Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation

Sinclair, Marie; Vaughan, Rhys; Angus, Peter W; Gow, Paul J; Parker, Frank; Hey, Penelope; Efthymiou, Marios

doi:10.1097/meg.0000000000000387

Cited by 44 publications

(75 citation statements)

References 19 publications

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“…This mortality rate was similar to a previous report of 28% by Sinclair et al, [22] but lower than another report of 52% by Vanbiervliet et al [12] In the study by Sinclair et al, the use of prophylactic antibiotics was not recorded. However, in the study by Vanbiervliet et al, the cause of death in the majority of the patients was sepsis, and this was explained by the low rate of prophylactic antibiotic usage (62%).…”

Section: Discussionsupporting

confidence: 90%

“…The incidence of EVL-induced ulcer bleeding in our study is higher than recently published rates of about 2.8%. [12,22] However, the rate of severe bleeding, which was defined as bleeding associated with hypotension or death, was 2.6%, similar to the previous reports. The high proportion (23%) of follow-up endoscopies within 1 to 2 weeks after EVL made it possible to detect minor EVL-induced ulcer bleeding and may explain the high prevalence in our study.…”

Section: Discussionsupporting

confidence: 87%

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Endoscopic variceal ligation-induced ulcer bleeding

Cho

Jun²,

Cho³

et al. 2017

Medicine

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This study was aimed to determine the risk factors of endoscopic variceal ligation-(EVL) induced ulcer bleeding.The prevalence of EVL-induced ulcer bleeding is reported to be 3.6%. However, there are only limited reports of this serious complication, and the risk factors and the treatment methods are not well established.A total of 430 patients who had undergone EVL in Chonnam National University Hospital from January 2014 to October 2016 were studied. EVL was performed for prophylaxis or acute hemorrhage. The patients were classified into 2 groups: a bleeding group (n = 33) and a non-bleeding group (n = 397). The patients who had endoscopically confirmed EVL-induced ulcer bleeding were included in the bleeding group.EVL-induced ulcer bleeding occurred in 7.7% (n = 33) of the patients. In a multivariate analysis, model for end-stage liver disease (MELD) score >10 (odds ratio [OR]: 3.42, 95% confidence interval [CI]: 1.10–10.64), concomitant GV F3 (OR: 14.1, 95% CI: 2.84–71.43), and detachment of o-ring bands on follow-up endoscopy (OR: 8.06, 95% CI: 2.55–25.64) were independent predictive factors of EVL-induced ulcer bleeding. Various endoscopic modalities were attempted for hemostasis (EVL in 8 cases [24.2%], endoscopic variceal obturation [EVO] with cyanoacrylate in 6 cases [18.2%], argon plasma coagulation [APC] in 1 case (3%), Sengstaken–Blakemore (SB) tube in 3 cases [9.1%]), and proton pump inhibitor therapy only in 15 cases (45.5%).MELD score >10, concomitant GV F3, and detachment of o-ring bands on follow-up endoscopy are risk factors for EVL-induced ulcer bleeding.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionsupporting

confidence: 87%

Endoscopic variceal ligation-induced ulcer bleeding

Cho

Jun²,

Cho³

et al. 2017

Medicine

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“…[17,18] In elective procedures, higher MELD score and reflux esophagitis were associated with significant EVLinduced ulcer hemorrhage. [23] The number of rubber bands applied per patient seems to have no correlation with rebleeding in most trials. [8] A prospective study showed that the placement of more than six bands per session was not associated with better outcomes but rather with prolonged banding, increased procedure time and more misfired bands.…”

Section: Risk Factorsmentioning

confidence: 99%

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

Lima

Silva

Romeiro

2018

CRIM

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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.

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“…In patients (n = 609) with EVL for bleed prophylaxis, the post-EVL ulcer bleed rate was 1.5% with 22% mortality, higher MELD, and reflux esophagitis were predictors of bleed. 1 The bleeding from post-EVL ulcers can be managed by pharmacotherapy; endoscopic banding or sclerotherapy, and transjugular intrahepatic portosystemic shunt (TIPSS). 2 The index patient has failed endoscopic approach and pharmacotherapy.…”

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confidence: 99%

Innovative Approach of Using Esophageal Stent for Refractory Post-Band Ligation Esophageal Ulcer Bleed Following Living Donor Liver Transplantation

Choudhary

Puri

Saigal

et al. 2016

Journal of Clinical and Experimental Hepatology

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Bleeding from post-banding esophageal ulcers is uncommon. It is associated with significant morbidity and mortality. The bleeding from post-banding ulcers is difficult to manage and may be refractory to endotherapy and pharmacological treatment; transjugular intrahepatic portosystemic shunt can be used in such cases. We present a case of refractory post-banding ulcer bleed in a liver transplant recipient, which was managed by placement of removable esophageal metal stent. ( J CLIN EXP HEPATOL 2016;6:149-150) A 54-year-old male had right lobe living donor liver transplantation for cryptogenic cirrhosis and decompensation (ascites, variceal bleed, hepatorenal syndrome). He was diagnosed as having cirrhosis 10 years back when he had variceal bleed. He had ascites for 1 year and his comorbidities included diabetes for 10 years with diabetic nephropathy (proteinuria) and hypothyroidism. He had variceal bleed 14 days before transplantation for which esophageal variceal banding was done. His CTP score was 8 and MELD score was 14 at the time of transplantation. A decision of early liver transplantation was taken in view of fluctuating renal function tests, which were normal at the time of transplantation. He had melena and fall of hemoglobin on postop day 8 (day 22 of variceal banding). An esophagogastroscopy was done, which showed post-endoscopic variceal ligation (EVL) ulcers and active ooze from one ulcer (as shown in Figure 1), for which sclerotherapy was done using sodium tetradecyl sulfate. He received inj. Terlipressin and blood transfusions. However, he continued to have melena and fall in hemoglobin; repeat gastroscopy next day showed ooze from the same site, which could not be controlled by endoscopic sclerotherapy. Option of esophageal fully covered self-expanding metallic stent (SEMS) was discussed with family, and after due consent, a Danis stent (13 cm length, diameter 30 mm at both ends, 25 mm in between, made by Ella, Kravlov, Czech Republic) was placed as shown in Figure 2. The patient remained hemodynamically stable. His chest X-ray done on the next day showed partially migrated stent in stomach, which was repositioned by pulling the Lasso attached to stent and upper end of stent was subsequently anchored with hemoclips. A feeding tube was placed in view of poor oral intake. A check endoscopy showed no bleed from any site with stent in situ (Figure 3). The patient did not have any further bleed. The stent was removed on 16th day after its placement. DISCUSSIONBleeding from post-EVL ulcers is uncommon. In a large study of 749 episodes of EVL (140 for acute hemorrhage), the authors reported 21 episodes (2.8%) of post-EVL ulcer bleed, five of whom subsequently died (28%). The authors found that acute variceal hemorrhage was the only significant factor for post-EVL ulcer bleed on multivariate Figure 1 Post-EVL ulcer with clot and fresh blood in esophageal lumen.

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Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation

Cited by 44 publications

References 19 publications

Endoscopic variceal ligation-induced ulcer bleeding

Endoscopic variceal ligation-induced ulcer bleeding

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

Innovative Approach of Using Esophageal Stent for Refractory Post-Band Ligation Esophageal Ulcer Bleed Following Living Donor Liver Transplantation

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