Introduction

Esophageal varices can lead to morbidity and mortality in patients with chronic liver diseases. There is a debate about the frequency of endoscopic variceal band ligation sessions needed for the eradication of esophageal varices.

Aims & Methods

We aimed to explore the optimal interval for endoscopic variceal band ligation sessions needed to obliterate esophageal varices. This study enrolled 374 patients with liver cirrhosis indicated for endoscopic variceal band ligation. After the first variceal band ligation, patients were randomly assigned to one of four groups regarding the interval of subsequent band ligation sessions: Group 1 (subsequent band ligation every week), Group 2 (subsequent band ligation every two weeks), Group 3 (subsequent band ligation every three weeks), and Group 4 (subsequent band ligation every four weeks). Patients were followed up till the point of eradicating esophageal varices with reporting of complications in the form of bleeding or post-banding ulcers.

Results

The studied groups had insignificant variations in terms of the mean number of sessions needed to eradicate varices completely and the mean number of subsequent band ligation sessions. Post-banding ulcers were highly incident in Group 1 (52.9%), followed by Group 2 (22.8%), Group 3 (8.0%), and Group 4 (2.7%), with a statistically significant difference between the studied groups (p<0.001). The incidence of bleeding after the first band ligation session was only reported in Group 2 (1.3%). Patients with higher number of sessions needed to obliterate esophageal varices (sessions) were associated with lower hemoglobin (9.75±1.60 vs. 10.48±2.19; p=0.003), lower INR (1.26±0.24 vs. 1.35±0.31; p=0.009), and larger spleen diameter (15.52±3.58 vs. 14.65±3.31; p=0.011) when compared with patients needed lower number of sessions to obliterate esophageal varices.

Conclusion

The four-week interval of elective variceal band ligation sessions is effective in achieving complete esophageal varices eradication with a lower rate of complications.

References

1- Iwakiri, Y.,J. Trebicka, Portal hypertension in cirrhosis: Pathophysiological mechanisms and therapy. JHEP Rep, 2021. 3(4): p. 100316.

Introduction

Esophageal varices are a leading cause of life-threatening upper gastrointestinal bleeding in cirrhotic patients. Carvedilol and endoscopic variceal ligation (EVL) are the main strategies for primary prophylaxis, but their comparative efficacy remains a topic of debate. Additionally, recent studies have explored combining carvedilol with EVL, but the potential added benefit of this approach remains unclear.

Aims & Methods

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs), performing a comprehensive search of PubMed, Embase, Cochrane, and ClinicalTrials.gov to identify and evaluate studies comparing carvedilol vs. EVL or carvedilol plus EVL vs. carvedilol alone in patients at risk of esophageal variceal bleeding. Statistical analyses were conducted using R and RStudio, applying a random-effects model with 95% confidence intervals.

Results

Nine RCTs comprising 1,443 patients were included. Carvedilol significantly reduced six-month variceal bleeding compared to EVL (RR 0.57; 95% CI 0.36–0.90; p=0.01; I²=0%). No significant differences were found in overall variceal bleeding (RR 0.97; 95% CI 0.61–1.53; p=0.90; I²=61%), one-year bleeding (RR 0.86; 95% CI 0.46–1.62; p=0.63; I²=51%), one-year all-cause mortality (RR 1.31; 95% CI 0.91–1.90; p=0.15; I²=0%), or bleeding-related mortality (RR 1.32; 95% CI 0.71–2.48; p=0.38; I²=0%). Hypotension occurred in 3% (95% CI 0.00–0.05) of patients receiving carvedilol. Dysphagia (52%; 95% CI 0.25–0.80) and variceal recurrence (14%; 95% CI 0.00–0.31) were reported in the EVL group. Combination therapy showed no clear benefit over monotherapy for six-month bleeding (RR 1.69; 95% CI 0.90–3.17; p=0.10; I²=0%) or mortality (RR 1.47; 95% CI 0.36–5.92; p=0.59; I²=61%).

Conclusion

Carvedilol and EVL appear similarly effective for primary prophylaxis of variceal bleeding, though carvedilol may offer short-term benefits with fewer adverse effects. Combination therapy did not demonstrate added efficacy over monotherapy.

References

1. AbdElRahim AY, et al. Efficacy of carvedilol versus propranolol versus VBL for primary prevention of variceal bleeding. Hepatol Int.2018.
2. Kanwal N, et al. Carvedilol vs EBL:primary prophylaxis of variceal bleed. Rawal Med J. 2022.
3. Khan M, et al. Comparison of Carvedilol and EBL for the Prevention of Variceal Bleed in Patients of Cirrhosis.
4. Kothakota SR, et al. Carvedilol versus Carvedilol plus Variceal band ligation in Primary Prophylaxis of Variceal Bleeding-RCT. J Gastroenterol Hepatol 2019.
5. Kumar JS, et al. Efficacy of carvedilol plus VBL compared to carvedilol alone in primary prophylaxis of variceal bleed in cirrhotics with high risk varices. J Clin Exp Hepatol 2024.
6. Panda G, et al. Comparative Evaluation of Endoscopic VBL and Carvedilol for Prevention of First Esophageal Variceal Bleed in High Risk Cirrhotics. J Gastrointest Liver Dis JGLD 2023.
7. Shah HA, et al. Carvedilol vs. esophageal VBL in the primary prophylaxis of variceal hemorrhage:a multicentre RCT. J Hepatol.2014.
8. Tripathi D, et al. RCT of carvedilol versus VBL for the prevention of the first variceal bleed.Hepatol Baltim Md.2009.
9. Tevethia HV, et al. Combination of carvedilol with VBL in prevention of first variceal bleed in Child-Turcotte-Pugh B and C cirrhosis with high-risk oesophageal varices: the “CAVARLY TRIAL”.Gut 2024.

Disclosure

Rodrigo V. Motta, MD has grant funding from PSC Support.
Remaining authors report no relationships that could be construed as conflicts of interest. All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Introduction

The role of proton pump inhibitors (PPIs) in reducing complications after endoscopic band ligation (EBL) of esophageal varices in cirrhotic patients remains uncertain. While PPIs are often prescribed to prevent post-banding ulcers and related bleeding, their clinical benefit in this setting is debated.

Aims & Methods

We conducted a systematic review and meta-analysis to evaluate whether PPI use is associated with reduced risk of bleeding and mortality within 8 weeks after EBL in cirrhotic patients, compared to non-use. A comprehensive search of PubMed, Web of Science, and CENTRAL was performed in January 2025. We included randomized controlled trials (RCTs) and observational studies comparing PPI use versus non-use following EBL. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane RoB 2 tool for RCTs, ROBINS-I for cohort and case-control studies, and AXIS for cross-sectional studies. A random-effects meta-analysis was conducted using restricted maximum-likelihood estimation. Relative risks (RRs) or odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for primary and secondary outcomes.

Results

Eleven studies (4 RCTs, 7 observational) including 7,459 patients with cirrhosis undergoing EBL were included. All studies provided data for the primary outcomes. In the pooled analysis, PPI use was associated with a reduced risk of bleeding within 8 weeks (OR 0.76; 95% CI: 0.62 - 0.92; I² = 29.6%) and lower mortality (OR 0.48; 95% CI: 0.24 - 0.97; I² = 0.0%). However, when analyzing adjusted odds ratios from five eligible observational studies (n = 5,907), PPI use was not significantly associated with reduced bleeding (OR 0.64; 95% CI: 0.33 - 1.23; I² = 72.2%). These negative findings were further supported by the pooled analysis of RCTs alone (n = 445), in which PPI use was not significantly associated with a reduction in bleeding (RR 0.71; 95% CI: 0.39 - 1.30; I² = 0.0%) or mortality (RR 0.75; 95% CI: 0.23 - 2.53; I² = 0.0%). Subgroup analysis based on the indication for EBL (elective vs emergency) also showed no significant differences. Finally, PPIs had no significant impact on the length of hospitalization. Data on post-banding ulcer size and number were inconsistently reported and could not be pooled.

Conclusion

This practice-changing meta-analysis does not support the routine use of PPIs to reduce severe complications after EBL for esophageal varices in patients with cirrhosis.

Introduction

Variceal gastrointestinal bleeding is a serious complication of cirrhosis.About one-third of patients have esophageal varices at the time of cirrhosis diagnosis,and this number increases over time.Early detection and grading of these varices are important to prevent bleeding,identify high-risk patients, and start appropriate treatment.However, endoscopic screening is invasive, expensive, and places a strain on endoscopy units.To address this, non-invasive methods have been suggested,such as using clinical and laboratory markers.One of these markers is thrombocytopenia (a low platelet count,below 150.000/μL),which may help predict the presence and severity of esophageal varices.

Aims & Methods

The aim of this study was to examine the relationship between platelet count and variceal grades to determine if platelet levels can be used as a reliable tool to predict variceal severity.
We conducted a descriptive and analytical study involving 51patients newly diagnosed with cirrhosis,all of whom presented with esophageal varices of varying grades confirmed by endoscopy.The diagnosis of cirrhosis was based on a combination of clinical,laboratory, imaging, and histological criteria.Patients with hepatocellular carcinoma,portal vein thrombosis,those receiving prophylactic beta-blockers, or with a history of endoscopic band ligation or sclerotherapy were excluded.
For each patient, we collected demographic data, laboratory findings (with a focus on platelet count),and results from esophagogastroduodenoscopy,particularly the grade of esophageal varices.
Patients were divided into 4 groups based on their platelet count:

• Group 1: < 50.000/μL
• Group 2: 50.000–99.000/μL
• Group 3: 100.000–150.000/μL
• Group 4: > 150,000/μL

Results

The study included a total of 51patients, of whom 66%were male and 34%female,with a mean age of 62 ±15.03years.Regarding platelet count,16% of patients(n=8)had a count below
50.000/μL,50%(n=25)had values between 50.000 and 99.000/μL,14%(n =7) between100,000 and 150.000/μL,and 20%(n=10) had counts above 150.000/μL.
Grade I esophageal varices were found in 26% of patients(n=11), grade IIin 28%(n=14),and grade III in 46% (n=23).The mean platelet count was 167.538/mm³ in patients with grade I varices,88.500/mm³ in those with grade II, and 59.043/mm³in those with grade III varices.
There was a statistically significant association between platelet count and variceal grade: patients with lower platelet counts were more likely to have high-grade varices,where as those with higher platelet counts tended to have low-grade varices(p < 0.001).
Spearman’s rank correlation analysis showed a significant negative correlation between platelet count and esophageal variceal grade (p < 0.001).
Receiver Operating Characteristic(ROC)curve analysis identified an optimal platelet count cutoff value of 91.000/mm³ for predicting the presence of large esophageal varices,with an area under the curve(AUC)of 0.9.At this cutoff,the sensitivity was 100%,specificity 81%, positive predictive value 65%,and negative predictive value 100%.

Conclusion

A significant negative correlation was observed between platelet count and esophageal variceal grade. Indeed, a low platelet count is associated with more severe esophageal varices. These results indicate that platelet count could serve as a predictive marker for esophageal variceal grade.