Identification of High-Risk Individuals for Bleeding from Post-Endoscopic Variceal Band Ligation Ulceration

Abstract Background and aims Endoscopic variceal band ligation (EVBL) plays an important role in management of esophageal varices for both primary prophylaxis and acute hemorrhage. However, life-threatening bleeding secondary to post-banding ulceration, whilst uncommon, can occur. This study aimed to identify rates of EVBL-induced ulcer bleeding in elective and non-elective settings, and to assess potential risk factors which contribute to this serious complication. Method This was a retrospective cross-sectional analysis of cirrhotic patients who underwent EVBL over a four-year period in a tertiary hospital in Australia. Differences between the bleeding group and controls were assessed using univariate analysis. Results 336 episodes of EVBL were identified with 19 episodes (5.6%) resulting in EVBL-induced ulcer bleeding. The mean time to re-bleeding occurred within 11 days (+/-1.36) of ligation. The incidence of EVBL-induced ulcer bleeding was 8.5% (N = 11) in the emergent setting compared to 4.0% (N = 8) in the elective setting. Factors found to significantly affect the rate of EVBL-induced ulcer bleeding included previous history of variceal bleeding (OR 2.91, p = 0.0333), presence of high-risk stigmata on endoscopy (OR 7.83, p = 0.016) and lower hemoglobin at time of initial endoscopy (mean 88.58 vs. 107.5, p = 0.0012). Unlike previous studies, proton pump inhibitor (PPI) use was not protective in reducing the risk of post EVBL-ulcer bleeding (OR 1.39, p = 0.62). Conclusion Strategies to address these risk factors should be adopted prior to endoscopic band ligation to minimise the risk of EVBL-ulcer bleeding. Consideration should also be given to investigating whether PPI use among this high-risk group confers any benefit.