Endoscopic Variceal Ligation Group Research Articles

Comparative efficacy of endoscopic variceal ligation versus non-selective beta-blockers in primary prevention of gastroesophageal varix type 2: an IPTW-adjusted study.

Practice guidelines recommend non-selective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) for primary prevention in cirrhosis patients with esophageal varices. However, there is no clear recommendation for primary prevention strategies for gastric varices, particularly GOV-2. Our objective is to investigate the incidence of initial bleeding and liver-related complications when NSBB and EVL are used for primary prevention in GOV-2. A retrospective analysis was conducted on data from patients with GOV-2 gastric varices. Patients were divided into the NSBB group or the EVL group. Differences in the incidence of initial bleeding within 1year, as well as the occurrence of complications such as hepatic encephalopathy and ascites, were compared between the two groups before and after adjustment for Inverse Probability of Treatment Weighting (IPTW). A Cox proportional hazards model was used to identify independent risk factors for the first bleeding event. There were 60 patients in the NSBB group and 66 patients in the EVL group. Before IPTW adjustment, there were differences between the two groups in sex, portal hypertensive gastropathy, esophageal variceal diameter, red signs, FIB-4, and MELD scores. After IPTW adjustment, these differences were balanced, with standardized mean differences (SMDs) within acceptable ranges. Kaplan-Meier survival analysis showed no difference in bleeding rates between the two groups before or after IPTW adjustment. After IPTW adjustment, Cox regression analysis identified esophageal variceal diameter (HR:5.59 (2.03-15.39), p < 0.001) and MELD score (HR:1.17 (1.01-1.23), p = 0.042) were independent risk factors for bleeding. NSBB treatment did not reduce the incidence of liver-related complications within one year compared to EVL. For primary prevention of bleeding in cirrhotic patients with GOV-2, EVL does not significantly reduce initial bleeding episodes or liver-related complications compared to NSBB.

Azygoportal disconnection or a combination of non-selective beta-blockers and endoscopic variceal ligation to prevent recurrent bleeding in patients with cirrhosis awaiting transplantation

Objective: to compare the efficacy of azygoportal disconnection (APD) surgery and a combination between endoscopic variceal ligation (EVL) and non-selective beta-blockers (NSBBs) in the prevention of recurrent variceal bleeding (RVB). To compare the incidence of gastric variceal bleeding (GVB) after these manipulations in patients with decompensated cirrhosis waitlisted for liver transplantation (LTx).Materials and methods. Patients with decompensated cirrhosis underwent RVB prophylaxis by APD surgery or by a combination of EVL and NSBBs.Results. There were no significant differences in clinical, laboratory, demographic parameters, MELD-Na and Child–Turcotte–Pugh (CTP) scores, and frequencies of medium- and large-sized varicose veins among subgroups of patients with different RVB prophylaxis methods Patients with decompensated cirrhosis who underwent APD surgery did not experience any RVB episodes during the LTx waiting period, which lasted two years from the start of bleeding prophylaxis. In the same period, RVB occurred in 100% of cases in the EVL plus NSBBs group. Using the Kaplan–Meier method with the Log-Rank test, a significant difference (p = 0.0001) was found between the proportions of non-RVB patients in the APD and EVL + NSBBs groups. In the meantime, 48.1% of patients who had APD surgery developed GVB, while 100% of cases in EVL + NSBBs group did not. The Kaplan–Meier method with the Log-Rank test revealed a significant difference (p = 0.0001) between the proportion of non-GVB patients in EVL + NSBBs and APD groups.

Endoscopic variceal ligation versus propranolol for the primary prevention of oesophageal variceal bleeding in patients with hepatocellular carcinoma: an open-label, two-centre, randomised controlled trial

ObjectiveThis randomised trial aimed to address whether endoscopic variceal ligation (EVL) or propranolol (PPL) is more effective at preventing initial oesophageal variceal bleeding (EVB) in patients with hepatocellular carcinoma (HCC).DesignPatients...

Clinical course of ascitic syndrome and acute kidney injury in the setting of nonselective beta‑blockers or endoscopic variceal ligation for primary prevention of bleeding in cirrhotic patients awaiting liver transplantation

Objective: to compare the effects of nonselective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) on patient survival, ascites dynamics, and development of acute kidney injury (AKI) during primary prevention of bleeding from the esophageal varices and cardia in patients with decompensated cirrhosis on the liver transplant waiting list (LTWL). Materials and methods. A retrospective comparative study of the clinical data of patients with severe ascites and esophageal varices without a bleeding history at the time of their inclusion in the LTWL was performed. Group 1 patients (n = 84) were prescribed NSBB, alpha and beta-adrenoblockers in order to prevent bleeding and reduce progression of decompensated cirrhosis. Group 2 patients underwent EVL. Results. Demographic, laboratory and instrumental parameters of patients in the compared groups had no significant differences. In both groups, there were no significant differences between the indicators of severity of liver lesions (MELD-Na, Child–Turcotte–Pugh), frequency of severe ascites, frequency of varicose nodes grades 2–3. At follow-up, bleeding developed in 22 patients (13.25%) – 13 patients in the NSBB group and 9 patients in the EVL group (15.47% and 10.97%, respectively, p &gt; 0.05). Patient survival was significantly higher in the EVL group than in the NSBB group. Incidence of refractory ascites, number of patients with grade 3 ascites, and AKI stages 2–3 in the NSBB group, were significantly higher (p &lt; 0.05) than in the EVL group. MELD-Na was the independent predictor of mortality in the EVL group, while low mean arterial pressure (mAP) and presence of AKI were those for patients receiving NSBB. Conclusion. NSBB and EVL are effective methods of primary prevention of bleeding. Mortality rate, number of patients with refractory ascites and severe ascites, and number of patients with AKI stages 2–3 were higher in the NSBB group than in the EVL cohort. In EVL patients, the independent predictor of death was MELD-Na, while in NSBB patients, the independent predictors of mortality were low mAP and presence of AKI.

A Retrospective Analysis of the Efficacy of Endoscopic Variceal Ligation versus Endoscopic Tissue Adhesive Injection in the Treatment of Esophagogastric Variceal Bleeding

Background: The aim of the study was to investigate the effectiveness and safety of endoscopic variceal ligation (EVL) and endoscopic tissue adhesive injection (TAI) in the treatment of esophagogastric variceal bleeding (EVB). Methods: A total of 245 patients with EVB who attended the First Affiliated Hospital of Bengbu Medical College from December 2017 to June 2021 were retrospectively collected. The participants were divided into the esophageal EVL (E-EVL) + gastric EVL (G-EVL) group (n = 103) and E-EVL + gastric TAI (G-TAI) group (n = 142), according to the procedure, comparing and assessing the clinical characteristics, laboratory results, operation time, rebleeding rate, efficacy, and complications. Results: The E-EVL + G-EVL group had significantly less varicose vein diameter and operative time than the E-EVL + G-TAI group (p < 0.05). No statistical difference in the length of hospital stay between the two groups was noted (p > 0.05). The total rebleeding rate in the E-EVL + G-EVL group was 9.7%, whereas that of the E-EVL + G-TAI group was 11.9%; no statistical difference between the two groups was noted (p > 0.05). The overall effective rate of the E-EVL + G-EVL group was 90.21%, whereas that of the E-EVL + G-TAI group was 92.81%; no statistical difference between the two groups was observed (p > 0.05). The postoperative ulcer in the E-EVL + G-EVL group was smaller and more superficial than that in the E-EVL + G-TAI group, and the wound surface was smoother. Conclusion: Both EVL and TAI have good therapeutic effects on EVB. Furthermore, owing to its effectiveness in preventing rebleeding, no reduction in efficacy and no increase in complications, shortened operative time, smaller and superficial ulcer, and smoother wounds, gastric EVL is worthy of further clinical promotion.

Novel balloon compression-assisted endoscopic injection sclerotherapy and endoscopic variceal ligation in the treatment of esophageal varices: a prospective randomized study

BackgroundHerein, our group designed a novel technology, termed balloon compression-assisted endoscopic injection sclerotherapy (bc-EIS), which was applied to improve the efficiency of eradicating esophageal varices (EVs). The present study aimed to compare the rate of eradication and efficacy between bc-EIS and endoscopic variceal ligation (EVL) in the management of EVs.MethodsNinety-five patients with esophageal variceal bleeding (EVB) were randomly assigned to receive bc-EIS or ligation alone. Additional treatment sessions were held 1 month later and then at 3-month intervals until eradication of the varices was achieved. Endoscopic follow-up examinations were carried out at 6-month intervals in the absence of recurrence or immediately if there was any recurrent bleeding.ResultsThe mean physical injection points per session were 2.89 ± 0.79, and the mean volume of lauromacrogol used per session was 17.74 ± 7.09 ml in the bc-EIS group. The mean band per session was 6.13 ± 0.86. The rate of eradication after one to three rounds of bc-EIS was obviously higher than that of the EVL group (89.36%, 97.87%, and 100% vs. 37.5%, 43.75%, and 47.92%, respectively). Retrosternal pain or discomfort in the bc-EIS group was slightly lower than that in the EVL group (23.4%, 11/47 vs. 31.25%, 15/48). Two and five patients showed mild abdominal bloating and distension between the bc-EIS and EVL groups, respectively (2/47, 4.26% vs. 5/48, 10.42% P > 0.05). Nausea and vomiting were reported in one patient (1/47, 2.13%) in the bc-EIS group and three patients (3/48, 6.25%) in the EVL group. However, there were no statistically significant differences between the two groups (P > 0.05). No fatal or severe complications, such as esophageal perforation, esophageal stricture or ectopic embolism, were observed.ConclusionThe bc-EIS method was effective in eradicating EVs and was accompanied by fewer complications.

Treatment Strategies in Emergency Endoscopy for Acute Esophageal Variceal Bleeding (CHESS1905): A Nationwide Cohort Study.

Background and AimsEmergency endoscopy is recommended for patients with acute esophageal variceal bleeding (EVB) and their prognosis has improved markedly over past decades due to the increased specialization of endoscopic practice. The study aimed to compare outcomes following emergency endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) in cirrhotic patients with acute EVB.MethodsCirrhotic patients with acute EVB who underwent emergency endoscopy were retrospectively enrolled from 2013 to 2020 across 34 university hospitals from 30 cities. The primary outcome was the incidence of 5-day rebleeding after emergency endoscopy. Subgroup analysis was stratified by Child-Pugh class and bleeding history. A 1:1 propensity score matching (PSM) analysis was performed.ResultsA total of 1,017 and 382 patients were included in EIS group and EVL group, respectively. The 5-day rebleeding incidence was similar between EIS group and EVL group (4% vs. 5%, P = 0.45). The result remained the same after PSM (P = 1.00). Among Child-Pugh class A, B and C patients, there were no differences in the 5-day rebleeding incidence between the two groups after PSM (P = 0.25, 0.82, and 0.21, respectively). As for the patients with or without bleeding history, the differences between EIS group and EVL group were not significant after PSM (P = 1.00 and 0.26, respectively).ConclusionThe nationwide cohort study indicates that EIS and EVL are both efficient emergency endoscopic treatment strategies for acute EVB. EIS should not be dismissed as an economical and effective emergency endoscopic treatment strategy of acute EVB. ClincialTrials.gov number NCT04307264.

Endoscopic injection sclerotherapy improves liver function compared with endoscopic variceal ligation

Liver function is a most important prognostic factor in patients with liver cirrhosis. Also, portal hypertension is a fatal complication of liver cirrhosis and variceal treatment is indispensable. However, changes of liver functions after endoscopic variceal treatments are unknown. The aim of this study was to evaluate prognosis and liver functions after endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL). A total of liver cirrhotic 103 patients who underwent prophylactic EIS and EVL were enrolled. Overall survival rate was higher in EIS group than EVL group (p = 0.03). Multivariate analysis showed that EIS was a negative factor for death (HR: 0.46, 95% confidence interval: 0.24–0.88, p = 0.02). Liver functions were assessed by blood test taken at before and 3 months after treatment. In EIS group, albumin and prothrombin time improved (p < 0.01), leading to improvement of Child–Pugh score, ALBI score and MELD score (p < 0.05). However, these did not improve in EVL group. EIS was a significant factor related to the elevated value of albumin after treatment in linear regression analysis (estimated regression coefficient: 0.17, 95% confidence interval: 0.05–0.29, p = 0.005). These results revealed that EIS could improve liver functions and prognosis.

Minimal and Maximal Extent of Band Ligation for Acute Variceal Bleeding during the First Endoscopic Session.

Background/AimsThe appropriate number of band ligations during the first endoscopic session for acute variceal bleeding is debatable. We aimed to compare the technical aspects of endoscopic variceal ligation (EVL) in patients with variceal bleeding according to the number of bands placed per session.MethodsWe retrospectively reviewed multicenter data from patients who underwent EVL for acute variceal bleeding. Patients were classified into minimal EVL (targeting only the foci with active bleeding or stigmata of recent bleeding) and maximal EVL (targeting potential bleeding sources in addition to the aforementioned targets) groups. The primary endpoint was 5-day treatment failure. The secondary endpoints were 30-day rebleeding, 30-day mortality, and intraprocedural adverse events.ResultsMinimal EVL was associated with lower rates of hypoxia and shock during EVL than maximal EVL (hypoxia, 0.9% vs 2.9%; shock, 1.3% vs 3.4%). However, treatment failure was higher in the minimal EVL group than in the maximal EVL group (odds ratio, 1.60; 95% confidence interval, 1.06 to 2.41). Age ≥60 years, Model for End-Stage Liver Disease score ≥15, Child-Turcotte-Pugh classification C, presence of hepatocellular carcinoma, and systolic blood pressure <90 mm Hg at initial presentation were also associated with treatment failure. In contrast, 30-day rebleeding and 30-day mortality did not differ between the minimal and maximal EVL groups.ConclusionsGiven that minimal EVL was associated with a high risk of treatment failure, maximal EVL may be a better option for variceal bleeding. However, the minimal EVL strategy should be considered in select patients because it does not affect 30-day rebleeding and mortality.

Esophageal Variceal Ligation Monotherapy versus Combined Ligation and Sclerotherapy for the Treatment of Esophageal Varices.

Currently, endoscopic variceal ligation (EVL) monotherapy is the standard therapy for managing esophageal variceal hemorrhage. Patients generally need several sessions of endoscopy to achieve optimal variceal ablation, and the varices can recur afterward. Endoscopic injection sclerotherapy (EIS) is an older technique, associated with certain complications. This study aimed to evaluate the clinical efficacy of EVL alone versus combined EVL and EIS in the treatment of esophageal varices. This retrospective study included 84 patients, of which 40 patients were treated with EVL monotherapy and 44 patients were treated with combined EVL + EIS. The main outcomes were rebleeding rates, recurrence at six months, number of treatment sessions, length of hospital stay, cost of hospitalization, and procedural complications. At six months, the rebleeding rate and recurrence were significantly lower in the EVL + EIS group compared to the EVL group (2.3% versus 15.0%; and 9.1% versus 27.5%, respectively). The number of treatment sessions, length of hospital stay, and cost of hospitalization were significantly lower in the EVL + EIS group compared to those in the EVL group (2.3 ± 0.6 versus 3.2 ± 0.8 times; 14.5 ± 3.4 versus 23.5 ± 5.9 days; and 23918.6 ± 4220.4 versus 26165.2 ± 4765.1 renminbi, respectively). Chest pain was significantly lower in the EVL + EIS group compared to that in the EVL group (15.9% versus 45.0%). There were no statistically significant differences in the presence of fever or esophageal stricture in both groups. In conclusion, combined EVL + EIS showed less rebleeding rates and recurrence at six months and less chest pain and was more cost effective compared to EVL alone in the treatment of gastroesophageal varices.

Effects of diabetes on the rebleeding rate following endoscopic treatment in patients with liver cirrhosis.

In the present study, the effects of diabetes on rebleeding following endoscopic treatment were assessed in patients with liver cirrhosis. A retrospective analysis of patients who underwent endoscopic variceal ligation (EVL) or endoscopic injection sclerotherapy (EIS) at the First Affiliated Hospital of Anhui Medical University (Hefei, China) between June 2015 and March 2018 was performed. The patients were divided into the EVL and the EIS groups and each group was subdivided into diabetic and non-diabetic groups. The post-operative rebleeding rate was compared between the EVL and the EIS groups and between the diabetic and non-diabetic patients. The differences in the post-operative rebleeding rate of diabetic patients with hepatogenic and non-hepatogenic diabetes and in patients with different liver function grades were also determined. In the total patient cohort, the rebleeding rate in the EVL subgroup (11.3, 16.5 and 23.5%) was not significantly different compared with that in the EIS subgroup (9.8, 17.4 and 29.3%) at 1, 3 and 6 months following surgery, respectively (P=0.724, 0.868 and 0.339). In the total diabetic group, the rebleeding rate in the EVL subgroup (25.0, 36.1 and 44.4%) was not significantly different compared with that in the EIS subgroup (20.6, 32.4 and 47.1%) at 1, 3 and 6 months following surgery (P=0.660, 0.741 and 0.826, respectively). In the EVL group, the rebleeding rate in the diabetic subgroup (25.0, 36.1 and 44.4%) was higher than that in the non-diabetic subgroup (5.1, 7.6 and 13.9%) at 1, 3, and 6 months following surgery and the differences were significant (P=0.005, <0.001 and <0.001, respectively). In the EIS group, the rebleeding rate in the diabetic subgroup (20.6, 32.4 and 47.1%) was significantly higher than that in the non-diabetic subgroup (3.4, 8.6 and 19.0%) at 1, 3 and 6 months following surgery (P=0.021, 0.004 and 0.004, respectively). Adjustment for age and liver function grade in the EVL and EIS groups was performed using binary logistic regression and the parameter diabetes was indicated to be a risk factor for post-operative rebleeding (P<0.05). No significant difference was noted in the rate of rebleeding between patients with hepatogenic diabetes and non-hepatogenic diabetes at 1, 3 and 6 months following surgery (P=0.634, 0.726 and 0.446, respectively). In the total diabetic group, the rebleeding rate in the Child-Pugh grade A subgroup (14.3, 17.9 and 25.0%) was lower than that in the Child-Pugh grade B/C subgroup (28.6, 45.2 and 59.5%) at 1, 3 and 6 months following surgery, respectively. No significant difference was noted between the two groups at 1 month following surgery (P=0.163). However, the differences were significant at 3 and 6 months following surgery (P=0.018 and 0.005, respectively). The results suggested that diabetes is a risk factor for post-operative rebleeding in patients with cirrhosis. Diabetic patients with poor liver function were more likely to bleed following surgery and the post-operative bleeding rate was not significantly different between patients with hepatogenic and non-hepatogenic diabetes. The study was registered in the Chinese Clinical Trial Registry (no. ChiCTR1800017772).

Endoscopic variceal ligation as primary prophylaxis for upper GI bleeding in children

Variceal hemorrhage can be a life-threatening adverse event of chronic liver disease. In contrast to the well-described guidelines for the management of portal hypertension (PH) in adults, there is limited evidence about the optimal prophylactic management of variceal bleeding in children. This study was carried out to assess the efficacy of endoscopic variceal ligation (EVL) as primary prophylaxis to prevent upper GI bleeding in children with PH. From January 2014 to April 2018, all pediatric patients with PH disease and medium to large esophageal varices or reddish spots, regardless of the grade of the varix, were prospectively included in the protocol of primary prophylaxis with EVL. A second retrospective group of patients was made after reviewing medical records of 32 pediatric patients with PH that presented esophageal varices in the upper endoscopy and had received propranolol as primary prophylaxis. Twenty-four patients (75%) reached varices eradication in the EVL group, with a median of 2 procedures (range, 1-4) before eradication and a median time to eradication of 3.40 months (range, 1.10-13.33). No EVL-related adverse events were observed. Statistically significant differences were observed in the bleeding rate at 3 years between propranolol and EVL groups (6/32 [21.9%] vs 1/32 [3.2%], P< .02). The hazard ratio for bleeding for patients treated with propranolol compared with those treated with EVL was 2.6 (95% confidence interval, 1.53-3.67). EVL is a safe and effective treatment to prevent upper GI bleeding in pediatric patients with PH. (Clinical trial registration number: NCT03943784.).

627 Carvedilol vs. Endoscopic Variceal Ligation in Primary Prevention of First Variceal Hemorrhage Episode: A Systematic Review and Meta-Analysis

INTRODUCTION: Either a non-selective beta blocker or endoscopic variceal ligation (EVL) is recommended for the primary prevention of a first variceal hemorrhage episode in patients with medium or large sized varices. Carvedilol has been used for this purpose because of its additional alpha-1 antagonist effect and fewer hemodynamic complications. However, data supporting this recommendation are based on two previous randomized controlled trials. More studies have been published since these trials to investigate the benefit of carvedilol. We wanted to compare carvedilol with EVL in patients with esophageal varices to prevent the first variceal hemorrhage episode and to reduce mortality. METHODS: We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2019. Included studies were randomized controlled trials that investigated the efficacy of carvedilol compared to EVL to prevent the first variceal bleeding and to reduce mortality. The first variceal bleeding episode was defined as melena and/or hematemesis with endoscopic evidence of bleeding stigmata or recent variceal hemorrhage. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled risk ratio (RR) and 95% confidence intervals. RESULTS: Four randomized controlled trials from 2009 to 2018 involving 556 patients (276 patients in the carvedilol group and 280 patients in the EVL group) were included in this meta-analysis. The mean age was 50 years. Compared to EVL, carvedilol did not significantly decrease the first variceal bleeding incidence or 1-year mortality (pooled RR 1.11 (0.56-2.19), P = 0.767, I2 = 53% and 1.22 (0.78-1.91), P = 0.38, I2 = 0%, respectively) (Figures 1 and 2). Serious adverse events that were intolerable and required specific therapy leading to discontinuation of the treatment arm was reported in 4 studies and did not show any significant difference between the carvedilol group and the EVL group (pooled RR 1.14 (0.78-1.68), P = 0.49, I2 = 6.8%) (Figure 3). CONCLUSION: Our study demonstrated a non-significant difference between carvedilol and EVL to prevent first variceal bleeding or decrease mortality. There was no difference in serious side effects. More randomized controlled trials with larger sample sizes and long term follow up are required to better understand the potential benefit of carvedilol. Our analysis supports the benefit of carvedilol as primary prophylaxis of variceal hemorrhage in cirrhotic patients.

Comparison of Endoscopic Variceal Ligation with Endoscopic Sclerotherapy for Secondary Prophylaxis of Variceal Hemorrhage: A Randomized Trial.

BackgroundThough endoscopic variceal ligation (EVL) is commonly being used and has overcome the disadvantages of sclerotherapy (ST), still sclerotherapy is used as a therapeutic procedure for bleeding esophageal varices in the present institute. Hence, the study was done to see the advantages of EVL over ST.MethodsPatients with portal hypertension and bleeding esophageal varices underwent banding if found to have grade 3 or 4 varices. They were randomized to EVL group, where they were reviewed after two weeks for any residual varices for which repeat banding was done and endoscopic sclerotherapy (EST) group, where ST was done until the varices were obliterated or reduced to grade 1. The efficacy, complications, recurrent bleeding rate and recurrence of varices were compared.ResultsA total of 60 patients were included, 30 in each group. In EVL group, four sessions were needed to eradicate the varices in 73% of patients while it was five sessions in EST group (46% patients) (p-value = 0.0001). The mean number of sessions needed in EVL and EST group was 3.73 and 5.36, respectively. The average time taken for eradication of varices was 78.6 and 134.6 days in EVL and EST group, respectively (p-value = 0.004). Complications were higher in EST group (p-value < 0.05).ConclusionEVL alone was effective than ST in terms of the number of sessions needed for eradication of varices and total duration required to completely obliterate them. The complications were less in EVL group with no significant difference in recurrent bleeding rate and recurrence of varices between the groups.

Addition of Somatostatin After Successful Endoscopic Variceal Ligation Does not Prevent Early Rebleeding in Comparison to Placebo: A Double Blind Randomized Controlled Trial

Efficacy of endoscopic sclerotherapy in controlling acute variceal bleeding is significantly improved when vasoactive drug is added. Endoscopic variceal ligation (EVL) is superior to sclerotherapy. Whether efficacy of EVL will also improve with addition of somatostatin is not known. We compared EVL plus somatostatin versus EVL plus placebo in control of acute variceal bleeding. Consecutive cirrhotic patients with acute esophageal variceal bleeding were enrolled. After emergency EVL, patients were randomized to receive either somatostatin (250mcg/hr) or placebo infusion. Primary endpoint was treatment failure within 5 days. Treatment failure was defined as fresh hematemesis ≥2h after start of therapy, or a 3gm drop in Hb, or death. 61 patients were enrolled (EVL plus somatostatin group, n=31 and EVL plus placebo group, n=30). The baseline characteristics were similar. Within the initial 5-day period, the frequency of treatment failure was similar in both the groups (EVL plus somatostatin group 8/31 [26%] versus EVL plus placebo group 7/30 [23%]; P=1.000). The mortality was also similar in the two groups (3/31 [10%] vs. 3/30 [10%]; P=1.000). Baseline HVPG ≥19mm Hg and active bleeding at index endoscopy were independent predictors of treatment failure. Addition of somatostatin infusion to EVL therapy does not offer any advantage in control of acute variceal bleeding or reducing mortality. The reason for this may be its failure to maintain sustained reduction in portal pressure for five days. Active bleeding at index endoscopy and high baseline HVPG should help choose early alternative treatment options. Trial registered with ClincalTrials.gov vide NCT01267669.

Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis.

To compare the effect of endoscopic variceal ligation (EVL) with that of endoscopic injection sclerotherapy (EIS) in the treatment of patients with esophageal variceal bleeding. We performed a systematic literature search of multiple online electronic databases. Meta-analysis was conducted to evaluate risk ratio (RR) and 95% confidence interval (CI) of combined studies for the treatment of patients with esophageal variceal bleeding between EVL and EIS. Fourteen studies comprising 1236 patients were included in the meta-analysis. The rebleeding rate in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR=0.68, 95%CI: 0.57-0.81). The variceal eradication rate in actively bleeding varices patients in the EVL group was significantly higher than that in the EIS group (RR=1.06, 95%CI: 1.01-1.12). There was no significant difference about mortality rate between the EVL group and EIS group (RR=0.95, 95%CI: 0.77-1.17). The rate of complications in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR=0.28, 95%CI: 0.13-0.58). Our meta-analysis has found that EVL is better than EIS in terms of the lower rates of rebleeding, complications, and the higher rate of variceal eradication. Therefore, EVL is the first choice for esophageal variceal bleeding.

Association of Endoscopic Esophageal Variceal Ligation With Increased Risk of Duodenal Ulcer

Introduction: This study was to explore the incidence of duodenal ulcer (DU), as well as other clinical characteristics occurring after endoscopic variceal ligation (EVL) of the esophagus. Methods: A total of 47 patients with severe esophageal varices (EVr) who had also undergone EVL and gastroscopic follow-up within 3 months of the procedure was retrospectively analyzed. The status of Helicobacter pylori (Hp) infection, Child-Pugh classification, and the grades of portal hypertensive gastropathy (PHG) were collected. Sixty EVr patients without EVL treatment, but with clinical data available, served as the control group. Results: The incidence of DU in the EVL group (29.8%, 14/47) was higher than that in the control group (6.7%, 4/ 60) (P<0.05). The Hp infection rate in EVL group was 19.15% (9/47), while in control group was 21.67% (13/60) (P>0.05). The Hp positive rate (12.5%, 1/8) in patients exhibited new DUs after EVL was comparable to that in patients without DU in the EVL group (12.1%, 4/33),( P>0.05). Patients with DU after EVL received 14 5.29 of ligating bands, while in those who did not exhibit DUs received 12 6.64 (P<0.05). A logistic regression analysis showed that the occurrence of DU was associated solely with applied band number, and not with age, gender, Child-Pugh classification, or the grade of PHG (P>0.05). Conclusion: Esophageal EVL is associated with a higher risk of DU, which is related to a larger number of applied bands but is not correlated with Hp infection status or other variables.

Carvedilol vs. esophageal variceal band ligation in the primary prophylaxis of variceal hemorrhage: A multicentre randomized controlled trial

Esophageal variceal bleed is a major problem in patients with cirrhosis. Endoscopic variceal ligation (EVL) has been shown to be equal to or better than propranolol in preventing first bleed. Carvedilol is a non-selective β blocker with alpha-1 adrenergic blocker activity. Hemodynamic studies have shown carvedilol to be more effective than propranolol at reducing portal pressure. We compared efficacy of carvedilol with EVL for primary prophylaxis of esophageal variceal bleed. Cirrhotic patients with esophageal varices were randomized to carvedilol 12.5mg daily or EVL at three university hospitals of Pakistan. End points were esophageal variceal bleeding, death or liver transplant. Two hundred and nine patients were evaluated. Eighty two and eighty six patients were randomized in carvedilol and EVL arms respectively. Mean age was 48 ± 12.2 years; 122 (72.7%) were males; 89.9% had viral cirrhosis; mean Child-Pugh score was 7.3 ± 1.6 and mean follow up was 13.3 ± 12.1 months (range 1-50 months). Both EVL and carvedilol groups had comparable variceal bleeding rates (8.5% vs. 6.9%), bleed related mortality (4.6% vs. 4.9%) and overall mortality (12.8% vs. 19.5%) respectively. Adverse events in carvedilol group were hypotension (n=2), requiring cessation of therapy, while transient nausea (n=18) and dyspnea (n=30) resolved spontaneously. In the EVL arm, post banding ulcer bleed (n=1) and chest pain (n=17), were termed as serious adverse events while transient dysphagia (n=58) resolved without treatment. Although our study is underpowered, the findings suggest that carvedilol is probably not superior to EVL in preventing first variceal bleed in patients with viral cirrhosis.

A retrospective comparative study of histoacryl injection and banding ligation in the treatment of acute type 1 gastric variceal hemorrhage

Background.Esophageal varices extending along lesser curvature side of stomach is classified as GOV1. The optimal therapy for GOV1 bleeding is still undetermined. Methods. One hundred and sixty-two patients diagnosed as acute hemorrhage from GOV1 were enrolled. At endoscopists' discretion, 118 patients received glue injection (Glue group) and 44 patients received ligation to arrest bleeding [endoscopic variceal ligation (EVL) group]. This study aimed to compare hemostasis, rebleeding, complications and mortality within 42 days. Results. Both groups were comparable in baseline data. In 109 patients (92%) in the Glue group and 36 patients (82%) in the EVL group (p = 0.07) 48-h hemostasis was achieved . Hemostasis of active bleeding was achieved in 49 of 55 patients (89%) in the Glue group and 24 of 28 patients (85%) in the EVL group (p = 0.70). Treatment failure was noted in 14% of the Glue group and 23% in the EVL group (p = 0.22). Eight patients in the Glue group and four patients in the EVL group rebled between 5 and 42 days (p = 0.73). A total of 48 and 19 adverse events occurred in the Glue and EVL groups, respectively (p = 0.85). Six patients in the Glue group and seven patients in the EVL group encountered posttreatment gastric ulcer bleeding (p = 0.04). Seventeen patients (14%) in the Glue group and 10 (23%) patients in the EVL group died within 42 days (p < 0.001). Conclusions. Banding ligation was similar to glue injection in achieving successful hemostasis of acute bleeding from GOV1. However, a higher incidence of posttreatment ulcer bleeding and mortality may be associated with banding ligation.

Percutaneous transhepatic variceal embolization combined with endoscopic ligation for the prevention of variceal rebleeding

To compare the efficiency of percutaneous transhepatic variceal embolization (PTVE) plus endoscopic variceal ligation (EVL) with EVL alone in the treatment of esophageal variceal bleeding. Cirrhotic patients with recent esophageal variceal bleeding from January 2007 to December 2011 were collected and assigned to PTVE + EVL (N = 41) or EVL (N = 47) groups. We performed chart reviews and prospective follow-up to determine variceal rebleeding, recurrence of varices and survival. During the follow-up period, recurrence of esophageal varices (EV) occurred in 8 patients (19.5%) in the PTVE + EVL group and 23 (48.9%) in the EVL group (P = 0.004). The time to recurrence of EV was 9.2 ± 2.7 months and 4.9 ± 2.1 months, respectively. Three patients (7.3%) in the PTVE + EVL group and 12 (25.5%) in the EVL group experienced rebleeding from all sources (P = 0.023). One patient (2.4%) in the PTVE + EVL group and 7 (14.9%) in the EVL group experienced rebleeding from EV (P = 0.024). Multivariate Cox analysis indicated that the treatment method was the only predictor of rebleeding. There was no significant difference in the survival rate between the two groups. With adequate and permanent obliteration of EV and their feeding veins, the combination of PTVE with cyanoacrylate and EVL is more effective than EVL alone in the prevention and treatment of EV recurrence and rebleeding.