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

Abstract

Objectives To investigate whether second‐look endoscopy (SLE)‐guided therapy could be used to prevent post‐endoscopic variceal ligation (EVL) early bleeding. Methods Consecutive cirrhotic patients with large esophageal varices (EV) receiving successful EVL for acute variceal bleeding (AVB) or secondary prophylaxis were enrolled. The patients were randomized into a SLE group and a non‐SLE group (NSLE) 10 days after EVL. Additional endoscopic interventions as well as proton pump inhibitors and octreotide administration were applied based on the SLE findings. The post‐EVL early rebleeding and mortality rates were compared between the two groups. Results A total of 252 patients were included in the final analysis. Post‐EVL early rebleeding (13.5% vs 4.8%, P = 0.016) and bleeding‐caused mortality (4.8% vs 0%, P = 0.013) were more frequently observed in the NSLE group than in the SLE group. However, post‐EVL early rebleeding and mortality rates were reduced by SLE in patients receiving EVL for AVB only but not in those receiving secondary prophylaxis. Patients with Child‐Pugh classification B to C at randomization (hazard ratio [HR] 8.77, P = 0.034), AVB at index EVL (HR 3.62, P = 0.003), discontinuation of non‐selective β‐blocker after randomization (HR 4.68, P = 0.001) and non‐SLE (HR 2.63, P = 0.046) were more likely to have post‐EVL early rebleeding. No serious adverse events occurred during SLE. Conclusion SLE‐guided therapy reduces post‐EVL early rebleeding and mortality rates in cirrhotic patients with large EV receiving EVL for AVB.

Predictors and management of post‐banding ulcer bleeding in cirrhosis: A systematic review and meta‐analysis

“…Eighteen studies were included in the systematic review (Figure 1) of which 14 were retrospective observational studies, 5,7,8,11–19,21,22 four studies were prospective, with two prospective observational studies 4,20 and two randomized controlled trials 23,24 . The main study characteristics are provided in Table S5.…”

“…Considering the treatment in case of acute PBUB, most studies used the vasoactive drug therapy used for variceal bleeding (somatostatin, octreotide or terlipressin) as well as intravenous PPI. More variability exists across the studies regarding the endoscopic type of treatment applied, with Re‐EBL being used to treat PBUB in eight studies 5,12,14–16,19,23,24 . Other types of endoscopic therapies were used as well (argon plasma coagulation, oesophageal variceal obliteration, like sclerotherapy and cyanoacrylate injection, epinephrine injection, hemoclip).…”

“…Cochrane's ROB 2 Risk of Bias Tool was used to assess the risk of bias in two randomized controlled trials (Table S4). These two included studies were at low risk of Bias 23,24 …”

“…Fifteen studies assessed the predictors of PBUs using multivariate analysis. These disclosed a wide range of predicting factors: higher MELD score (six studies), 5,8,12,[14][15][16] emergency ligation for acute variceal bleeding (four studies), 8,11,16,24 ulcers with high-risk stigmata on endoscopy (three studies), 13,14,18 Child-Pugh score C (three studies) 4,16,20 or high APRI score (one study), 7 previous variceal bleeding (one study), 7 peptic oesophagitis (two studies), 7,8 lack of administration of proton pump inhibitors (PPI) (one study), 21 concomitant gastric varices (two studies), 15,21 high risk varices on endoscopy (one study), 16 higher number of bands (two studies), 11,13 low propanonol dose (two studies), 5,24 presence of hepatocellular carcinoma (HCC; one study) 5 and low haemoglobin level (one study). 18 Even though most studies assessed the coagulation parameters and platelets as potential predictors of PBUB, only one study 7 identified an impairment on coagulation (low prothrombin index) as an independent predictor of PBUB.…”

Minimal and Maximal Extent of Band Ligation for Acute Variceal Bleeding during the First Endoscopic Session

“…Given that hypoxia and shock were more common in the maximal EVL group than in the minimal EVL group, the minimal EVL strategy may be chosen for patients with variceal bleeding with poor general conditions or hemodynamic instability. Although the effects of second-look endoscopic treatment were not analyzed during this study, Wang et al 23 recently reported that second-look endoscopic treatment, which is performed after EVL for acute bleeding of large endoscopic varices, is an option for reducing early rebleeding.…”