Management of variceal haemorrhage in cirrhotic patients Reply

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Abstract
Editor,—We have serious concerns about several of the recent UK guidelines for the management of variceal haemorrhage in cirrhotic patients ( Gut 2000; 46 (suppl 3 and 4):iiiI–iii115), particularly those that contradict current published evidence. We highlight below the ones we feel are the most important. In the management of acute variceal bleeding, variceal ligation is not the method of first choice which was given an AI recommendation. Meta-analysis of all trials of acute bleeding of banding versus injection sclerotherapy have shown no statistically significant difference between the two treatments for either control of bleeding or survival (data derived from 12 studies with 419 patients), with no statistical heterogeneity.1 The implication of recommending ligation for acute bleeding is that double intubation would be necessary in a patient who is actively bleeding so as to attach the ligation device after the initial diagnostic endoscopy. Although there is no evidence, this would create more risk to the patient; it is common sense that a single intubation would be preferable and would take less time. At best the recommendation should be that either endoscopic technique could be used as first choice, dependent on operator expertise and facilities. Secondly, there is evidence from randomised studies of vasoactive drug therapy combined with endoscopic techniques that combination therapy is superior in terms of control of bleeding. This is based on five randomised studies with 610 patients (pooled odds ratio 0.42, 95% confidence interval 0.29–0.6).1 Publication bias assessment has shown that 29 null or negative studies would be needed to render the results non-significant, and thus this effect is fairly robust. Moreover, in several of these studies vasoactive drugs were given before diagnostic endoscopy, demonstrating their utility during the period of resuscitation before endoscopy could be safely performed, which in practice may be several … Dr R Jalan, Institute of Hepatology, University College London Medical School, 69–75 Chenies Mews, London WC1E 6HX, UK. r.jalan{at}ucl.ac.uk Dr R Jalan, Institute of Hepatology, University College London Medical School, 69–75 Chenies Mews, London WC1E 6HX, UK. r.jalan{at}ucl.ac.uk