Introduction

Esophageal varices are present in up to 40% and 85% of patients with compensated and decompensated cirrhosis, respectively. Endoscopic treatment of esophageal varices is used for the prevention of first variceal bleeding, treatment of active variceal bleeding, and prevention of rebleeding. Endoscopic variceal ligation (EVL) is the most common treatment. Multiple EVL sessions are often required to eradicate them. We aimed to detect factors predicting lower number of endoscopic treatments.

Aims & Methods

The study recruited all cirrhotic patients admitted to the hospital within the last two years, who have been treated for esophageal varices by EVL and achieved eradication through this endoscopic treatment. For each patient, main demographical and clinical characteristics were collected, including, etiology of cirrhosis, severity of liver disease according to Child-Pugh and MELD score and main laboratory tests. Varices were described according to the Japanese classification, and for each EVL session number of placed bands was recorded. Binomial logistic regression was used for univariate and multivariate analysis and odds ratios (OR) were calculated.

Results

A total of 31 patients (71% males, mean age 62.7±9.2) with liver cirrhosis and esophageal variceal (F2 41.9% and F3 58.1%) were included. The most frequent etiologies were alcoholic cirrhosis, non-alcoholic steatohepatitis and cryptogenic cirrhosis, in 8 (25.8%), 9 (29%) and 4 (12.9%), respectively. Esophageal Varices with Red Color Sign on Endoscopy, Cherry Red Spot (CRS), Red Wale Markings (RWM) and Hematocystic Spots (HCS), were detected in 19 (61.3%) 23 (74.2%) 5 (16.1%) patients. Only 8 patients (25.8 %) had gastroesophageal varices (GOV) while 30 subjects (96,8%) had congestive gastropathy. Concerning severity of cirrhosis, there were 13 (41,9%), 17 (54,8%), 1(3,2%) patients in Child Pugh’s class A, B and C, respectively. In 14 subjects, a single session was sufficient to eradicate varices, while 9 patients required ≥3 sessions. At multivariate analysis, higher platelet count (OR=0.98, p=0.15), higher number of rubber bands (OR=0.67 p=0.16) and female sex (OR= 0.24, p=0,11) predicted the fewer number of endoscopic sessions required for eradication of varices, while at multivariate analysis, only higher platelet count demonstrated a non significative trend (OR= 0.98, p=0,07).

Conclusion

When performing endoscopic ligation of esophageal varices, the number of platelets could influence the number of endoscopic sessions to eradicate esophageal varices.

Introduction

Esophageal variceal bleeding (EVB) is a severe complication of liver cirrhosis. An effective prophylactic intervention and treatment option in EVB is endoscopic band ligation (EBL). An average post-banding bleeding (PBB) rate of approximately 3.5% within two weeks post-intervention has been reported¹. This study aims to assess the risk of bleeding after EBL of esophageal varices and to identify patient-specific and procedure-related risk factors for PBB.

Aims & Methods

For risk stratification, a retrospective analysis was conducted on 233 patients who underwent ligation therapy for esophageal varices at a tertiary care centre between January 2019 and February 2023. In total, 616 ligation therapies were analysed with regard to the occurrence of PBB within 21 days post-intervention. Data collected included laboratory parameters, type and severity of underlying liver disease, recent alcohol consumption, anticoagulant use, and procedural details such as the number of bands applied and intra-procedural bleeding. Data was analysed using R and SPSS statistical software.

Results

In our study, PBB occurred in 30 of 616 EBL procedure (4.9%). Importantly, for interventions to treat acute variceal bleedings, the PBB rate was 20.8% (16/77 cases), whereas ligature in patients without acute bleeding had a low PBB rate of only 2.6% (14/539 cases, p<0.001). Additionally, recent alcohol abuse within 28 days prior to the procedure was reported in 50% (15/30) of interventions with PBB, whereas alcohol abuse was observed in only 20.3% (119/586) of non-PBB cases (p < 0.001). Furthermore, impaired liver function assessed by Child-Pugh and MELD scores was associated with an increased risk of PBB (p < 0.001). Conversely, low platelet counts below 50 G/L or even below 30 G/L did not show a significant increase in the occurrence of PBB in our patient cohort, suggesting that EBL can be safely performed in patients with platelet counts < 50 G/L². Additionally, the use of acetyl salicylic acid (ASA) was not associated with a significantly higher incidence of PBB in this cohort.

Conclusion

While the overall risk of PBB following EBL is relatively low, we could identify several risk factors that increased the likelihood of esophageal variceal bleeding following EBL. Relevant risk factors were ligature for acute EVB, impaired liver function, and active alcohol abuse. In contrast, patients with low platelet counts (<50 G/L) or those taking ASA medication did not show an increased risk of PBB in our cohort. These findings allow for a more precise risk stratification for PBB and will be useful to assess which patients require extended in-hospital observation after EBL and who can be safely discharged shortly after the procedure.

References

1. Vanbiervliet G, Giudicelli-Bornard S, Piche T, et al. Predictive factors of bleeding related to post banding ulcer following endoscopic variceal ligation in cirrhotic patients: a case-control study. Aliment Pharmacol Ther. 2010;32(2):225-232
2. Katsumi, T. and Y. Ueno, Prospects for treatment of esophageal varices considering the safety of endoscopic band ligation. Hepatology International, 2023. 17(5): p. 1079-1081

Clinical Case Summary

Case: W present a case of a 43-year-old man with hepatic cirrhosis complicated by hypertensive gastrointestinal bleeding, in a program to eradicate esophageal varices. One week after an elective endoscopic variceal ligation (EVL), he presented with fever, anorexia, pain in the dorsolumbar region, headaches, and psychomotor retardation. Subsequently, there was the appearance of focal motor seizures. The analyses showed C-reactive protein of 113 mg/L, without leukocytosis. Peripheral blood cultures were negative. A head computed tomography (CT) showed mild left parietal and occipital cortical hypodensities. Analysis of the cerebrospinal fluid was compatible with central nervous system (CNS) infection. Cerebral magnetic resonance revealed multiple supra and infratentorial rounded lesions, compatible with abscesses and ventriculitis. He started antibiotics with a meningeal dose. Hospitalization was complicated by SARS-COV 2 infection, so a chest CT was performed after 1 month of hospitalization, and was identified a mediastinal abscess with 5 cm with fistulization from the esophagus, compatible with iatrogenic esophageal perforation after EVL. Other possible causes of brain abscesses were excluded. He completed several weeks of antibiotic and parenteral nutrition, with normalization of the neurological status and resolution of brain lesions. About 1 month after targeted antibiotic treatment, he performed an endoscopy, revealing a deformed area in the distal esophagus but no evidence of an orifice or suppuration. Conclusion: Neurological manifestations in patients with liver cirrhosis are usually due to hepatic encephalopathy (HE). However, CNS infection, especially in patients who underwent recent procedures, such as EBL, should be considered in the differential diagnosis, given that early treatment influences the prognosis. Clinically, CNS infection can be very variable, however, it is important to be aware of atypical signs of HE, such as focal neurological deficits.

References

Krige JE, Bornman PC, Shaw JM, Apostolou C. Complications of endoscopic variceal therapy. S Afr J Surg. 2005 Nov;43(4):177-88, 190-4.

Disclosure

Nothing to disclosure

Introduction

Endoscopic submucosal dissection (ESD) is the technique of choice for treating early gastric cancer deemed to have very low risk of lymph node metastasis based on endoscopic evaluation. However, currently, up to 20% of ressected lesions do not meet curative criteria, underlining the importance of patient selection.

Aims & Methods

We aimed to evaluate predictive factors for non curative ressection. We conducted a retrospective cohort study including consecutive gastric epithelial lesions removed by ESD between January of 2005 and June of 2024. Incomplete ESD were excluded. Non curative resection was defined using the high-risk resection criteria from the European Society of Gastrointestinal Endoscopy guidelines. Univariate and multivariate analysis were used to identify predictive factors.

Results

From 990 ESD, 974 were included in the final analysis: median size of lesion 19mm (P25-P75: 15-25), presence of ulceration in 25 (2.8%), deep submucosal invasion in 74 (7.6%), en bloc resection in 944 (96.9%), R0 resection in 901 (92.5%) and non curative resection in 116 (11.9%). In this sample, the following independent predictive factors for non curative resection were identified: location on the superior third of the stomach [adjusted Odds Ratio (aOR) 2.275; IC95% 1.248-4.148], lesion size > 20mm (aOR 4.212; IC95% 2.618-6.775), depressed/ulcerated lesion (aOR 2.394; IC95% 1.328-4.315) or sessile/pedunculated lesion (aOR 4.186; IC95% 2.083-8.411), presence of high-grade dysplasia (aOR 4.372; IC95% 2.139-8.939) or carcinoma (aOR 12.484; IC95% 5.995-25.998) in previous biopsies.

Conclusion

Location, size and morphology of lesion, as well as previous biopsy results are predictive factors for non curative resection, and may assist in decision-making regarding treatment alocation of gastric superficial lesions.

References

Dinis-Ribeiro M, et al. Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025. Endoscopy, 2025 May;57(5):504-554. doi: 10.1055/a-2529-5025.
Vasconcelos AC, et al. Endoscopic Resection of Early Gastric Cancer and Pre-malignant Gastric Lesions. Cancers, 2023 Jun 7;15(12):3084. doi: 10.3390/cancers15123084.

Introduction

Post-procedural bleeding (PPB) is the most common adverse event after gastric endoscopic submucosal dissection (ESD). The BEST-J score was created to predict PPB risk following gastric ESD.

Aims & Methods

We aimed to evaluate predictive factors of PPB and validate the BEST-J score in a large European cohort. We conducted a retrospective cohort study including consecutive gastric epithelial lesions removed by ESD between January of 2005 and June of 2024. Incomplete ESD and patients with missing information that prevented the score calculation were excluded. PPB was defined as presence of compatible clinical picture in the 28 days following the procedure. Univariate and multivariate analysis were used to identify predictive factors of PPB, and the diagnostic ability of the BEST-J score was calculated in this cohort.

Results

From 990 ESD, 874 were included in the final analysis. PPB occurred in 53 patients (6.1%), with a median time after procedure of 2 days (P25-P75: 1-7). PPB was significantly superior in patients with higher risk as evaluated by the BEST-J score (PPB rate of 3.7%, 3.9%, 19.2% and 35.7% for low, intermediate, high and very-high risk, respectively). The area under the curve for PPB prediction using the BEST-J score was 0.684 (IC95% 0.598-0.679). For a score ≥ 3 (high and very-high risk), the sensitivity and specificity for PPB detection were 47.2% (IC95% 34.2-60.5) e 88.7% (IC95% 86.4-90.7), respectively. In this sample, the following predictive factors for PPB were identified: ischemic cardiopathy [adjusted Odds Ratio (aOR) 4.351; IC95% 1.660-11.404], medication with warfarin (aOR 18.339; IC95% 4.541-74.064) or direct oral anticoagulants (aOR 7.596; IC95% 2.666-21.641) and lesion size > 20mm (aOR 2.563; IC95% 1.246-5.272).

Conclusion

The BEST-J score presented moderate discrimination for PPB following gastric ESD in our cohort. The identified factors may assist the decision of implementing prophylactic measures in high-risk patients and the creation of more precise prediction models.

References

Vasconcelos AC, et al. Endoscopic Resection of Early Gastric Cancer and Pre-malignant Gastric Lesions. Cancers, 2023 Jun 7;15(12):3084. doi: 10.3390/cancers15123084.
Hatta W, et al. Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut, 2021 Mar;70(3):476-484. doi: 10.1136/gutjnl-2019-319926

Introduction

Variceal bleeding accounts for approximately 20–30% of cirrhosis-related deaths and remains a major complication of portal hypertension in patients with liver cirrhosis (1). The National Institute for Health and Care Excellence (NICE) in the United Kingdom (UK) recommends the administration of propranolol or carvedilol, or endoscopic variceal ligation (EVL) as primary prevention of medium to large oesophageal varices. (2). However, the comparative efficacy and safety profiles of these approaches remain unclear.

Aims & Methods

A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Electronic databases were searched to identify randomised controlled trials (RCTs) comparing EVL and propranolol for the primary prevention of variceal bleeding in patients with liver cirrhosis. Primary outcomes included incidence of variceal bleeding, all-cause mortality, and bleeding-related mortality. Secondary outcomes included adverse effects related to prophylactic treatment. Data were pooled using fixed or random-effects models depending on heterogeneity.

Results

Nine RCTs comprising a total of 916 patients were included. EVL was associated with a significantly lower risk of variceal bleeding compared to propranolol (odds ratio [OR] 0.44; 95% confidence interval [CI]: 0.28–0.67; p = 0.0002) and reduced bleeding-related mortality (OR 0.57; 95% CI: 0.33–0.99; p = 0.05). Adverse effects were also significantly less frequent in the EVL group (OR 0.46; 95% CI: 0.32–0.67; p < 0.0001). No statistically significant difference was found in all-cause mortality between the two interventions (OR 0.93; 95% CI: 0.63–1.37; p = 0.72).

Conclusion

EVL is more effective than propranolol for the primary prevention of variceal bleeding in patients with cirrhosis, demonstrating lower rates of first variceal bleed, bleeding-related mortality, and treatment-related adverse events. Although no difference in all-cause mortality was observed, the findings support the consideration of EVL as a first-line prophylactic option. Further well-designed, multicentre RCTs with standardised outcomes, extended follow-up, and robust cost-effectiveness analyses are essential to optimise clinical decision-making and support personalised treatment strategies.

References

1. García-Tsao G, Bosch J. Varices and variceal hemorrhage in cirrhosis: A new view of an old problem. Clin Gastroenterol Hepatol. 2015;13(12):2109–2117.
2. National Institute for Health and Care Excellence (NICE). Cirrhosis in over 16s: assessment and management. NICE guideline [NG50]. 2016. Available at: https://www.nice.org.uk/guidance/ng50