Upper GI bleed: prevention of bleeding: beta-blockers are effective, but surgery increases mortality.

Clinical bottom line (level 1a)

  1. Patients with cirrhosis and oesophageal varices who have prophylactic portocaval shunt surgery are less likely to have a first bleed (NNT = 6 at unknown) , but are more likely to develop hepatic encephalopathy (NNH = 6 at unknown) or die (NNH = 9 at unknown) .
  2. Patients with cirrhosis and varices who receive beta-blockers are less likely to have a first bleed (NNT = 10 at unknown) . There is no clear effect on mortality.
  3. Patients with cirrhosis and oesophageal varices who have prophylactic sclerotherapy may have less chance of bleeding or dying.
D'Amico et al: Hepatology 1995; 22: 332-354
Expires October 2002

The study

Systematic review of all randomised controlled trials of
  • Patients: cirrhosis and oesophageal varices
  • Intervention: 1)prophylactic portocaval shunt surgery 2) beta-blockers 3)sclerotherapy compared with no treatment
  • Outcome: prevention of first bleed, chronic or recurrent hepatic encephalopathy, death


Articles found in ?English using MEDline, ? (search terms: ? ) and by searching reference lists of published articles or reviews and congress abstracts.

Selection criteria: randomised controlled trials (articles or abstracts)
Appraisal criteria: not given
Articles excluded if: not given

?number found: 4 trials on surgery involving 302 patients, 9 trials on beta-blockers involving 996 patients, 19trials on sclerotherapy involving 1630 patients.
Studies on sclerotherapy were found to be significantly heterogeneous.

The evidence

treatments for portal hypertension
Outcome Time to outcome CER OR
(95% CI)		 NNT
(95% CI)
first bleed following shunt surgery unknown 44/156
(28.2%)		 0.31
(0.17 to 0.56) 		6
(5 to 10)
encephalopathy following shunt surgery unknown 36/125
(28.8%)		 2.0
(1.2 to 3.1) 		-6
(-23 to -4)
mortality following shunt surgery unknown 62/156
(39.7%)		 1.6
(1.02 to 2.57) 		-9
(-210 to -4)
first bleed following beta-blockers unknown 125/507
(24.7%)		 0.54
(0.39 to 0.74) 		10
(7 to 19)
mortality on beta-blockers unknown 143/507
(28.2%)		 0.75
(0.57 to 1.06) 		18
(NNT = 250 to infinity;
NNH = 10 to infinity)
first bleed following sclerotherapy weeks 281/836
(33.6%)		 0.58
(0.47 to 0.72) 		9
(7 to 14)
mortality following sclerotherapy unknown 300/836
(35.9%)		 0.74
(0.62 to 0.94) 		15
(10 to 71)

Citation

  1. D'Amico G, Pagliaro L, Bosch J: the treatment of portal hypertension: a meta-analytic review. Hepatology 1995; 22: 332-354
Contributor: Alan Townsend and Chris Ball, October 1999
Reviewer: Tim Ringrose

Clinical Question.
    Patient cirrhosis, oesophageal varices, esophageal varices
    Intervention or Exposure beta-blockers, portocaval shunt surgery, sclerotherapy
    Outcome first bleed, death,encephalopathy