Proton Pump Inhibitor Therapy Is Associated With Reduction of Early Bleeding Risk After Prophylactic Endoscopic Variceal Band Ligation

Abstract

Endoscopic variceal band ligation (EVL) is an effective procedure to control and prevent variceal bleeding in patients with liver cirrhosis, but it can be complicated by bleeding from post-EVL ulcers. Several studies have reported that proton pump inhibitors (PPIs) decrease the size of post-EVL ulcers. However, evidence are limited as to whether PPIs actually reduce the risk of bleeding after EVL. This study aimed to analyze the factors associated with bleeding after prophylactic EVL and to assess the effect of PPI therapy.Five hundred and five cirrhotic patients with high risk esophageal varices who received primary prophylactic EVL were included for this retrospective cohort study. Post-EVL bleeding was defined as bleeding after prophylactic EVL within 8 weeks evidenced by the occurrence of melena or hematemesis, or by a decrease of hemoglobin by >2.0 g/dL. If evidence of bleeding from ulceration of the EVL sites was confirmed by endoscopy, we defined it as post-EVL ulcer bleeding.Fourteen patients developed bleeding after prophylactic EVL. Factors associated with post-EVL bleeding included alcohol as etiology, low albumin, high total bilirubin, high Child-Pugh score, high MELD score, coexistence of gastric varices, and not administrating PPI medication by univariate analysis. In multivariate logistic analysis, Co-existing gastric varix (odds ratio [OR] 5.680, P = 0.005] and not administrating PPIs (OR 8.217, P = 0.002) were associated with bleeding after prophylactic EVL. In the subgroup analysis excluding patients whose gastric varices were treated, not administering PPI medication (OR 8.827, P = 0.008) was the sole factor associated with post-EVL bleeding.We suggest that PPI therapy needs to be considered in patients receiving prophylactic EVL to reduce the risk of bleeding after prophylactic EVL.

Second‐look endoscopy‐guided therapy under sedation prevents early rebleeding after variceal ligation for acute variceal bleeding

“…However, a previous RCT suggested that the long‐term use of PPI reduced the risk of post‐EVL bleeding . A recent retrospective study also demonstrated that the lack of PPI administration was associated with bleeding after EVL . It was reported that gastroesophageal reflux occurred frequently in patients with portal hypertension and that acid suppression could help heal post‐EVL ulcers .…”

“…22 A recent retrospective study also demonstrated that the lack of PPI administration was associated with bleeding after EVL. 23 It was reported that gastroesophageal reflux occurred frequently in patients with portal hypertension and that acid suppression could help heal post-EVL ulcers. 24 In these studies, octreotide or PPI was administered from the first day after EVL when post-EVL ulcers had not formed.…”

New Developments in Managing Variceal Bleeding

“…7,15 Available evidence does not support a role of proton pump inhibitors for long-term prophylaxis of portal hypertension-related bleeding; however, the use of short-course proton pump inhibitor postendoscopic variceal ligation could reduce postbanding ligation ulcer size. 16 The use of an intravenous prokinetic agent (e.g., erythromycin) should be considered during the pre-endoscopy patient management phase. Barkun et al 17 reported that an intravenous infusion of different prokinetic agents administered up to 2 hours before endoscopy in patients with acute upper GI bleeding improved endoscopic visualization and significantly decreased the need for repeat endoscopy.…”

Frequency and Risk Factors of Post Banding Ulcer Bleeding Following Endoscopic Variceal Ligation in Patients with Liver Cirrhosis

“…This result is consistent with Shaheen et al [31] who found that pantoprazole reduces the size of post-banding ulcers after EVL. Also, Kang et al [32] concluded that non-use of PPI was independent risk factor for bleeding after prophylactic EVL (P= 0.002). On the other hand, Vanbiervliet et al [10] and Sinclair et al [27] found that PPI use was not associated with reduced risk of bleeding (P= 0.69 and 0.747 respectively).…”