A multicenter analysis of the role of prophylactic transfusion of blood products in patients with cirrhosis and esophageal varices undergoing endoscopic band ligation

Annabel Blasi; Salvador Machlab; Raquel Risco; Joao Pedro Costa-Freixas; Geovanny Hernández-Cely; Diana Horta; Alex Bofill; Pablo Ruiz-Ramirez; Joaquim Profitos; Josep Marti Sanahuja; Alejandro Fernandez-Simon; Mercedes Vergara Gómez; Jordi Sánchez-Delgado; Andrés Cardenas

doi:10.1016/j.jhepr.2021.100363

A multicenter analysis of the role of prophylactic transfusion of blood products in patients with cirrhosis and esophageal varices undergoing endoscopic band ligation

JHEP Rep. 2021 Sep 16;3(6):100363. doi: 10.1016/j.jhepr.2021.100363. eCollection 2021 Dec.

Authors

Annabel Blasi^{1

2

3}, Salvador Machlab⁴, Raquel Risco¹, Joao Pedro Costa-Freixas⁴, Geovanny Hernández-Cely^{5

6}, Diana Horta⁷, Alex Bofill⁶, Pablo Ruiz-Ramirez⁷, Joaquim Profitos⁸, Josep Marti Sanahuja^{1

3}, Alejandro Fernandez-Simon⁶, Mercedes Vergara Gómez^{4

2}, Jordi Sánchez-Delgado^{4

2}, Andrés Cardenas^{2

9

3}

Affiliations

¹ Anesthesia Department, Hospital Clinic, Barcelona, Spain.
² Ciber de Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain.
³ Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona Spain.
⁴ Digestive Diseases Department, Corporació Sanitària Universitària Parc Taulí, Institut d' Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Spain.
⁵ Fundación Cardioinfantil, Gastroenterology and Hepatology Department, Colombia.
⁶ GI Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Barcelona, Spain.
⁷ Gastroenterology Department, Hospital Universitario Mutua de Terrassa, Spain.
⁸ Gastroenterology Department, Consorci Sanitari de Terrassa, Spain.
⁹ GI & Liver Transplant Unit, Institut de Malalties Digestives i Metaboliques, Hospital Clinic, Barcelona, Spain.

Abstract

Background & aims: Prophylactic administration of platelets and fresh frozen plasma (FFP) has been recommended in patients with cirrhosis with low platelets and/or prolonged international normalized ratio (INR) without scientific evidence to support this practice. In this analysis, we evaluated the use of prophylactic administration of blood products in outpatients with cirrhosis undergoing endoscopic band ligation (EBL).

Methods: This is a multicenter retrospective analysis of consecutive EBL procedures in patients with cirrhosis at 4 hospitals in Spain from 01/2010-01/2017. FFP and/or platelet transfusion were given at the discretion of the physician if INR was >1.5 and/or platelet count <50x10⁹/L. Patient demographics, endoscopic findings, bleeding events after EBL, and the use of prophylactic FFP or platelets were recorded.

Results: A total of 536 patients underwent 1,472 EBL procedures: 72% male; main etiology HCV and alcohol (72%); median MELD score 11; Child-Pugh A/B/C (59/33/8%). EBL procedures were performed for primary (51%) or secondary (49%) prophylaxis. A median of 2 procedures per patient were performed.^1-4 FFP and/or platelets were administered in 41 patients (7.6%). The prophylactic transfusion protocol was followed in 16% and 28% of procedures with high INR and/or low platelets, respectively. Post-EBL bleeding occurred in 26 out of 536 patients (4.8%) and in 33 out of 1,472 procedures (2.2%). Bleeding was due to post-EBL ulcers in 21 patients and due to band dislodgment in 5. In 6 patients, bleeding occurred within 24 hours and in the remaining patients it occurred within 2 weeks after EBL. In those that bled, 7 met criteria for transfusion (2 for FFP and 5 for platelets), of whom only 1 received FFP and 4 received platelets; the remaining 19 patients did not meet criteria for transfusion. There was no association between INR or platelet count and bleeding events. Univariate and multivariate analysis revealed that Child-Pugh and MELD scores were risk factors for post-EBL bleeding.

Conclusions: The incidence of post-EBL bleeding is low and is associated with advanced liver disease. Post-EBL bleeding was not related to baseline INR/platelet count and most outpatients with post-EBL bleeding did not meet criteria for prophylactic transfusion.

Lay summary: Patients with chronic liver disease or cirrhosis and enlarged veins (varices) of the esophagus that can potentially bleed commonly need an endoscopy to treat these varices with elastic rubber bands (endoscopic band ligation). Some patients have low platelet counts or prolonged coagulation tests. This analysis of 4 centers evaluated the use of prophylactic administration of blood products in outpatients with cirrhosis undergoing endoscopic band ligation. The results showed that bleeding after band ligation is uncommon and that if bleeding occurs it does not seem to be related with coagulation tests or the administration of blood products to prevent bleeding after band ligation of esophageal varices.

Keywords: Child Score; EBL, endoscopic band ligation; FFP, fresh frozen plasma; INR, international normalized ratio; MELD score; MELD, model for end-stage liver disease; acute variceal bleeding; cirrhosis; endoscopic band ligation; esophageal varices; fresh frozen plasma; gastrointestinal bleeding; platelet transfusion; platelets; post-band ligation ulcer; primary prophylaxis; secondary prophylaxis.