Aggressive versus conservative endotherapy for gastric varices in cirrhosis: a randomized controlled trial

Gastric variceal bleeding in cirrhosis remains a challenging clinical problem with variations in management strategies. This randomized controlled trial compared aggressive versus conservative cyanoacrylate therapy for gastric varices in patients with cirrhosis presenting with their first variceal bleed.

Patients with cirrhosis and large gastric varices (GOV1, GOV2, IGV1) and a first episode of variceal bleeding were randomized to receive aggressive endotherapy (Group A) or conservative endotherapy (Group B). In Group A, all visible gastric varices were obliterated using cyanoacrylate glue; in Group B, only varices with stigmata of recent hemorrhage or high-risk features were treated. The primary outcome was variceal rebleeding at 1 year. Secondary outcomes included all-cause mortality, variceal obliteration time, and adverse events.

145 patients were analyzed (Group A 72; Group B 73). At 1 year, the cumulative incidence of rebleeding was comparable between groups (18.2% vs. 15.0%). All-cause mortality at 1 year was also similar (22.2% vs. 32.9%), with a hazard ratio of 0.63 (95%CI 0.33–1.18; P = 0.15), suggesting a nonsignificant 37% reduction in mortality risk with aggressive endotherapy. Time to obliteration of GOV1 varices was shorter in Group A, with a median (range) of 4 (4–20) vs. 8 (4–116) weeks in Group B. Similarly, the number of endoscopic sessions required for GOV1 obliteration was fewer in Group A (1 [1–4] vs. 2 [1–5] sessions). Adverse event rates were comparable across both groups.

Aggressive endotherapy resulted in rebleeding and mortality rates similar to those of conservative therapy.