Letter: Post‐Banding Ulcer Bleeding Is More Common With Urgent EBL and Renal Dysfunction

We read with great interest the study by de Brito Nunes and colleagues reporting a substantial burden of post-banding ulcer bleeding (PBUB) after endoscopic band ligation (EBL) with an incidence of 17.5% (36/206) per patient and 6.8% per procedure. They identified urgent EBL and higher creatinine as independent risk factors for PBUB [1]. The relevance of risk stratification for PBUB in patients undergoing EBL for acute variceal bleeding (AVB) is underscored by its considerable associated mortality [2]. In fact, PBUB is difficult to treat, sometimes requiring rescue techniques, such as SX-ELLA Danis stent [3]. We assessed the risk factors for PBUB reported by de Brito Nunes et al. in a large, real-world patient cohort recruited from two tertiary Vienna centres [4]. We included patients undergoing EBL in the settings of (i) AVB (i.e., urgent EBL) or (ii) primary/secondary bleeding prophylaxis (i.e., elective EBL) [5]. We assessed PBUB incidence within 14 days after EBL. Among 920 EBLs, we observed PBUB in 3.4% (31/920). Rates differed markedly by setting: 7.5% after urgent EBL (22/294) versus 1.4% after elective EBL (9/626). Although the absolute incidence of PBUB in our cohort was lower than the per-patient incidence reported by Nunes et al. (17.5%), these estimates are not directly comparable due to potential differences in definitions, liver disease severity of the included cohort, follow-up, and likely also due to unmeasured bias. In multivariable modelling, urgent indication remained strongly associated with PBUB (adjusted odds ratio, aOR: 5.15; 95% confidence interval (95% CI): 2.32–11.46; Fine–Grey adjusted subdistribution hazard ratio, asHR: 4.97; 95% CI: 2.27–10.88; Figure 1). Renal dysfunction also emerged as a key risk factor for PBUB in our cohort, as patients with serum creatinine (sCrea) ≥ 1.5 mg/dL experienced a PBUB rate of 8.9% (7/79) – which was significantly higher than in lower creatinine strata (2.4%–2.9%). Importantly, sCrea ≥ 1.5 mg/dL independently predicted PBUB (aOR: 2.88; 95% CI 1.14–7.27; aSHR: 2.68, 95% CI 1.12–6.43; Figure 1). In summary, our findings align well with the results reported by de Brito Nunes et al., who found higher sCrea and urgent EBL independently associated with the risk of PBUB [1]. Methodological differences should be acknowledged: our analysis was restricted to index EBL and used a time-based 14 days post-EBL bleeding definition rather than endoscopically confirmed PBUB across all sessions, which limits direct comparison of absolute incidence. Nevertheless, both cohorts identified urgent EBL and impaired renal function as relevant risk factors for PBUB—substantiating the evidence for the higher post-EBL bleeding risk in these clinical conditions. We agree with the authors that standardised PBUB definitions and multicentre prospective datasets are needed. Meanwhile, a simple sCrea threshold (e.g., ≥ 1.5 mg/dL) combined with urgent EBL indication may offer a bedside framework to identify patients who warrant heightened surveillance and consideration of preventive strategies. Jurij Maurer: writing – original draft, writing – review and editing. Christian Sebesta: writing – review and editing, methodology. David J. M. Bauer: software, methodology, writing – review and editing, visualization. Nikolaus Pfisterer: data curation. Michael Gschwantler: supervision. Christian Madl: supervision. Thomas Reiberger: conceptualization, writing – review and editing, validation, methodology, formal analysis, project administration, resources, supervision. The authors have nothing to report. The authors declare no conflicts of interest. This article is linked to de Brito Nunes et al. paper. To view this article, visit https://doi.org/10.1111/apt.70495. The data that support the findings of this study are available from the corresponding author upon reasonable request.