Secondary Prophylaxis of Gastric Variceal Bleeding: A Systematic Review and Network Meta-Analysis

Challenges in the Management of Esophagogastric Varices and Variceal Hemorrhage in Cirrhosis - A Narrative Review

Over the past decade, significant advancements in pharmacological, endoscopic, and radiographic treatments have emerged in the management of patients with cirrhosis and esophagogastric varices or variceal hemorrhage. These advances have been in several areas, including the role of screening and primary prophylaxis (preventing an initial variceal bleed), evaluation and management of acute esophagogastric variceal hemorrhage, and in preventing variceal rebleeding. Therefore, we believe there is a need for an updated, evidence-based "narrative review" on this important clinical topic that will be relevant for internists, hospitalists, intensive care unit physicians, and those in training. We believe the guidance presented in this narrative review will enhance daily medical practice of health care professionals and has the potential to improve quality of care for these complex patients.

[Trends in endovascular treatment and prevention of portal bleeding]

Bleeding from esophageal and gastric varices is a major factor of mortality in patients with portal hypertension. The gold standard for diagnosis of portal hypertension is hepatic venous pressure gradient determining the treatment algorithms and risk of recurrent bleeding. Combination of endoscopic methods and therapy is limited by varix localization and not always effective. In these cases, endovascular bypass and decoupling techniques are preferred. Early endovascular treatment of portal bleeding is effective for hemostasis and higher transplantation-free survival of patients. Early transjugular intrahepatic portosystemic bypass should be associated with 8-mm covered stents of controlled dilation. Combination of endovascular techniques reduces the complications of each technique and potentiates their positive effect. Endovascular treatment and prevention of portal bleeding should be determined by anatomical features of portal venous system.

Guidelines for the Management of Esophagogastric Variceal Bleeding in Cirrhotic Portal Hypertension

To standardize the diagnosis, treatment, and management of esophagogastric variceal bleeding (EVB) in patients with cirrhotic portal hypertension, the Chinese Society of Hepatology, the Chinese Society of Gastroenterology, and the Chinese Society of Digestive Endoscopy of the Chinese Medical Association brought together relevant experts, reviewed the latest national and international progress in clinical research on EVB in cirrhotic portal hypertension, and followed evidence-based medicine to update the Guidelines on the Management of EVB in Cirrhotic Portal Hypertension. The guidelines provide recommendations for the diagnosis, treatment, and management of EVB in cirrhotic portal hypertension and with the aim to improve the level of clinical treatment of EVB in patients with cirrhotic portal hypertension.

Gastric varices

PURPOSE OF REVIEW

Gastric varices are a rare cause of gastrointestinal bleeding in patients with portal hypertension. There have been significantly advances within endoscopic ultrasound for treatment of gastric varices over the past 5 years in addition to the conventional endoscopic and endovascular therapies. In this review, we will review the latest literature on gastric varices with emphasis on changes to the conventional classification systems and comparisons among the different treatment options for gastric varices in terms of efficacy and safety.

RECENT FINDINGS

There have been new guidelines proposed by the American Gastrointestinal Association on a simpler classification system compared to the conventional Sarin classification. In addition, endoscopic ultrasound guided coil embolization, a novel treatment pioneered over the past 5 years for gastric varices, has shown increased efficacy and reduced adverse event profile compared to cyanoacrylate glue, the more traditional therapy for gastric variceal bleeding. Options for endovascular therapy overall have not significantly changed over the recent years.

SUMMARY

Based on our literature review, we recommend a step-up approach with initial medical and endoscopic management with consideration of endovascular therapies when initial therapies fail.

Long-Term Prognosis and Related Factors in Patients with Cirrhosis Treated with Balloon-Occluded Retrograde Transvenous Obliteration

INTRODUCTION

Balloon-occluded retrograde transvenous obliteration (BRTO) was developed as an effective treatment for gastric varices in patients with cirrhosis. Because liver fibrosis in these patients is assumed to be advanced, their prognosis is expected to be poor. In this study, we investigated the prognosis and characteristics of the patients.

METHODS

We enrolled 55 consecutive patients with liver cirrhosis treated with BRTO between 2009 and 2021 at our department. To evaluate factors related to variceal recurrence and long-term prognosis, survival analysis was performed on 45 patients, excluding those who died within 1 month, had an unknown prognosis, or whose treatments were converted to other treatments.

RESULTS

During a mean follow-up period of 2.3 years, esophageal varices recurred in 10 patients and could be treated endoscopically. Non-alcoholic steatohepatitis (NASH) was related to the variceal recurrence (hazard ratio [HR] = 4.27, 95% CI: 1.17-15.5, p = 0.028). The survival rate after the procedure at 1, 3, and 5 years was 94.2%, 74.0%, and 63.5%, respectively, and 10 patients died of hepatocellular carcinoma (n = 6), liver failure (n = 1), sepsis (n = 1), and unknown reasons (n = 2). The estimated glomerular filtration rate (eGFR) level was proved to be a significant poor prognostic factor (HR = 0.96, 95% CI: 0.93-0.99, p = 0.023). The comorbid hypertension (HTN) was the main cause of low eGFR, and HTN was also significantly related to survival (HR = 6.18, 95% CI: 1.57-24.3, p = 0.009). Most of the patients with HTN were treated with calcium channel blocker and/or angiotensin receptor blocker.

CONCLUSION

The clinical course of patients with cirrhosis treated with BRTO was dependent on the metabolic factors including renal function, comorbid HTN, and NASH.

Pharmacotherapies for Portal Hypertension: Current Status and Expanding Indications

Purpose

Non-selective beta blockers remain pharmacotherapy of choice for prevention of first episode of variceal bleeding (primary prevention) and for prevention of its recurrence after initial hemostasis (secondary prophylaxis). This review will update the current and emerging pharmacological therapies for portal hypertension.

Recent findings

Data have emerged on carvedilol in preventing hepatic decompensation and improving patient survival among patients with clinically significant portal hypertension. Because measurement of WHVP is invasive and not feasible in routine practice, non-invasive tests with liver stiffness measurement in combination with platelet count may be accurate in identifying clinically significant portal hypertension.

Summary

Carvedilol is more effective in reducing portal pressure compared to nadolol or propranolol. Its use has expanded to reduce risk of hepatic decompensation among patients with CSPH, which can be identified non-invasively using liver stiffness and platelet count. Studies are needed on non-invasive biomarkers to guide and optimize pharmacological treatment of portal hypertension.

Comprehensive treatment of patients with gastric variceal bleeding

Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Bleeding from gastric varices is usually severe and is associated with higher mortality and a higher risk of rebleeding than from esophageal varices. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiological interventions. In terms of treatment, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires prompt intervention to stop it and achieve long-term hemostasis. This review describes the features of pharmacological, endoscopic and interventional radiological prophylactic and treatment options in gastric variceal bleeding. We searched the literature in the MedLine database on the PubMed platform.

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

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.

Endoscopic tissue adhesive injection for gastric varices secondary to hepatic cirrhosis: Complications and management strategies

Gastric varices is a common clinical presentation of portal hypertension induced by hepatic cirrhosis, and gastric variceal bleeding is an emergency with high mortality. Endoscopic tissue adhesive injection plays an important role in the primary and secondary prophylaxis of gastric variceal bleeding, and acute bleeding control. However, this is a technique-demanding operation with nonnegligible complications, of which some may be fatal, such as ectopic embolism. Therefore, the prevention and treatment of such complications are of great importance. Herein, we present a review summarizing the complications and treatment strategies of endoscopic tissue adhesive injection for gastric varices secondary to hepatic cirrhosis.