Subscribe to RSS
DOI: 10.1055/a-1939-4887
Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline
![](https://www.thieme-connect.de/media/endoscopy/202211/lookinside/thumbnails/22411_10-1055-a-1939-4887-1.jpg)
Main Recommendations
1 ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.
Strong recommendation, moderate quality evidence.
2 ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2–4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3–6 months in the first year following eradication.
Strong recommendation, moderate quality evidence.
3 ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70–90 g/L is desired.
Strong recommendation, moderate quality evidence.
4 ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child–Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.
Strong recommendation, high quality of evidence.
5 ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.
Strong recommendation, high quality evidence.
6 ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.
Strong recommendation, high quality evidence.
7 ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30–120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.
Strong recommendation, high quality evidence.
8 ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.
Strong recommendation, moderate quality evidence.
9 ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).
Strong recommendation, high quality evidence.
10 ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child–Pugh C ≤ 13 or Child–Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.
Strong recommendation, high quality evidence.
11 ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).
Strong recommendation, moderate quality evidence.
12 ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.
Strong recommendation, high quality evidence.
13 ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.
Strong recommendations, moderate quality evidence.
14 ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.
Weak recommendation, low quality evidence.
15 ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).
Strong recommendation, moderate quality evidence.
16 ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.
Strong recommendation, high quality evidence.
Publication History
Article published online:
29 September 2022
© 2022. European Society of Gastrointestinal Endoscopy. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
References
- 1 Guyatt GH, Oxman AD, Vist GE. et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924-926
- 2 Hassan C, Ponchon T, Bisschops R. et al. European Society of Gastrointestinal Endoscopy (ESGE) Publications Policy – Update 2020. Endoscopy 2020; 52: 123-126
- 3 de Franchis R. Baveno VI Faculty. 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
- 4 Maurice JB, Brodkin E, Arnold F. et al. Validation of the Baveno VI criteria to identify low risk cirrhotic patients not requiring endoscopic surveillance for varices. J Hepatol 2016; 65: 899-905
- 5 Thabut D, Bureau C, Layese R. et al. Validation of Baveno VI criteria for screening and surveillance of esophageal varices in patients with compensated cirrhosis and a sustained response to antiviral therapy. Gastroenterology 2019; 156: 997-1009
- 6 Nawalerspanya S, Sripongpun P, Chamroonkul N. et al. Validation of original, expanded Baveno VI, and stepwise & platelet-MELD criteria to rule out varices needing treatment in compensated cirrhosis from various etiologies. Ann Hepatol 2020; 19: 209-213
- 7 Wang H, Wen B, Chang X. et al. Baveno VI criteria and spleen stiffness measurement rule out high-risk varices in virally suppressed HBV-related cirrhosis. J Hepatol 2021; 74: 584-592
- 8 Bai W, Abraldes JG. Noninvasive assessment oesophageal varices: impact of the Baveno VI criteria. Curr Opin Gastroenterol 2022; 38: 206-215
- 9 Sacher-Huvelin S, Calès P, Bureau C. et al. Screening of esophageal varices by esophageal capsule endoscopy: results of a French multicenter prospective study. Endoscopy 2015; 47: 486-492
- 10 Colli A, Gana JC, Turner D. et al. Capsule endoscopy for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2014; 2014: CD008760
- 11 McCarty TR, Afinogenova Y, Njei B. Use of wireless capsule endoscopy for the diagnosis and grading of esophageal varices in patients with portal hypertension: a systematic review and meta-analysis. J Clin Gastroenterol 2017; 51: 174-182
- 12 Sharma M, Singh S, Desai V. et al. Comparison of therapies for primary prevention of esophageal variceal bleeding: a systematic review and network meta-analysis. Hepatology 2019; 69: 1657-1675
- 13 Villanueva C, Sapena V, Lo GH. et al. Stratified efficacy of first-line therapy to prevent first variceal bleeding according to previous decompensation of cirrhosis. A competing-risk meta-analyses of individual participant data. J Hepatol 2022; 77 (Suppl. 01) FRI520
- 14 Reiberger T, Ulbrich G, Ferlitsch A. et al. Carvedilol for primary prophylaxis of variceal bleeding in cirrhotic patients with haemodynamic non-response to propranolol. Gut 2013; 62: 1634-1641
- 15 Villanueva C, Torres F, Sarin SK. et al. Carvedilol reduces the risk of decompensation and mortality in patients with compensated cirrhosis in a competing-risk meta-analysis. J Hepatol 2022; DOI: 10.1016/j.jhep.2022.05.021.
- 16 Gluud LL, Krag A. Banding ligation versus beta-blockers for primary prevention in oesophageal varices in adults. Cochrane Database Syst Rev 2012; 2012: CD004544
- 17 Funakoshi N, Duny Y, Valats JC. et al. Meta-analysis: beta-blockers versus banding ligation for primary prophylaxis of esophageal variceal bleeding. Ann Hepatol 2012; 11: 369-383
- 18 Tian S, Li R, Guo Y. et al. Carvedilol vs endoscopic band ligation for the prevention of variceal bleeding: a meta-analysis. Ther Clin Risk Manag 2019; 15: 191-200
- 19 Baradarian R, Ramdhaney S, Chapalamadugu R. et al. Early intensive resuscitation of patients with upper gastrointestinal bleeding decreases mortality. Am J Gastroenterol 2004; 99: 619-622
- 20 Lu B, Li M-Q, Li J-Q. The use of limited fluid resuscitation and blood pressure-controlling drugs in the treatment of acute upper gastrointestinal hemorrhage concomitant with hemorrhagic shock. Cell Biochem Biophys 2015; 72: 461-463
- 21 Kwan I, Bunn F, Chinnock P. et al. Timing and volume of fluid administration for patients with bleeding. Cochrane Database Syst Rev 2014; 2014: CD002245
- 22 Duan C, Li T, Liu L. Efficacy of limited fluid resuscitation in patients with hemorrhagic shock: a meta-analysis. Int J Clin Exp Med 2015; 8: 11645-11656
- 23 Carrick MM, Morrison CA, Tapia NM. et al. Intraoperative hypotensive resuscitation for patients undergoing laparotomy or thoracotomy for trauma: Early termination of a randomized prospective clinical trial. J Trauma Acute Care Surg 2016; 80: 886-896
- 24 Lewis SR, Pritchard MW, Evans DJ. et al. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev 2018; 2018: CD000567
- 25 Hammond DA, Lam SW, Rech MA. et al. Balanced crystalloids versus saline in critically ill adults: a systematic review and meta-analysis. Ann Pharmacother 2020; 54: 5-13
- 26 Semler MW, Self WH, Wanderer JP. et al. Balanced crystalloids versus saline in critically ill adults. NEJM 2018; 378: 829-839
- 27 Mohanty A, Kapuria D, Canakis A. et al. Fresh frozen plasma transfusion in acute variceal haemorrhage: Results from a multicentre cohort study. Liver Int 2021; 41: 1901-1908
- 28 Kwon JO, MacLaren R. Comparison of fresh-frozen plasma, four-factor prothrombin complex concentrates, and recombinant factor VIIa to facilitate procedures in critically ill patients with coagulopathy from liver disease: a retrospective cohort study. Pharmacotherapy 2016; 36: 1047-1054
- 29 Bosch J, Thabut D, Bendtsen F. et al. Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial. Gastroenterology 2004; 127: 1123-1130
- 30 Bosch J, Thabut D, Albillos A. et al. Recombinant factor VIIa for variceal bleeding in patients with advanced cirrhosis: A randomized, controlled trial. Hepatology 2008; 47: 1604-1614
- 31 Koch DG, Arguedas MR, Fallon MB. Risk of aspiration pneumonia in suspected variceal hemorrhage: the value of prophylactic endotracheal intubation prior to endoscopy. Dig Dis Sci 2007; 52: 2225-2228
- 32 Rehman A, Iscimen R, Yilmaz M. et al. Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage. Gastrointest Endosc 2009; 69: e55-e59
- 33 Tang YM, Wang W. Prophylactic endotracheal intubation prior to urgent endoscopy in patients with suspected variceal hemorrhage: an evaluation of outcomes and complications. J Gastroenterol Hepatol Res 2017; 6: 2324-2328
- 34 Perisetti A, Kopel J, Shredi A. et al. Prophylactic pre-esophagogastroduodenoscopy tracheal intubation in patients with upper gastrointestinal bleeding. Proc Bayl Univ Med Cent 2019; 32: 22-25
- 35 Almashhrawi AA, Rahman R, Jersak ST. et al. Prophylactic tracheal intubation for upper GI bleeding: A meta-analysis. World J Meta-Anal 2015; 3: 4-10
- 36 Alshamsi F, Jaeschke R, Baw B. et al. Prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy: a systematic review and meta-analysis. Saudi J Med Juschka Sci 2017; 5: 201-209
- 37 Chaudhuri D, Bishay K, Tandon P. et al. Prophylactic endotracheal intubation in critically ill patients with upper gastrointestinal bleed: A systematic review and meta-analysis. JGH Open 2020; 4: 22-28
- 38 Rout G, Deepak GunjunS, Mahapatra SJ. et al. Thromboelastography-guided blood product transfusion in cirrhosis patients with variceal bleeding: a randomized controlled trial. J Clin Gastroenterol 2020; 54: 255-262
- 39 Odutayo A, Desborough MJR, Trivella M. et al. Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials. Lancet Gastroenterol Hepatol 2017; 2: 354-360
- 40 Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L. et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40: 793-801
- 41 Abraldes JG, Villanueva C, Bañares R. et al. Hepatic venous pressure gradient and prognosis in patients with acute variceal bleeding treated with pharmacologic and endoscopic therapy. J Hepatol 2008; 48: 229-236
- 42 García-Pagán JC, Caca K, Bureau C. et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. NEJM 2010; 362: 2370-2379
- 43 Lv Y, Zuo L, Zhu X. et al. Identifying optimal candidates for early TIPS among patients with cirrhosis and acute variceal bleeding: a multicentre observational study. Gut 2019; 68: 1297-1310
- 44 Fortune BE, Garcia-Tsao G, Ciarleglio M. et al. Child-Turcotte-Pugh Class is best at stratifying risk in variceal hemorrhage: analysis of a US multicenter prospective study. J Clin Gastroenterol 2017; 51: 446-453
- 45 Nicoară-Farcău O, Han G, Rudler M. et al. Effects of early placement of transjugular portosystemic shunts in patients with high-risk acute variceal bleeding: a meta-analysis of individual patient data. Gastroenterology 2021; 160: 193-205
- 46 Bambha K, Kim WR, Pedersen R. et al. Predictors of early re-bleeding and mortality after acute variceal haemorrhage in patients with cirrhosis. Gut 2008; 57: 814-820
- 47 Al-Freah MAB, Gera A, Martini S. et al. Comparison of scoring systems and outcome of patients admitted to a liver intensive care unit of a tertiary referral centre with severe variceal bleeding. Aliment Pharmacol Ther 2014; 39: 1286-1300
- 48 Reverter E, Tandon P, Augustin S. et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology 2014; 146: 412-419
- 49 Motola-Kuba M, Escobedo-Arzate A, Tellez-Avila F. et al. Validation of prognostic scores for clinical outcomes in cirrhotic patients with acute variceal bleeding. Ann Hepatol 2016; 15: 895-901
- 50 Rudler M, Bureau C, Carbonell N. et al. Recalibrated MELD and hepatic encephalopathy are prognostic factors in cirrhotic patients with acute variceal bleeding. Liver Int 2018; 38: 469-476
- 51 Conejo I, Guardascione MA, Tandon P. et al. Multicenter external validation of risk stratification criteria for patients with variceal bleeding. Clin Gastroenterol Hepatol 2018; 16: 132-139
- 52 Corley DA, Cello JP, Adkisson W. et al. Octreotide for acute esophageal variceal bleeding: a meta-analysis. Gastroenterology 2001; 120: 946-954
- 53 Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003; 2003: CD002147
- 54 Wells M, Chande N, Adams P. et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35: 1267-1278
- 55 Zhou X, Tripathi D, Song T. et al. Terlipressin for the treatment of acute variceal bleeding: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97: e13437
- 56 Yan P, Tian X, Li J. Is additional 5-day vasoactive drug therapy necessary for acute variceal bleeding after successful endoscopic hemostasis? A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97: e12826
- 57 Huaringa-Marcelo J, Huaman MR, Brañez-Condorena A. et al. Vasoactive agents for the management of acute variceal bleeding: a systematic review and meta-analysis. J Gastrointest Liver Dis 2021; 30: 110-121
- 58 Rengasamy S, Ali SM, Sistla SC. et al. Comparison of 2 days versus 5 days of octreotide infusion along with endoscopic therapy in preventing early rebleed from esophageal varices: a randomized clinical study. Eur J Gastroenterol Hepatol 2015; 27: 386-392
- 59 Azam Z, Hamid S, Jafri W. et al. Short course adjuvant terlipressin in acute variceal bleeding: a randomized double blind dummy controlled trial. J Hepatol 2012; 56: 819-824
- 60 Jha SK, Mishra M, Jha A. et al. Comparison of continuous versus intermittent infusions of terlipressin for the control of acute variceal bleeding in patients with portal hypertension: An open-label randomized controlled trial. Indian J Gastroenterol 2018; 37: 313-320
- 61 Lee S, Saxinger L, Ma M. et al. Bacterial infections in acute variceal hemorrhage despite antibiotics-a multicenter study of predictors and clinical impact. United European Gastroenterol J 2017; 5: 1090-1099
- 62 Soares-Weiser K, Brezis M, Tur-Kaspa R. et al. Antibiotic prophylaxis of bacterial infections in cirrhotic inpatients: a meta-analysis of randomized controlled trials. Scand J Gastroenterol 2003; 38: 193-200
- 63 Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F. et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther 2011; 34: 509-518
- 64 Fernández J, Ruiz del Arbol L, Gómez C. et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology 2006; 131: 1049-1056
- 65 Lee TH, Huang CT, Lin CC. et al. Similar rebleeding rate in 3-day and 7-day intravenous ceftriaxone prophylaxis for patients with acute variceal bleeding. J Formos Med Assoc 2016; 115: 547-552
- 66 Chang TS, Tsai YH, Lin YH. et al. Limited effects of antibiotic prophylaxis in patients with Child-Pugh class A/B cirrhosis and upper gastrointestinal bleeding. PLoS One 2020; 15: e0229101
- 67 Intagliata NM, Argo CK, Stine JG. et al. Concepts in coagulation in liver disease: a summary of the 7th International Coagulation in Liver Disease Conference. Thromb Haemost 2018; 118: 1491-1506
- 68 Radaelli F, Dentali F, Repici A. et al. Management of anticoagulation in patients with acute GI bleeding. Dig Liver Dis 2015; 47: 621-627
- 69 Eisenberg MJ, Richard PR, Libersan D. et al. Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. Circulation 2009; 119: 1634-1642
- 70 Veitch AM, Radaelli F, Alikhan R. et al. Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update. Gut 2021; 70: 1611-1628
- 71 Dasa O, Pepine CJ, Pearson TA. Aspirin in primary prevention: what changed? A critical appraisal of current evidence. Am J Cardiol 2021; 141: 38-48
- 72 Antithrombotic Trialists (ATT) Collaboration. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomized trials. Lancet 2009; 373: 1849-1860
- 73 Sung JJY, Lau JYW, Ching JYL. et al. Continuation of low dose aspirin therapy in peptic ulcer bleeding: a randomized trial. Ann Intern Med 2010; 152: 1-9
- 74 Chan FKL, Leung KiE-L, Wong GLH. et al. Risks of bleeding recurrence and cardiovascular events with continued aspirin use after lower gastrointestinal hemorrhage. Gastroenterology 2016; 151: 271-277
- 75 Cerini F, Gonzalez JM, Torres F. et al. Impact of anticoagulation on upper-gastrointestinal bleeding in cirrhosis. A retrospective multicenter study. Hepatology 2015; 62: 575-583
- 76 Barkun AN, Bardou M, Martel M. et al. Prokinetics in acute upper GI bleeding: a meta-analysis. Gastrointest Endosc 2010; 72: 1138-1145
- 77 Mantides A, Xynos E, Chrysos F. et al. The effect of erythromycin in gastric emptying of solids and hypertonic liquids in healthy subjects. Am J Gastroenterol 1993; 88: 198-202
- 78 Altraif B, Handoo FA, Aljumah A. et al. Effect of erythromycin before endoscopy in patients presenting with variceal bleeding: a prospective, randomized, double-blind, placebo-controlled trial. Gastrointest Endosc 2011; 73: 245-250
- 79 Habashi SL, Lambiase LR, Kottoor R. Prokinetics infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind & placebo-controlled trial. Am J Gastroenterol 2007; 102: S526
- 80 Sussman DA, Deshpande AR, Parra JL. et al. Intravenous metoclopramide to increase mucosal visualization during endoscopy in patients with acute upper gastrointestinal bleeding: a randomized, controlled study [abstract]. Gastrointest Endosc 2008; 67: AB247
- 81 Jung DH, Huh CW, Kim NJ. et al. Optimal endoscopy timing in patients with acute variceal bleeding: A systematic review and meta-analysis. Sci Rep 2020; 10: 4046
- 82 Bai Z, Wang R, Cheng G. et al. Outcomes of early versus delayed endoscopy in cirrhotic patients with acute variceal bleeding: a systematic review with meta-analysis. Eur J Gastroenterol Hepatol 2021; 33 (Suppl. 01) e868-e876
- 83 Huh CW, Kim JS, Jung DH. et al. Optimal endoscopy timing according to the severity of underlying liver disease in patients with acute variceal bleeding. Dig Liver Dis 2019; 51: 993-998
- 84 Yoo JJ, Chang Y, Cho EJ. et al. Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding. World J Gastroenterol 2018; 24: 5025-5033
- 85 Gralnek IM, Stanley AJ, Morris AJ. et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021. Endoscopy 2021; 53: 300-332
- 86 European Association for the Study of the Liver. EASL Clinical Practice Guidelines on prevention and management of bleeding and thrombosis in patients with cirrhosis. J Hepatol 2022; 76: 1151-1184
- 87 Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995; 123: 280-287
- 88 de Quados Onofrio F, Pereira-Lima JC, Valenca FM. et al. Efficacy of endoscopic treatments for acute esophageal variceal bleeding in cirrhotic patients: systematic review and meta-analysis. Endosc Int Open 2019; 7: e1503-e1514
- 89 Ramirez FC, Colon VJ, Landan D. et al. The effects of the number of rubber bands placed at each endoscopic session upon variceal outcomes: a prospective, randomized study. Am J Gastroenterol 2007; 102: 1372-1376
- 90 Lee SW, Lee TY, Chang CS. Independent factors associated with recurrent bleeding in cirrhotic patients with esophageal variceal hemorrhage. Dig Dis Sci 2009; 54: 1128-1134
- 91 Xu L, Ji F, Xu QW. et al. Risk factors for predicting early variceal rebleeding after endoscopic variceal ligation. World J Gastroenterol 2011; 17: 3347-3352
- 92 Ibrahim M, El-Mikkawy A, Abdel Hamid M. et al. Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: a randomised trial. Gut 2019; 68: 844-853
- 93 Lv Y, Yang Z, Liu L. et al. Early TIPS with covered stents versus standard treatment for acute variceal bleeding in patients with advanced cirrhosis: a randomised controlled trial. Lancet Gastroenterol Hepatol 2019; 4: 587-598
- 94 Vangeli M, Patch D, Burroughs AK. Salvage tips for uncontrolled variceal bleeding. J Hepatol 2002; 37: 703-704
- 95 Maimone S, Saffioti F, Filomia R. et al. Predictors of re-bleeding and mortality among patients with refractory variceal bleeding undergoing salvage transjugular intrahepatic portosystemic shunt (TIPS). Dig Dis Sci 2019; 64: 1335-1345
- 96 Panés J, Teres J, Bosch J. et al. Efficacy of balloon tamponade in treatment of bleeding gastric and esophageal varices. Results in 151 consecutive episodes. Dig Dis Sci 1988; 33: 454-459
- 97 Hubmann R, Bodlaj G, Czompo M. et al. The use of self-expanding metal stents to treat acute esophageal variceal bleeding. Endoscopy 2006; 38: 896-901
- 98 Zehetner J, Shamiyeh A, Wayand W. et al. Results of a new method to stop acute bleeding from esophageal varices: implantation of a self-expanding stent. Surg Endosc 2008; 22: 2149-2152
- 99 McCarty TR, Njei B. Self-expanding metal stents for acute refractory esophageal variceal bleeding: A systematic review and meta-analysis. Dig Endosc 2016; 28: 539-547
- 100 Escorsell À, Pavel O, Cardenas A. et al. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: A multicenter randomized, controlled trial. Hepatology 2016; 63: 1957-1967
- 101 Saad WE, Sabri SS. Balloon-occluded retrograde transvenous obliteration (BRTO): technical results and outcomes. Semin Intervent Radiol 2011; 28: 333-338
- 102 Kumamoto M, Toyonaga A, Inoue H. et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol 2010; 25: 1129-1135
- 103 Pagán JCG, Barrufet M, Cardenas A. et al. Management of gastric varices. Clin Gastroenterol Hepatol 2014; 12: 919-928
- 104 Sarin SK, Lahoti D, Saxena SP. et al. Prevalence, classification, and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16: 1343-1349
- 105 Ye X, Huai J, Chen Y. Cyanoacrylate injection compared with band ligation for acute gastric variceal hemorrhage: a meta-analysis of randomized controlled trials and observational studies. Gastroenterol Res Pract 2014; 2014: 806586
- 106 Qiao W, Ren Y, Bai Y. et al. Cyanoacrylate injection versus band ligation in the endoscopic management of acute gastric variceal bleeding: meta-analysis of randomized, controlled studies based on the PRISMA statement. Medicine (Baltimore) 2015; 94: e1725
- 107 Ríos Castellanos E, Seron P, Gisbert JP. et al. Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. Cochrane Database Syst Rev 2015; 2015: CD010180
- 108 Hu Z, Zhang D, Swai J. et al. Risk of rebleeding from gastroesophageal varices after initial treatment with cyanoacrylate; a systematic review and pooled analysis. BMC Gastroenterol 2020; 20: 181
- 109 Chirapongsathorn S, Manatsathit W, Farrell A. et al. Safety and efficacy of endoscopic cyanoacrylate injection in the management of gastric varices: A systematic review and meta-analysis. JGH Open 2021; 5: 1047-1055
- 110 El Amin H, Abdel Baky L, Sayed Z. et al. A randomized trial of endoscopic variceal ligation versus cyanoacrylate injection for treatment of bleeding junctional varices. Trop Gastroenterol 2010; 31: 279-284
- 111 Cheng LF, Wang ZQ, Li CZ. et al. Low incidence of complications from endoscopic gastric variceal obturation with butyl cyanoacrylate. Clin Gastroenterol Hepatol 2010; 8: 760-766
- 112 Bhurwal A, Makar M, Patel A. et al. Safety and efficacy of thrombin for bleeding gastric varices: a systematic review and meta-analysis. Dig Dis Sci 2022; 67: 953-963
- 113 Binmoeller KF, Weilert F, Shah JN. et al. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74: 1019-1025
- 114 Mohan BP, Chandan S, Khan SR. et al. Efficacy and safety of endoscopic ultrasound-guided therapy versus direct endoscopic glue injection therapy for gastric varices: systematic review and meta-analysis. Endoscopy 2020; 52: 259-267
- 115 McCarty TR, Bazarbashi AN, Hathorn KE. et al. Combination therapy versus monotherapy for EUS-guided management of gastric varices: A systematic review and meta-analysis. Endosc Ultrasound 2020; 9: 6-15
- 116 Paleti S, Nutalapati V, Fathallah J. et al. Balloon-occluded retrograde transvenous obliteration (BRTO) versus transjugular intrahepatic portosystemic shunt (TIPS) for treatment of gastric varices because of portal hypertension: a systematic review and meta-analysis. J Clin Gastroenterol 2020; 54: 655-660
- 117 Yu Q, Liu C, Raissi D. Balloon-occluded retrograde transvenous obliteration versus transjugular intrahepatic portosystemic shunt for gastric varices: a meta-analysis. J Clin Gastroenterol 2021; 55: 147-158
- 118 Tripathi D, Stanley AJ, Hayes PC. et al. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Clinical Services and Standards Committee of the British Society of Gastroenterology. Gut 2015; 64: 1680-1704
- 119 Garcia-Tsao G, Abraldes JG, Berzigotti A. et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017; 65: 310-335
- 120 Harewood GC, Baron TH, Song LM. Factors predicting success of endoscopic variceal ligation for secondary prophylaxis of esophageal variceal bleeding. J Gastroenterol Hepatol 2006; 21: 237-241
- 121 Lo GH. The role of endoscopy in secondary prophylaxis of esophageal varices. Clin Liver Dis 2010; 14: 307-323
- 122 Wang HM, Lo GH, Chen WC. et al. Randomized controlled trial of monthly versus biweekly endoscopic variceal ligation for the prevention of esophageal variceal rebleeding. J Gastroenterol Hepatol 2014; 29: 1229-1236
- 123 Sheibani S, Khemichian S, Kim JJ. et al. Randomized trial of 1-week versus 2-week intervals for endoscopic ligation in the treatment of patients with esophageal variceal bleeding. Hepatology 2016; 64: 549-555
- 124 Salerno F, Guevara M, Bernardi M. et al. Refractory ascites: pathogenesis, definition and therapy of a severe complication in patients with cirrhosis. Liver Int 2010; 30: 937-947
- 125 Gonzalez R, Zamora J, Gomez-Camarero J. et al. Meta-analysis: combination endoscopic and drug therapy to prevent variceal rebleeding in cirrhosis. Ann Intern Med 2008; 149: 109-122
- 126 Cheung J, Zeman M, van Zanten SV. et al. Systematic review: secondary prevention with band ligation, pharmacotherapy or combination therapy after bleeding from oesophageal varices. Aliment Pharmacol Ther 2009; 30: 577-588
- 127 Thiele M, Krag A, Rohde U. et al. Meta-analysis: banding ligation and medical interventions for the prevention of rebleeding from oesophageal varices. Aliment Pharmacol Ther 2012; 36: 1155-1165
- 128 Puente A, Hernández-Gea V, Graupera I. et al. Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review. Liver Int 2014; 34: 823-833
- 129 Albillos A, Zamora J, Martínez J. et al. Stratifying risk in the prevention of recurrent variceal hemorrhage: Results of an individual patient meta-analysis. Hepatology 2017; 66: 1219-1231
- 130 Hung HH, Chang CJ, Hou MC. et al. Efficacy of non-selective β-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: a randomized controlled trial. J Hepatol 2012; 56: 1025-1032
- 131 Chen WC, Hsin IF, Chen PH. et al. Addition of carvedilol to gastric variceal obturation does not decrease recurrence of gastric variceal bleeding in patients with cirrhosis. Clin Gastroenterol Hepatol 2019; 17: 2356-2363
- 132 Osman KT, Nayfeh T, Abdelfattah AM. et al. Secondary prophylaxis of gastric variceal bleeding: a systematic review and network meta-analysis. Liver Transpl 2022; 28: 945-958
- 133 Schmitz RJ, Sharma P, Badr AS. et al. Incidence and management of esophageal stricture formation, ulcer bleeding, perforation, and massive hematoma formation from sclerotherapy versus band ligation. Am J Gastroenterol 2001; 96: 437-441
- 134 Petrasch F, Grothaus J, Mossner J. et al. Differences in bleeding behavior after endoscopic band ligation: a retrospective analysis. BMC Gastroenterol 2010; 10: 5
- 135 Vanbiervliet G, Giudicelli-Bornard S, Piche T. et al. Predictive factors of bleeding related to post-banding ulcer following endoscopic variceal ligation in cirrhotic patients: A case-control study. Aliment Pharmacol Ther 2010; 32: 225-232
- 136 Kang SH, Yim HJ, Kim SY. et al. Proton pump inhibitor therapy is associated with reduction of early bleeding risk after prophylactic endoscopic variceal band ligation a retrospective cohort study. Medicine (Baltimore) 2016; 95: 1-9
- 137 Sinclair M, Vaughan R, Angus PW. et al. Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation. Eur J Gastroenterol Hepatol 2015; 27: 928-932
- 138 Shaheen NJ, Stuart E, Schmitz SM. et al. Pantoprazole reduces the size of postbanding ulcers after variceal band ligation: A randomized, controlled trial. Hepatology 2005; 41: 588-594
- 139 Jang WS, Shin HP, Lee JI. et al. Proton pump inhibitor administration delays rebleeding after endoscopic gastric variceal obturation. World J Gastroenterol 2014; 20: 17127-17131
- 140 Kim KR, Jun CH, Cho KM. et al. Can proton pump inhibitors reduce rebleeding following Histoacryl sclerotherapy for gastric variceal hemorrhage?. Korean J Intern Med 2015; 30: 593-601
- 141 Bajaj JS, Zadvornova Y, Heuman DM. et al. Association of proton pump inhibitor therapy with spontaneous bacterial peritonitis in cirrhotic patients with ascites. Am J Gastroenterol 2009; 104: 1130-1134
- 142 Bajaj JS, Ratliff SM, Heuman DM. et al. Proton pump inhibitors are associated with a high rate of serious infections in veterans with decompensated cirrhosis. Aliment Pharmacol Ther 2012; 36: 866-874
- 143 Deshpande A, Pasupuleti V, Thota P. Acid-suppressive therapy is associated with spontaneous bacterial peritonitis in cirrhotic patients: a meta-analysis. J Gastroenterol Hepatol 2013; 28: 235-242
- 144 Merli M, Lucidi C, Di G. et al. The chronic use of beta-blockers and proton pump inhibitors may affect the rate of bacterial infections in cirrhosis. Liver Int 2015; 35: 362-369
- 145 Vilstrup H, Amodio P, Bajaj J. et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology 2014; 60: 715-735
- 146 de Franchis R, Bosch J, Garcia-Tsao G. et al. Baveno VII – renewing consensus in portal hypertension: Report of the Baveno VII Consensus Workshop: personalized care in portal hypertension. J Hepatol 2022; 76: 959-974
- 147 Sharma P, Agrawal A, Sharma BC. et al. Prophylaxis of hepatic encephalopathy in acute variceal bleed: a randomized controlled trial of lactulose versus no lactulose. J Gastroenterol Hepatol 2011; 26: 996-1003
- 148 Wen J, Liu Q, Song J. et al. Lactulose is highly potential in prophylaxis of hepatic encephalopathy in patients with cirrhosis and upper gastrointestinal bleeding: results of a controlled randomized trial. Digestion 2013; 87: 132-138
- 149 Rolachon A, Zarski JP, Lutz JM. et al. Is the intestinal lavage with a solution of mannitol effective in the prevention of post-hemorrhagic hepatic encephalopathy in patients with liver cirrhosis? Results of a randomized prospective study. Gastroenterol Clin Biol 1994; 18: 1057-1062
- 150 Tromm A, Griga T, Greving I. et al. Orthograde whole gut irrigation with mannite versus paromomycine + lactulose as prophylaxis of hepatic encephalopathy in patients with cirrhosis and upper gastrointestinal bleeding: results of a controlled randomized trial. Hepatogastroenterology 2000; 47: 473-477
- 151 Higuera-de-la-Tijera F, Servín-Caamaño A, Salas-Gordillo F. et al. Primary prophylaxis to prevent the development of hepatic encephalopathy in cirrhotic patients with acute variceal bleeding. Can J Gastroenterol Hepatol 2018; 2018: 3015891