Safety of Anticoagulation When Undergoing Endoscopic Variceal Ligation: A Systematic Review and Meta-Analysis

The safety of continuing anticoagulation therapy during endoscopic variceal ligation (EVL) remains controversial. We performed a systematic review and meta-analysis to evaluate the safety of anticoagulation therapy in EVL.

We systematically searched four electronic databases from their inception until 1 June 2024, for studies that evaluated anticoagulation use and risk of rebleeding among patients undergoing EVL. The primary endpoint was rebleeding after EVL. The secondary endpoints were post-banding ulcer bleeding (PBUB) and variceal eradication rate. The PROSPERO registration number is CRD42024556094.

A total of 5617 participants from nine studies (eight cohort studies and one randomised trial) were included. The most common type of anticoagulation is low-molecular-weight heparin, followed by warfarin and direct oral anticoagulants (DOAC). The pooled risk of rebleeding was 10.9% (95%CI: 6.3-16.5; I² = 65.5%). Concurrent anticoagulation during EVL did not increase the risk of overall rebleeding (OR, 1.10; 95%CI: 0.85-1.42, I² = 0%), PBUB (OR, 1.04; 95%CI, 0.48-2.24; I² = 24%) or severe bleeding (OR, 0.94; 95%CI, 0.31-2.85; I² = 0%). Variceal eradication rates were similar, regardless of the use of anticoagulation therapy during EVL.

Anticoagulation did not increase the risk of rebleeding in patients who underwent EVL. Since the certainty of evidence is low, these findings should be confirmed in future randomised trials.