Prior decompensation Identifies Patients at High Mortality Risk Despite Standard Therapy After Variceal Hemorrhage: An IPD Meta-analysis

Why clinicians should know about it

• Picked for Gastroenterology (top studies of the week, 26 July 2026).
• Picked for Hepatology (top studies of the week, 26 July 2026).

Abstract

BACKGROUND: In patients with variceal hemorrhage (VH), non-selective beta-blockers plus endoscopic variceal ligation (NSBB + EVL) are recommended to prevent rebleeding, when pre-emptive TIPS is not indicated or placed. OBJECTIVE: To determine whether decompensating events occurring before VH are associated with worse outcomes in patients treated with NSBB+EVL to prevent recurrent VH. DESIGN: Systematic review and individual participant data meta-analysis (IPD-MA) of studies including patients with cirrhosis and VH not-eligible for p-TIPS in Child-Pugh (CP) class A-B and receiving NSBB+EVL to prevent recurrent bleeding. All-cause mortality and new or worsening decompensation were analyzed using cause-specific Cox models and random-effects IPD-MA. RESULTS: 13 studies (5 RCTs, 8 observational) contributed 1659 patients, CP class A 805, B 853; 606 had had prior decompensation, 121 ascites, 154 encephalopathy (alone or combined), 106 ascites plus VH, 225 VH alone. Two-year mortality was 25.1% with prior decompensation and 13.5% without (p<0.0001): specific aHRs were 1.8(CI 1.2-2.6) for prior ascites, 1.7(CI 1.3-2.3) encephalopathy, 0.83 (CI 0.6-1.2) VH and 1.4(CI 0.92-2.3) VH + ascites. IPD-meta-analysis showed a pooled aHR for death of 1.4 (CI 1.1-1.7) with prior decompensation. New or worsening decompensation was also significantly higher with any prior decompensation: pooled aHR 1.7(CI 1.15-2.44). CONCLUSIONS: Among patients with Child-Pugh class A-B cirrhosis who were not candidates for preemptive TIPS and were treated with NSBBs plus EVL after VH, prior decompensation identified a subgroup at increased risk of mortality in whom the potential benefit of TIPS warrants further investigation.

Abstract as published, via PubMed.