Off-Hours Endoscopic Management and Clinical Outcomes in Acute Esophageal Variceal Bleeding: A Real-World Cohort Study

Background and Objectives: Acute esophageal variceal bleeding is a life-threatening gastrointestinal emergency associated with high morbidity and mortality. Endoscopy plays a central role in its management; however, the impact of off-hours endoscopic care on clinical outcomes remains controversial. This study aimed to compare regular-hours and off-hours endoscopic management in patients with acute esophageal variceal bleeding. Materials and Methods: This retrospective single-center cohort study included adult patients who underwent endoscopy for acute esophageal variceal bleeding between January 2020 and January 2025. Patients were divided into regular-hours and off-hours groups according to the timing of endoscopy. Demographic characteristics, laboratory findings, liver disease severity scores, endoscopy timing, and clinical outcomes were retrospectively evaluated. The primary endpoint was in-hospital mortality. Secondary endpoints were early rebleeding, length of hospital stay, and 6-week mortality. Results: A total of 253 patients were included; 160 (63.2%) underwent endoscopy during regular hours, and 93 (36.8%) during off-hours. Ascites was more frequent in the off-hours group (73.1% versus 58.8%; p = 0.022), and albumin levels were lower (2.7 versus 3.1 g/dL; p = 0.024). The groups were similar in terms of age, sex, cirrhosis etiology, Child-Pugh-Turcotte class, and MELD-Na score. Most patients (90.3%) underwent endoscopy within 12 h, with no significant difference between groups. In-hospital mortality, 6-week mortality, early rebleeding, and length of hospital stay were also comparable. In multivariable logistic regression analysis adjusted for ascites, albumin level, and hepatic encephalopathy, off-hours endoscopic intervention was not independently associated with in-hospital mortality. Conclusions: Off-hours endoscopic management was not associated with worse mortality or rebleeding outcomes in acute esophageal variceal bleeding. These findings suggest that in well-organized centers with continuous endoscopy availability, clinical outcomes may be preserved regardless of the time of endoscopic intervention.