Case Control Study of Post-endoscopic Variceal Ligation Bleeding Ulcers in Severe Liver Disease: Outcomes and Management

Abstract

Background and Aims: The management of post-endoscopic variceal ligation (EVL) bleeding ulcers (PEBUs) is currently based on local expertise and patients liver disease status. The present retrospective study investigated associations between the endoscopic morphology of PEBUs and patient outcomes. Methods: Patients underwent EVL (primary or secondary), from January 2015 to January 2018, in two tertiary care hospitals in India (ILBS New Delhi and Dharamshila Narayana New Delhi). Mortality rates were determined at post-EVL day five and week six. PEBUs were typified based on Jamwal & Sarin classification system as follows: A, ulcer with active spurting; B, ulcer with ooze; C, ulcer base with visible vessel or clot; and D, clean or pigmented base. Results: Of 3854 EVL procedures, 141 (3.6%) patients developed PEBU, and 46/141 (32.6%) suffered mortality. Among the former, the PEBU types A, B, C, and D accounted for 17.7, 26.2, 36.3, and 19.8%, respectively. Of those who died, 39.1, 30.4, 21.7, and 8.8% had PEBU types A, B, C, and D. Treatments included transjugular intrahepatic portosystemic shunts (TIPS), esophageal self-expandable metal stent (SEMS), glue and sclerosant injection, Sengstaken-Blakemore tube placement and liver transplant. On univariate analysis, no correlation with hepatic venous pressure gradient, TIPS placement, size of varices, or number of bands was found. The Model for End-Stage Liver Disease (MELD)-sodium score correlated positively with outcome. After adjusting for MELD-sodium score, mortality was best predicted by type-A ulcer ( p = 0.024; OR 8.95, CI 1.34–59.72). Conclusions: PEBU occurred in 3.6% of a large EVL cohort. Stratifying patients based on PEBU type can help predict outcomes, independent of the MELD-sodium score. Classifying PEBUs by endoscopic morphology may inform treatment strategies, and warrants further validation.

Predictors of early bleeding after endoscopic variceal ligation for esophageal varices: a systematic review and meta-analysis

“…The pooled incidence of early post-EVL bleeding was 7.7% (95% CI: 6.1-9.3, I 2 = 91.9%) with data from 16 studies [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] (Fig. 2).…”

“…A total of 879 records were identified, out of which 794 were screened after removal of duplicates. Thirty reports were assessed for eligibility and 16 studies [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] were included in the final analysis. Figure 1 outlines the detailed search strategy as per the PRISMA guidelines.…”

“…The duration of follow-up varied from 2 weeks to 6 weeks. Among the included studies, 6 were of high quality [12,13,16,19,23,26], while 10 had high risk of bias [14, 15, 17, 18, 20-22, 24, 25, 27].…”

Update on the management of refractory variceal bleeding

“…coagulopathy (increased PT, INR and low platelets) 3. post EVL band ulcers (PEBU's), 4. slippage of bands or 5. presence of SRH (stigmata of recent hemorrhage -platelet plug, ulcer) or RCS (red color signs -red wale signs, cherry red spots) [2][3][4].…”

“…The management in this group of patients depends upon the general condition of the patient and the underlying liver disease status. There was a recent study which showed that endoscopic appearance of post banding ulcers can determine the patient outcomes in addition and independent to MELD-Na score [4]. It is a combined team effort involving a hepatology, diagnostic radiology, intervention radiology and a liver transplant team.…”