Endoscopic treatment of bleeding esophageal varices

We read with great interest the meta-analysis by Triantos et al. [1] on the role of sclerotherapy in the treatment of acute variceal bleeding in relation to vasoactive drugs and ligation. Regarding vasoactive drugs, the analysis confirmed the findings of other meta-analyses [2] [3]. However, regarding the role of ligation, the authors concluded, ”Sclerotherapy can remain a gold standard in variceal bleeding,” despite their having shown a significant difference in favor of ligation with respect to the control of bleeding. We believe that the conclusions contradict the results of their own and of previous meta-analyses [4] [5]. According to the Baveno IV consensus, ligation can be considered to be the first-choice or ”gold standard” treatment [6].

The meta-analysis does not take the complications associated with sclerotherapy into account. It is stated, but not supported by evidence, that the double intubation necessary for ligation increases the risk of complications and lengthens the procedure. Current evidence based on the use of vasoactive drugs at admission [2] [3] or even before admission [7] has shown that massive spurting bleeding or oozing is seldom seen at the time of endoscopy, and therefore the suggested problem of double intubation and visibility through the ligation cap is rarely a problem in clinical practice. Therefore, contrasting this undocumented problem with the scientific evidence that the complication rate is significantly less with ligation compared with sclerotherapy, we question the plausibility of the conclusion, which also conflicts with other guidelines and recommendations [6] [8] [9].

Among the eight published studies selected for the meta-analysis, seven studies with 684 patients [10] [11] [12] [13] [14] [15] [16] reported significantly fewer complications in the ligation group, while only one study with 103 patients [17] reported comparable complication rates for the two treatment methods. The complications of sclerotherapy were mainly esophageal strictures and/or ulcers, pneumonia, and other infections. Other studies that were not included in the meta-analysis, including a recent randomized study with 179 patients, also found ligation to be significantly superior to sclerotherapy with regard to side effects [18] [19].

In conclusion, we do not find evidence or new data in the literature to support modification of the Baveno IV recommendations [6]: ”Ligation is the recommended form of endoscopic therapy for acute variceal bleeding although sclerotherapy may be used in the acute setting if ligation is technically difficult.” Furthermore, it is noteworthy that ligation is already an integral part of the treatment of esophageal varices, because ligation is the endoscopic treatment of choice for secondary prophylaxis and in cases where there are contraindications to or intolerance of beta-blockers for primary prophylaxis, due to its efficacy and safety [5] [20] [21] [22].

Competing interests: None

References

• 1 Triantos C K, Goulis J, Patch D. et al . An evaluation of emergency sclerotherapy of varices in randomized trials: looking the needle in the eye.  Endoscopy. 2006;  38 797-807
• 2 Ioannou G, Doust J, Rockey D C. Terlipressin for acute esophageal variceal hemorrhage.  Cochrane Database Syst Rev. 2003;  1 CD002147
• 3 Gotzsche P C, Hrobjartsson A. Somatostatin analogues for acute bleeding oesophageal varices.  Cochrane Database Syst Rev. 2005;  1 CD000193
• 4 Gross M, Schiemann U, Muhlhofer A. et al . Meta-analysis: efficacy of therapeutic regimens in ongoing variceal bleeding.  Endoscopy. 2001;  33 737-746
• 5 Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding: a meta-analysis.  Ann Intern Med. 1995;  123 280-287
• 6 de Franchis R. Evolving consensus in portal hypertension: report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension.  J Hepatol. 2005;  43 167-176
• 7 Levacher S, Letoumelin P, Pateron D. et al . Early administration of terlipressin plus glyceryl trinitrate to control active upper gastrointestinal bleeding in cirrhotic patients.  Lancet. 1995;  346 865-868
• 8 Jalan R, Hayes P C. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. British Society of Gastroenterology.  Gut. 2000;  46 (Suppl 3 - 4) III1-III15
• 9 Sharara A I, Rockey D C. Gastroesophageal variceal hemorrhage.  N Engl J Med. 2001;  345 669-681
• 10 Lo G H, Lai K H, Cheng J S. et al . A prospective, randomized trial of sclerotherapy versus ligation in the management of bleeding esophageal varices.  Hepatology. 1995;  22 466-471
• 11 Laine L, el-Newihi H M, Migikovsky B. et al . Endoscopic ligation compared with sclerotherapy for the treatment of bleeding esophageal varices.  Ann Intern Med. 1993;  119 1-7
• 12 Stiegmann G V, Goff J S, Michaletz-Onody P A. et al . Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices.  N Engl J Med. 1992;  326 1527-1532
• 13 Lo G H, Lai K H, Cheng J S. et al . Emergency banding ligation versus sclerotherapy for the control of active bleeding from esophageal varices.  Hepatology. 1997;  25 1101-1104
• 14 Shafqat F, Khan A A, Alam A. et al . Band ligation vs endoscopic sclerotherapy in esophageal varices: a prospective randomized comparison.  J Pak Med Assoc. 1998;  48 192-196
• 15 Sarin S K, Govil A, Jain A K. et al . Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: influence on gastropathy, gastric varices and variceal recurrence.  J Hepatol. 1997;  26 826-832
• 16 Hou M C, Lin H C, Kuo B I. et al . Comparison of endoscopic variceal injection sclerotherapy and ligation for the treatment of esophageal variceal hemorrhage: a prospective randomized trial.  Hepatology. 1995;  21 1517-1522
• 17 Gimson A E, Ramage J K, Panos M Z. et al . Randomised trial of variceal banding ligation versus injection sclerotherapy for bleeding oesophageal varices.  Lancet. 1993;  342 391-394
• 18 Villanueva C, Piqueras M, Aracil C. et al . A randomized controlled trial comparing ligation and sclerotherapy as emergency endoscopic treatment added to somatostatin in acute variceal bleeding.  J Hepatol. 2006;  45 560-567
• 19 Masci E, Stigliano R, Mariani A. et al . Prospective multicenter randomized trial comparing banding ligation with sclerotherapy of esophageal varices.  Hepatogastroenterology. 1999;  46 1769-1773
• 20 D’Amico G, Pagliaro L, Bosch J. The treatment of portal hypertension: a meta-analytic review.  Hepatology. 1995;  22 332-354
• 21 Jutabha R, Jensen D M, Martin P. et al . Randomized study comparing banding and propranolol to prevent initial variceal hemorrhage in cirrhotics with high-risk esophageal varices.  Gastroenterology. 2005;  128 870-881
• 22 Khuroo M S, Khuroo N S, Farahat K L. et al . Meta-analysis: endoscopic variceal ligation for primary prophylaxis of oesophageal variceal bleeding.  Aliment Pharmacol Ther. 2005;  21 347-361