S5311 From Banding to Bleeding: Rescue Therapy for Post-Banding Ulcer Bleeding (PBUB) Using Self-Expanding Metal Stents (SEMS)

Introduction: Esophageal varices are commonly managed with non-selective beta-blockers and endoscopic variceal band ligation (EVBL), based on individual risk profiles and variceal severity. Post-banding ulceration is a recognized complication of EVBL, particularly in patients treated for active variceal bleeding. Management options for post-banding ulcer bleeding (PBUB) include pharmacologic therapy, endoscopic interventions, and transjugular intrahepatic portosystemic shunt (TIPS) placement. However, these modalities are not suitable for all patients, necessitating alternative strategies. This case series explores the use of self-expanding metal stents (SEMS) as an effective but underutilized option for controlling PBUB in such scenarios. Case Description: Five patients with cirrhosis (ages 38-72; mean age 54 years), including 4 with alcohol-associated cirrhosis and 1 with hepatitis C-associated cirrhosis, presented with hemodynamically unstable PBUB. All were deemed ineligible for TIPS due to factors such as hepatic encephalopathy, elevated MELD scores, or imminent liver transplantation. A 20 × 100 mm fully covered through the scope SEMS was deployed under endoscopic vision as a bridging measure to control bleeding. Hemostasis was achieved immediately in all cases. Two patients experienced stent migration with recurrent bleeding at 24 hours and 10 days post-placement respectively. One of these patients underwent successful repeat SEMS placement followed by liver transplantation. The other continued to bleed despite additional interventions and died. The remaining 3 patients were discharged alive with 2 undergoing transplant evaluation and 1 transferring to hospice care due to poor functional status. Discussion: This series highlights SEMS as a viable rescue therapy for PBUB in critically ill patients who are not candidates for conventional treatments. SEMS can serve as an effective bridging strategy to definitive interventions such as liver transplantation or TIPS in hemodynamically unstable patients. However, while SEMS provided prompt hemostasis in all cases, stent migration posed a notable risk for rebleeding and warrants vigilant post-placement monitoring.