High-Frequency Intraluminal Ultrasound Versus Esophagogastroduodenoscopy for Predicting Variceal Hemorrhage After Prophylactic Endoscopic Variceal Ligation

Background/Objectives: The role of endoscopic ultrasonography (EUS) in surveillance after endoscopic variceal ligation (EVL) for primary prophylaxis of esophageal variceal hemorrhage remains uncertain. This study compared the predictive value of high-frequency intraluminal ultrasound (HFIUS) and esophagogastroduodenoscopy (EGD) for subsequent variceal hemorrhage after prophylactic EVL. Methods: In this retrospective study, follow-up EGD and HFIUS were performed in 40 patients with liver cirrhosis who underwent EVL as primary prophylaxis against variceal hemorrhage. EGD-based variceal grade and variceal cross-sectional area (CSA) measured by HFIUS were compared in all 40 patients. Among them, 31 who achieved variceal eradication or reduction to grade 0/1 on surveillance EGD were subsequently followed to evaluate subsequent variceal hemorrhage and clinical outcomes. Results: Spearman’s correlation analysis revealed a statistically significant yet weak positive correlation between EGD-based variceal grade and variceal CSA measured by HFIUS (ρ = 0.347, p = 0.028). Among the 31 patients with grade 0/1 varices on follow-up EGD, the mean follow-up duration was 32.4 ± 8.8 months, during which variceal hemorrhage occurred in seven patients and five patients died. In this exploratory analysis based on seven hemorrhagic events, a preliminary variceal CSA cutoff of 9.8 mm2 predicted subsequent hemorrhage with an apparent sensitivity of 85.7% and specificity of 91.7% (optimism-corrected 75.3% and 90.0%; bootstrap-corrected AUC 0.945). Multivariate analysis showed that variceal CSA measured by HFIUS was independently associated with variceal hemorrhage (OR, 1.302; 95% CI, 1.040–2.020; p = 0.016), whereas EV grade assessed by surveillance EGD was not predictive of variceal hemorrhage. Conclusions: HFIUS-derived variceal CSA was associated with subsequent hemorrhage among patients with grade 0/1 varices after EVL and may provide prognostic information not captured by endoscopic grade alone. Incorporation of HFIUS-based EUS into post-EVL surveillance may help identify patients at persistent bleeding risk who may benefit from intensified prophylactic strategies, even when grade 0/1 eradication has been confirmed on surveillance EGD. Given the small number of events, the proposed cutoff is preliminary and requires external validation.