Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review
Version of Record online: 24 JAN 2014
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Volume 34, Issue 6, pages 823–833, July 2014
How to Cite
Liver Int. 2014: 34: 823–833
- Issue online: 17 JUN 2014
- Version of Record online: 24 JAN 2014
- Accepted manuscript online: 24 DEC 2013 03:23AM EST
- Manuscript Accepted: 15 DEC 2013
- Manuscript Received: 26 APR 2013
- Fondo de Investigaciones Sanitarias. Grant Number: PI10/01552
- Fundació Investigació Sant Pau
- combined therapy;
- variceal ligation;
- variceal rebleeding
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.
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.
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).
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.