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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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Xu X, Guo X, Tacke F, Shao X, Qi X. Use of nonselective β blockers after variceal eradication in cirrhotic patients undergoing secondary prophylaxis of esophageal variceal bleeding: a critical review of current evidence. Ther Adv Chronic Dis 2019; 10:2040622319862693. [PMID: 31321015 PMCID: PMC6628526 DOI: 10.1177/2040622319862693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/14/2019] [Indexed: 02/05/2023] Open
Abstract
Nonselective β blockers (NSBBs) combined with esophageal variceal ligation (EVL) are recommended for secondary prophylaxis of esophageal variceal bleeding (EVB) in cirrhotic patients according to the current practice guidelines and consensus. However, until now, there is a paucity of recommendations regarding the use of NSBBs in cirrhotic patients who achieved variceal eradication. In this review paper, we firstly introduced a case who achieved variceal eradication after additional use of NSBBs for secondary prophylaxis of EVB and then did not require further endoscopic therapy during repeated endoscopic surveillance, and subsequently discuss the importance of NSBBs for secondary prophylaxis of EVB, the effect of NSBBs after variceal eradication, adherence to NSBBs, screening for variceal recurrence, and timing of endoscopic surveillance after variceal eradication.
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Affiliation(s)
- Xiangbo Xu
- Department of Gastroenterology, General Hospital
of Northern Theater Command (formerly General Hospital of Shenyang Military
Area), Shenyang, China
- Postgraduate College, Shenyang Pharmaceutical
University, Shenyang, China
| | - Xiaozhong Guo
- Department of Gastroenterology, General Hospital
of Northern Theater Command (formerly General Hospital of Shenyang Military
Area), Shenyang, China
| | - Frank Tacke
- Department of Gastroenterology and Hepatology,
Charité University Medical Center, Berlin, Germany
| | - Xiaodong Shao
- Department of Gastroenterology, General Hospital
of Northern Theater Command (formerly General Hospital of Shenyang Military
Area), Shenyang, China
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Aggeletopoulou I, Konstantakis C, Manolakopoulos S, Triantos C. Role of band ligation for secondary prophylaxis of variceal bleeding. World J Gastroenterol 2018; 24:2902-2914. [PMID: 30018485 PMCID: PMC6048424 DOI: 10.3748/wjg.v24.i26.2902] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/05/2018] [Accepted: 06/25/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To summarize and critically examine the role of band ligation in secondary prophylaxis of variceal bleeding in patients with cirrhosis.
METHODS A literature review was performed using the MEDLINE and PubMed databases. The search terms consisted of the words “endoscopic band ligation” OR “variceal band ligation” OR “ligation” AND “secondary prophylaxis” OR “secondary prevention” AND “variceal bleeding” OR “variceal hemorrhage” AND “liver cirrhosis”. The data collected from relevant meta-analyses and from the most recent randomized studies that were not included in these meta-analyses were used to evaluate the role of endoscopic band ligation in an effort to demonstrate the most recent advances in the treatment of esophageal varices.
RESULTS This study included 11 meta-analyses published from 2002 to 2017 and 10 randomized trials published from 2010 to 2017 that evaluated the efficacy of band ligation in the secondary prophylaxis of variceal bleeding. Overall, the results proved that band ligation was superior to endoscopic sclerotherapy. Moreover, the use of β-blockers in combination with band ligation increased the treatment effectiveness, supporting the current recommendations for secondary prophylaxis of variceal bleeding. The use of transjugular intrahepatic portosystemic shunt was superior to combination therapy regarding rebleeding prophylaxis, with no difference in the survival rates; however, the results concerning the hepatic encephalopathy incidence were conflicting. Recent advances in the management of secondary prophylaxis of variceal bleeding have targeted a decrease in portal pressure based on the pathophysiological mechanisms of portal hypertension.
CONCLUSION This review suggests that future research should be conducted to enhance current interventions and/or to develop innovative treatment options with improved clinical endpoints.
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Affiliation(s)
| | | | - Spilios Manolakopoulos
- 2nd Department of Internal Medicine, Hippokration General Hospital of Athens, Athens 11527, Greece
| | - Christos Triantos
- Department of Gastroenterology, University Hospital of Patras, Patras 26504, Greece
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Abstract
Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.
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Affiliation(s)
- Yeon Seok Seo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Can Non-Selective Beta-Blockers (NSBBs) Prevent Enlargement of Small Esophageal Varices in Patients with Cirrhosis? A Meta-analysis. J Clin Exp Hepatol 2017; 7:275-283. [PMID: 29234190 PMCID: PMC5715455 DOI: 10.1016/j.jceh.2017.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 09/24/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Non-selective beta-blockers (NSBBs) are recommended for prophylaxis of first variceal bleeding in patients of cirrhosis with large esophageal varices. However, the data is conflicting whether NSBBs can also prevent growth of small esophageal varices to large size. AIM To perform a meta-analysis of the randomized clinical trials comparing NSBBs with placebo for prevention of development of large esophageal varices in patients of cirrhosis with small esophageal varices. METHODS The PubMed, EMBASE, Science Direct, and Cochrane library databases were searched for relevant papers. A meta-analysis was performed using risk ratios (RRs) with 95% confidence interval (CI) as the effect sizes. RESULTS Overall, 314 trials were initially retrieved from the database searches, of which five randomized controlled trials were included in the meta-analysis. The incidence of development of large varices (RR = 0.91, 95%CI: 0.29-2.86; P = 0.87) was similar between NSBB and placebo groups. However, the heterogeneity among studies was significant (P < 0.01) with an I2 of 93%. The incidences of first variceal bleeding (RR = 0.72, 95%CI: 0.25-2.12; P = 0.55) and death (RR = 0.76, 95%CI: 0.50-1.15; P = 0.19) were also similar between NSBB and placebo groups; with no heterogeneity. The incidence of adverse events was significantly higher in the NSBB group compared with the placebo group (RR = 4.66, 95%CI: 1.36-15.91; P = 0.01). CONCLUSION The results of this meta-analysis indicate that NSBBs are not effective in preventing growth of small varices and may lead to significant adverse effects. Hence, NSBBs should not be recommended for cirrhotic patients with small varices.
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Rodríguez-Almendros N, Toapanta-Yanchapaxi LN, Aguirre Valadez J, Espinola Zavaleta N, Muñoz-Martínez SG, García-Juárez I. [Portopulmonary hypertension: Updated review]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 88:25-38. [PMID: 27986561 DOI: 10.1016/j.acmx.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 11/08/2016] [Accepted: 11/08/2016] [Indexed: 11/19/2022] Open
Abstract
Portopulmonary hypertension (PPH) is a rare condition worldwide, although epidemiological data are unknown in Mexico. However, chronic liver diseases are very prevalent in Mexico. PPH is the 4th subtype in frequency in the group of pulmonary arterial hypertension. Its diagnosis is made within 2 scenarios: patients with suspected pulmonary hypertension and candidates for orthotopic liver transplantation (OLT). Both echocardiogram and a right cardiac catheterisation are crucial for diagnosis in both cases. PPH is a challenge for OLT, since it can significantly increase perioperative mortality. The use of specific therapy is the cornerstone of this disease, as a measure to improve the outcome of those who become candidates for OLT with moderate to severe PPH. It is important to recognise that PPH can be a contraindication to OLT. The role of lung-liver transplantation or heart-lung-liver transplantation as a measure to heal pulmonary vascular disease in patients with PPH is still uncertain.
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Affiliation(s)
- Nielzer Rodríguez-Almendros
- Departamento de Hipertensión Pulmonar y Función Ventricular Derecha, UMAE Cardiología, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México, D.F., México
| | - Liz N Toapanta-Yanchapaxi
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Jonathan Aguirre Valadez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Nilda Espinola Zavaleta
- Departamento de Ecocardiografia, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Sergio G Muñoz-Martínez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México
| | - Ignacio García-Juárez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Ciudad de México, México.
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Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64:1680-704. [PMID: 25887380 PMCID: PMC4680175 DOI: 10.1136/gutjnl-2015-309262] [Citation(s) in RCA: 363] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022]
Abstract
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Charles Millson
- Gastrointestinal and Liver Services, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - James W Ferguson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon P Olliff
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John M Christie
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Devon, UK
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Triantos C, Kalafateli M. Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol 2014; 20:13015-13026. [PMID: 25278695 PMCID: PMC4177480 DOI: 10.3748/wjg.v20.i36.13015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/15/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
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.
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Puente A, Hernández-Gea V, Graupera I, Roque M, Colomo A, Poca M, Aracil C, Gich I, Guarner C, Villanueva C. Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review. Liver Int 2014; 34:823-33. [PMID: 24373180 DOI: 10.1111/liv.12452] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 12/15/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Combined therapy with endoscopic variceal ligation (EVL) and β-blockers ± isosorbide mononitrate (ISMN) is currently recommended to prevent variceal rebleeding. However, the role of this combined therapy has been challenged by some studies. We performed a systematic review to assess the value of combined therapy with EVL and β-blockers ± ISMN as compared with each treatment alone to prevent rebleeding. METHODS Databases, references and meeting abstracts were searched to retrieve randomized trials comparing combined therapy with EVL and β-blockers ± ISMN vs either treatment alone, to prevent variceal rebleeding in cirrhosis. Random-effects model was used for meta-analysis. RESULTS We identified five studies comparing EVL alone or combined with drugs, including a total of 476 patients. Combination therapy reduced overall rebleeding [risk ratios (RR) = 0.44, 95% confidence interval (CI) = 0.28-0.69], and showed a trend towards lower mortality (RR = 0.58, 95% CI = 0.33-1.03), without increasing complications. We identified four trials comparing drugs alone or associated with EVL, including 409 patients. All used β-blockers plus ISMN. Variceal rebleeding decreased with combined therapy (P < 0.01) but rebleeding from oesophageal ulcers increased (P = 0.01). Overall, there was a trend towards lower rebleeding (RR = 0.76, 95% CI = 0.58-1.00) without effect on mortality (RR = 1.24, 95% CI = 0.90-1.70). CONCLUSIONS The addition of drug therapy to EVL improves the efficacy of EVL alone. However, the addition of EVL to β-blockers and ISMN achieves a non-significant decrease of rebleeding with no effect on mortality. Although combination therapy with EVL plus β-blockers ± ISMN is adequate to prevent rebleeding, β-blockers + ISMN alone may be a valid alternative.
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Affiliation(s)
- Angela Puente
- Gastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Autonomous University, Barcelona, Spain
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Abstract
Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of ∼20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child-Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in ∼60% of patients 1-2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.
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Sauerbruch T, Appenrodt B, Schmitz V, Spengler U. The conservative and interventional treatment of the complications of liver cirrhosis: Part 2 of a series on liver cirrhosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:126-32, I. [PMID: 23505400 DOI: 10.3238/arztebl.2013.0126] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 05/30/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND It is estimated that 1 million persons in Germany suffer from hepatic cirrhosis, which is the final stage of chronic inflammation of the liver. Cirrhosis has multiple causes, all of which lead to structural changes of the liver and to portal hypertension. The main complications of cirrhosis arise in turn: These include bleeding from collateral veins, ascites, hepatocellular carcinoma, encephalopathy, and infection leading to organ failure. METHODS We present the treatment of the main complications of liver cirrhosis with reference to the relevant literature (phase II and III trials, meta-analyses, and reviews). RESULTS Endoscopic treatment (ligation) is used for the primary and secondary prophylaxis of variceal bleeding. Drugs to lower portal pressure (e.g., beta-blockers) are an established means of preventing initial or recurrent variceal bleeding over the long term. Vasoconstrictors such as terlipressin are mainly used to treat acute hemorrhage and type 1 hepatorenal syndrome. The main treatment of ascites is with spironolactone, in combination with a loop diuretic where indicated. A shunt (TIPS) is used to treat severe or repeat variceal hemorrhage or refractory ascites. Antibiotics play a well-established role in the treatment of acute hemorrhage, in the treatment and prevention of spontaneous bacterial peritonitis, and in the treatment of encephalopathy. The treatment of hepatocellular carcinoma depends on its extent of spread and on the degree of decompensation of cirrhosis. CONCLUSION For most of the main complications of liver cirrhosis, there are treatments that have been well-tested in randomized trials. Liver transplantation should also be considered in every case.
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Affiliation(s)
- Tilman Sauerbruch
- Department of Internal Medicine I at the University Hospital of Bonn, Bonn, Germany.
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Chang FF, Du YJ. Progress in prevention and treatment of rebleeding after endoscopic band ligation for esophageal variceal bleeding. Shijie Huaren Xiaohua Zazhi 2012; 20:2795-2799. [DOI: 10.11569/wcjd.v20.i29.2795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hemorrhage from esophageal varices is a serious and common complication of decompensated cirrhosis and carries a significant rate of morbidity and mortality. Endoscopic variceal ligation (EVL) is an effective treatment for esophageal varices; however, there is a very high rate of rebleeding. Prevention and treatment of rebleeding after EVL are important for improving survival in patients with liver cirrhosis. Currently, many measures, including endoscopy, surgery, medication, and a combination of them, have been developed to prevent the occurrence of rebleeding after EVL. Many clinical trials have been done to evaluate the effectiveness of various treatments, alone or in combination, for rebleeding.
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Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis: a meta-analysis. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:147-55. [PMID: 21499579 DOI: 10.1155/2011/346705] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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 betablockers (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 betablockers plus isosorbide mononitrate may be the best choice for the prevention of rebleeding.
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Gluud LL, Langholz E, Krag A. Meta-analysis: isosorbide-mononitrate alone or with either beta-blockers or endoscopic therapy for the management of oesophageal varices. Aliment Pharmacol Ther 2010; 32:859-71. [PMID: 20839387 DOI: 10.1111/j.1365-2036.2010.04418.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The evidence concerning the use of isosorbide-mononitrate (IsMn) for oesophageal varices is equivocal. AIM To assess the effects of IsMn for patients with oesophageal varices and no previous bleeding (primary prevention) or previous variceal bleeding (secondary prevention). METHODS Systematic review with meta-analyses of randomized trials on IsMn alone or with beta-blockers or endoscopic therapy for oesophageal varices. Electronic and manual searches were combined. Randomized trials on primary and secondary prevention were included. The primary outcome measure was mortality. Intention-to-treat random effects meta-analyses were performed. The robustness of the results was assessed in trial sequential analyses. RESULTS Ten randomized trials on primary and 17 on secondary prevention were included. Evidence of bias was identified. No apparent effect of IsMn on mortality compared with placebo or beta-blockers or IsMn plus beta-blockers vs. beta-blockers was identified. Compared with endoscopic therapy, IsMn plus beta-blockers had no apparent effect on bleeding, but did seem to reduce mortality in secondary prevention (RR 0.73, 95% CI 0.59-0.89), but not in primary prevention. The effect of IsMn plus beta-blockers on mortality in secondary prevention was not confirmed in trial sequential analysis. CONCLUSIONS Isosorbide-mononitrate used alone or in combination with beta blockers does not seem to offer any reduction in bleeding in the primary or secondary prevention of oesophageal varices. Compared with endoscopic therapy, there may be a survival advantage in using IsMn and beta-blockers, but additional large multicentre trials are needed to verify this finding.
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Affiliation(s)
- L L Gluud
- Department of Internal Medicine, Copenhagen University Hospital, Gentofte, Denmark.
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