Diagnosis, management and prophylaxis of bleeding related to post-esophageal variceal band ligation ulcer in cirrhotic patients

Abstract

Esophageal varices develop in half of cirrhotic patients. Endoscopic variceal band ligation is the current treatment for acute bleeding and applicable for primary and secondary prophylaxis. However, there is a risk of complications, including ligationinduced ulcer bleeding. The aim of this study is to review the current diagnosis, management and prophylaxis of bleeding related to post-esophageal variceal band-ligation ulcers in cirrhotic patients. PubMed and Google Scholar were searched for English language articles about the theme. The main findings were that Child-Pugh class C, higher model of end-stage liver disease, emergency ligation, presence of hepatocellular carcinoma, peptic esophagitis and bacterial infection were reported as the most important risk factors for post-banding ulcer hemorrhage. There are few studies with proton pump inhibitors and sucralfate showing size reduction of post-banding ulcers. Many treatment modalities have been used to control post band ulcer bleeding, such as band local injection of epinephrine or cyanoacrylate, balloon tamponade, stent placement and ligation of the ulcerated bleeding site. However, the optimal management remains uncertain. The principal conclusions of the study were that post-banding ulcer bleeding is potentially life-threatening and must be suspected in the presence of hematemesis, melena or anemia after endoscopic variceal band ligation (EVL). Predictors of rebleeding must be assessed and controlled as much as possible before band ligation. The post-banding treatment with proton pump inhibitors or sucralfate seems advisable, in particular for high-risk patients. Further investigation and new approaches are still required to achieve optimal management of this complication.

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

“…Both variceal hemorrhage and post-EVL ulcers can contribute to post-EVL bleeding or rebleeding [6]. Although post-EVL ulcer is an uncommon complication of EVL, it is associated with significant mortality [7].…”