Optimal interval times for rescoping after an acute variceal haemorrhage

We read with great interest the British Society of Gastroenterology guideline by Tripathi et al ¹ on the management of variceal haemorrhage in patients with cirrhosis. The authors recommend interval of 2–4 weeks for endoscopic variceal ligation (EVL) for secondary prophylaxis in this guidance.

However, confusion remains due to the wide variation in the recommendations concerning the optimal timings of variceal band ligation (VBL) after index endoscopy. The recommendations from the leading endoscopic guidelines are summarised in table 1.

Table 1.

The recommended variceal band ligation (VBL) schedules for the secondary prophylaxis of variceal haemorrhage from the leading gastroenterology guidelines^1–3

Title	UK guidelines on the management of variceal haemorrhage in cirrhotic patients1	The role of endoscopy in the management of variceal haemorrhage2	Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis3
Author	British Society of Gastroenterology	The American Society of Gastrointestinal Endoscopy	The American Association for the Study of Liver Diseases
Date of publication	2015	2014	2007
Recommendation for VBL protocol for secondary prophylaxis	2–4 weekly intervals	1–8 weekly intervals	1–2 weekly interval

The authors have recognised that the optimal protocol for VBL sessions for secondary prophylaxis of variceal haemorrhage is indeed debatable. First, there is a lack of evidence characterising the optimal delivery of VBL for secondary prophylaxis. Second, the recent evidence authors have based their recommendation on did not demonstrate a significant difference in recurrence, rebleeding and mortality in either group.⁴ In this study, Wang et al compared outcome in patients’ randomised to variceal obliteration either monthly or biweekly. Patients receiving EVL monthly had similar rebleeding rate, variceal recurrence and mortality to those receiving EVL biweekly for secondary prophylaxis of variceal bleeding; however, the monthly interval was associated with fewer post-EVL ulcers than in biweekly group at follow-up endoscopies (11% vs 57%, p<0.001).

Your guideline does not consider the research by Harewood et al, ⁵ who reported that rebanding in <3-week intervals was associated with a higher rebleeding rate. This may well be linked to fewer post-VBL ulcers when rescoping occurs at longer intervals.

With the lack of evidence, it is difficult to estimate an optimal VBL schedule for the secondary prophylaxis of variceal haemorrhage. Further prospective research, with large patient numbers, is required to guide the recommendations. To avoid confusion in practice, recommendations should be explicit in the lack of understanding and the uncertainty that this area presents alongside an acknowledgement of the variations between guidelines. With limited patchy evidence at this stage, it may be more beneficial to practice in accordance with local guidelines and for the guidelines to reference the research available that creates this debate.