Proton pump inhibitor reduces bleeding risk after endoscopic variceal band ligation

Abstract

Background: Endoscopic variceal band ligation (EVL) is an effective procedure to control and prevent variceal bleeding, but can be complicated by bleeding from post EVL ulcers. Several studies have reported that proton pump inhibitors (PPI) decrease size of post-EVL ulcers. However, no evidence has been provided whether PPI reduce the actual risk of bleeding after EVL. The aim of this study was to analyze factors associated with bleeding after prophylactic EVL and to assess the effect of PPI.

Methods: Liver cirrhosis patients with high-risk esophageal varices who received elective EVL to prevent variceal bleeding between January 1998 and April 2011 were included. High risk varices were defined as large esophageal varices with red color sign. Patients who had history of acute variceal bleeding were excluded. Post EVL bleeding was defined as; (1) decrease in hemoglobin by >20g/L, or (2)occurrence of active bleeding evidenced by melena or hematemesis after prophylactic EVL within 60 days.

Results: 505 patients were included for this analysis. 25 patients (5%)developed bleeding after prophylactic EVL. 359 patients(71.1%) received PPI after EVL. Factors associated with bleeding included low serum Na [odds ratio (OR) 3.209, 95% CI(confidence interval), 1.217-8.464, p=0.018], high ALT [OR2.582, 95% CI: 1.075-6.200, p=0.034], high Child-Pugh score [OR 3.636, 95% CI: 1.499-8.820, p=0.004], gastric varix [OR 3.598, 95% CI: 1.592-8.132, p=0.002, and no PPI medication [OR 7.09, 95% CI: 2.89-17.24, p<0.001] by univariate analysis. In multivariate logistic analysis, no PPI therapy[OR 6.41, 95% CI: 2.5-16.39, p<0.001] and presence of gastric varix [OR 4.61, 95% CI: 1.82-11.62, p=0.001] were independent factors for bleeding. Subgroup analysis was performed after excluding patients with gastric varix, and low serum Na [odds ratio (OR) 4.144, 95% CI (confidence inter-val), 1.217-14.116, p=0.023], high ALT [OR 3.226, 95% CI:1.021-10.187, p=0.046], high Child-Turcotte-Pugh score [OR5.198, 95% CI: 1.624-16.638, p=0.005], and no PPI medication [OR 8.55, 95% CI: 2.31-31.25, p=0.001] were predictor factors of bleeding by univariate analysis. In multivariate logistic analysis, administrating PPI [OR 6.94, 95% CI: 1.77-27.03, p=0.005] or not was only associated with bleeding after prophylactic EVL.

Conclusions: No administration of PPI was significantly associated with increased risk of bleeding after prophylactic EVL. Especially, PPI medication was the only predictor factor in the case of no gastric varix. We suggest PPI therapy should be routinely performed in patients receiving EVL to reduce the risk of post EVL bleeding.