# Factors Associated with Early Rebleeding After Endoscopic Variceal Ligation in Cirrhotic Patients: A Retrospective Cohort Study

## TL;DR

This study identifies factors that increase the risk of early rebleeding after a procedure called endoscopic variceal ligation in patients with cirrhosis.

## Contribution

The study distinguishes predictors for variceal rebleeding versus post-banding ulcer rebleeding and identifies six-week mortality risk factors in cirrhotic patients.

## Key findings

- Lower hemoglobin and higher ALBI grade increase the risk of variceal rebleeding.
- More bands applied during the procedure reduce the risk of variceal rebleeding.
- Lower fibrinogen levels are linked to post-banding ulcer rebleeding.

## Abstract

Background: Early rebleeding after endoscopic variceal ligation (EVL) represents a serious complication in patients with cirrhosis and is associated with poor short-term outcomes. This study aimed to identify independent predictors of early rebleeding after EVL, with a particular focus on distinguishing factors associated with variceal rebleeding from those related to post-banding ulcer (PBU) bleeding, and to assess predictors of six-week mortality. Methods: We conducted a retrospective cohort study including 217 cirrhotic patients who underwent first emergency EVL for an index episode of esophageal variceal bleeding at a tertiary referral center. Early rebleeding was defined as recurrent upper gastrointestinal bleeding occurring between days 6 and 42 after the index EVL. Results: Early rebleeding occurred in 38/217 patients (17.5%): 27/38 (71.1%) variceal rebleeding and 11/38 (28.9%) PBU rebleeding. In multivariable logistic regression analysis, lower hemoglobin (OR = 0.19, 95% CI: 0.067–0.539, p = 0.002) and a higher albumin–bilirubin (ALBI) grade (OR = 24.94, 95% CI: 1.134–548.342, p = 0.041) were independently associated with increased odds of early variceal rebleeding, whereas a higher number of bands applied during index EVL (OR = 0.52, 95% CI: 0.302–0.896, p = 0.019) was independently associated with reduced odds of rebleeding, with excellent model discrimination (area under the curve [AUC] 0.981; 95% CI: 0.959–1.000). For PBU rebleeding, lower fibrinogen level was the only independent predictor (OR = 0.957, 95% CI: 0.916–1.000, p = 0.047), with strong discriminative performance (AUC 0.945; 95% CI: 0.909–0.982). Model for End-Stage Liver Disease (MELD) score, serum albumin, platelet count, and PBU rebleeding independently predicted six-week mortality. Conclusions: Markers of liver function, along with endoscopic parameters, predict early rebleeding after EVL, emphasizing the importance of the complete assessment of cirrhotic patients for refined risk stratification and tailored post-EVL management.