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In a recent issue of Gut García-Pagán et al1 describe a multicentre, randomised controlled trial investigating the benefit of adding endoscopic banding ligation (EBL) to pharmacological treatment in the prevention of recurrent oesophageal variceal bleeding. We were particularly interested in their finding of bleeding due to oesophageal ulceration caused by EBL. They report that bleeding requiring hospitalisation occurred in four out of 80 (5%) patients who underwent EBL in addition to receiving nadolol and mononitrate for secondary prophylaxis of oesophageal varices. This more or less negated the observed slight benefit of adding EBL to drug therapy in preventing rebleeding from varices per se.
We wish to report a similar experience of bleeding from oesophageal ulcers after EBL for primary prophylaxis of high risk oesophgeal varices in patients with cirrhosis.
Recommendations regarding primary prophylaxis of high-risk oesophageal varices vary according to different guidelines.2 3 Some advocate beta-blockers while others recommend endoscopic variceal band ligation (EBL) as first line prophylaxis. To determine the frequency of bleeding from oesophageal ulcers in patients who had undergone EBL as primary prophylaxis for high risk oesophageal varices, a retrospective, observational study was carried out at the University Medical Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka. Patient records over a 2-year period from April 2007 to March 2009 were evaluated. All patients who had undergone EBL for large varices which had never bled but were high risk for haemorrhage (Child B/C or variceal red whale markings on endoscopy) or had contraindications or intolerance for beta-blockers were included. A uniform management policy is followed in the unit: after the initial EBL, repeated EBLs are performed at three-weekly intervals until varices were obliterated; intravenous ceftriaxone 1 g is administered during the procedure followed by oral ciprofloxacin 500 mg twice daily for one week at the end of each session; oral omeprazole 20 mg twice daily is also given for 2 weeks following each procedure.
Twenty-seven patients (median age 43 years (range, 14–64), 21 men) had undergone 86 EBL sessions for primary prophylaxis at which 314 varices had been banded. Of the 27, 19 were Child class A and eight Child Class B. Among patients in Child class A, 17 had large varices with red signs and two had large varices without red signs but had contraindications to beta-blockers. Among the Child class B patients, two had large varices with red signs and six patients had large varices without red signs but had contraindications or intolerance to beta-blockers. Two patients (32 and 46 years old, both male, both Child class B) had upper gastrointestinal bleeding from EBL-induced ulcers requiring hospitalisation 7 and 8 days following the procedure, respectively. One died and the other patient recovered after multiple blood transfusions and prolonged intensive care treatment. The oesophageal ulceration rate per patient was 7.4% and the rate per session was 2.3%. The mortality rate per patient was 3.7% and the rate per session was 1.2%.
EBL can lead to oesophageal ulcers which may bleed and require hospitalisation, repeat endoscopy and blood transfusion, and may even result in death; an unacceptable complication for a prophylactic procedure. Fatal bleeding associated with the ligation procedure has been previously observed in two (2.6%) out of 75 patients who underwent EBL for primary prophylaxis of varices.4 Such severe complications are especially likely in Child class C patients.5 However, neither of our patients who bled was Child class C. The existing guidelines for prophylaxis of oesophageal varices may have to be revised taking these issues into account, and investigation to identify factors that cause or may predict this dangerous complication is warranted.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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