Prophylactic endoscopic band ligation (EBL) is used to prevent variceal bleeding in patients with liver cirrhosis. The association of thrombocytopenia, high INR (international normalized ratio) and liver dysfunction with the risk of procedure-related bleeding (PRB) remains debated and recommendations are controversial.
We analyzed real-life data of cirrhotic patients undergoing elective EBL at two large Viennese centers between Q1/2000–Q1/2018. PRB was defined as bleeding occurring within 30 days after EBL.
We included 617 patients undergoing a total of 1178 prophylactic EBL procedures (median 2 per patient). Sixteen (2.6%) of 617 patients experienced PRB after a median of 12.5 (IQR 17.3) days with no difference in characteristics and laboratory values between the two groups. The proportion of patients with platelets (PLT) < 50 G/L or INR ≥ 1.5 was similar in patients with vs. without PRB. A higher MELD showed a non-significant association with EBL-related bleeding risk (odds ratio, OR 1.07; 95% confidence interval 95% CI 1.00–1.16, p = 0.058). While serum bilirubin was a significant predictor for PRB (OR: 1.10; 95% CI 1.03–1.18), the presence of large varices (OR 0.85 vs. small varices; 95% CI 0.20–3.84), INR (OR 0.50; 95% CI 0.10–3.14), PLT (OR 1.00; 95% CI 1.00–1.01) and the use of non-selective betablockers (OR 1.20; CI 95% 0.38–3.76) were not associated with PRB.
EBL is safe and procedure-related bleedings are rare (2.6%) including in patients with thrombocytopenia < 50 G/L or high INR ≥ 1.5. Only high MELD, and especially high bilirubin seem to be linked to an increased risk of EBL-related bleeding.
Esophageal variceal (EV) bleeding is a severe complication of portal hypertension in patients with liver cirrhosis and the bleeding-related mortality is still high up to 20% [1,2,3,4,5]. To avoid (re-)bleeding episodes in primary and secondary prophylaxis, current guidelines recommend treatment with non-selective betablockers (NSBBs) or/and endoscopic band ligation (EBL) [6,7,8,9,10]. This approach has been shown to effectively reduce bleeding and mortality rates [11,12,13,14,15,16].
Furthermore, EBL is also a standard treatment for acute variceal bleeding, but if it fails, self‐expandable metal stent and/or rescue transjugular intrahepatic portosystemic shunt (TIPS) are indicated [7, 9, 17].
Esophageal ulcers may form after EBL, but are usually only superficial and heal within 2–3 weeks .
Compared to NSBB, EBL is associated with a lower rate of adverse events, however, potential adverse events of EBL could be more severe and life-threatening (e.g. EBL-related ulcer bleeding) [21, 22]. Bleeding from banding ulcers represents the main severe complication of EBL and has been described to occur in 2.3% to 10% of patients [22,23,24,25,26,27,28,29,30,31]. The role of potential risk factors (e.g. liver function, platelets count, number of rubber bands placed, etc.) for PRB has not yet been entirely clarified, but a better understanding of these factors could help to avoid such complications. Furthermore, no consensus has been established on the actual risk factors for PRB and their management [7, 9, 32].
The aim of this retrospective multicenter study was to assess potential risk factors for procedure-related bleeding (PRB) within 30 days after first elective/prophylactic EBL in patients with liver cirrhosis and portal hypertension.
Patients and methods
This retrospective study was conducted in two tertiary clinical centers (Vienna General Hospital of the Medical University of Vienna and Klinik Landstrasse in Vienna) including patients with liver cirrhosis and portal hypertension. Patients undergoing endoscopic band ligation (EBL) for esophageal varices (EV) were included between January 2000 and May 2020. Inclusion criteria were the presence of EV at endoscopy, elective EBL, age > 18 years and diagnosis of liver cirrhosis.
Patients with non-cirrhotic portal hypertension receiving EBL, other than EBL endoscopic treatment, previous transjugular intrahepatic portosystemic shunt (TIPS) implantation or orthotopic liver transplantation, occlusive portal vein thrombosis, patients with fundal varices only, patients with acute and/or uncontrolled variceal bleeding at baseline and insufficient medical/endoscopic records were excluded from this study. However, patients with hepatocellular carcinoma at baseline who fulfilled the Milan criteria were included in this study .
We intentionally excluded patients undergoing emergency EBL (i.e. therapeutic EBL) performed to treat active gastrointestinal bleeding, since this setting would have not allowed us to discriminate EBL-related (i.e. strictly procedure-related) bleeding from early rebleeding.
The baseline characteristics were compared between a group with a perceived lower bleeding risk (platelets > 50 and international normalized ratio (INR) < 1.5, respectively) and a group with a perceived increased bleeding risk (platelets ≤ 50 G/L or INR ≥ 1.5, respectively, Tables 1 and 2). Patients with no available platelets and/or INR values at baseline were excluded from this study.
Our aim was to determine factors associated with procedural-related bleeding (PRB) as defined as any clinically significant episode of hematemesis, melena or both occurring within 30 days after elective EBL.
In this study laboratory (aspartate transaminase, alanine transaminase, gamma-glutamyl transferase, serum-bilirubin, prothrombin time, international normalized ratio and platelet count), endoscopic (size of varices, presence of additional gastric varices, presence of red spots and bleeding during examination), clinical parameters (age, sex, etiology of cirrhosis, presence and grade of ascites, and presence and grade of hepatic encephalopathy) were extracted from medical records. During further follow-up, we recorded specific clinical outcomes, i.e. acute variceal bleeding, TIPS implantation, liver transplantation and death (including its cause). Early variceal (re-)bleeding after EBL was defined as the presence of haematemesis and/or clinical and laboratory evidence of acute blood loss from esophageal varices, which occurred within 30 days from the first EBL. Important to note, that other (portal-hypertensive) bleeding events occurring later during follow-up were not counted as PRB.
Laboratory, endoscopic, clinical parameters and specific data on clinical outcomes were collected. Continuous variables were reported as median with interquartile range (IQR) and categorical variables were reported as absolute numbers (and proportions, %) of patients.
Comparisons of continuous variables in Tables 1 and 2 (age, creatinine, serum albumin, serum bilirubin, liver enzymes, MELD, number of endoscopies and EBL per year) were performed using Student t test or Mann–Whitney U-test, as applicable. Chi-square or Fisher’s exact test was used for group comparisons of categorical variables (sex, etiology of cirrhosis, size of varices, Child–Pugh score/grade, grade of ascites, number of additional gastric varices and use of NSBB) in Tables 1 and 2.
Kaplan–Meier curves were used to visualize procedure-related bleeding (PRB) rates within 30 days according to potential risk factors, such as the size of varices, serum bilirubin, INR and platelet count—and group comparisons were performed using the log-rank test.
Potential liver-related risk factors (serum bilirubin, creatinine, albumin, platelet count, Child–Pugh score, MELD, size of varices, alcohol intake, use of non-selective betablockers and the number of rubber bands placed in the respective EBL procedures), as well as age and sex, were included into a Cox regression model to assess their effect on EBL-related bleeding. The odds ratio (OR) including the 95% confidence interval (95%CI) was calculated for each individual risk factor. In order to identify independent predictors for PRB multivariate Cox regression models were performed. A p value ≤ 0.05 was considered statistically significant. IBM SPSS statistics Version 28 (SPSS Inc., Armonk, New York, USA) and GRAPHPAD Prism 9 (GRAPHPAD Software, La Jolla, California, USA) were used for statistical analyses.
A total of 1178 patients underwent endoscopic treatment for esophageal varices (EV). After the exclusion of 561 patients, a total number of 617 patients were included in this study.
Among the 16 (2.6%) patients, who experienced procedure-related bleeding (PRB) within 30 days after the first elective endoscopic band ligation (EBL), 9 (1.5%) patients bled within 14 days and bleeding-related mortality was observed in 6 patients (37.5%), 2 of them (0.3%) owing to uncontrolled bleeding. The mortality within 30 days in patients who did not bleed within 30 days was lower with n = 19 (3.2%). A higher median platelet count of 125.5 G/L (interquartile range, IQR 127) was observed compared to patients, who did not bleed within 30 days (91 G/L, IQR 75.5) and the median INR was the same in both groups (Bleeding within 30 days: 1.3 IQR 0.3 vs. no bleeding within 30 days: 1.3 IQR 0.3). Interestingly, the median interval to the previous EBL after PRB was 12.5 (IQR 17.3) days and the median interval between the EBLs in patients with no PRB was 42 (IQR 58) days.
The median overall follow-up of our patient cohort was 28 (IQR 42.8) months; importantly, PRB was only evaluated in the first 30 days after elective EBL. PRB in the first 30 days occurred in patients with large and in patients with small varices were 3.1% (2/65) and 2.6% (14/531). The rate of PRB was not significantly different (p = 0.691). In patients in which PRB occurred, the number of previous EBL sessions was significantly lower than in patients without PRB (1 IQR 1 vs. 2 IQR 1, p = 0.001). However, the number of rubber bands being placed within 30 days was comparable in both groups (PRB: 5 IQR 2 vs. No PRB: 5 IQR 2, p = 0.532).
The baseline characteristics were stratified into 2 groups: one group with a perceived lower bleeding risk with platelets > 50 or INR < 1.5, respectively and one group with a perceived increased bleeding risk with platelets ≤ 50 G/L or INR ≥ 1.5, respectively. A total number of n = 92 had thrombocytopenia with platelets ≤ 50 G/L and n = 525 patients had platelet counts > 50 G/L. Alcohol intake was the most common cause of liver cirrhosis. Patients with platelets ≤ 50 G/L had significantly higher MELD (13 IQR 8 vs. 12 IQR 6, p = 0.015), especially higher serum bilirubin levels (2.0 IQR 2.1 vs. 1.6 IQR 1.9 mg/dL, p = 0.007). Otherwise, patients with platelets > 50 G/L were older (53.1 IQR 15.4 vs. 58.7 IQR 15.9 years, p = 0.001) and had higher GGT values (65 IQR 94 vs. 100 IQR 136 IU/L, p = 0.001). Importantly, there were no significant differences between patients with platelets ≤ 50 G/L vs. platelets > 50 G/L regarding other laboratory parameters, sex, size of varices, presence of additional gastric varices, Child–Pugh score, presence of ascites, use of NSBB, and the number of endoscopies or EBL sessions per year. The rate of PRB in patients with large varices (1.3% vs. 2.9%, p = 0.276) and patients with small varices (12.5% vs. 1.6%, p = 0.705) were not statistically different between patients with platelets ≤ 50 G/L and platelets > 50.
When we stratified patients according to INR and compared baseline characteristics, alcohol intake was the most common cause of liver cirrhosis in both groups. Patients with INR < 1.5 had significantly higher serum creatinine values (0.9 IQR 0.3 vs. 0.8 IQR 0.4 mg/dL, p = 0.007) and were older than patients with INR ≥ 1.5 (59.0 IQR 16.6 vs. 53.6 IQR 15.6 years, p = 0.001). On the other side, patients with INR ≥ 1.5 had a significantly higher MELD (11 IQR 4 vs.17 IQR 7, p = 0.001). Lower serum albumin (34.8 IQR 8.4 vs. 31.1 IQR 8.8 g/dL, p = 0.001) and higher bilirubin (1.4 IQR 1.5 vs. 2.8 IQR 3.7 mg/dL, p = 0.001) were seen in patients with INR ≥ 1.5. There were no significant differences in other characteristics between patients with INR < 1.5 and INR ≥ 1.5, except for AST (43 IQR 41 vs. 55.5 IQR 50.8, p = 0.002). Furthermore, the PRB were also not significantly different regarding high/low INR when assessing patients with large varices (2.8% vs. 2.2%, p = 0.999) or small varices (2.1% vs. 5.9%, p = 0.470) separately.
Risk factors associated with procedure-related bleeding within 30 days after elective endoscopic band ligation (Table 3, Fig. 2)
Higher MELD showed a trend to a higher risk of PRB (odds ratio, OR 1.07, confidence interval 95% CI 1.00–1.16, p = 0.058; Table 3). Neither the Child–Pugh score (OR 1.12, 95% CI 0.89–1.41, p = 0.330) nor Child-stage C (OR 1.56, 95% CI 0.49–5.02, p = 0.452) were significantly associated with a risk for PRB.
Serum bilirubin levels were associated with a higher risk of PRB within 30 days on univariate analyses (OR 1.10, 95% CI 1.02–1.17, p=0.009) and on multivariate analysis (OR 1.10, 95% CI 1.03–1.18, p = 0.007). The Kaplan Meier analysis showed a trend towards higher bleeding rates of patients with a high bilirubin level of ≥ 2 mg/dL (hazard ratio HR 2.62, 95% CI 0.96–7.13, log-rank p = 0.0597, Fig. 2B).
Other MELD components, i.e. serum creatinine (OR 1.16, 95% CI 0.75–1.80, p = 0.500) and INR (OR 1.01, 95% CI 0.21–4.91, p=0.992) were no significant risk factors for bleeding. Serum albumin was not a significant risk factor for PRB (OR 1.03, 95% CI 0.95–1.11, p = 0.491).
Patients with an INR ≥ 1.5, did not show higher bleeding rates in our Kaplan Meier analyses (HR 1.00, 95% CI 0.32–3.08, log-rank p = 0.983, Fig. 2C) and did not show a higher risk of PRB in the univariate analyses (OR 1.10, 95% CI 0.31–3.02, p = 0.943).
We found no association between bleeding and large varices undergoing banding (OR 0.85 95% CI 0.20–3.84, p = 0.836). Similarly, a higher post-EBL bleeding risk in patients undergoing banding of large varices was not confirmed by Kaplan Meier (HR 0.81, 95% CI 0.16–4.00, log-rank p = 0.825, Fig. 2A). Furthermore, the number of rubber bands being placed was not a risk factor for PRB (OR 1.08, 95% CI 0.79–1.48, p=0.634).
Concerning platelet count, no significant link between PRB within 30 days and the platelet count (OR 1.00, 95% CI 1.00–1.01, p = 0.296) was found. Thrombocytopenia of < 50 G/L was also neither associated with a higher rate of PRB on Kaplan-Maier analysis (HR 1.16, 95% CI 0.29–4.70, log-rank p = 0.836, Fig. 2D) nor a risk factor for PRB (OR 0.81, 95% CI 0.18–3.63, p=0.784).
Furthermore, the use of NSBB (OR 1.20, 95% CI 0.38–3.76, p = 0.758), alcohol-related cirrhosis (OR 0.96, 95% CI 0.36–2.59, p=0.932), male sex (OR 1.42, 95% CI 0.45–4.46, p = 0.548) or age (OR 1.00, 95% CI 0.96–1.04, p=807) were all not associated with PRB events within 30 days after EBL.
We assessed procedure-related (re-)bleeding (PRB) rates within 30 days after elective endoscopic band ligation (EBL) in a large real-life cohort of patients with liver cirrhosis treated at two major liver units. The result of this study showed that only bilirubin was a strong predictor for PRB and remained an independent risk factor for bleeding within 30 days after EBL after adjustment for covariates. Other MELD components, which are surrogate parameters for the severity of liver disease, such as creatinine and INR were not associated with a higher risk of (re-)bleeding within 30 days.
Comparable to our study, Drolz et al.  reported risk factors for early (presumably procedure-related) variceal bleeding after elective EBL in 444 patients with liver cirrhosis. In their study , bleeding was observed in 38 (5%) patients within 30 days and elevated bilirubin was associated with a 50% increased risk of (hazard ratio 1.5), which is in line with our study. High bilirubin was also reported as a risk factor for EBL-related bleeding in other studies [23, 34] Along the same line, impaired hepatic function—as reflected by higher MELD, low prothrombin time and Child–Pugh stage C—has been linked to PRB risk in several previous reports [21, 27, 29, 30, 33].
The size of varices correlates with the portal pressure; therefore, a larger size of varices may be predictive of (re-)bleeding risk [35,36,37]. Our real-life data showed that the size of varices was not associated with PRB. Furthermore, in our study the rate of PRB in patients with large vs. small varices, was not significantly different (p = 0.691). In contrast, some other studies [23, 38] found a larger variceal size (grade III/IV according to Paquet) as a risk factor for (re-)bleeding within 30 days of prophylactic EBL.
Furthermore, a recent mucosal injury due to a banding ulcer may be a relevant risk factor for PRB (especially when more rubber bands are placed in the same session), however, the impact of the time interval between two prophylactic EBL procedures on 30-day bleeding remains largely unknown. Interestingly, although there were no significant differences between patients with PRB and without PRB within 30 days regarding the number of rubber bands being placed (p = 0.532), patients who did suffer from PRB had significantly lower previous EBL sessions than patients without bleeding within 30 days (p = 0.001).
One study  demonstrated a high aspartate transaminase-to-platelet ratio index (APRI) to be an independent risk factor for PRB. Interestingly, our study found no significant link between PRB within 30 days and the platelet count. Furthermore, a lower platelet count < 50 G/L was also not associated with a higher rate of PRB. These results show that EBL is safe for patients with low platelet counts < 50 G/L. These results were also in line with several other studies [22, 23, 30, 31].
Non-selective betablockers (NSBB) are recommended to be used in all patients with clinically significant portal hypertension (CSPH) in order to prevent first hepatic decompensation (i.e. acute variceal bleeding, development of ascites…) and mortality [6, 7, 9, 12, 39, 40].
The rate of using NSBB for prophylaxis in this study around 70% seems low. Still, most patients in primary prophylaxis (130/434, 30%) were treated only with endoscopic band ligation (EBL) which is aligned with current guidelines [7, 9]. However, as we report on real-life, retrospective data, we can only speculate on the reasons. Importantly, we have previously conducted a survey among Austrian physicians and found that 47.1% of the surveyed persons would use NSBB for primary prophylaxis and 87.1% would perform combined treatment with NSBB and EBL for secondary prophylaxis of variceal bleeding . Thus, it seems that despite the recommendation to preferentially use NSBB for primary prophylaxis and the combination of NSBB and EBL in secondary prophylaxis, many physicians (or endoscopists) do not use NSBB according to their own preference. In our specific study setting, the use of NSBB had no significant effect on PRB. Interestingly, another prospective study including 175 patients showed a lower risk of PRB with NSBBs .
In our cohort, 16 (2.6%) of 617 patients experienced PRB and 6 patients (37.5%) died in the further course after elective EBL. These results confirm the low bleeding rate and good safety of EBL in previous studies [22, 23, 28,29,30,31]. Interestingly, the median time from previous EBL to PRB was 12.5 days and more than half of the patients bled within 14 days. Thus, PRB mainly occurs after a short time following the elective procedure and the patients should be informed because they are usually discharged from the hospital one day after the procedure.
The retrospective design of this study represents an important limitation. However, the results are based on a large real-life patient sample. Adherence to specifically dietary recommendations after EBL was not recorded, which could have affected the rebleeding rates [42,43,44].
In conclusion, elective EBL is a very safe procedure with a low risk of procedure-associated bleedings even in patients with low platelet counts < 50 G/L or with INR > 1.5.
Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146:412–19.e3
Stokkeland K, Brandt L, Ekbom A, Hultcrantz R. Improved prognosis for patients hospitalized with esophageal varices in Sweden 1969–2002. Hepatology [Internet]. 2006 ;43:500–5. http://doi.wiley.com/https://doi.org/10.1002/hep.21089. Cited 14 Jan 2020
Jairath V, Rehal S, Logan R, Kahan B, Hearnshaw S, Stanworth S, et al. Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit. Dig Liver Dis [Internet]. 2014;46:419–26. http://linkinghub.elsevier.com/retrieve/pii/S1590865813006981. Cited 6 Nov 2017
D’Amico G, de Franchis R, Cooperative Study Group. Upper digestive bleeding in cirrhosis. Post-therapeutic outcome and prognostic indicators. Hepatology [Internet]. 2003 ;38:599–612. http://doi.wiley.com/https://doi.org/10.1053/jhep.2003.50385. Cited 6 Nov 2017
Cerqueira RM, Andrade L, Correia MR, Fernandes CD, Manso MC. Risk factors for in-hospital mortality in cirrhotic patients with oesophageal variceal bleeding. Eur J Gastroenterol Hepatol [Internet]. 2012;24:551–7. http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00042737-201205000-00013. Cited 14 Jan 2020
de Franchis R, Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol [Internet]. 2015;63:743–52. http://linkinghub.elsevier.com/retrieve/pii/S0168827815003499. Cited 6 Nov 2017
Reiberger T, Püspök A, Schoder M, Baumann-Durchschein F, Bucsics T, Datz C, et al. Austrian consensus guidelines on the management and treatment of portal hypertension (Billroth III). Wien Klin Wochenschr [Internet]. 2017;129:135–158. Available from: http://link.springer.com/https://doi.org/10.1007/s00508-017-1262-3. Cited 6 Nov 2017
Garcia‐Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology [Internet]. 2017;65:310–335. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27786365. Cited 16 Feb 2020
de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C, Abraldes JG, et al. Baveno VII—renewing consensus in portal hypertension. J Hepatol. 2022;76:959–974
Pfisterer N, Unger LW, Reiberger T. Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis. World J Hepatol [Internet]. 2021;13:731–746. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/34367495/. Cited 16 Mar 2022
Sharma M, Singh S, Desai V, Shah VH, Kamath PS, Murad MH, et al. Comparison of therapies for primary prevention of esophageal variceal bleeding: a systematic review and network meta-analysis. Hepatology [Internet]. 2019;69:1657–1675. http://www.ncbi.nlm.nih.gov/pubmed/30125369. Cited 3 Dec 2020
Pfisterer N, Dexheimer C, Fuchs E-M, Bucsics T, Schwabl P, Mandorfer M, et al. Betablockers do not increase efficacy of band ligation in primary prophylaxis but they improve survival in secondary prophylaxis of variceal bleeding. Aliment Pharmacol Ther [Internet]. 2018;47:966–979. http://www.ncbi.nlm.nih.gov/pubmed/29388229. Cited 16 Jan 2020
Funakoshi N, Duny Y, Valats JC, Ségalas-Largey F, Flori N, Bismuth M, et al. Meta-analysis: beta-blockers versus banding ligation for primary prophylaxis of esophageal variceal bleeding. Ann Hepatol. 2012;11:369–383
Li L, Yu C, Li Y. Endoscopic band ligation versus pharmacological therapy for variceal bleeding in cirrhosis: a meta-analysis. Can J Gastroenterol [Internet]. 2011;25:147–55. http://www.ncbi.nlm.nih.gov/pubmed/21499579. Cited 3 Dec 2020
Jachs M, Reiberger T. Prevention of variceal bleeding and rebleeding by nonselective beta-blockers: a tailored approach. Clin Liver Dis [Internet]. 2021;25:311–326. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/33838852/. Cited 16 Mar 2022
Jachs M, Hartl L, Schaufler D, Desbalmes C, Simbrunner B, Eigenbauer E, et al. Amelioration of systemic inflammation in advanced chronic liver disease upon beta-blocker therapy translates into improved clinical outcomes. Gut [Internet]. 2020;Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/33199442/. Cited 10 Feb 2021
Pfisterer N, Riedl F, Pachofszky T, Gschwantler M, König K, Schuster B, et al. Outcomes after placement of a SX-ELLA oesophageal stent for refractory variceal bleeding—a national multicentre study. Liver Int [Internet]. 2019;39:290–298. http://www.ncbi.nlm.nih.gov/pubmed/30248224. Cited 2 Aug 2020
Baroncini D, Milandri GL, Borioni D, Piemontese A, Cennamo V, Billi P, et al. A prospective randomized trial of sclerotherapy versus ligation in the elective treatment of bleeding esophageal varices. Endoscopy [Internet]. 1997 ;29:235–240. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/9255524/. Cited 13 Mar 2022
Laine L, El-Newihi HM, Migikovsky B, Sloane R, Garcia F. Endoscopic ligation compared with sclerotherapy for the treatment of bleeding esophageal varices. Ann Intern Med [Internet]. 1993;119:1–7. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/8498757/. Cited 13 Mar 2022
Polski JM, Brunt EM, Saeed ZA. Chronology of histological changes after band ligation of esophageal varices in humans. Endoscopy [Internet]. 2001;33:443–447. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/11396765/. Cited 7 Jul 2022
Lo G-H, Chen W-C, Wang H-M, Lee C-C. Controlled trial of ligation plus nadolol versus nadolol alone for the prevention of first variceal bleeding. Hepatology [Internet]. 2010;52:230–7. http://www.ncbi.nlm.nih.gov/pubmed/20578138. Cited 28 Jul 2020
Sinclair M, Vaughan R, Angus PW, Gow PJ, Parker F, Hey P, et al. Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation. Eur J Gastroenterol Hepatol [Internet]. 2015;27:928–32. http://www.ncbi.nlm.nih.gov/pubmed/25951490. Cited 27 Jul 2020
Drolz A, Schramm C, Seiz O, Groth S, Vettorazzi E, Horvatits T, et al. Risk factors associated with bleeding after prophylactic endoscopic variceal ligation in cirrhosis. Endoscopy [Internet]. 2020: http://www.ncbi.nlm.nih.gov/pubmed/32894867. Cited 18 Sep 2020
Sarin SK, Govil A, Jain AK, Guptan RC, Issar SK, Jain M, et al. Prospective randomized trial of endoscopic sclerotherapy versus variceal band ligation for esophageal varices: Influence on gastropathy, gastric varices and variceal recurrence. J Hepatol [Internet]. 1997 ;26:826–832. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/9126795/. Cited 20 Jan 2021
Stiegmann G v., Goff JS, Michaletz-Onody PA, Korula J, Lieberman D, Saeed ZA, et al. Endoscopic Sclerotherapy as Compared with Endoscopic Ligation for Bleeding Esophageal Varices. New England Journal of Medicine [Internet]. 1992;326:1527–1532. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/1579136/. Cited 20 Jan 2021
Lo GH, Chen WC, Chen MH, Lin CP, Lo CC, Hsu PI, et al. Endoscopic ligation vs. nadolol in the prevention of first variceal bleeding in patients with cirrhosis. Gastrointest Endosc [Internet]. 2004;59:333–338. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/14997127/. Cited 16 Mar 2022
Xu L, Ji F, Xu QW, Zhang MQ. Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation. World J Gastroenterol [Internet]. 2011;17:3347–3352. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/21876624/. Cited 16 Mar 2022
Vanbiervliet G, Giudicelli-Bornard S, Piche T, Berthier F, Gelsi E, Filippi J, 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 [Internet]. 2010 32:225–232. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/20412065/. Cited 7 Jul 2022
Tierney A, Toriz BE, Mian S, Brown KE. Interventions and outcomes of treatment of postbanding ulcer hemorrhage after endoscopic band ligation: a single-center case series. Gastrointest Endosc [Internet]. 2013;77. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/23062759/. Cited 7 Jul 2022
Vieira da Rocha EC, D’Amico EA, Caldwell SH, Flores da Rocha TR, Soares E Silva CSS, dos Santos Bomfim V, et al. A prospective study of conventional and expanded coagulation indices in predicting ulcer bleeding after variceal band ligation. Clin Gastroenterol Hepatol [Internet]. 2009 ;7:988–993. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/19410018/. Cited 7 Jul 2022
Dueñas E, Cachero A, Amador A, Rota R, Salord S, Gornals J, et al. Ulcer bleeding after band ligation of esophageal varices: risk factors and prognosis. Dig Liver Dis. 2020;52:79–83
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology [Internet]. 2017;65:310–335. http://doi.wiley.com/https://doi.org/10.1002/hep.28906.Cited 15 Jan 2018
Mazzaferro V, Bhoori S, Sposito C, Bongini M, Langer M, Miceli R, et al. Milan criteria in liver transplantation for hepatocellular carcinoma: an evidence-based analysis of 15 years of experience. Liver Transpl [Internet]. 2011;17 Suppl 2. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/21695773/. Cited 16 Mar 2022
Tafarel JR, Tolentino LHL, Correa LM, Bonilha DR, Piauilino P, Martins FP, et al. Prediction of esophageal varices in hepatic cirrhosis by noninvasive markers. Eur J Gastroenterol Hepatol [Internet]. 2011;23:754–8. http://www.ncbi.nlm.nih.gov/pubmed/21691209. Cited 8 Dec 2020
Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atterbury CE, Glickman M. Portal pressure, presence of gastroesophageal varices and variceal bleeding. Hepatology [Internet]. 1985;5:419–24. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3873388. Cited 3 Dec 2020
Wadhawan M, Dubey S, Sharma BC, Sarin SK. Hepatic venous pressure gradient in cirrhosis: correlation with the size of varices, bleeding, ascites, and child’s status. Dig Dis Sci [Internet]. 2006 ;51:2264–2269. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/17080245/. Cited 15 Mar 2022
Moitinho E, Escorsell A, Bandi JC, Salmerón JM, García-Pagán JC, Rodés J, et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology [Internet]. 1999;117:626–31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10464138. Cited 7 Dec 2020
Paquet KJ. Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices—a prospective controlled randomized trial. Endoscopy [Internet]. 1982;14:4–5. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/7035153/. Cited 15 Mar 2022
Villanueva C, Albillos A, Genescà J, Garcia-Pagan JC, Calleja JL, Aracil C, et al. β blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet [Internet]. 2019;393:1597–1608. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/30910320/. Cited 15 Jan 2021
Reiberger T. The value of liver and spleen stiffness for evaluation of portal hypertension in compensated cirrhosis. Hepatol Commun [Internet]. 2022;6:950–964. https://pubmed.ncbi.nlm.nih.gov/34904404/. Cited 17 Oct 2022
Pfisterer N, Schmidbauer C, Riedl F, Maieron A, Stadlbauer V, Hennlich B, et al. Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria. Wien Klin Wochenschr [Internet]. 2020 https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/33270161/. Cited 4 Jan 2021
Li Y, Guo X, Bai Z, Shao X, Wang R, Li H, et al. Banana may be forbidden after endoscopic variceal ligation: a case report. Transl Gastroenterol Hepatol [Internet]. 2019;4. https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/30976716/. Cited 16 Mar 2022
Hou MC. Is there adequate evidence to encourage early feeding in patients with acute esophageal variceal bleeding? J Chin Med Assoc [Internet]. 2015;78:631–632. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/26360242/. Cited 16 Mar 2022
Lo GH, Lin CW, Hsu YC. A controlled trial of early versus delayed feeding following ligation in the control of acute esophageal variceal bleeding. J Chin Med Assoc [Internet]. 2015;78:642–647. Available from: https://pubmed-ncbi-nlm-nih-gov.ez.srv.meduniwien.ac.at/26341455/. Cited 16 Mar 2022
Open access funding provided by Medical University of Vienna. The authors have not disclosed any funding for this study.
Conflict of interest
N. Pfisterer received travel support from Abbvie and MSD. Mattias Mandorfer has served as a speaker and/or consultant and/or advisory board member for AbbVie, Bristol‐Myers Squibb, Gilead, Janssen and W. L. Gore & Associates and has received a research award from Medis. Thomas Reiberger received travel support from Boehringer‐Ingelheim, WL Gore, Gilead, Roche and MSD; grant support from Abbvie, Boehringer‐Ingelheim, Gilead, WL Gore, Phenex Pharmaceuticals and Philipps; served on advisory boards for Abbvie, Bayer, Boehringer‐Ingelheim, Gilead and MSD; and received lecture fees from Boehringer‐Ingelheim, Gore, MSD and Roche. Michael Trauner received travel support from Abbvie, Falk, Gilead, and Intercept and Jannsen; research grants from Albireo, Alnylam, Cymabay, Falk, Gilead, Intercept, MSD and Takeda and Ultagenyx; advisory board fees from Abbvie, Albireo, BiomX, Boehringer Ingelheim, Falk, Genfit, Gilead, Hightide, Intercept, Janssen, MSD, Novartis, Phenex, Pliant, Regulus, Siemens and Shire; lecture fees from BMS, Falk, Gilead, Intercept, and MSD and Roche; he is co-inventor of patents on the medical use of norUDCA filed by the Medical University of Graz. The other authors declared that they have no conflict of interest.
This retrospective study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of the Medical University of Vienna (EK#1666/2015) and the ethics committee of the Wiener Gesundheitsverbund in Vienna (MA-15, EK#15-280-VK).
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Pfisterer, N., Schwarz, M., Jachs, M. et al. Endoscopic band ligation is safe despite low platelet count and high INR. Hepatol Int 17, 1205–1214 (2023). https://doi.org/10.1007/s12072-023-10515-y