S2911 Trends and Disparities in Mortality From Esophageal Variceal Hemorrhage Among Adults With Cirrhosis in the United States, 1999–2020: A Retrospective Analysis

Introduction: Esophageal variceal hemorrhage (EVH) is a life-threatening complication of cirrhosis, increasingly affecting younger populations due to rising burden of Metabolic dysfunction-Associated Steatotic Liver Disease (MASLD) and alcohol-related liver disease (ALD). Despite therapeutic advances, national trends and demographic disparities in EVH-related mortality remain undercharacterized. Methods: Using CDC WONDER multiple cause-of-death data (1999–2020), we identified adult deaths (≥25 years) listing alcoholic and nonalcoholic cirrhosis (International Classification of Diseases, Tenth Revision code: K70.3, K74.0–K74.6) and esophageal varices with bleeding (I85.01). Age-adjusted mortality rates (AAMRs) per 1,000,000 population were calculated. Joinpoint regression assessed annual percent changes (APCs), stratified by age, sex, race/ethnicity, region, and urbanization. Results: A total of 29,434 EVH-related deaths were identified. Overall AAMR declined from 5.8 in 1999 to 4.2 in 2006 (APC 2001-2006: –11.25%, 95% CI: –15.62 to –6.66, P < 0.001), then increased significantly to 7.4 by 2020 (APC: +2.87%, 95% CI: +2.05 to +3.69, P < 0.001). Middle-aged adults (45–64 years) accounted for 61% of deaths (n = 18,415), with AAMRs rising from 7.2 in 2006 to 11.9 in 2020 (APC: +12.49% CI: –11.21 to +42.52, 2006–2009; +0.73% CI: –0.78 to +2.25, 2009–2020). Among young adults (25–44 years), AAMR declined from 3.3 in 2001 to 1.5 in 2006 (APC: –15.16%, 95% CI: –24.23 to –5.08, P = 0.008), followed by a rise to 2.3 in 2018 (APC: +2.63%, 95% CI: +0.25 to +5.08; P = 0.033), and a spike to 3.5 in 2020. By 2020, AAMRs were higher in men 10.9 than women 4 and highest among American Indian/Alaska Native 31.4, followed by Hispanic 12.3, non-Hispanic (NH) Whites 6.9, and NH Black individuals 5.6. Rates were highest in the West (8.6), followed by South 6, Midwest 5.2, and Northeast 5.1. Non-metropolitan areas showed higher rates 6.4 compared to metropolitan areas 6.2. Rising trends were evident across nearly all stratified subgroups after 2006. Conclusion: EVH-related mortality is increasing in U.S. adults with cirrhosis, especially among middle-aged and younger populations with 18,415 of 29,434 deaths. Addressing this trend requires a layered public health response. Broadly, efforts must focus on reducing the upstream burden of MASLD and ALD through prevention and early detection. Specifically, strategies should include expanded MASLD screening, routine fibrosis assessment in primary care, improved access to alcohol cessation services and targeted cirrhosis surveillance.