Efficacy and safety of high-dose intravenous esomeprazole in cirrhotic patients with acute variceal bleeding: a retrospective cohort study

Proton pump inhibitors (PPIs) are widely used in cirrhotic patients with acute variceal bleeding (AVB), but their use is predominantly empirical, and the optimal dosing strategy remains unclear. Therefore, this study aimed to compare the efficacy and safety of high-dose intravenous esomeprazole with standard-dose esomeprazole in managing AVB in cirrhotic patients. This retrospective cohort study compared cirrhotic patients with AVB receiving either high-dose (HD-IVP) or standard-dose (SD-IVP) intravenous esomeprazole. Propensity score matching (PSM) was utilized to balance baseline characteristics between the two groups. The primary outcome was the incidence of further bleeding. Secondary outcomes included in-hospital mortality, 30-day readmission for bleeding, length of hospital stay, and transfused blood products. Safety outcomes included spontaneous bacterial peritonitis (SBP) and hepatic encephalopathy (HE). A total of 280 patients were included, with 93 patients per group remaining after 1:1 PSM. No significant differences between the HD-IVP group and the SD-IVP group regarding the primary efficacy outcome of further bleeding (OR = 1.594, 95% CI 0.737–3.444, P = 0.236). Similarly, no significant differences were found in secondary outcomes, including in-hospital mortality (HR = 0.815, 95% CI 0.187–3.555, P = 0.786), 30-day readmission for bleeding (P = 0.297), length of stay (P = 0.904) and transfused blood products (P = 0.528). Safety outcomes, including SBP (P = 0.701) and HE (P = 0.336), also showed no significant differences. Notably, the use of Sengstaken-Blakemore tube was identified as an independent risk factor associated with further bleeding (P = 0.029). Short-term high-dose esomeprazole provided no additional benefit over standard dosing in AVB management. Importantly, high-dose therapy did not show a significant increase in the risk of SBP or HE, suggesting its potential use in cirrhotic patients when clinically indicated for concomitant conditions such as peptic ulcer bleeding. This study was retrospectively registered as retrospective observational study on 2020/01/22 at chictr.org.cn (ChiCTR2000029299).