Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding: A meta-analysis

Ding, Shifang; Liu, Jun; Wang, Jianping

doi:10.3748/wjg.15.2151

Cited by 21 publications

(19 citation statements)

References 16 publications

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“…It should also be taken into account that a large proportion of deaths are not related to rebleeding but to other complications of portal hypertension or liver dysfunction . Both liver function and portal hypertension are not affected by therapies that act locally on varices but are not pathophysiologically oriented, such as EVL . Accordingly, an improvement in mortality may occur more likely with therapies that improve portal hypertension .…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review

Puente

Hernández‐Gea

Graupera

et al. 2014

Liver International

111

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Background & Aims: Combined therapy with endoscopic variceal ligation (EVL) and b-blockers ± isosorbide mononitrate (ISMN) is currently recommended to prevent variceal rebleeding. However, the role of this combined therapy has been challenged by some studies. We performed a systematic review to assess the value of combined therapy with EVL and b-blockers ± ISMN as compared with each treatment alone to prevent rebleeding. Methods: Databases, references and meeting abstracts were searched to retrieve randomized trials comparing combined therapy with EVL and bblockers ± ISMN vs either treatment alone, to prevent variceal rebleeding in cirrhosis. Random-effects model was used for meta-analysis. Results: We identified five studies comparing EVL alone or combined with drugs, including a total of 476 patients. Combination therapy reduced overall rebleeding [risk ratios (RR) = 0.44, 95% confidence interval (CI) = 0.28-0.69], and showed a trend towards lower mortality (RR = 0.58, 95% CI = 0.33-1.03), without increasing complications. We identified four trials comparing drugs alone or associated with EVL, including 409 patients. All used b-blockers plus ISMN. Variceal rebleeding decreased with combined therapy (P < 0.01) but rebleeding from oesophageal ulcers increased (P = 0.01). Overall, there was a trend towards lower rebleeding (RR = 0.76, 95% CI = 0.58-1.00) without effect on mortality (RR = 1.24, 95% CI = 0.90-1.70). Conclusions: The addition of drug therapy to EVL improves the efficacy of EVL alone. However, the addition of EVL to b-blockers and ISMN achieves a non-significant decrease of rebleeding with no effect on mortality. Although combination therapy with EVL plus b-blockers ± ISMN is adequate to prevent rebleeding, b-blockers + ISMN alone may be a valid alternative.Patients who have recovered from acute variceal haemorrhage have a median rebleeding rate of 63% within 1-2 years and mortality of 33% (1). For many years, nonselective b-blockers and endoscopic sclerotherapy (EST) were the first-line therapy to prevent rebleeding (1, 2). However, endoscopic variceal ligation (EVL) has been shown to improve the safety and the efficacy of EST and is the current endoscopic treatment of choice (2, 3). Adding EST to EVL to obliterate perforating veins has shown no additional beneficial effects as compared with EVL alone (4, 5). Pharmacological therapy also has been improved in recent years. The combination of b-blockers and isosorbide mononitrate (ISMN) enhances the reduction of portal pressure induced by b-blockers (6). This combined drug therapy has been shown to be superior to b-blockers alone and to EST (7,8). Meta-analyses of trials comparing b-blockers + ISMN with EVL have shown no significant differences in rebleeding or survival (9-11). A recent study suggests an improvement in survival favouring combined drug therapy over EVL in the long-term follow-up (12).Combining endoscopic and pharmacological therapies seems a rational approach because b-blockers may protect against rebleeding before variceal obl...

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Section: Discussionmentioning

confidence: 99%

“…This combined drug therapy has been shown to be superior to β‐blockers alone and to EST . Meta‐analyses of trials comparing β‐blockers + ISMN with EVL have shown no significant differences in rebleeding or survival . A recent study suggests an improvement in survival favouring combined drug therapy over EVL in the long‐term follow‐up .…”

mentioning

confidence: 99%

Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review

Puente

Hernández‐Gea

Graupera

et al. 2014

Liver International

111

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“…Other randomized trials on IsMn vs. beta‐blockers or IsMn plus beta‐blockers vs. beta‐blockers or endoscopic therapy have reached equivocal results 9, 10 . Recent meta‐analyses including between four and 25 randomized trials have found that the combination of endoscopic and pharmacological therapy with beta‐blockers alone or combined with IsMn may be more effective in reducing the risk of rebleeding than either of the therapeutic options used alone 11–13 . No clear effect on mortality was identified.…”

Section: Introductionmentioning

confidence: 99%

Meta‐analysis: isosorbide‐mononitrate alone or with either beta‐blockers or endoscopic therapy for the management of oesophageal varices

Gluud

Langholz

Krag

2010

Aliment Pharmacol Ther

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“…18,19 However, this treatment has a high recurrence rate, also needs advanced technique and incurs high cost. 20,21 Endoscopic variceal band ligation is mostly performed in the in-patient setting and is effective inprimary and secondary prophylaxis of bleeding esophageal varices in patients with cirrhosis. 18 Our study was a single centered descriptive observational study in which EVL therapy after pre-endoscopic preparation of the patients and confirmation of esophageal varices was done to see the required numbers of sessions to obliterate the esophageal varices in LC patients.…”

Section: Discussionmentioning

confidence: 99%

Outcome of Endoscopic Variceal Band Ligation

Shrestha

Chaudhary

et al. 2017

J Nepal Med Assoc

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Introduction: Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices.Methods: This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved. Results: Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL.Conclusions: EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices, with very few complications.Keywords: acute variceal bleeding; cirrhosis; endoscopic variceal ligation; large varices; red color sign. [PubMed]

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Efficacy of β-adrenergic blocker plus 5-isosorbide mononitrate and endoscopic band ligation for prophylaxis of esophageal variceal rebleeding: A meta-analysis

Abstract: AIM:To systematically assess the efficacy and safety of β-adrenergic blocker plus 5-isosorbide mononitrate (BB + ISMN) and endoscopic band ligation (EBL) on prophylaxis of esophageal variceal rebleeding. METHODS:

Cited by 21 publications

References 16 publications

Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review

Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review

Meta‐analysis: isosorbide‐mononitrate alone or with either beta‐blockers or endoscopic therapy for the management of oesophageal varices

Outcome of Endoscopic Variceal Band Ligation

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