EFFICACY OF ENDOSCOPIC TREATMENTS FOR ACUTE ESOPHAGEAL VARICEAL BLEEDING IN CIRRHOTICS: SYSTEMATIC REVIEW AND META-ANALYSIS

Aims:

Most guidelines recommend and consider the use of ligation and vasoactive drugs as the first line therapy and grade A evidence for acute variceal bleeding (AVB), although Western studies about this issue are lacking. We performed a systematic review and meta-analysis of randomized controlled trials (RCT) to evaluate the efficacy of endoscopic treatments for AVB.

Methods:

Systematic review and meta-analysis of RCT evaluating endoscopic treatments for AVB in adult patients with cirrhosis. Trials that included patients with hepatocellular carcinoma or other malignancies, use of portocaval shunts or esophageal resection, use of balloon tamponade as first bleeding control measure, or that received placebo or elective treatment in one study arm were excluded.

Results:

8382 publications were searched, and 36 RCT with 3593 patients included. Ligation was associated with a significant improvement in bleeding control [relative risk (RR) 1.08; 95% confidence interval (CI) 1.02 – 1.15] when compared to sclerotherapy. Sclerotherapy combined with vasoactive drugs showed higher efficacy in active bleeding control compared to sclerotherapy alone [RR 1.17; 95% CI 1.10 – 1.25]. The combination of ligation and vasoactive drugs was not superior to ligation alone in terms of overall rebleeding [RR 2.21; 95% CI 0.55 – 8.92] and in-hospital mortality [RR 1.97; 95% CI 0.78 – 4.97]. Other treatments did not generate meta-analysis.

Conclusions:

This study showed that ligation is superior to sclerotherapy, although with moderate heterogeneity. The combination of sclerotherapy and vasoactive drugs was more effective than sclerotherapy alone. Although current guidelines recommend the combined use of ligation with vasoactive drugs in the treatment of esophageal variceal bleeding, this study failed to demonstrate the superiority of this combined treatment.