Predicting Mortality and Rebleeding in Acute Variceal Hemorrhage: A Real-World Study of Endoscopy Timing in Cirrhosis

Abstract

Background: Esophageal variceal bleeding (EVB) is a life-threatening complication of cirrhosis and a major contributor to morbidity and mortality. Although early endoscopic intervention is recommended, the optimal timing of endoscopy remains debated, and robust tools for predicting rebleeding risk are lacking. Objectives: To evaluate the effects of different endoscopy-timing strategies on short-term outcomes in cirrhotic patients with acute EVB and to develop a predictive model for 30-day rebleeding risk. Methods: This retrospective cohort study was conducted at a tertiary medical center from January 2018 to December 2023. A total of 350 patients with cirrhosis and acute EVB were included and categorized into 3 groups based on endoscopy timing: < 6 hours (super-early), 6 - 12 hours (standard), and > 12 hours (delayed). Multivariable logistic regression was used to identify independent predictors of 30-day rebleeding. A nomogram was constructed for individualized risk estimation, and its performance was evaluated using receiver operating characteristic analysis and Hosmer-Lemeshow calibration testing. Results: Among 583 screened patients, 350 met the inclusion criteria. Of these, 50 underwent super-early endoscopy, 180 underwent standard-timing endoscopy, and 120 underwent delayed endoscopy. The standard group had the lowest 30-day rebleeding rate (5%), compared with the super-early (10%) and delayed (12%) groups (P = 0.03). The 30-day mortality rate did not differ significantly among the groups (super-early, 6%; standard, 4%; delayed, 8%; P = 0.12). Independent predictors of rebleeding included endoscopy timing, Child-Pugh class, shock at admission, hemoglobin level, and international normalized ratio (INR). The predictive nomogram demonstrated strong discriminatory ability (area under the curve [AUC] = 0.82) and good calibration (Hosmer-Lemeshow P = 0.09). Conclusions: In this retrospective cohort, endoscopy performed within 6 - 12 hours was associated with a lower 30-day rebleeding rate, whereas 30-day mortality was similar among the timing groups. The proposed nomogram may facilitate individualized estimation of 30-day rebleeding risk and support clinical decision-making.