S2431 Propranolol Versus Endoscopic Variceal Ligation for Primary Prevention of Variceal Bleeding: A Systematic Review and Meta-Analysis

Introduction: Variceal bleeding is a significant and life-threatening complication of portal hypertension in patients with liver cirrhosis, accounting for approximately 20–30% of cirrhosis-related deaths. To prevent first bleeding episodes, current clinical practice guidelines recommend either nonselective beta-blockers, such as propranolol or carvedilol, or endoscopic variceal ligation (EVL) for patients with medium to large oesophageal varices. Despite widespread use, the comparative efficacy and safety of these primary prophylactic strategies remain incompletely defined and continue to be a subject of clinical debate. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Electronic databases were searched to identify randomized controlled trials (RCTs) comparing EVL and propranolol for the primary prevention of variceal bleeding in patients with liver cirrhosis. Primary outcomes included incidence of variceal bleeding, all-cause mortality, and bleeding-related mortality. Secondary outcomes included adverse effects related to prophylactic treatment. Data were pooled using fixed or random-effects models depending on heterogeneity. Results: Nine RCTs comprising a total of n = 916 patients were included. EVL was associated with a significantly lower risk of variceal bleeding compared to propranolol (odds ratio [OR] 0.44; 95% confidence interval [CI]: 0.28–0.67; P = 0.0002) and reduced bleeding-related mortality (OR 0.57; 95% CI: 0.33–0.99; P = 0.05). Adverse effects were also significantly less frequent in the EVL group (OR 0.46; 95% CI: 0.32–0.67; P < 0.0001). No statistically significant difference was found in all-cause mortality between the 2 interventions (OR 0.93; 95% CI: 0.63–1.37; P = 0.72). Conclusion: EVL is more effective than propranolol for the primary prevention of variceal bleeding in patients with cirrhosis, demonstrating lower rates of first variceal bleed, bleeding-related mortality, and treatment-related adverse events. Although no difference in all-cause mortality was observed, the findings support the consideration of EVL as a first-line prophylactic option. Further well-designed, multicentre RCTs with standardised outcomes, extended follow-up, and robust cost-effectiveness analyses are essential to optimise clinical decision-making and support personalised treatment strategies.