Emergency sclerotherapy versus medical interventions for bleeding oesophageal varices in cirrhotic patients (Cochrane Review)

A substantive amendment to this systematic review was last made on 07 November 2001. Cochrane reviews are regularly checked and updated if necessary.

Background: Emergency sclerotherapy is widely used as a first line therapy for variceal bleeding in cirrhosis, although pharmacological treatment may stop bleeding in the majority of patients.

Objectives: To assess whether emergency sclerotherapy is superior to pharmacological treatment for variceal bleeding in cirrhosis.

Search strategy: Search of trials was based on The Cochrane Hepato-Biliary Group Controlled Trials Register (April 2001), The Cochrane Controlled Trials Register (Cochrane Library Issue 2, 2001), MEDLINE (January 1966 to April 2001), and EMBASE (1985 to April 2001). Reference lists of pertinent studies and other identified literature were scanned as well as proceedings of the most relevant international congresses ( AASLD, EASL, UEGW) were handsearched.

Selection criteria: Randomised clinical trials comparing sclerotherapy with vasoactive treatments (vasopressin (± nitroglycerin), terlipressin, somatostatin, or octreotide) for acute variceal bleeding in cirrhotic patients.

Data collection and analysis: Two independent reviewers identified eligible trials and extracted data. Outcome measures were failure to control bleeding, five-day treatment failure, rebleeding before other elective treatments, 42-day rebleeding, mortality before other elective treatments, 42-day 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, fixed effects model analyses, type of publication, methodological quality, and adequacy of generation of the randomisation list and of allocation concealment.

Main results: Twelve trials including 1146 patients (pts) were identified. One trial compared sclerotherapy with vasopressin, one with terlipressin, four with somatostatin, and six with octreotide. No significant differences were found comparing sclerotherapy with each vasoactive drug for any outcomes. Combining all the trials irrespective of the vasoactive drug, risk differences (95% confidence intervals) were: failure to control bleeding (11 RCTs, 977 pts) -0.03 (-0.07 to 0.01); five-day failure rate (7 RCTs, 759 pts) -0.05 (-0.12 to 0.01); rebleeding (11 RCTs, 1082 pts) -0.01(-0.06 to 0.04); rebleeding before other elective treatments (9 RCTs, 975 pts) -0.02 (-0.06 to 0.03); mortality (12 RCTs, 1146 pts) -0.04 (-0.08 to 0.00); mortality before other elective treatments (5 RCTs, 474 pts) -0.02 (-0.07 to 0.04); transfused blood units (7 RCTs, 793 pts) (weighted mean difference) -0.17 (-0.52 to 0.19). Adverse events (11 RCTs, 1082 pts) and serious adverse events (5 RCTs, 602 pts) were significantly more frequent with sclerotherapy: risk differences 0.08 (0.02 to 0.14) and 0.05 (0.02 to 0.08), respectively. Results were consistent across all the other sensitivity analyses.

Reviewers' 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.

Citation: D'Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy versus medical interventions for bleeding oesophageal varices in cirrhotic patients (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.

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