Hemorrhage from sloughing of the esophageal slough, which has a severe prognosis, is a rare complication of esophageal variceal ligation (EVL) in cirrhotic patients. The aim of this study was to identify risk factors for hemorrhage associated with this complication at the time of EVL.

This retrospective study included patients with cirrhotic portal hypertension who underwent esophageal ligation between April 2021 and October 2025. A retrospective analysis of these patients was performed, followed by a case-control study comparing patients who experienced a first bleeding episode due to sloughing of the esophageal ulcer during their first esophageal ligation (EVL) session (13 cases) with 120 cirrhotic patients (controls) treated during the same period during their first EVL. Univariate and multivariate analyses were conducted to determine predictive factors for bleeding from sloughing of the esophageal ulcer after EVL. The procedure was performed under propofol-induced general anesthesia. Eleven patients experienced a bleeding episode following EVL. Post-EVL sloughing of the esophageal ulcer was confirmed in all cases endoscopically by the presence of active bleeding at one or more sites of post-EVL esophageal ulceration .

Bedsore sloughing occurred in 13 patients with a mean age of 54 years [ 34; 75], with a

 M/F sex ratio of 1.5.

All of the patients were admitted through the emergency department for gastrointestinal bleeding.

Cirrhosis was non-B/non-C in 8 patients (61.5%), of viral origin (Hepatitis B) in 3 patients (23%), of alcoholic origin in 1 patient (7.6%), and of dysmetabolic origin in 1 patient (7.6%).

Seven patients (53.8%) had child-onset C , 4 patients (30.7%) had child-onset B, and 2 patients (15.3%) had child -onset A.

Hemorrhage from sloughing of eschar occurred within an average of 6 days, inducing hemodynamic instability in 2 patients (15.3%) requiring transfusion. This complication induced severe bleeding in all patients and was significantly associated in the case-control study with the presence of gastroesophageal reflux (p<0.001), a history of gastrointestinal bleeding (p=0.02), a low prothrombin level (p=0.01), a high Child- Pugh score (p=0.02), and elevated C- reactive protein. protein (p=0.04) and units of fresh plasma transfused (p=0.03). Two patients (15.3%) died following this complication. In multivariate analysis, a history of gastrointestinal bleeding (OR: 1.2), the presence of gastroesophageal reflux ( OR: 4.5), an APRI score greater than 3.3 (OR: 1.54), and a prothrombin level less than 46% (OR: 0.54) were independent predictors of post-LVO eschar sloughing bleeding.

In conclusion, hemorrhage from sloughing of post-LVO eschar in cirrhotic patients is a severe complication with independent risk factors including a history of gastrointestinal bleeding, gastroesophageal reflux , a high APRI score and a low prothrombin level.