Portal Hypertensive Bleeding

Prevention of recurrent haemorrhage

“…In the first study, 27 combined medical treatment with beta-blockers and nitrates was superior to ligation with respect to rebleeding rate, with no difference in survival. In the second study, 28 ligation was superior to medical treatment with respect to rebleeding rate but not to survival, whereas a third study, 29 as well as a meta-analysis 25 [including a fourth study (Ref. 30) published in abstract form], could not assess differences between both treatment arms [rebleeding rate: pooled odds ratio (POR) 0.97, CI 0.66e1.41; death POR 0.72, CI 0.47e1.1].…”

“…6,7 This is sustained by two meta-analyses of 13 and 20 randomized controlled trials, respectively, including more than 1000 patients each. 24,25 In the first meta-analysis, 24 the rebleeding rate was lower with ligation than with sclerotherapy but survival was not different. The second analysis found ligation to be superior to sclerotherapy in terms of rebleeding rate and survival.…”

“…The second analysis found ligation to be superior to sclerotherapy in terms of rebleeding rate and survival. 25 Thereafter, the question arose of whether a combination of endoscopic band ligation and sclerotherapy might be more effective than band ligation alone. A recent meta-analysis on this question, including eight studies, found no significant difference with respect to risk of rebleeding [relative risk (RR) 1.05 95% confidence interval (CI) ¼ 0.67e1.64] and mortality (RR 0.99; 95% CI ¼ 0.68e1.44).…”

The Role of Endoscopy in Portal Hypertension

“…While their effect on rebleeding differs -with shunt procedures being the most effi cient -their impact on improvement of survival is far less clear-cut. It has also been shown that the most potent treatment with respect to rebleeding, namely, placement of a portacaval shunt, bears a rather high risk of mortality, at least in patients with decompensated cirrhosis [21] . Therefore, endoscopy has retained its relevance, especially since introduction of banding ligation [22] .…”

“…When obliteration of varices has been achieved, which may take 6-8 weeks, recurrent varices occur less frequently than after ligation. Ligation, however, has several advantages: the rebleeding risk is reduced somewhat more effi ciently (by 30 vs. 40% in sclerotherapy) and the complication rate is signifi cantly lower [21] . The combination of both methods is not superior to ligation alone and the rate of complications is higher [26] , but sclerotherapy may be suitable in very small varices remaining after initial ligation which are not amenable to banding.…”