Pharmacotherapy plus endoscopic intervention is more effective than pharmacotherapy or endoscopy alone in the secondary prevention of esophageal variceal bleeding: a meta-analysis of randomized, controlled trials

Gastrointest Endosc. 2009 Oct;70(4):658-664.e5. doi: 10.1016/j.gie.2009.02.029. Epub 2009 Jul 29.


Background: Previous clinical trials on the treatment of esophageal variceal bleeding yielded mixed results regarding the efficacy of endoscopic procedures compared with pharmacotherapy only.

Objective: To compare the efficacy of endoscopic procedures with that of pharmacotherapy in the prevention of mortality and rebleeding.

Design and setting: A systematic literature review was performed to identify randomized, controlled trials of the efficacy of pharmacotherapy and endoscopic therapy. A meta-analysis was performed by using the Comprehensive MetaAnalysis software package. A 2-sided alpha error <.05 was considered statistically significant (P < .05).

Patients: Twenty-five clinical trials with a total of 2159 patients were eligible for meta-analysis.

Outcome measurements: Relative risk (RR) with 95% confidence interval (CI) was computed for all-cause mortality, mortality from rebleeding, all-cause rebleeding, and rebleeding caused by varices.

Results: Pharmacotherapy was as effective as endoscopic procedures in preventing rebleeding (RR 1.067; 95% CI, 0.865-1.316; P = .546), variceal rebleeding (RR 1.143; 95% CI, 0.791-1.651; P = .476), all-cause mortality (RR 0.997; 95% CI, 0.827-1.202, P = .978), and mortality from rebleeding (RR 1.171; 95% CI, 0.816-1.679; P = .39). Pharmacotherapy combined with endoscopic procedures did not reduce all-cause mortality (RR 0.787; 95% CI, 0.587-1.054; P = .108) or mortality caused by rebleeding (RR 0.786; 95% CI, 0.445-1.387; P = .405) compared with endoscopic procedures. However, combination therapy (endoscopic procedure plus pharmacotherapy) significantly reduced the incidence of all rebleeding (RR 0.623; 95% CI, 0.523-0.741; P < .001) and variceal rebleeding (RR 0.601; 95% CI, 0.440-0.820; P < .001).

Limitations: Heterogeneity of patient population and different treatment protocols may have affected our meta-analysis.

Conclusion: Pharmacotherapy may be as effective as endoscopic therapy in reducing rebleeding rates and all-cause mortality. Pharmacotherapy plus endoscopic intervention is more effective than endoscopic intervention alone.

Publication types

  • Comparative Study
  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Adrenergic beta-Antagonists / therapeutic use
  • Combined Modality Therapy
  • Esophageal and Gastric Varices / drug therapy
  • Esophageal and Gastric Varices / etiology
  • Esophageal and Gastric Varices / mortality
  • Esophageal and Gastric Varices / prevention & control*
  • Esophagoscopy
  • Gastrointestinal Hemorrhage / drug therapy
  • Gastrointestinal Hemorrhage / etiology
  • Gastrointestinal Hemorrhage / mortality
  • Gastrointestinal Hemorrhage / prevention & control*
  • Humans
  • Ligation
  • Randomized Controlled Trials as Topic
  • Recurrence
  • Risk Factors
  • Sclerosing Solutions / administration & dosage
  • Sclerotherapy


  • Adrenergic beta-Antagonists
  • Sclerosing Solutions