Endoscopic variceal ligation-induced ulcer bleeding: incidence by indication, real-world treatment, and outcomes

PURPOSE: Endoscopic variceal ligation (EVL) - induced ulcer bleeding is a rare but potentially life-threatening complication. While the incidence following elective and emergency EVL has been reported, semi-elective procedures performed during hospitalization for acute decompensation of cirrhosis have not been separately examined. Additionally, real-world data on endoscopic treatment strategies, hemostasis rates and outcomes are scarce. METHODS: We conducted a retrospective cohort study analyzing all ligation procedures performed in adults with portal hypertension and esophageal varices at Charité University Hospital, Campus Virchow and Campus Mitte, from 01/01/2016 until 06/30/2023. We assessed incidence and risk factors by ligation indication, described endoscopic treatment strategies and analyzed predictors of 5-day rebleeding and 6-week mortality. RESULTS: Among 1,864 EVLs, 61 (3.3%) resulted in EVL-induced ulcer bleeding; 60 were analyzed. Incidence varied significantly by indication: 0.44% after elective, 8.5% after emergency and 15.9% after semi-elective EVL. Repeat ligation was the most common endoscopic treatment (32.4%), followed by fibrin glue (14.7%) and balloon tamponade (11.7%); the overall primary hemostasis rate was 82.8%. Ten patients (16.7%) underwent TIPS. The 5-day rebleeding rate was 25% and the 6-week mortality rate 41.7%. Multivariate logistic regression analysis revealed that 5-day rebleeding (OR: 8.05; 1.66-39.2; p = 0.01) and post-bleeding sepsis (OR 7.27; 1.15-45.73; p = 0.035) were strongly associated with 6-week mortality. CONCLUSIONS: Semi-elective EVL carries 45-fold higher odds for EVL-induced ulcer bleeding. Endoscopic hemostasis is achievable, but early rebleeding and post-bleeding sepsis drive mortality, suggesting that considering early TIPS in high-risk patients and preventing sepsis deserve more attention.