Prognostic Relevance of Active Bleeding Seen During Endoscopy on Outcomes in Patients with Child-A Cirrhosis with Acute Variceal Bleeding: A Prospective Observational Study

Background: While relevant in deciding the outcomes in patients with advanced(Child-B/C) cirrhosis, the prognostic significance of active bleeding seen on esophago- gastroduodenoscopy(EGD) in acute variceal bleeding(AVB) in patients with Child-A cirrhosis is inadequately explored. Aim: To study the relevance of active bleed on EGD in determining the prognosis of AVB in patients with Child-A cirrhosis. Methods: In this prospective study, patients with Child-A cirrhosis with no baseline infection presenting with AVB with available clinical, laboratory parameters, endoscopic findings were assessed for relevant 6-week outcomes such as mortality, early rebleeding (within 5 days), need for rescue treatment and incidence of infections. The outcomes described were compared in patients stratified by active bleeding on EGD. Active bleeding on EGD was defined as the presence of ooze/spurt from varices or presence of stigmata of recent haemorrhage in the variceal column with fresh blood in the lumen. Results: Patients with Child-A cirrhosis(n=131) presenting with AVB(mean age:44±11 years, 80% males) of alcoholic liver disease(49%), non-alcoholic steatohepatitis(21.3%), viral cirrhosis(10%) and other etiologies(19.7%) were included and analysed for outcomes. Overall, the 6-week mortality, early rebleeding and infection rates during AVB episode were 4.5%, 12.2% and 10.6%, respectively. Twenty-five out of 131 patients(19%) had active bleed on EGD. Patients with active bleed had a shorter door to scope time(12±4 hrs vs 17±9 hrs, P=0.001), higher serum lactate(3.5mmol/L vs 1.9mmol/L, P=0.002), lower serum albumin (3.1g/dL vs 3.6g/dL, P=0.002) and a higher INR(1.35 vs 1.27, P=0.04) at baseline. Other baseline characteristics and types of variceal bleeding were comparable between two groups. Patients with active bleed had a higher 6-week mortality(17.4% vs 2%, P=0.01), higher early rebleeding(48% vs 3.8%, P<0.001) and increased incidence of bacterial infections(28% vs 6.6%, P=0.006) compared to those without active bleed on EGD. Conclusion: Active bleeding on EGD portends poorer outcomes in AVB even in patients with Child-A cirrhosis.