Background: Combined pharmacological and endoscopic therapy, particularly endoscopic variceal ligation (EVL), is the first-line treatment for acute esophageal variceal bleeding (EVB). In patients with rebleeding, the rescue treatment with a transjugular intrahepatic portosystemic shunt (TIPS) is recommended. However, in a real world setting where the accessibility to TIPS is limited, repeated endoscopic therapy is inevitably performed.
Objective: To study the outcomes of EVL on rebleeding and mortality in the resource-limited setting.
Materials and Methods: Patients who underwent EVL during 2017 to 2018 are included. Patients were treated with vasoactive drugs and EVL until the eradication of varices. We focus on the outcome of a second attempt at EVL to control EVB. The rebleeding and mortality rate within 6 months after the combined treatment were collected. Logistic regression analysis was performed to identify risk factors of rebleeding.
Results: There were 339 EVL performed during the 2-year period. Of these procedures, EVL was indicated to control acute EVB in 118 patients. EVB in 98 patients (83%) were successfully controlled in only one session of EVL, while those of 20 patients (17%) required at least 2 sessions to control the recurrent EVB. In the rebleeding group, no patient rebled within 5 days after the first EVL, while 15 patients (75%) rebled within 6 weeks. Once rebled, the second EVL was performed. There were 5 patients (25%) whom the second EVL failed to control the recurrent EVB. Those recurrent EVB were finally controlled by the other endoscopic therapy. The 6-week mortality after rebleeding was 15%. Hepatocellular carcinoma and creatinine are factors associated with recurrent EVB within 6 weeks with odds ratio (OR) 5.96 (95% CI 1.41 to 25.19, p = 0.02) and OR 1.47 (95% CI: 1.02 to 2.11, p = 0.04), respectively.
Conclusion: The second attempt at endoscopic therapy can be considered to control recurrent EVB after the first EVL with a success rate of 75% in area where an accessibility to a treatment with TIPS is limited.

Keywords: Endoscopic therapy, Outcomes, Real world, Recurrent, Variceal bleeding