Endoscopic treatment of variceal upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline

Introduction

Patients with variceal gastrointestinal bleeding are encountered daily in endoscopic departments around the world. Risk factors include infectious diseases such as hepatitis B and C virus and schistosomiasis, as well as alcohol consumption and metabolic syndrome with development of nonalcoholic fatty liver disease [1]. Globally, prevalence and incidence of chronic liver disease and cirrhosis varies markedly between countries [2]. High-quality epidemiological data from the majority of African countries are lacking; nevertheless, development of cirrhosis and related consequences are a major burden for public health systems in the continent [2] [3] [4]. In Africa, mortality from cirrhosis is estimated at 12.9 to 24.2 per 100,000 person-years range and prevalence of hepatitis B virus is among the highest in the world at 6,100 per 100,000 inhabitants [5] [6].

The latest update of the Baveno guideline describes in detail how to prevent and manage variceal bleeding, as well as how to avoid recurrent bleeding [7]. The majority of recommendations in the guideline are based on high levels of evidence and many years of practice. However, some of the recommendations are resource-sensitive and may be unavailable in low-resource settings due to factors such as extensive costs, lack of sufficient health professional training and logistical limitations.

The European Society of Gastrointestinal Endoscopy (ESGE) has implemented a cascade methodology in a joint effort with the World Endoscopy Organization (WEO), aiming to adapt existing guidelines to make them applicable to resource-limited regions (including some African countries) [8]. Previously, two cascade guidelines have been published focusing on endoscopic management of non-variceal upper gastrointestinal bleeding and upper gastrointestinal obstruction, respectively [8] [9] [10]. This ESGE cascade guideline aims to standardize endoscopic management of patients with variceal gastrointestinal bleeding.

Publication History

Received: 19 May 2020

Accepted: 21 May 2020

Article published online:
01 July 2020

• References

• 1 James SL, Abate D, Abate KH. et al. GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392: 1789-1858
• 2 Moon AM, Singal AG, Tapper EB. Contemporary epidemiology of chronic liver disease and cirrhosis. Clin Gastroenterol Hepatol 2019; DOI: 10.1016/j.cgh.2019.07.060.
• 3 Study GBoD. Accessed 3rd Jan 2020. https://vizhub.healthdata.org/gbd-compare
• 4 Byass P. The global burden of liver disease: a challenge for methods and for public health. BMC Med 2014; 12: 159
• 5 Mokdad AA, Lopez AD, Shahraz S. et al. Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis. BMC Med 2014; 12: 145
• 6 World Health Organization. Global hepatitis report. 2017 https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/
• 7 de Franchis R, Baveno VIF. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
• 8 Hassan C, Aabakken L, Ebigbo A. et al. Partnership with African Countries: European Society of Gastrointestinal Endoscopy (ESGE) - Position Statement. Endosc Int Open 2018; 6: E1247-E1255
• 9 Karstensen JG, Ebigbo A, Aabakken L. et al. Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2018; 6: E1256-E1263
• 10 Ebigbo A, Karstensen JG, Aabakken L. et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2019; 7: E833-E836
• 11 Milholland AV, Wheeler SG, Heieck JJ. Medical assessment by a Delphi group opinion technic. N Engl J Med 1973; 288: 1272-1275
• 12 Shiha G, El-Sayed SS. Gastric variceal ligation: a new technique. Gastrointest Endosc 1999; 49: 437-441