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Meta-Analysis
. 2010 Mar 17;2010(3):CD002233.
doi: 10.1002/14651858.CD002233.pub2.

Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients

Gennaro D'Amico  1 , Luigi Pagliaro, Giada Pietrosi, Ilaria Tarantino
Affiliations
Meta-Analysis

Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients

Gennaro D'Amico et al. Cochrane Database Syst Rev. .

Abstract

Background: Emergency sclerotherapy is still widely used as a first line therapy for variceal bleeding in patients with cirrhosis, particularly when banding ligation is not available or feasible. However, pharmacological treatment may stop bleeding in the majority of these patients.

Objectives: To assess the benefits and harms of emergency sclerotherapy versus vasoactive drugs for variceal bleeding in cirrhosis.

Search strategy: Search of trials was based on The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded through January 2010.

Selection criteria: Randomised clinical trials comparing sclerotherapy with vasoactive drugs (vasopressin (with or without nitroglycerin), terlipressin, somatostatin, or octreotide) for acute variceal bleeding in cirrhotic patients.

Data collection and analysis: Outcome measures were failure to control bleeding, five-day treatment failure, rebleeding, mortality, number of blood transfusions, and adverse events. Data were analysed by a random-effects model according to the vasoactive treatment. Sensitivity analyses included combined analysis of all the trials irrespective of the vasoactive drug, type of publication, and risk of bias.

Main results: Seventeen trials including 1817 patients were identified. Vasoactive drugs were vasopressin (one trial), terlipressin (one trial), somatostatin (five trials), and octreotide (ten trials). No significant differences were found comparing sclerotherapy with each vasoactive drug for any outcome. Combining all the trials irrespective of the vasoactive drug, the risk differences (95% confidence intervals) were failure to control bleeding -0.02 (-0.06 to 0.02), five-day failure rate -0.05 (-0.10 to 0.01), rebleeding 0.01 (-0.03 to 0.05), mortality (17 randomised trials, 1817 patients) -0.02 (-0.06 to 0.02), and transfused blood units (8 randomised trials, 849 patients) (weighted mean difference) -0.24 (-0.54 to 0.07). Adverse events 0.08 (0.03 to 0.14) and serious adverse events 0.05 (0.02 to 0.08) were significantly more frequent with sclerotherapy.

Authors' conclusions: We found no convincing evidence to support the use of emergency sclerotherapy for variceal bleeding in cirrhosis as the first, single treatment when compared with vasoactive drugs. Vasoactive drugs may be safe and effective whenever endoscopic therapy is not promptly available and seems to be associated with less adverse events than emergency sclerotherapy. Other meta-analyses and guidelines advocate that combined vasoactive drugs and endoscopic therapy is superior to either intervention alone.

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Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 EVS versus vasopressin, Outcome 1 Failure, rebleeding, mortality, adverse events.
2.1
2.1. Analysis
Comparison 2 EVS versus terlipressin, Outcome 1 Failure, rebleeding, mortality, adverse events.
2.2
2.2. Analysis
Comparison 2 EVS versus terlipressin, Outcome 2 Transfusions.
3.1
3.1. Analysis
Comparison 3 EVS versus somatostatin, Outcome 1 Failure, rebleeding, mortality, adverse events.
3.2
3.2. Analysis
Comparison 3 EVS versus somatostatin, Outcome 2 Transfusions.
4.1
4.1. Analysis
Comparison 4 EVS versus octreotide, Outcome 1 Failure, rebleeding, mortality, adverse events.
4.2
4.2. Analysis
Comparison 4 EVS versus octreotide, Outcome 2 Transfusions.
5.1
5.1. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 1 Failure to control bleeding.
5.2
5.2. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 2 Five‐day failure rate.
5.3
5.3. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 3 Rebleeding.
5.4
5.4. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 4 Rebleeding before other elective treatments.
5.5
5.5. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 5 Mortality.
5.6
5.6. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 6 Mortality before other elective treatments.
5.7
5.7. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 7 Transfusions.
5.8
5.8. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 8 Adverse events.
5.9
5.9. Analysis
Comparison 5 Sensitivity analysis 1: all trials, Outcome 9 Serious adverse events.
6.1
6.1. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 1 Failure to control bleeding.
6.2
6.2. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 2 Five‐day failure rate.
6.3
6.3. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 3 Rebleeding.
6.4
6.4. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 4 Rebleeding before other elective treatments.
6.5
6.5. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 5 Mortality.
6.6
6.6. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 6 Mortality before other elective treatments.
6.7
6.7. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 7 Transfusions.
6.8
6.8. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 8 Adverse events.
6.9
6.9. Analysis
Comparison 6 Sensitivity analysis 2: full reports, Outcome 9 Serious adverse events.
7.1
7.1. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 1 Failure to control bleeding.
7.2
7.2. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 2 Five‐day failure rate.
7.3
7.3. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 3 Rebleeding.
7.4
7.4. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 4 Rebleeding before other elective treatments.
7.5
7.5. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 5 Mortality.
7.6
7.6. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 6 Mortality before other elective treatments.
7.7
7.7. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 7 Transfusions.
7.8
7.8. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 8 Adverse events.
7.9
7.9. Analysis
Comparison 7 Sensitivity analysis 3: randomised trials with adequate control of bias, Outcome 9 Serious adverse events.
8.1
8.1. Analysis
Comparison 8 Sensitivity analysis 4: EVS versus somatostatin, excluding the Escorsell's study, Outcome 1 Mortality.
9.1
9.1. Analysis
Comparison 9 Sensitivity analysis 1.1: all trials excluding the Escorsell's study., Outcome 1 Mortality.
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References to other published versions of this review

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