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.
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.
Ravipati
Mamata
M
VA Medical Center, Toledo, Ohio, USA. mamata.ravipati1@va.gov
Katragadda
Srikanth
S
Swaminathan
Paari Dominic
PD
Molnar
Janos
J
Zarling
Edwin
E
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
D000319:Adrenergic beta-Antagonists; D012597:Sclerosing Solutions