Friday, September 4, 2009

Endoscopic ligation plus terlipressin prevents rebleeding of esophageal varices

NEW YORK (Reuters Health) - Combining the vasoconstrictor terlipressin with endoscopic variceal ligation reduces very early bleeding of esophageal varices significantly more than terlipressin alone, Taiwanese researchers report in the September issue of Gut.
"Acute esophageal variceal hemorrhage is a dreadful complication of portal hypertension," note Dr. Gin-Ho Lo and co-researchers at I-Shou University in Taipei. Even after treatment, "a high frequency of early rebleeding (30%-50%) may still be encountered in the first few days of acute hemostasis."
To see if dual therapy would lessen that risk, the research team studied 93 adult patients with cirrhosis who did not have active variceal bleeding at initial emergency endoscopy, comparing endoscopic variceal ligation plus two days of terlipressin infusion (intravenous infusion 1 mg every 6 hours for 48 hours) with five days of
terlipressin alone. Between February 2005 and January 2007, the study recruited patients from 18 to 75 years old, with 46 randomized to the terlipressin-only group and 47 assigned to the combination-therapy group.
Very early rebleeding (within 48 to 120 hours) was seen in seven patients in the terlipressin-only group, but in none of the patients who also received endoscopic variceal ligation (p = 0.006).
Treatment failure, defined as failure to control acute bleeding episodes or very early rebleeding or death within five days, occurred in 24% of the terlipressin-only group and only 2% of the combined-therapy group (p = 0.002). In addition, the need for transfusion was significantly lower in the terlipressin-plus-ligation group, as was the likelihood of needing intensive care.
Three patients died in the terlipressin group (two from variceal hemorrhage and aspiration pneumonia in one), and one patient in the combined group died of sepsis.
Nonetheless, the researchers noted that complication rates and 6-week survival were similar in both groups.
Although endoscopic therapy plus vasoconstrictors is the standard therapy for acute variceal hemorrhage, Dr. Lo told Reuters Health, there has been concern that the use of endoscopic therapy could increase adverse events.
An accompanying editorial by Drs. Francesco Salerno and Massimo Cazzaniga of the University of Milan, Italy, noted that the risk of death from shock, terminal liver failure, kidney failure, sepsis or multiorgan failure is "markedly increased by early rebleeding."
Both the report and the editorial noted that, considering the reasons for which patients were excluded from the study (such as hepatocellular carcinoma, age over 75 or taking beta-blockers), the results apply only to the specific subpopulation studied.
Gut 2009;58:1182-1183,1275-1280.

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