title: Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials.
abstract: BACKGROUND
  Previous clinical trials on the treatment of esophageal variceal bleeding yielded mixed results regarding the efficacy of endoscopic procedures compared with pharmacotherapy only.
  
  
  OBJECTIVE
  To compare the efficacy of endoscopic procedures with that of pharmacotherapy in the prevention of mortality and rebleeding.
  
  
  METHODS
  A systematic literature review was performed to identify randomized, controlled trials of the efficacy of pharmacotherapy and endoscopic therapy. A meta-analysis was performed by using the Comprehensive MetaAnalysis software package. A 2-sided alpha error <.05 was considered statistically significant (P < .05).
  
  
  METHODS
  Twenty-five clinical trials with a total of 2159 patients were eligible for meta-analysis.
  
  
  METHODS
  Relative risk (RR) with 95% confidence interval (CI) was computed for all-cause mortality, mortality from rebleeding, all-cause rebleeding, and rebleeding caused by varices.
  
  
  RESULTS
  Pharmacotherapy was as effective as endoscopic procedures in preventing rebleeding (RR 1.067; 95% CI, 0.865-1.316; P = .546), variceal rebleeding (RR 1.143; 95% CI, 0.791-1.651; P = .476), all-cause mortality (RR 0.997; 95% CI, 0.827-1.202, P = .978), and mortality from rebleeding (RR 1.171; 95% CI, 0.816-1.679; P = .39). Pharmacotherapy combined with endoscopic procedures did not reduce all-cause mortality (RR 0.787; 95% CI, 0.587-1.054; P = .108) or mortality caused by rebleeding (RR 0.786; 95% CI, 0.445-1.387; P = .405) compared with endoscopic procedures. However, combination therapy (endoscopic procedure plus pharmacotherapy) significantly reduced the incidence of all rebleeding (RR 0.623; 95% CI, 0.523-0.741; P < .001) and variceal rebleeding (RR 0.601; 95% CI, 0.440-0.820; P < .001).
  
  
  CONCLUSIONS
  Heterogeneity of patient population and different treatment protocols may have affected our meta-analysis.
  
  
  CONCLUSIONS
  Pharmacotherapy may be as effective as endoscopic therapy in reducing rebleeding rates and all-cause mortality. Pharmacotherapy plus endoscopic intervention is more effective than endoscopic intervention alone.
authors: VA Medical Center, Toledo, Ohio, USA. mamata.ravipati1@va.gov
authors: Mamata
authors: M
authors: Ravipati
authors: Srikanth
authors: S
authors: Katragadda
authors: Paari Dominic
authors: PD
authors: Swaminathan
authors: Janos
authors: J
authors: Molnar
authors: Edwin
authors: E
authors: Zarling
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D003131:Combined Modality Therapy; D004932:Esophageal and Gastric Varices / Q000188:drug therapy / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D004945:Esophagoscopy; D006471:Gastrointestinal Hemorrhage / Q000188:drug therapy / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D006801:Humans; D008026:Ligation; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012307:Risk Factors; D012597:Sclerosing Solutions / Q000008:administration & dosage; D015911:Sclerotherapy
chemical_list: D000319:Adrenergic beta-Antagonists; D012597:Sclerosing Solutions