P0936 - Carvedilol Equals Endoscopic Band Ligation for Preventing First Variceal Bleed and Death: An Updated Systematic Review and Meta-Analysis of 8 Randomized Controlled Trials

Award: ACG Presidential Poster Award

Ashesh Das, MBBS¹, Venkata Dileep Kumar Veldi, MBBS², Anchit Chauhan, ³, M. Rafiqul Islam, ⁴, Akif Shahid. Khan, MBBS⁵, Urvashi Bharia, ⁶, Anushka Anand. Hanchate, MBBS⁷, Jana Al Jnainati, MD⁸, Nigham Al Dirani, MS⁹
1KPC Medical College and Hospital , Kolkata, India, Kolkata, West Bengal, India; 2Gayatri Vidya Parishad Institute of Health care and Medical Technology, Visakhapatnam, Andhra Pradesh, India; 3Maulana Azad Medical College, New Delhi, Delhi, India; 4Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh, Dhaka, Dhaka, Bangladesh; 5Northwest School of Medicine, Nowshera, North-West Frontier, Pakistan; 6Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Navi Mumbai, Maharashtra, India; 7Mgm Medical College and Hopsital , Kamothe ,Navi mumbai, Mumbai, Maharashtra, India; 8University of Milan–Bicocca: Universita degli Studi di Milano-Bicocca, Bergamo, Lombardia, Italy; 9Lebanese University,Faculty of medical Sciences, Beirut, Mont-Liban, Lebanon

Introduction: Acute oesophageal-variceal haemorrhage remains one of the deadliest decompensation events in cirrhosis, driving substantial global mortality and rehospitalisation costs. Although current guidelines endorse either non-selective β-blockers (NSBBs) or endoscopic variceal band ligation (EVBL) for primary prophylaxis, direct comparative data are limited. Carvedilol—a vasodilatory NSBB that achieves greater portal-pressure reduction than propranolol—has been elevated to preferred status in the Baveno VII recommendations, yet its relative efficacy and safety versus EVBL have not been systematically synthesised.

Methods: A systematic search of PubMed, Embase, Scopus, and Cochrane Library identified Randomized Controlled Trials (RCTs) comparing carvedilol with Band Ligation in managing variceal bleeding through May 2025. Data were analysed using RevMan 4.2.1. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using Mantel-Haenszel methods. Random- or fixed-effects models were applied based on heterogeneity (Higgins’ I²). Statistical significance was set at p < 0.05. Risk of bias was assessed using RoB 2.0.

Results: Across eight RCTs enrolling 1,481 cirrhotic patients, first-bleed rates were 11.6 % (85/736) vs 12.1 % (90/745), giving RR 0.92 (95 % CI 0.60–1.41; p = 0.72; I² = 47 %). Five trials (n = 832) found no difference in all-cause mortality (16.6 % vs 14.4 %; RR 1.15, 95 % CI 0.84–1.58; p = 0.39; I² = 0 %). Safety was comparable: six trials (n = 1,025) showed numerically fewer adverse events with carvedilol (23.8 % vs 29.0 %; RR 0.85, 95 % CI 0.64–1.13; p = 0.26; I² = 56 %), and four trials (n = 592) reported similar bleed-related mortality (6.8 % vs 5.4 %; RR 1.26, 95 % CI 0.67–2.37; p = 0.47; I² = 0 %).

Discussion: Carvedilol prevented first variceal bleeding, all-cause death and bleed-related mortality as effectively as EVBL, while showing a non-significant trend toward fewer adverse events. The lack of superiority for EVBL, coupled with carvedilol’s oral administration, low cost and capacity to reduce portal pressure systemically, supports its use as a pragmatic first-line option—particularly where endoscopic resources are constrained or patients prefer to avoid repeated procedures. These findings strengthen the guideline momentum toward β-blocker-based prophylaxis and highlight the need for implementation studies that integrate quality-of-life and cost-effectiveness .


Figure: Forest Plot Showing First Variceal Bleed, All Cause Mortality, Bleeding Mortality and Adverse Events

Disclosures:
Ashesh Das indicated no relevant financial relationships.
Venkata Dileep Kumar Veldi indicated no relevant financial relationships.
Anchit Chauhan indicated no relevant financial relationships.
M. Rafiqul Islam indicated no relevant financial relationships.
Akif Khan indicated no relevant financial relationships.
Urvashi Bharia indicated no relevant financial relationships.
Anushka Hanchate indicated no relevant financial relationships.
Jana Al Jnainati indicated no relevant financial relationships.
Nigham Al Dirani indicated no relevant financial relationships.

Ashesh Das, MBBS¹, Venkata Dileep Kumar Veldi, MBBS², Anchit Chauhan, ³, M. Rafiqul Islam, ⁴, Akif Shahid. Khan, MBBS⁵, Urvashi Bharia, ⁶, Anushka Anand. Hanchate, MBBS⁷, Jana Al Jnainati, MD⁸, Nigham Al Dirani, MS⁹. P0936 - Carvedilol Equals Endoscopic Band Ligation for Preventing First Variceal Bleed and Death: An Updated Systematic Review and Meta-Analysis of 8 Randomized Controlled Trials, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.