Jacob Korula, MD
In patients with cirrhosis and bleeding esophageal varices, is a combination of endoscopic and drug therapy more effective than either therapy alone?
Studies selected compared endoscopic therapy (sclerotherapy or band ligation) plus drug therapy (nonselective β-blockers) with either therapy alone for prevention of rebleeding in patients with cirrhosis and a previous episode of esophageal variceal hemorrhage. Outcomes were rebleeding (from any upper gastrointestinal source after control of the initial hemorrhage) and mortality.
MEDLINE, EMBASE/Excerpta Medica, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, abstracts from scientific meetings, personal reference files, references, and clinical trial registers (to Dec 2007) were searched for randomized controlled trials (RCTs). 23 RCTs (n = 1860, mean age 53 y, 75% men) met the selection criteria. 8 trials reported adequate allocation concealment, and 2 trials were double-blinded. 15 RCTs were published as full articles.
Combination therapy reduced rebleeding more than endoscopic or drug therapy alone, but the reductions in mortality did not reach statistical significance (Table). Treatment effect was similar regardless of type of endoscopic therapy, time to variceal obliteration or start of β-blocker therapy, or cause or stage of liver disease.
In patients with cirrhosis and bleeding esophageal varices, combination of endoscopic and drug therapy is more effective for preventing rebleeding than either therapy alone.
Endoscopic plus drug therapy vs either therapy alone in patients with cirrhosis and bleeding esophageal varices*
*Abbreviations defined in Glossary. RRR, NNT, and CI calculated from data in article using a fixed-effects model. Median follow-up was 19 months in trials that used endoscopic therapy as the comparator and 24 months in trials that used drug therapy as the comparator.
†Heterogeneity in treatment effect present among trials; random-effects model used.
Korula J. Review: Endoscopic plus drug therapy prevents rebleeding more than either one alone in cirrhosis with bleeding esophageal varices. Ann Intern Med. ;149:JC5–10. doi: 10.7326/0003-4819-149-10-200811180-02010
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Published: Ann Intern Med. 2008;149(10):JC5-10.
Gastroenterology/Hepatology, Liver Disease.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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