Endoscopic Variceal Ligation and ß-Blocker Combination Versus Ligation Monotherapy as Variceal Esophagus Bleeding Secondary Prevention
(1) Faculty of Medicine, Universitas Indonesia, Jakarta
(2) Division of Gastroenterology, Department of Internal Medicine, Dr. Cipto Mangunkusumo General National Hospital, Jakarta
Background: Variceal esophagus' risk of re-bleeding in the first year is 60-70%. Mortality rate of acute bleeding is 20-35%. Latest guidelines of esophageal rupture suggest endoscopic ligation and Non-selective b-Blocker combination for re-bleeding prevention. However, monotherapy still can be chosen, depends on the clinical judgement and patient preference. The previous meta-analysis still gave inconclusive results on therapy combination effectivity. Moreover, there is no side effect discussion between both treatment choices. Hence, this evidence-based case report analyses the effectivity of combination treatment for esophageal bleeding secondary prevention.
Method: Literature searching in Scopus, ProQuest, PubMed, ScienceDirect, and EBSCOhost used keywords and their synonyms. Three articles selected included two meta-analyses and one RCT. Critical appraisal on validity, importance, and applicability based on Oxford Center of EBM 2011 was conducted.
Results: Two meta-analysis prove treatment combination is significantly effective decreasing variceal re-bleeding. Ravipati et al. results in RR 0.601 (95% CI 0.44 - 0.82). However, Kumar et al. shows non-significant result. On the other hand, three articles show that therapy combination failed to significantly lower the mortality rates RR 0,786 (95% IK 0,45 - 1,39). This is due to the limitation of treatment combination to prevent cirrhotic progression and other complications. Moreover, this also is due to contraindications and non-suitability of the patients toward non-selective b-Blocker in 30-40% cases.
Conclusion: Endoscopic ligation and non-selective b-Blocker combination is recommended for variceal esophagus bleeding secondary prevention, but other treatments are needed to lower the mortality rate1.
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