Controlled Trial of Ligation Plus Vasoconstrictor versus Proton Pump Inhibitor in the Control of Acute Esophageal Variceal Bleeding

Gin-Ho Lo; Daw-Shyong Perng; Chi-Yang Chang; Chi-Ming Tai; Huay-Min Wang; Hui-Chen Lin

Disclosures

J Gastroenterol Hepatol. 2013;28(4):684-689. 

In This Article

Abstract and Introduction

Abstract

Background: Endoscopic therapy combined with vasoconstrictor was generally recommended to treat acute variceal bleeding. However, up to 30% of patients may still encounter treatment failure.

Objectives: This trial was to evaluate the efficacy of combination with endoscopic variceal ligation (EVL) and proton pump inhibitor (PPI) infusion in patients with acute variceal bleeding.

Methods: Cirrhotic patients presenting with acute esophageal variceal bleeding were rescued by emergency EVL. Soon after arresting of bleeding varices, eligible subjects were randomized to two groups. Vasoconstrictor group received either somatostatin or terlipressin infusion. PPI group received either omeprazole or pantoprazole. End points were initial hemostasis, very early rebleeding rate, and adverse events.

Results: Sixty patients were enrolled in vasoconstrictor group and 58 patients in PPI group. Both groups were comparable in baseline data. Initial hemostasis was achieved in 98% in vasoconstrictor group and 100% in PPI group (P = 1.0). Very early rebleeding within 48–120 h occurred in one patient (2%) in vasoconstrictor group and one patient (2%) in the PPI group (P = 1.0). Treatment failure was 4% in vasoconstrictor group and 2% in PPI group (P = 0.95). Adverse events occurred in 33 patients (55%) in vasoconstrictor group and three patients (6%) in PPI group (P < 0.001). Two patients in vasoconstrictor group and one patient in PPI group encountered esophageal ulcer bleeding.

Conclusions: After successful control of acute variceal bleeding by EVL, adjuvant therapy with PPI infusion was similar to combination with vasoconstrictor infusion in terms of initial hemostasis, very early rebleeding rate, and associated with fewer adverse events.

Introduction

Acute esophageal variceal hemorrhage is a dreadful complication of portal hypertension. Its management evolved rapidly in recent years. Vasoconstrictors have been shown to control approximately 80% of bleeding episodes, are generally used as a first-line therapy. Previous studies showed that combination of endoscopic therapy with vasoconstrictor is better than either vasoconstrictor or endoscopic therapy alone in achieving successful hemostatsis of bleeding varices.[1–6] However, the combination therapy does not improve 5-day or 42-day mortality, while it may be associated with increased adverse events. Thus, it is claimed by scholars that the advantages of the combination of pharmacologic and endoscopic therapy should be explored in large randomized, controlled trials.[7] The rationale of using vasoconstrictor is to enhance the efficacy of hemostasis by endoscopic therapy. On the other hand, because of fewer complications and higher hemostatic rate, endoscopic variceal ligation (EVL) has replaced endoscopic injection sclerotherapy (EIS) as the endoscopic treatment of choice in the arresting of acute esophageal variceal hemorrhage.[8–10] However, early rebleeding due to ligation-induced ulcer may be encountered.[11–13] A previous study revealed that pantoprazole reduced the size of postbanding ulcers after EVL.[14] Thus, we designed a controlled trial to compare the value of adjuvant therapy with vasoconstrictors or proton pump inhibitor (PPI) infusion in cirrhotic patients with acute variceal bleeding arrested by emergency EVL.

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