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Drugs, ligation or both for the prevention of variceal rebleeding?
  1. Michael Schepke
  1. Michael Schepke, Department of Internal Medicine, Gastroenterology and Hepatology, Helios Clinic, Ringstr 49, 53721 Siegburg, Germany; michael.schepke{at}helios-kliniken.de

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There is general consensus that patients surviving a first bleeding episode from oesophageal varices should receive rebleeding prophylaxis.1 Almost two decades ago, band ligation (EBL) proved to be the superior endoscopic procedure compared to injection sclerotherapy. Since then, EBL or drug treatment (non-selective beta-blocker ± nitrates) have become the two first-line treatment options in this situation.

Theoretically, it is attractive to combine these two procedures since both act via two different mechanisms: local obliteration of varices by banding immediately stops the blood flow in these vessels, while drugs lower portal pressure and the related risk of rebleeding. According to a recent meta-analysis addressing this issue, combined endoscopic and drug treatment appeared to be superior to either drugs or endoscopic treatment alone.2 However, the relevance of this meta-analysis is limited: the majority of trials included used sclerotherapy as endoscopic method which is clearly inferior to ligation and has therefore been abandoned for elective treatment of oesophageal varices. When looking at the trials using EBL, the only two fully published ones show that adding drugs to ligation further lowers the rebleeding rate (not mortality) compared to ligation alone.3 4 Consequently, some authors recommend combination of band ligation plus drugs as best option …

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