Association between baseline FIB-4 score and bleeding presentation among cirrhotic patients with F3 esophageal varices without high-risk stigmata

Aims: Esophageal variceal bleeding (EVB) remains a major cause of morbidity and mortality in patients with liver cirrhosis. Although endoscopic grading is central to risk stratification, it remains uncertain whether non-invasive fibrosis-based indices provide additional discriminatory value among patients with advanced (F3) esophageal varices without high-risk endoscopic stigmata. Methods: This retrospective single-center cohort study included 69 cirrhotic patients with F3 esophageal varices without red wale marks at index endoscopy. Baseline Child-Pugh, Model for endstage liver disease (MELD), Aminotransferase-to-Platelet Ratio Index (APRI), and fibrosis-4 (FIB-4) scores were calculated using laboratory measurements obtained within one week of the index endoscopy. The primary outcome was the mode of clinical presentation during follow-up, defined as acute variceal bleeding requiring emergency endoscopy or elective endoscopic band ligation following the development of newly detected red wale marks during scheduled surveillance. Receiver operating characteristic (ROC) analysis and logistic regression were performed to evaluate the association and discriminatory performance of baseline non-invasive markers. Results: During follow-up, 49 patients presented with acute variceal bleeding and 20 underwent elective endoscopic band ligation after developing newly detected red wale marks. Baseline FIB-4 scores were significantly higher in the bleeding presentation group than in the elective intervention group (4.9 vs. 2.9, p<0.001). FIB-4 demonstrated good discriminatory ability [area under the curve=0.816; 95% confidence interval (CI), 0.710-0.910] and remained independently associated with bleeding presentation in multivariable logistic regression analysis (odds ratio 1.86, 95% CI 1.24-2.79; p=0.003). APRI and MELD showed lower discriminatory performance and were not independently associated with the study outcome. Conclusion: Among cirrhotic patients with F3 esophageal varices without high-risk endoscopic stigmata, higher baseline FIB-4 scores were independently associated with bleeding presentation during follow-up. These findings suggest that FIB-4 may provide complementary biological information beyond conventional endoscopic assessment and may contribute to individualized risk stratification following prospective validation.