Decision analysis of prophylactic treatment for patients with high-risk esophageal varices

• Published in: Gastrointestinal endoscopy 2000-12, Vol.52 (6), p.707-714
• Main Authors: Aoki, Noriaki, Kajiyama, Toru, Beck, J.Robert, Cone, Richard W., Soma, Kazui, Fukui, Tsuguya
• Format: Article
• Language: English
• Subjects: Adrenergic beta-Antagonists - administration & dosage; Biological and medical sciences; Confidence Intervals; Decision Support Techniques; Esophageal and Gastric Varices - prevention & control; Esophageal and Gastric Varices - therapy; Esophagus; Gastroenterology. Liver. Pancreas. Abdomen; Gastrointestinal Hemorrhage - prevention & control; Humans; Ligation - methods; Male; Markov Chains; Medical sciences; Middle Aged; Models, Theoretical; Monte Carlo Method; Other diseases. Semiology; Probability; Risk Assessment; Sensitivity and Specificity; Time Factors
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1067/mge.2000.110729

Background: Clinical decision analyses were conducted to quantify the uncertainty and to identify important factors in selection of prophylactic therapy for patients with esophageal varices. Methods: A Markov model compared variceal ligation, β-blockers, and “watchful waiting” strategies in terms of bleeding-free life years. Transition probabilities were obtained from meta-analyses of published data. A hypothetical 50-year-old white man with high-risk esophageal varices and cirrhosis served as the prototypical baseline case. Traditional n-way sensitivity analyses were applied to clarify the influence of each factor, and Monte Carlo probabilistic sensitivity analyses were used to investigate clinical uncertainty. Results: Probabilistic sensitivity analyses demonstrated that 77.0% of hypothetical cases had more bleeding-free life years after variceal ligation, whereas 23% had more when treated with β-blockers. On the basis of one-way sensitivity analyses, only 2 factors (variceal bleeding rates after ligation and treatment with β-blockers) influenced the strategy choice. Conclusions: Variceal ligation is an effective prophylactic therapy in many cases, but nearly one quarter of patients with high-risk esophageal varices and cirrhosis may benefit more from prophylactic treatment with β-blockers. Additional clinical studies identifying key variceal bleeding risk factors may lead to more effective clinical decision making for these patients. (Gastrointest Endosc 2000;52:707-14.)