Variceal Band Ligation Feasible for Cirrhosis Treated With Anticoagulants

For patients with chronic liver diseases treated with anticoagulant therapy, variceal band ligation is practical due to its lowered incidence of bleeding, according to a recent study published in the European Journal of Gastroenterology and Hepatology.

Study researchers designed a single-center retrospective study using 3 local databases housing medical charts of patients with cirrhosis treated with anticoagulants for portal vein thrombosis who had received scheduled variceal band litigation from Geneva University Hospitals between 2014 and 2017. Study researchers followed the patients until liver transplantation, death, or the end of the study, which was in March 2018. Study researchers focused on assessing the incidence and the severity of upper gastrointestinal bleeding after elective variceal band litigation. The study end point defined significant bleeding as “a ≥2 g drop in hemoglobin requiring re-endoscopy that occurred within two weeks postvariceal band ligation.” The severity of bleeding was assessed as follows: hospitalization, transfusion, hemorrhagic shock, and death related to bleeding event.

Of 750 patients with cirrhosis and portal vein thrombosis, 32 were included in the study (due to treatment with anticoagulants and prophylactic variceal band litigation). Most of these patients had alcohol-related cirrhosis (n=16; 50%) and history of variceal bleeding (n=17; 53%). Twenty-three (72%) of the patients received anticoagulant medication that included enoxaparin with a median dose of 80 mg twice daily.

Study researchers found that 22% (n=7) of the patients experienced upper gastrointestinal bleeding within 2 weeks after previous variceal band litigation. Among those 7 patients, 3 developed upper gastrointestinal bleeding that was “directly attributed to the previous variceal band litigation, since an active bleeding on one or more litigation ulcer was identified at endoscopy.” These 3 patients had alcohol-related cirrhosis, 2 were men (aged 58 and 68), and 1 was a woman (aged 69). When comparing patients who had developed upper gastrointestinal bleeding attributed with previous band litigation vs patients who had not, the study researchers saw significance with decompensated cirrhosis (P =.03) and secondary prophylaxis (P =.05) with bleeding related to variceal band ligation.

Limitations of the study included a small number of patients, no control group, and a relatively heterogeneous population.

The rate of bleeding directly related to variceal band ligation was 9%, in this small group of patients with cirrhosis under anticoagulant therapy for portal vein thrombosis. Study researchers “confirm that variceal ligation is feasible in patients with cirrhosis under anticoagulant therapy.” However, they also note that “further studies are needed to precisely evaluate the safety of variceal band ligation in patients with decompensated cirrhosis.”

Reference

Ponthus S, Spahr L, Casini A, et al.  Safety of variceal band ligation in patients with cirrhosis and portal vein thrombosis treated with anticoagulant therapy: a retrospective study [published online August 27, 2019]. Eur J Gastroenterol Hepatol. doi: 10.1097/MEG.0000000000001522