Esophageal Variceal Band Ligation Research Articles

Outcome of proton pump inhibitor plus sucralfate vs sucralfate alone vs proton pump inhibitor alone vs no treatment post endoscopic esophageal variceal band ligation- a randomized controlled trial

Outcome of proton pump inhibitor plus sucralfate vs sucralfate alone vs proton pump inhibitor alone vs no treatment post endoscopic esophageal variceal band ligation- a randomized controlled trial

Budd-chiari syndrome: case report

Budd-Chiari Syndrome (BCS) is a rare pathological condition characterized by an obstruction of the hepatic venous outflow. It can be classified as primary, due to an intra-luminal venous lesion, or secondary, resulting from extrinsic compression or invasion of the venous system. This study aims to report a case of Budd-Chiari Syndrome, emphasizing the importance of diagnosis and treatment in preventing progression to chronic liver disease. We report the case of a 47-year-old patient who presented to the emergency department with severe pain in the right hypochondriac region and abdominal distension. A total abdominal CT scan was performed and revealed thrombosis of the suprahepatic veins, confirming the diagnosis of BCS. The patient developed portal hypertension and signs of chronic liver disease. Treatment was administered with Spironolactone and Marevan. After six months of Marevan use, the patient experienced worsening of the esophageal varices and hematemesis, requiring esophageal variceal band ligation. Liver transplantation was not recommended as the patient's MELD score was 14. Therefore, an accurate diagnosis of BCS is crucial for appropriate therapeutic intervention in order to prevent the progression to chronic liver disease, with permanent damage to liver functionality and the patient’s quality of life.

A201 AORTO-ESOPHAGEAL FISTULA AS A COMPLICATION OF ESOPHAGEAL VARICEAL BANDING

Abstract Aims This is the first reported case of bleeding from an aorto-esophageal fistula as a consequence of ischemic esophageal ulceration post esophageal variceal banding. Methods A 46-year-old male presented with epigastric pain for one-week, which was not associated with fever, jaundice, or symptoms of GI bleed. He was hemodynamically stable with an unremarkable exam and basic labs. He underwent a CT scan which showed chronic portal vein thrombosis extending from the main portal vein into the superior mesenteric vein and evidence of portal hypertension, along with massive esophageal varices. Anticoagulation was not started due to risk of GI bleed. Upper endoscopy confirmed the presence of three columns of large esophageal varices in the distal and mid esophagus, the largest was 3 cm in size. There was no stigmata of recent bleeding and no gastric varices. Seven bands were applied. CT abdomen was repeated on the seventh day of admission, showing extension of portal vein thrombosis. As such, the thrombosis team started a low dose of anticoagulation. (dalteparin 7500 IU). He tolerated it well and showed no signs of bleeding prior to discharge. The day after discharge, the patient presented again with an episode of melena. Examination was remarkable for tachycardia, hypotension and melena. Hemoglobin was stable. Patient was admitted with impression of upper GI bleed most likely secondary to post banding ulcer. He was started on medical therapy. Anticoagulation was held. Next day, the patient had an episode of hematemesis with large amount of blood and clots. Emergent upper endoscopy showed active bleeding in the distal esophagus. Further examination showed a full-thickness, 7 mm defect in the lower esophagus with fresh red blood emptying from it into the esophagus (Figure 1). Thoracic surgery was consulted and suspected a perforated esophageal ulceration at the site of previous banding, with an aorto-esophageal fistula. Patient deteriorated immediately and passed away. The cause of death was cardiac arrest secondary to acute blood loss anemia. Results AEF is a recognized cause of upper GI bleeding with a high mortality rate. While rare, it can occur secondary to ischemic esophageal ulcer post EV banding. Conclusions This is the first reported case of an aorto-esophageal fistula as a consequence esophageal variceal band ligation. While extremely rare, this complication should be considered as a potentially fatal complication of variceal banding, especially in the setting of a diseased or previously repaired aorta.

Current Pediatric Endoscopy Training Situation in the Asia-Pacific Region: A Collaborative Survey by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition Endoscopy Scientific Subcommittee.

To date, there is no region-specific guideline for pediatric endoscopy training. This study aimed to illustrate the current status of pediatric endoscopy training in Asia-Pacific region and identify opportunities for improvement. A cross-sectional survey, using a standardized electronic questionnaire, was conducted among medical schools in the Asia-Pacific region in January 2024. A total of 57 medical centers in 12 countries offering formal Pediatric Gastroenterology training programs participated in this regional survey. More than 75% of the centers had an average case load of <10 cases per week for both diagnostic and therapeutic endoscopies. Only 36% of the study programs employed competency-based outcomes for program development, whereas nearly half (48%) used volume-based curricula. Foreign body retrieval, polypectomy, percutaneous endoscopic gastrostomy, and esophageal variceal hemostasis, that is, sclerotherapy or band ligation (endoscopic variceal sclerotherapy and endoscopic variceal ligation), comprised the top four priorities that the trainees should acquire in the autonomous stage (unconscious) of competence. Regarding the learning environment, only 31.5% provided formal hands-on workshops/simulation training. The direct observation of procedural skills was the most commonly used assessment method. The application of a quality assurance (QA) system in both educational and patient care (Pediatric Endoscopy Quality Improvement Network) aspects was present in only 28% and 17% of the centers, respectively. Compared with Western academic societies, the limited availability of cases remains a major concern. To close this gap, simulation and adult endoscopy training are essential. The implementation of reliable and valid assessment tools and QA systems can lead to significant development in future programs.

Post Banding Ulcer Haemorrhage: a Contributor to Morality in Patients with Liver Cirrhosis

Objectives: To evaluate the frequency, risk factors and mortality of post-banding bleeding in cirrhosis. Study Design: Retrospective longitudinal Study. Place and Duration of Study: Department of Medicine, Fauji Foundation Hospital, Rawalpindi Pakistan, from Feb to Jul 2021. Methodology: Esophageal variceal band ligation (EVBL) was done in 123 patients. The study cohort was divided into two groups: Group-1 without re-bleed and Group-2 with re-bleed. Blood chemistry, Child-Pugh and MELD score, including the indications of EVBL and risk factors, were also analysed. Regression analysis was performed. Results: Re-bleed occurred in 10.6% (n=13) of patients. The mean duration between ligation and re-bleed was 8.75±2.8 days. Oesophageal ulcers were the most common cause of re-bleeding (38.5%). Mortality rates among the two groups were 21.8 %( n=24) and 30.8 %( n=4), respectively. The model for end-stage liver disease score (OR 2.177, CI 1.069-4.43, p .03), APTT (OR 0.593, CI 0.397-0.887, p .01) and Sodium (OR 1.345, CI 1.07-1.69, p&lt;0.01) were detected as the predictors of re-bleed. Conclusion: Although re-bleeding after banding occurs in a trivial number of patients, it contributes to mortality. Coagulopathy, high sodium and MELD score are major predictors.

Single or multiple treatments with lusutrombopag in subjects with thrombocytopenia and chronic liver disease needing an invasive procedure

Thrombocytopenia is one of the most frequent implications of liver cirrhosis. This condition, when present in the severe form [platelet count (PLT) less than 50 × 109/L] correlates, with an increased risk of bleeding during the main diagnostic-therapeutic procedures which cirrhotic patients usually undergone. In these cases, generally, an infusion of platelets is performed, albeit in recent years has been replaced by a cycle of second generation thrombopoietin receptor (TpoR) agonists. This article reports two different cases concerning respectively an 83-year-old female patient suffering from arterial hypertension, aneurysm of the sub-renal aorta, hepatitis C virus (HCV)-positive liver cirrhosis responsive to treatment with antiviral drugs, and a 2.0 cm diameter hepatocellular carcinoma (HCC) nodule localized in the hepatic segment III and a 53-year-old female patient with HCV-positive liver cirrhosis complicated by portal hypertension with splenomegaly, thrombocytopenia, and F3 esophageal varices at high risk of bleeding. Both of them, eligible for invasive procedures such as HCC transarterial chemoembolization (TACE) and for esophageal variceal band ligation, were prescribed prophylaxis with TpoR agonists due to their severe and persistent thrombocytopenia. These two cases show how a short course of lusutrombopag allows to safely perform one or more invasive procedures and how the administration of the drug can be repeated without losing efficacy. Furthermore, this drug shows an excellent safety profile and avoids the risks of platelet transfusion. In conclusion, second generation TpoR agonists can be considered the prophylactic treatment of choice to reduce the risk of bleeding in patients with liver cirrhosis and severe thrombocytopenia.

An unexpected cause of hiccups: esophageal variceal band ligation

An unexpected cause of hiccups: esophageal variceal band ligation

Prophylactic cyanoacrylate injection for gastric extension of esophageal varices: a randomized controlled trial

Aim of the studyGastric variceal bleeding is more severe and fatal than esophageal bleeding. Injection of cyanoacrylate into bleeding gastric varices is recommended, but prophylactic injection is debatable. Aim of this study is to evaluate prophylactic cyanoacrylate injection into gastric extension of esophageal varices type 2 (GOV2).Material and methodsThis randomized controlled trial included 75 patients (3 groups) with risky or bleeding esophageal varices and non-bleeding GOV2. Group A received a cyanoacrylate GOV2 injection, esophageal variceal band ligation (EBL), and β-blocker (BB); group B received EBL and BB; and group C received EBL. Follow-up for ≥ 24 weeks to check for bleeding or death was performed.ResultsBaseline variables were comparable among the 3 groups. During follow-up (median, 37.5 weeks), increasing gastric extension and or bleeding risk signs were significantly lower in group A (0%) than B (12%) and C (32%) (p < 0.001). Bleeding occurred more in groups B (24%) and C (24%) than in A (8%) (p = 0.2). Gastric extension size was an independent predictor of bleeding (p = 0.03). Portal hypertensive gastropathy (PHG) decreased in groups A (24%) and B (24%) more than in C (8%) (p = 0.5). Mortality rates were 0.0% in group A, 8% in B, and 4% in C (p = 0.2).ConclusionsProphylactic cyanoacrylate injection into GOV2 before EBL significantly decreased the varix size and risk signs for bleeding with a statistically insignificant tendency to decrease the bleeding rate. A large gastric extension was an independent predictor of bleeding. Adding β-blockers can potentially decrease PHG and bleeding risk. An independent study with a larger sample size is recommended to confirm the rate of bleeding and test the mortality difference.

Esophageal ulcer after band ligation of esophageal varices

IntroductionBand ligation plays an important role in the management of esophageal varices (EV), but banding ligation carries a risk of band slippage, postbanding esophageal ulcer formation, and postbanding bleeding.AimThe predisposing factors and frequency of esophageal ulcer after banding ligation of EV were assessed.Patients and methodsA total of 130 cirrhotic patients with EV were subjected to therapeutic or prophylactic banding ligation, and then the patients were observed for 14 days for detection of incidence of esophageal ulcer bleeding after postbanding ligation. This was a prospective study done to compare the cirrhotic patients without endoscopic variceal ligation (EVL)-induced esophageal ulcer as a complication (nonbleeder group, n==118) with bleeding patients after EVL owing to postbanding ulcer (bleeder group, n = 12). Full present and past medical history taking for all patients, physical examination, laboratory investigation, ultrasonography of abdomen and/or triphasic computed tomography abdomen, upper endoscopy, and EVL, were done. Re-endoscopy was done if rebleeding happens after EVL.ResultsAfter EVL, the incidence of esophageal ulcer bleeding in cirrhotic patients was 9.2%, and the mortality within the 2-week follow-up was 16.7%. The risk factors of postbanding ulcer bleeding were esophageal reflux, increased aspartate transaminase to platelet ratio index score, and focal hepatic lesion.ConclusionBleeding of esophageal ulcer after EVL is not a rare complication of EVL, which is most commonly detected within 14 days after EVL. Reflux esophagitis, increase in aspartate transaminase to platelet ratio index score, and presence of focal hepatic lesion are predisposing factors for postbanding esophageal ulcer bleeding.

S3300 Is it Necessary to Transfuse FFP and Platelets Before Esophageal Variceal Band Ligation in Acute Variceal Bleeding Patients? Southeast Asia Experience. RIP FFP and Platelets Transfusion!

S3300 Is it Necessary to Transfuse FFP and Platelets Before Esophageal Variceal Band Ligation in Acute Variceal Bleeding Patients? Southeast Asia Experience. RIP FFP and Platelets Transfusion!

S2249 Esophageal Hematoma Causing Dysphagia as a Complication of Esophageal Variceal Band Ligation in a Patient With End Stage Liver Disease

S2249 Esophageal Hematoma Causing Dysphagia as a Complication of Esophageal Variceal Band Ligation in a Patient With End Stage Liver Disease

A multicenter analysis of the role of prophylactic transfusion of blood products in patients with cirrhosis and esophageal varices undergoing endoscopic band ligation

Background & AimsProphylactic administration of platelets and fresh frozen plasma (FFP) has been recommended in patients with cirrhosis with low platelets and/or prolonged international normalized ratio (INR) without scientific evidence to support this practice. In this analysis, we evaluated the use of prophylactic administration of blood products in outpatients with cirrhosis undergoing endoscopic band ligation (EBL).MethodsThis is a multicenter retrospective analysis of consecutive EBL procedures in patients with cirrhosis at 4 hospitals in Spain from 01/2010-01/2017. FFP and/or platelet transfusion were given at the discretion of the physician if INR was >1.5 and/or platelet count <50x109/L. Patient demographics, endoscopic findings, bleeding events after EBL, and the use of prophylactic FFP or platelets were recorded.ResultsA total of 536 patients underwent 1,472 EBL procedures: 72% male; main etiology HCV and alcohol (72%); median MELD score 11; Child-Pugh A/B/C (59/33/8%). EBL procedures were performed for primary (51%) or secondary (49%) prophylaxis. A median of 2 procedures per patient were performed.1-4 FFP and/or platelets were administered in 41 patients (7.6%). The prophylactic transfusion protocol was followed in 16% and 28% of procedures with high INR and/or low platelets, respectively. Post-EBL bleeding occurred in 26 out of 536 patients (4.8%) and in 33 out of 1,472 procedures (2.2%). Bleeding was due to post-EBL ulcers in 21 patients and due to band dislodgment in 5. In 6 patients, bleeding occurred within 24 hours and in the remaining patients it occurred within 2 weeks after EBL. In those that bled, 7 met criteria for transfusion (2 for FFP and 5 for platelets), of whom only 1 received FFP and 4 received platelets; the remaining 19 patients did not meet criteria for transfusion. There was no association between INR or platelet count and bleeding events. Univariate and multivariate analysis revealed that Child-Pugh and MELD scores were risk factors for post-EBL bleeding.ConclusionsThe incidence of post-EBL bleeding is low and is associated with advanced liver disease. Post-EBL bleeding was not related to baseline INR/platelet count and most outpatients with post-EBL bleeding did not meet criteria for prophylactic transfusion.Lay summaryPatients with chronic liver disease or cirrhosis and enlarged veins (varices) of the esophagus that can potentially bleed commonly need an endoscopy to treat these varices with elastic rubber bands (endoscopic band ligation). Some patients have low platelet counts or prolonged coagulation tests. This analysis of 4 centers evaluated the use of prophylactic administration of blood products in outpatients with cirrhosis undergoing endoscopic band ligation. The results showed that bleeding after band ligation is uncommon and that if bleeding occurs it does not seem to be related with coagulation tests or the administration of blood products to prevent bleeding after band ligation of esophageal varices.

P-8 PRESERVATION OF THROMBIN GENERATION IN CIRRHOSIS DESPITE ABNORMAL RESULTS OF INTERNATIONAL NORMALIZED RATIO: IMPLICATIONS FOR INVASIVE PROCEDURES

Thrombin generation (TG) is normal or elevated in patients with cirrhosis when tested in the presence of thrombomodulin (TM), the activator of the main natural anticoagulant protein C. However, the relationship between TG with bleeding has been little explored in literature. To assess the relation among TG potential, measured without and in presence of TM, INR and the occurrence of bleeding after endoscopic band ligation of esophageal varices. 97 consecutive patients with cirrhosis were prospectively included (58 men; 54±10 years) and divided into two groups INR< 1.5 (n=72) or INR ≥1.5 (n=25). 46 healthy individuals were tested as controls. Endogenous thrombin potential (ETP) was measured without and with the addition of TM. ETP measured without TM was reduced in patients with cirrhosis when compared to controls, but no significant difference was found between the INR< 1.5 and INR ≥1.5 groups (1,250±315.7 versus 1,186±238 nmol/L x min; p= 0.3572). After addition of TM, both groups generated thrombin comparable to controls (INR ≥1.5: 965.9±232.3; INR<1.5: 893.0±368.6; controls: 915.0±458 nmol/L x min). 80% of patients had high ETP without/with TM ratio, indicating trend to hypercoagulability, which was more marked in the INR ≥1.5 group (0.81±0.1 versus 0.69±0.2; p=0.0042). Post-EVL bleeding occurred in 5.2% of the patients (INR<1.5, n=3; INR ≥1.5, n=2), all of them with ETP. without/with TM ratio ranging from 0.72 to 0.90 (controls 0.57±0.21). This study shows that TG in the presence of TM was normal in most patients with cirrhosis, including those with high INR value, but did not correlate with post-EVL bleeding. INR values and RETP values according to Child-Pugh class.

Variceal band ligation and its outcome: A single tertiary care centre study.

Objectives: To determine the frequency of complications after esophageal variceal band ligation in patients of decompensated chronic liver disease. Study Design: Descriptive Case study Setting: Department of Gastroenterology Lahore General Hospital, Lahore. Period: June 2015 to June 2016. Material &amp; Methods: In the present study, the cases of both genders and age more than 20 years having esophageal variceal of any grade on variceal screening esophagogastroduodenoscopy and duration of decompensated liver cirrhosis of at least 6 months or more were included. Esophageal variceal band ligation was performed using a multiband ligation device (Six-shooter, Wilson-Cook Inc., Winston-Salem, NC) and up to 6 bands were placed per session and next session was performed at 2 week intervals until esophageal varices were eradicated, which was defined as a complete disappearance of varices and/or the presence of a varix being too small to be ligated. All patients were followed every month regarding complications in terms of ulcer bleed and esophageal strictures. Results: In this study there were total 720 cases out of which 450 (62.5%) were males and 270 (37.5%) females. The mean age of the subjects was 33.504±4.00 years, mean duration of cirrhosis was 9.086±2.54 months and mean weight was 72.44±13.78Kg. Ulcer bleed was seen in 6.9% patients and esophageal strictures was seen in 2.5% patients. Conclusion: Complications of esophageal variceal band ligation are not that common and amongst them ulcer bleed is the salient one. Both ulcer bleed and esophageal stricture are significantly associated with varices more than 2.

Impact of COVID-19 pandemic on hospital admission for endoscopy unit; single center study

Background: COVID-19 pandemic has resulted in exceptional human, public, and economic impacts worldwide. We aimed to evaluate the impact of COVID-19 on hospital admission for endoscopy unit during the COVID-19 pandemic, 2020 in com-parison to similar periods in non COVID-19, 2019. Methods: Data from endoscopy unit (between 1st April to the end of June 2020 were collected and compared to a similar pre-COVID-19period in 2019 as regards, hospitalization rate and endoscopy indication. Result: Compared with non COVID-19 period in 2019, there was a significant reduction during the similar period of COVID-19 pandemic in 2020 as regards; total number of patients who were admitted to endoscopy unit (p < 0.0001), admittion for diagnostic endoscopy due to persistent abdominal pain (14.76% versus 17.81%, p < 0.0001) and follow up band ligation of esophageal varices (48.70% Vs 50.52, p < 0.0001). No significant change between both studied times as regards hospital admission due to gastrointestinal bleeding (25.38% Vs 23.89, p= 0.51) and foreign body swallows. Admitted patients had a similar gender distribution in both studied periods (p= 0.61). In comparison to non COVID-19 times, the majority of admitted patients during pandemic time of COVID 19 were younger than 60 years (65.68% Vs 39.20%, p < 0.0001). Conclusion: Our result demonstrated a significantly lower admission rate for endoscopy during pandemic time of COVID-19 in comparison to similar non pandemic time in 2019, however, hospitalization for urgent endoscopy dose not affected by pandemic time especially for upper gastrointestinal bleeding, suspected malign-ancy and foreign body swallows.

S2107 Successful Management of Refractory Esophageal Variceal Bleeding Secondary to Chronic Portal Vein Thrombosis by Transsplenic Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt

INTRODUCTION: Trans-jugular intrahepatic portosystemic shunt (TIPS) becomes challenging in the presence of portal vein thrombus (PVT). We describe a case of successful management of refractory esophageal variceal bleeding secondary to chronic PVT and splenic vein thrombosis (SVT) by portal vein recanalization – TIPS through transsplenic and transhepatic approach. CASE DESCRIPTION/METHODS: A 29-year-old male with a history of homozygous methylenetetrahydrofolate reductase mutation with normal homocysteine levels on warfarin presented with acute hematemesis. He underwent emergent endoscopic band ligation of esophageal and GOV1 gastric varices. He had a history of chronic PVT with prior mechanical thrombectomy and thrombolysis two years ago, and received band ligation for bleeding esophageal varices in the last year, but did not follow up for surveillance. MRI of abdomen and pelvis revealed chronic PVT with cavernous transformation (Fig A) and chronic SVT. No further bleeding was reported after endoscopy. Liver biopsy one year ago showed benign liver tissue with focal mild congestion and sinusoidal dilation. There was a normal hepatic venous pressure gradient. Given concerns about his compliance and risk of re-bleeding, multidisciplinary team discussion led to consideration of a high-risk TIPS with splenic vein recanalization and stenting. Under ultrasound and fluoroscopic guidance, TIPS was placed using two snare targets. One snare was placed in the occluded portal vein via splenic vein access, and another was placed in the middle hepatic vein via internal jugular vein access. Using the gun-sight technique, a 21-gauge Chiba needle was advanced transhepatically through both the loop snares and then a guidewire was advanced until it could be captured by both the above snares (Fig B). With this newly obtained access, TIPS and splenic stents were successfully deployed (Fig C). Pressure gradient across TIPS was lowered to 6 mm Hg from 16 mm Hg. As varices did not fill on post TIPS portogram, embolization was not performed. He was started on aspirin in addition to his warfarin. Repeat CTA at 3 months demonstrated patent TIPS and splenic stent, and no further episodes of hematemesis were reported. DISCUSSION: In our patient, the gunsight TIPS approach helped decompress portal hypertension and prevent recurrent variceal bleeding when other alternatives including Sugiura surgery carried high morbidity and were not amenable. Post TIPS re-stenosis is a known complication, and may be prevented by aspirin and warfarin use.Figure 1.: Magnetic resonance imaging (MRI) of the abdomen and pelvis showing chronic portal vein thrombosis with cavernous transformation.Figure 2.: Fluoroscopic image showing gun-sight technique: Guide-wire is captured by the first snare in the presumed right portal vein and second snare in the middle hepatic vein.Figure 3.: Fluoroscopic image showing successful deployment of TIPS.

Proton-pump-inhibitor use associated with lower short-term rebleeding and mortality in patients receiving esophageal variceal band ligation: a retrospective cohort study.

The impact of proton-pump inhibitor (PPI) therapy on subsequent hemorrhage and mortality after variceal hemorrhage is unclear. Evaluate the associations of PPI use with upper gastrointestinal bleeding (UGIB) and death within 30 days of undergoing esophageal variceal band ligation (EBL) separately in inpatient and outpatient settings. Retrospective review of cirrhotic patients with variceal hemorrhage who underwent EBL between 2005 and 2018. Endoscopic findings, PPI use at admission (inpatients only), PPI use at discharge (inpatients and outpatients), and adverse outcomes data (liver transplant, UGIB, transjugular intrahepatic portosystemic shunt, and death within 30 days of discharge or death during hospitalization) were reviewed. A total of 446 patients (164 inpatients, 282 outpatients) were included. The most commonly observed outcomes were death within 30 days of discharge in inpatients (12.8%), UGIB within 30 days of discharge in inpatients (21.3%), and UGIB within 30 days of discharge in outpatients (8.5%). For inpatients, prescription of PPI at discharge was associated with a lower risk of bleeding within 30 days (odds ratio: 0.30, P = 0.025) and death within 30 days (odds ratio = 0.16, P = 0.002). No other significant associations of PPI with death or UGIB were reported. Post-EBL PPI therapy is associated with reduced risk of bleeding and death within 30 days after variceal hemorrhage in hospitalized patients.

Preservation of platelet function in patients with cirrhosis and thrombocytopenia undergoing esophageal variceal ligation

BackgroundThrombocytopenia is a possible risk factor for bleeding after band ligation of esophageal varices. However, elevated von Willebrand factor (VWF) in cirrhosis improves platelet function and could decrease this risk. Our objective was to assess platelet function in patients with cirrhosis undergoing esophageal variceal ligation (EVL). MethodsThe assessment consisted of platelet count, antigen and activity of VWF and VWF-cleaving protease ADAMTS-13 activity, and a platelet adhesion and aggregation test simulating vascular flow in vivo (Impact-RⓇ) prior to EVL. ResultsTotally 111 patients were divided into three groups according to platelet count: (1) < 50 × 109/L (n = 38, 34.2%); (2) 50 × 109/L to 100 × 109/L (n = 47, 42.3%); and (3) > 100 × 109/L (n = 26, 23.4%). No statistically significant difference was found in the aggregate size of platelets [group 1: 41.0 (31.8–67.3) µm2; group 2: 47.0 (33.8–71.3) µm2; and group 3: 47.0 (34.0–66.0) µm2; P = 0.60] and no significant correlation was found between aggregate size and platelet count (Spearman r = 0.07; P = 0.47). Surface coverage was 4.1% (2.8%–6.7%), 8.5% (4.0%–10.0%), and 9.0% (7.1%–12.0%) (P < 0.001) in groups 1, 2 and 3, respectively and correlated with platelet count (Spearman r = 0.39; P < 0.0001). There was no significant difference between groups in VWF or ADAMTS-13. Post-EVL bleeding occurred in six (5.4%) patients (n = 2 in group 1, n = 1 in group 2, and n = 3 in group 3; P = 0.32). Patients with bleeding had higher MELD scores [15.0 (11.3–20.3) versus 12.0 (10.0–15.0); P = 0.025], but no difference was demonstrated for platelet function parameters. ConclusionPlatelet function is preserved even in the presence of thrombocytopenia, including in the patients with post-EVL bleeding.

Outcome of Post Esophageal Variceal Band Ligation with Sucralfate and Proton Pump Inhibitor vs. Proton Pump Inhibitor Alone in Cirrhotic Patients

Introduction: Endoscopic band ligation is the mainstay of treatment in bleeding varices in cirrhosis. Subsequent bleeding from the band ulcers is a possible complication. Proton pump inhibitors and Sucralfate are commonly used post band ligation and often in combination. The aim of the study was to identify the advantage of combining Sucralfate to proton pump inhibitor in reducing the number and size of band ulcers.Materials and Methods: This was an open-label comparative study conducted in a tertiary level hospital of Nepal. Patients with cirrhosis after band ligation were included. Eligible patients were randomized into a proton pump inhibitor alone (Group A) or proton pump inhibitor and sucralfate group (Group B) and they underwent upper gastrointestinal endoscopy after two weeks. Baseline parameters, number and mean size of band ulcers were compared.Results: A total of 58 patients, 29 in each group, were evaluated. The baseline characteristics were comparable. EBL was done for bleeding varices in 51.7% and as primary prophylaxis in the rest of them. All the patients had band ulcers after two weeks. The mean size of the largest ulcer was 1.62±0.72 and 1.10±0.60 (p=0.78) respectively in groups A and B. Low albumin was significantly associated with OR of 8.7 (95% CI:1.68-44.99) for the formation of multiple (more than two) ulcers (p=0.01).Conclusions: The ulcer formation was universal after band application. The addition of sucralfate did not offer more benefits in terms of the number and mean size of the ulcer. Low albumin was the independent predictor for multiple ulcer formation.

Ulcer bleeding after band ligation of esophageal varices: Risk factors and prognosis

BackgroundPost-banding ulcer bleeding is a rare complication of endoscopic band ligation of esophageal varices with high morbidity and mortality. There exist no management guidelines for this complication. AimsTo determine the incidence, outcome and risk factors of post-banding ulcer bleeding. MethodsData for cirrhotic patients with acute variceal bleeding during a six-year period were prospectively collected, and all band ligation sessions performed were retrospectively analyzed. Demographic, analytic and endoscopic data were recorded, as well as complications, outcome and management of each episode of post-banding ulcer bleeding. ResultsThe study includes 521 band ligation sessions performed on 175 patients. There were 24 cases of post-banding ulcer bleeding in 21 patients (incidence 4.6%). Independent risk factors for post-banding ulcer bleeding were MELD score, hepatocellular carcinoma and total beta-blocker dose. Mortality during the bleeding episode was 23.8%. Active bleeding or adherent clots at the time of endoscopy was associated with treatment failure or death. ConclusionsPost-banding ulcer bleeding is an uncommon but severe complication of esophageal banding. Patients with hepatocellular carcinoma, poor liver function and a low beta-blocker dose have higher risk of post-banding ulcer bleeding. An aggressive treatment should be considered in case of active bleeding at endoscopy.