Is there adequate evidence to encourage early feeding in patients with acute esophageal variceal bleeding?

Acute esophageal variceal bleeding (EVB) is a major consequence of liver cirrhosis. However, the typical outcome of acute EVB has improved since the onset of the use of modern standard treatment, including early vasoactive agents, antibiotic prophylaxis, and endoscopic treatment. Nonetheless, EVB is still characteristic of a high rebleeding rate of approximately 20% and 40% bleeding-related mortality in patients with liver cirrhosis. This underscores the fact that consecutive improvement of patients’ medical management is required. The correct targeted timing of feeding following endoscopic treatment of gastrointestinal bleeding is an important issue, where some observers have wondered whether early feeding influenced the outcomes of early rebleeding. A previous study found that there was no difference in rebleeding rates between earlyand late-feeding patients with low-risk peptic ulcer bleeding. However, the impact of feeding after endoscopic treatment of EVB has rarely been investigated. Adequate feeding is necessary to prevent catabolic disadvantage in relatively malnourished cirrhotic patients. Dietary protein restriction should be avoided in patients with cirrhosis, except possibly for a very short period in patients with gastrointestinal bleeding while undergoing stabilization. However, theoretically, oral feeding may cause postprandial hyperemia of mesenteric circulation and, in turn, lead to an increase of portal pressure, which is the primary mechanism of variceal rupture. Moreover, it is also possible that oral feeding may irritate the sloughing wound on varices after endoscopic ligation (EVL). Therefore, it is reasonable to hypothesize that early feeding may increase early rebleeding after EVL in patients with EVB. However, can the bench concept be really translated into a clinical scenario? We were excited to have the chance to read the study conducted by Lo et al, where the authors intended to determine whether early versus delayed feeding following EVL can improve hemostatic outcomes of patients with acute EVB. All their patients followed the current consensus/guideline for the treatment of acute EVB. They randomized 36 patients into an early-feeding group after fasting for 4 hours following EVL, and 34 patients into a delayed-feeding group after fasting for 48 hours following EVL. They found that very