Endoscopic ligation in the treatment of variceal bleeding

Endoscopic treatment of esophageal varices in patients with liver cirrhosis

Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.

Antacids for preventing oesophagogastric variceal bleeding and rebleeding in cirrhotic patients

BACKGROUND

Ruptured gastroesophageal varices are the most severe and frequent cause of gastrointestinal bleeding in cirrhotic patients, leading to death in 5% to 8% of patients during the first 48 hours and oesophagogastric varices account for 60% to 80% of first bleeding in patients with portal hypertension. Antacids are often used for emergency treatment of bleeding oesophageal varices in patients with cirrhosis of the liver.

OBJECTIVES

To evaluate the beneficial and harmful effects of antacids for preventing oesophagogastric bleeding and rebleeding.

SEARCH STRATEGY

We identified relevant randomised clinical trials by searching The Cochrane Hepato-Biliary Group Controlled Trials Register (June 2007), the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2, 2007), MEDLINE (1950 to June 2007), EMBASE (Excerpta Medica Database) (1980 to June 2007), and the Science Citation Index Expanded (SCI-EXPANDED) (1945 to June 2007). Additional randomised trials were sought from the reference lists of the trials found and reviews identified by the electronic searches.

SELECTION CRITERIA

We planned to include randomised clinical trials.

DATA COLLECTION AND ANALYSIS

We planned to summarise data using Cochrane Collaboration methodologies.

MAIN RESULTS

We could not find any randomised clinical trials on antacids for preventing oesophagogastric variceal bleeding and bleeding in cirrhotic patients.

AUTHORS' CONCLUSIONS

it is not possible to determine whether antacids are beneficially effective or harmful for preventing oesophagogastric variceal bleeding and rebleeding in cirrhotic patients since randomised clinical trials investigating it are lacking.