Purpose Endoscopic variceal ligation (EVL) - induced ulcer bleeding occurs rarely after variceal ligation, but is potentially life-threatening. Limited data exist regarding incidence across different clinical settings, treatment efficacy, and prognostic factors.Methods We conducted a retrospective cohort study analyzing all ligation procedures performed in adults with portal hypertension and esophageal varices at Charité University Hospital, Campus Virchow and Campus Mitte, from 01/01/2016 until 06/30/2023. We assessed bleeding incidence by ligation indication, described endoscopic treatment strategies, and analyzed predictors of 5-day rebleeding and 6-week mortality.Results Among 1864 EVLs, 61 (3.3%) resulted in EVL-induced ulcer bleeding; 60 were analyzed. Incidence varied significantly by indication: 0.44% after elective, 8.5% after emergency and 15.9% after semi-elective EVL, which was performed in patients during hospitalization for acute decompensation of cirrhosis. Repeat ligation was the most common endoscopic treatment (32.4%), followed by fibrin glue (14.7%) and balloon tamponade (11.7%); primary hemostasis was achieved in 82.8% of cases with active bleeding. Ten patients (16.7%) received TIPS within 14 days after bleeding. The 5-day bleeding recurrence rate was 25% and the 6-week mortality rate was 41.7%. In multivariate analysis, sepsis after EVL-induced ulcer bleeding (OR 8.13–55.5; p = 0.014) and 5-day bleeding recurrence (OR: 10.85; 2.40–61.80; p = 0.003) were the strongest predictors of 6-week mortality.Conclusions EVL-induced ulcer bleeding occurs more frequently following semi-elective or emergency variceal ligations, with multiple endoscopic interventions demonstrating high primary hemostasis rates in clinical practice. Prevention of sepsis and rebleeding are critical targets for mortality reduction.