Are PPIs necessary after endoscopic band ligation?

Routine use of proton pump inhibitors (PPIs) after endoscopic band ligation (EBL) of esophageal varices in patients with cirrhosis lacks sufficient evidence, according to a systematic review and meta-analysis.

A team of investigators searched major databases through January 2025 for randomized clinical trials (RCTs) and observational studies comparing PPI use vs nonuse after EBL of esophageal varices in patients with cirrhosis. They then conducted random-effects meta-analyses using restricted maximum likelihood estimation and calculated risk ratios (RRs), odd ratios (ORs), or standardized mean differences.

Eleven studies comprising 7,459 patients with cirrhosis undergoing EBL met the eligibility criteria. Of these, four were RCTs and seven observational.

Pooled unadjusted analyses revealed the association of PPI use with reduced post-EBL bleeding (OR, 0.76, 95 percent confidence interval [CI], 0.62‒0.92; I², 29.6 percent) and all-cause mortality (OR, 0.48, 95 percent CI, 0.24‒0.97; I², 0.0 percent).

However, further analyses did not show any benefit, with adjusted observational data for post-EBL bleeding and RCT data for post-EBL bleeding and all-cause mortality not reaching significance (p>0.05). Likewise, RCT data did not exhibit a statistically significant effect for the mechanistic outcome of post-EBL ulcer bleeding (RR, 0.54, 95 percent CI, 0.25‒1.16; I², 0.0 percent).

“Trial sequential analysis confirmed that the cumulative RCT evidence for bleeding is underpowered,” the investigators said.