Emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis: a Cochrane meta-analysis.
OBJECTIVE
Emergency sclerotherapy is used as a first-line therapy for variceal bleeding in cirrhosis, although pharmacologic treatment stops bleeding in most patients. We performed a meta-analysis comparing emergency sclerotherapy with pharmacologic treatment.


METHODS
MEDLINE (1968-2002), EMBASE (1986-2002), and the Cochrane Library (2002;4) were searched to retrieve randomized controlled trials comparing sclerotherapy with vasopressin (+/- nitroglycerin), terlipressin, somatostatin, or octreotide for variceal bleeding in cirrhosis. Outcome measures were failure to control bleeding, rebleeding, blood transfusions, adverse events, and mortality.


RESULTS
Fifteen trials were identified. Sclerotherapy was not superior to terlipressin, somatostatin, or octreotide for any outcome and to vasopressin for rebleeding, blood transfusions, death, and adverse events; it was superior to vasopressin for the control of bleeding in a single trial flawed by a potential detection bias. Sclerotherapy was associated with significantly more adverse events than somatostatin. In a predefined sensitivity analysis, combining all of the trials irrespective of the control treatment, risk differences (sclerotherapy minus control) and confidence intervals (CIs) were as follows: failure to control bleeding, -0.03 (-0.06 to 0.01); mortality, -0.035 (-0.07 to 0.008); adverse events, 0.08 (0.02 to 0.14). Mortality risk difference was -0.01 (-0.07 to 0.04) in good-quality trials and -0.08 (-0.14 to -0.02) in poor-quality trials.


CONCLUSIONS
Available evidence does not support emergency sclerotherapy as the first-line treatment of variceal bleeding in cirrhosis when compared with vasoactive drugs, which control bleeding in 83% of patients. Therefore, endoscopic therapy might be added only in pharmacologic treatment failures.
Department of Medicine, Ospedale V Cervello, Palermo, Italy. gedamico@libero.it
Gennaro
G
D'Amico
Giada
G
Pietrosi
Ilaria
I
Tarantino
Luigi
L
Pagliaro
D000208:Acute Disease; D004632:Emergency Medical Services; D004932:Esophageal and Gastric Varices / Q000188:drug therapy*; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy*; D006490:Hemostatics / Q000627:therapeutic use*; D006728:Hormones / Q000627:therapeutic use; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008236:Lypressin / Q000031:analogs & derivatives* / Q000627:therapeutic use; D015282:Octreotide / Q000627:therapeutic use; D016032:Randomized Controlled Trials as Topic; D015911:Sclerotherapy; D013004:Somatostatin / Q000627:therapeutic use; D000077585:Terlipressin; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D014667:Vasopressins / Q000627:therapeutic use*
D006490:Hemostatics; D006728:Hormones; D014662:Vasoconstrictor Agents; D014667:Vasopressins; D008236:Lypressin; D013004:Somatostatin; D000077585:Terlipressin; D015282:Octreotide