.26-0.50; number-needed-to-treat (NNT) = 4) and mortality (RR = 0.55, 0.43-0.71; NNT = 5) as compared to no therapy [1].Beta-blockers are also effective in decreasing first variceal bleeding (NNT = 11), with a trend to decreased mortality, compared to placebo or inactive therapy in meta-analysis of 11 randomized trials with median follow-up of 24 months [2].Issues to consider in deciding whether to choose endoscopic ligation or beta-blocker therapy include efficacy, safety/tolerability, patient preference, and cost/cost-effectiveness. EfficacyMeta-analyses consistently document a significantly lower incidence of first upper gastrointestinal bleeding and variceal bleeding with ligation vs. beta-blockers [3][4][5]. Relative risk reductions are approximately 35% and NNTs approximately 14. The metaanalyses, however, show no suggestion of a benefit in mortality.Subgroup analyses (e.g., based on size or methodologic quality of studies) have been performed as part of meta-analyses [5,6]. Point estimates and widely overlapping confidence intervals from these analyses indicate that the treatment effect of ligation vs. beta-blockers is not significantly different across the subgroups assessed. Safety and tolerabilityThe incidence of severe adverse events or adverse events leading to discontinuation of therapy is significantly lower with ligation than with beta-blockers, with relative risk reductions of approximately 65-75% and NNTs of approximately 10 [3,4]. Critics of ligation point out that although adverse events are less common with ligation, rare side effects such as ligation-induced ulcer bleeding can be much more severe than most beta-blocker adverse events and are even rarely fatal. However, in almost all published studies, if ligation-induced ulcer bleeding occurred it was included in the primary bleeding endpoint. In addition, meta-analyses show significant benefit when all bleeding episodes are considered-not just when variceal bleeding is considered [3]. Thus, even when ligation-induced ulcer bleeding is included in the primary efficacy endpoint, ligation is still significantly more effective than beta-blockers in a population of patients with esophageal varices that have not previously bled. Patient preferenceIncorporating patient preferences into clinical decision-making is of great importance. A recent study assessed preferences of patients and physicians [7]. Patients ...

Efficacy and Safety of Ligation Combined With Sclerotherapy for Patients With Acute Esophageal Variceal Bleeding in Cirrhosis: A Meta-Analysis

“…EIS refers to the injection of a sclerosing agent into the tissue of varicose vein or adjacent to varicose vein, which shows ischemia and necrosis in the tissue of varicose vein, and then produces fibrosis, to eliminate varicose veins ( 24 ). With the continuous development of endoscopic technology and the evolution of sclerosing agents, the clinical application of EVL and EVs is also evolving ( 25 ).…”

Bêtabloquants dans l’hypertension portale : des restrictions inattendues !

“…Cette prophylaxie repose actuellement sur les BBs ou la ligature endoscopique de varices oesophagiennes (LVO) ; le choix entre ces deux traitements, dépendant étroitement des ressources locales et de l'expertise des centres, fait toujours l'objet de controverses : d'un côté, les défenseurs des BBs argumentent que la LVO est source de saignement post-ligature parfois fatale, qu'elle est plus onéreuse et plus complexe à mettre en oeuvre et qu'elle ne prévient pas la gastropathie d'HTP contrairement aux BBs ; de plus, les BBs ont l'avantage de leur facilité d'utilisation et de la rareté des effets secondaires sévères [4]. D'un autre côté, la LVO aurait la préférence des patients (surtout du fait d'un nombre plus faible d'évènements indésirables) et une réduction significative du risque de première hémorragie en présence de varices oesophagiennes de grade II ou III (réduction de 9,2 % : IC95 % : 5,2-13,1 %) [4,5]. Ce faible avantage disparaissait lorsqu'on ne tenait compte que des essais ayant un long suivi et des effectifs suffisants ; toutefois, aucune différence de survie n'était mise en évidence [6].…”