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November 2022, The European Society of Gastrointestinal Endoscopy (ESGE) has published guidelines
for the endoscopic diagnosis and treatment of oesophageal variceal bleeding.
Portal hypertension can cause bleeding from oesophageal varices and requires emergency evaluation and management
.
This article summarizes the main recommendations of the guidelines
.
01
Advanced chronic liver disease (ACLD; Nonselective β selective beta) due to viral, alcoholic, and/or non-obese [BMI<30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] >10 mmHg and/or transient elastography showing liver stiffness >25 kPa).
blocker, NSBB) therapy (preferably carvedilol) to prevent the development
of variceal bleeding.
.
02For
patients whose upper gastrointestinal endoscopy shows a high risk of oesophageal varices and cannot be treated with NSBB, endoscopic band ligation (EBL) is the preferred endoscopic prophylactic treatment
。 EBL should be repeated every 2~4 weeks until varicose vein eradication
is achieved.
Endogastroduodenoscopy (EGD) monitoring
should be performed every 3~6 months in the first year after eradication.
Highly recommended, moderate-certainty evidence
.
03For
patients with acute upper GI hemorrhage (UGIH) who are hemodynamically stable and have no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy with a hemoglobin threshold ≤ 70 is recommended g/L, suggesting RBC
infusion.
Expected haemoglobin after transfusion is 70 to 90 g/L
.
Highly recommended, moderate-certainty evidence
.
04
Suspected acute variceal bleeding is recommended based on the Child–Pugh score and the Model for end-stage liver disease (MELD) score, as well as active/inactive bleeding recorded during upper endoscopy Risk stratification
occurs in patients with ACLD.
Highly recommended, high-quality evidence
.
05
It is recommended that patients with suspected acute variceal bleeding start the vasoactive drugs terlipressin, octreotide or somatostatin at the time of presentation for 5 days
.
Highly recommended, high-quality evidence
.
06Antibiotic
prophylaxis of ceftriaxone 1 g/day is recommended for all patients with ACLD with acute variceal bleeding for up to 7 days, or antibiotic prophylaxis
depending on local antibiotic resistance and patient allergy.
Highly recommended, high-quality evidence
.
07In
the absence of contraindications, it is recommended to inject erythromycin 250 mg intravenously 30~120 minutes before upper gastrointestinal endoscopy in patients with suspected acute variceal bleeding
.
Highly recommended, high-quality evidence
.
08For
patients with suspected variceal bleeding, endoscopic evaluation should be performed within 12 hours of the patient's presentation, provided that the patient has undergone hemodynamic resuscitation
.
Highly recommended, moderate-certainty evidence
.
09EBL
is recommended for the treatment of acute esophageal variceal hemorrhage (EVH).
Highly recommended, high-quality evidence
.
10
In patients at high risk of recurrence of oesophageal variceal bleeding after successful endoscopic hemostasis (active EVH and Child–Pugh C≤13 or Child–Pugh B > 7; or HVPG > 20 mmHg) despite vasoactive agents), transjugular intrahepatic shunt must be considered preemptively within 72 hours, preferably within 24 hours portosystemic shunt，TIPS)
。
Highly recommended, high-quality evidence
.
11
Emergency remedial TIPS (if available)
should be considered for patients who received vasoactive agents and endoscopic hemostasis but still have persistent oesophageal variceal bleeding.
Highly recommended, moderate-certainty evidence
.
12
For patients with acute gastric varices GOV2, IGV1 type, endoscopic injection of cyanoacrylate is
recommended.
(Note: GOV2, esophageal varices extend to the fundus; IGV1, isolated gastric varices located in the fundus)
is strongly recommended, high-certainty evidence
.
13Endoscopic
injection of cyanoacrylate or EBL is recommended for patients with acute gastric variceal
GOV1-specific bleeding.
(Note: GOV1, esophageal varices extending along the curvature of the stomach to subcardia)
is highly recommended, moderate-certainty evidence
.
14
When endoscopic hemostasis fails or early recurrent bleeding occurs, emergency remedial TIPS or balloon-occluded retrograde retrograde is recommended for patients with gastric variceal bleeding or transballoon-occluded retrograde under balloon-occluded retrograde transvenous obliteration ，BRTO)
。
Weak recommendation, low-certainty evidence
.
15
It is recommended that patients who receive EBL treatment for acute EVH undergo EBL follow-up every 1~4 weeks to eradicate esophageal varices (secondary prevention).
Highly recommended, moderate-certainty evidence
.
16
NSBB (propranolol or carvedilol) in combination with endoscopic therapy is recommended for secondary prevention
of EVH in patients with ACLD.
Highly recommended, high-quality evidence
.
References: Gralnek I M, Duboc M C, Garcia-Pagan J C, et al.
Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline[J].
Endoscopy, 2022, 54(11): 1094-1120.
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