Terlipressin or sclerotherapy for acute variceal bleeding?

Terlipressin or sclerotherapy for acute variceal bleeding?

Report by Duncan McAuley, Consultant

Checked by Usman Jaffer, Surgical SHO

Addenbrookes Hospital, Cambridge, UK

Abstract

A short cut review was carried out to establish whether terlipressin or sclerotherapy is more effective at reducing acute bleeding and mortality in acute oesophageal variceal bleeding. 327 papers were found using the reported searches, of which one presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of this best paper is tabulated. It is concluded that terlipressin may be as effective as sclerotherapy in acute variceal bleeding and should certainly be considered if there is delay to endoscopy.

Clinical scenario

A 56 year old patient with known oesophageal varices presents to the emergency department with a large haematemesis. Despite your best efforts you cannot organise endoscopy in less than 4 hours. You wonder whether terlipressin (glypressin) is an effective alternative to sclerotherapy.

Three part question

In [adults with known varices] is [terlipressin or sclerotherapy] more effective at [reducing acute bleeding and mortality]?

Search strategy

MEDLINE using the OVID interface 1966 to January Week 1 2006

Embase using the OVID interface 1980 to 2006 Week 02

[varice$.mp. OR exp Gastrointestinal Hemorrhage/OR exp “Esophageal and Gastric Varices”/] AND [sclerotherapy.mp. or exp Sclerotherapy/OR exp Hemostasis, Endoscopic/] AND [glypressin.mp. OR terlipressin.mp. OR vasopressin.mp. OR exp Vasopressins/] LIMIT to Humans and English Language and Abstracts only

The Cochrane Library Issue 4 2005

[esophageal and gastric varices {MeSH explode all trees}] AND [sclerotherapy {MeSH explode all trees}] AND [vasopressins {MeSH explode all trees} OR glypressin {all fields} OR terlipressin {all fields} OR lypressin {all fields}].

Search outcome

327 papers found of which three were relevant. One meta‐analysis and one Cochrane review (by the same authors) referred to the single RCT quoted below

Table 2.

Author, date, and country	Patient group	Study type	Outcomes	Key results	Study weaknesses
Escorsell A, et al, 2000, Spain	219 cirrhotic patients with endoscopy proven variceal bleeding.	Multi‐centre unblinded randomised controlled trial	48‐hour failure to control bleeding	Failure rates were 33% for terlipressin and 32% for sclerotherapy (not significant)	Not blinded, ie assessors of outcomes not clearly blinded to treatment allocation.
			5 day rebleeding rate	Rebleeding rates were the same (14% vs 14%)
			42 day mortality rate	26 out of 105 terlipressin patients died versus 19 of the 114 sclerotherapy patients (not significant)	Intention‐to‐treat analysis not stated
			Pre‐defined side effects	Trend towards more side effects with sclerotherapy (30% v 20%, p = 0.6)

Comment(s)

Only one randomised controlled trial was found. No significant difference in control of bleeding or mortality was demonstrated; there was a trend towards fewer side effects with terlipressin.

Clinical bottom line

Terlipressin (glypressin) may well be as effective as sclerotherapy for acute variceal bleeds. It could be considered when there is a delay to endoscopy. Many centres now use band ligation rather than sclerotherapy; this has not been compared to vasoactive drugs.