S5523 Banding Ulcer Hemorrhage Controlled by Esophageal Stent Placement as a Bridge to Transplant

Introduction: Banding ulcers are an uncommon but potentially life-threatening complication of variceal banding in patients with cirrhosis, with bleeding estimated to occur in approximately 3% of cases. The ulcers can erode into adjacent vasculature and cause hemorrhagic shock that is often refractory to conventional therapies due to the ulcer’s location and friability of the mucosa. Although esophageal self-expanding metal stents (SEMS) are often used more commonly as a salvage therapy for refractory bleeding, their role for managing hemorrhage from banding ulcers is not well defined currently. We present a case of severe bleeding from esophageal banding ulcers that was successfully managed by SEMS as a bridge to liver transplantation. Case Description/Methods: A 41-year-old man with recently diagnosed alcohol-associated decompensated cirrhosis was transferred to our institution for emergent liver transplant evaluation following an episode of esophageal variceal hemorrhage managed with band ligation at an outside hospital. On arrival, he developed melena and worsening anemia. Esophagogastroduodenoscopy (EGD) demonstrated grade II distal esophageal varices and 2 superficial ulcers. Due to the ulcer’s location, the decision was made against further banding. Over the following 24 hours, the patient continued to have signs of further bleeding with worsening hemodynamic instability requiring vasopressor support. Given his high Model for End-Stage Liver Disease score and concern that a transjugular intrahepatic portosystemic shunt (TIPS) would worsen underlying liver dysfunction, the decision was made to place an esophageal stent across the distal esophagus for hemostasis. Bleeding resolved shortly after the stent placement, and vasopressors were discontinued within 12 hours. The patient underwent successful orthotopic liver transplantation within 72 hours of the initial stent placement. The SEMS was removed uneventfully one month later during follow-up EGD as an outpatient. Discussion: This case demonstrates the potential role that esophageal self-expanding metal stents can provide for controlling bleeding from banding ulcers. Although banding ulcers are uncommon, they are a potential cause of massive hemorrhage in this patient population, who are commonly not appropriate candidates for TIPS due to the severity of their underlying liver dysfunction. In these cases, SEMS can potentially lead to successful hemostasis and serve as a bridge to definitive therapy, such as liver transplantation, for high-risk patients.