Upper GI bleed: acute variceal bleeding: emergency sclerotherapy is effective at controlling bleeding and reducing mortality, but surgery is better at preventing rebleeding

Clinical bottom line (level 1a)

  1. Patients with active variceal bleeding who receive emergency sclerotherapy compared with sham treatment are more likely to have bleeding controlled (NNT = 3 at unknown) , and more likely to survive (NNT = 5 at unknown) . There is no clear effect on rebleeding within the next 6weeks.
  2. Patients with active variceal bleeding who have emergency sclerotherapy compared with vasopressin are more likely to have bleeding controlled (NNT = 9 at unknown) . There is no clear difference in rebleeding at 6 weeks or mortality.
  3. There is no clear difference between sclerotherapy and somatostatin.
  4. Patients who have emergency sclerotherapy compared with balloon tamponade insertion are more likely to have control of bleeding (NNT = 3 at unknown) . There is no clear difference in recurrence of bleeding at 6 weeks or mortality.
  5. Patients with active variceal bleeding who have surgery compared with emergency sclerotherapy are less likely to rebleed within 6 weeks (NNT = 4 at 6 weeks) . There is no clear difference in control of bleeding or mortality.
  6. A fifth of patients have serious complications from sclerotherapy - 2%die.
D'Amico et al: Hepatology 1995; 22: 332-354
Expires October 2002

The study

Systematic review of all randomised controlled trials of
  • Patients: active variceal bleeding
  • Intervention: emergency sclerotherapy compared with placebo, vasopressin,somatostatin, balloon tamponade,surgery
  • Outcome: failure of first bleed, 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: 20 studies included
Studies were not found to be significantly heterogeneous.

The evidence

Outcome Time to outcome CER OR
(95% CI)		 NNT
(95% CI)
failure to control bleeding:sclerotherapy v. sham unknown 17/43
(39.5%)		 0.13
(0.05 to 0.36) 		3
(3 to 5)
rebleeding rate: sclerotherapy v.sham 6 weeks 18/43
(41.9%)		 0.47
(0.19 to 1.46) 		6
(NNT = 3 to infinity;
NNH = 11 to infinity)
death: sclerotherapy v. sham unknown 21/43
(48.8%)		 0.39
(0.17 to 0.95) 		5
(3 to 78)
failure to control bleeding: sclerotherapy v. vasopressin unknown 31/123
(25.2%)		 0.51
(0.27 to 0.97) 		9
(6 to 180)
rebleeding rate: sclerotherapy. vasopressin 6 weeks 75/216
(34.7%)		 0.66
(0.44 to 1.00) 		11
(6 to infinity)
death: sclerotherapy v.vasopressin unknown 63/216
(28.7%)		 0.65
(0.42 to 1.01) 		13
(NNT = 7 to infinity;
NNH = 490 to infinity)
failure to control bleeding: sclerotherapy v. somatostatin unknown 38/166
(22.9%)		 0.70
(0.40 to 1.22) 		18
(NNT = 8 to infinity;
NNH = 27 to infinity)
rebleeding rate: sclerotherapy v. somatostatin 6 weeks 14/58
(24.1%)		 0.43
(0.14 to 1.30) 		8
(NNT = 5 to infinity;
NNH = 20 to infinity)
death: sclerotherapy v. somatostatin unknown 42/146
(%)		 0.97
(0.56 to 1.65) 		160
(NNT = 10 to infinity;
NNH = 9 to infinity)
failure to control bleeding: sclerotherapy v. balloon tamponade unknown 10/42
(%)		 0.15
(0.04 to 0.53) 		3
(4 to 10)
rebleeding rate: sclerotherapy v. balloon tamponade 6 unknown 71/186
(38.2%)		 0.68
(0.44 to 1.04) 		12
(NNT = 6 to infinity;
NNH = 100 to infinity)
death: sclerotherapy v. balloon tamponade 6 weeks 78/186
(41.9%)		 0.75
(0.49 to 1.15) 		15
(NNT = 6 to infinity;
NNH = 29 to infinity)
failure to control bleeding: sclerotherapy v. surgery unknown 7/68
(10.3%)		 2.24
(0.85 to 5.87) 		-10
(NNT = 71 to infinity;
NNH = 3 to infinity)
rebleeding rate: sclerotherapy v. surgery unknown 7/78
(9.0%)		 6.05
(3.30 to 11.2) 		-4
(-6 to -2)
death: sclerotherapy v.surgery 6 weeks 64/146
(43.8%)		 0.91
(0.56 to 1.46) 		43
(NNT = 7 to infinity;
NNH = 11 to infinity)

  • Overall18% of patients had severe complications from emergency sclerotherapy (12trials:bleeding from post-sclerosis ulcers, stenosis, oesophageal perforation) and of these 15%died.

Comments

  1. Many of the studies were too small to show any effect.
  2. Note that these trials were looking at the acute control of bleeding. As most authorities would recommend repeated sclerotherapy or banding in the early phase after initial control the optimum management is probably combined treatment.

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 oesophageal varices bleeding
    Intervention or Exposure drug therapy, balloon tamponade
    Outcome failure to control bleeding,death