Abstract
Background: Endoscopic variceal ligation (EVL) is the recommended method to manage esophageal variceal bleeding with lower variceal ulceration and rebleeding rates compared to sclerotherapy. A proportion of patients develops EVL induced ulcers and present with massive bleeding. In these cases, endotherapy is difficult and often unsuccessful and definitive methods, such as TIPS need to be evaluated. Aim: Determine the effectiveness of reduction in portal pressure by polytetrafluoroethylene-covered transjugular stenting (TIPS) for band-induced esophageal ulcer bleeding. Method: Following admission within 24 hours, consecutive patients with cirrhosis and EVL induced bleeding ulcers were prospectively treated using standard therapy (endoscopy and vasoactive drugs; Group 1, n=17) or standard therapy plus TIPS (Group 2, n=22). Primary end-point was survival at 6 wks. Secondary end-points were early and late rebleeding. Results: Total 488 cirrhotic patients who underwent EVL from 2010-11, 36 (7%) (Median age 42 (range 32-72), 90% males) developed bleeding EVL ulcer. These patients were enrolled and offered either of the two treatments. Baseline parameters including age, presence of ascites, HE, HRS, platelets, PT (INR), HVPG, Child and MELD score were similar in both the groups. After follow-up of 6 wks, 10 patients (62%) in group 1 and 5 (25%) in group 2 died (P<0.05). The incidence of failure to control bleed/early rebleed was seen in 9 patients (56%) in group1 and in 1(5%) in group 2 (P <0.05). Similarly, the incidence of late rebleeding was seen in 5 patients (45.4%) in group 1 while in 1(5%) in group2 (P <0.05). The median time to death was 2.5 (0.5-12) days and 13 (2-21) days in the two groups (P <0.05). Conclusion: Around 7% patients develop life threatening EVL induced ulcer bleeding. Portal pressure reduction with the TIPS is significantly superior in the control of bleeding, preventing rebleeding and reduction in mortality.
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