Secondary Prophylaxis in Variceal Hemorrhage: In Search of the Ideal Endoscopic Timing

Aims Variceal hemorrhage is a potentially fatal complication of cirrhosis. The role of endoscopy in secondary prophylaxis is well-established, but the optimal timing remains a matter of consensus. A temporal limit of 4 weeks has been suggested as a quality criterion, but its applicability is complex. The aims of our study were to compare overall mortality and 12-month follow-up mortality in patients who initiated combined therapy for secondary prophylaxis≤120 days and>120 days.

Methods A retrospective single-center study of a cirrhotic population that initiated secondary prophylaxis after an episode of variceal bleeding between January 2017 and September 2022. Patients who died, underwent transplantation, or were lost to follow-up before the first endoscopic reevaluation were excluded.

Results Included 102 patients (68% male; mean age 60.75±10.8 years), 60.8% with Child-Pugh class B cirrhosis, mostly of alcoholic etiology (62%). 70% of patients initiated combined therapy for secondary prophylaxis within 120 days after the index event. The median follow-up was 13 months with an overall mortality rate of 38.2%.

In univariate analysis, older age, higher Child, MELD, and Charlson index scores, longer disease duration, and initiation of secondary prophylaxis after 120 days significantly increased the risk of death in the first year (p<0.10). [1] [2]

In multivariate analysis, using Cox regression models and adjusting for confounding variables, the initiation of secondary prophylaxis after 120 days of the hemorrhagic event remained an independent predictor of the risk of death in the first year (HR 4.06, CI 1.75-9.43; p=0.001). Mortality in the first year was statistically higher in patients who initiated secondary prophylaxis after 120 days of variceal rupture (44% vs. 17%; p=0.004).

Conclusions Despite the retrospective nature, the initiation of dual prophylaxis after 120 days from the index event was associated with higher mortality, with an increased risk during the first 12 months of follow-up.

Publication History

Article published online:
15 April 2024

• References

• 1 Everett BT, Lidofsky SD.. Adherence to surveillance endoscopy following hospitalization for index esophageal variceal hemorrhage. World J Gastrointest 4 Surg 2018; 10 04: 40-8 5
• 2 Hagström H, Shang Y, Tapper EB. et al. Secondary Prevention of Esophageal Variceal Bleeding Is Often Imperfect: A National, Population-Based Cohort Study of 3592 Patients. Clin Gastroenterol Hepatol 2023; S1542-3565 (23) 00347-6