Guidelines for the management of esophagogastric variceal bleeding in cirrhotic portal hypertension

Portal hypertension, often caused by liver cirrhosis, results from increased pressure in the portal venous system due to obstructed blood flow and/or increased blood volume. This condition leads to complications such as ascites, gastroesophageal varices (GOV), esophagogastric variceal bleeding (EVB), and hepatic encephalopathy. Among these, EVB is particularly critical due to its high mortality rate, making it one of the most urgent digestive system emergencies. The pathophysiology involves elevated static pressure in the portal vein, collateral circulation formation, and significant clinical manifestations that require timely and effective management.

To address the challenges of EVB in cirrhotic portal hypertension, the Chinese Society of Hepatology, Chinese Society of Gastroenterology, and Chinese Society of Digestive Endoscopy have developed and updated guidelines over the years, starting with a consensus in 2008 and followed by more comprehensive guidelines in 2016. These guidelines have been informed by advancements in both basic and clinical research, as well as international recommendations such as the Baveno VII consensus. The recent update aims to incorporate the latest evidence-based practices, providing a framework for the prevention, diagnosis, and treatment of EVB and improving clinical outcomes for patients with cirrhotic portal hypertension.

The updated guidelines aim to assist clinicians in making informed decisions regarding the diagnosis and treatment of EVB. However, they are not mandatory and cannot address every clinical scenario. Clinicians are encouraged to use these guidelines as a reference while considering individual patient conditions, preferences, and available medical resources. The recommendations are graded using the GRADE system, ensuring that the level of evidence and strength of recommendations are clearly outlined. The ultimate goal is to enhance the quality of care for patients with cirrhotic portal hypertension through evidence-based, individualized treatment strategies.

The guidelines review the natural history, pathogenesis, and classification of GOV, the primary and secondary prevention of EVB, the treatment of acute esophageal-gastric variceal bleeding (AEVB), and the treatment of special types of varicose veins. Problems are also proposed as follows.

1. Re-compensation and Portal Hypertension in Liver Cirrhosis: Future research should aim to clarify the definitions and clinical diagnostic criteria for liver cirrhosis re-compensation and the reversal of portal hypertension. Emphasis should also be placed on advancing noninvasive technologies and biomarkers for measuring portal pressure or hepatic venous pressure gradient, which are essential for accurate risk stratification and improved diagnosis in cirrhosis patients.
2. Management of GOV and EVB: Studies are needed to enhance noninvasive methods for assessing the severity of GOV in cirrhosis. This includes evaluating the effectiveness and safety of non-selective beta-blockers (NSBB) and endoscopic variceal ligation for the primary prevention of EVB and decompensation. The development of new drugs targeting portal pressure reduction is also a key area of focus. Additionally, research should investigate the optimal use of vasoactive medications, NSBB, endoscopic sequential therapy, and transjugular intrahepatic portosystemic shunt in acute EVB, as well as strategies for secondary prevention and determining the appropriate timing for NSBB withdrawal.
3. Mechanisms and Adjunctive Therapies: Further exploration of the mechanisms by which traditional Chinese medicine (TCM) combats liver fibrosis and cirrhosis is crucial. Additionally, the impact of albumin levels, portal vein thrombosis, and platelet counts on EVB and cirrhosis progression should be studied. Comprehensive evaluation of the timing, duration, and safety of low molecular weight heparin anticoagulation therapy in cirrhosis patients is also necessary to optimize treatment outcomes.

Future research should focus on defining re-compensation and portal hypertension reversal in cirrhosis, advancing noninvasive diagnostic tools, optimizing GOV and EVB management, exploring TCM mechanisms, and evaluating adjunctive therapies like anticoagulation to improve patient outcomes.

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https://www.xiahepublishing.com/2310-8819/JCTH-2023-00061

The study was recently published in the Journal of Clinical and Translational Hepatology.

The Journal of Clinical and Translational Hepatology (JCTH) is owned by the Second Affiliated Hospital of Chongqing Medical University and published by XIA & HE Publishing Inc. JCTH publishes high quality, peer reviewed studies in the translational and clinical human health sciences of liver diseases. JCTH has established high standards for publication of original research, which are characterized by a study’s novelty, quality, and ethical conduct in the scientific process as well as in the communication of the research findings. Each issue includes articles by leading authorities on topics in hepatology that are germane to the most current challenges in the field. Special features include reports on the latest advances in drug development and technology that are relevant to liver diseases. Regular features of JCTH also include editorials, correspondences and invited commentaries on rapidly progressing areas in hepatology. All articles published by JCTH, both solicited and unsolicited, must pass our rigorous peer review process.

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