Lack of difference among terlipressin, somatostatin, and octreotide in the control of acute gastroesophageal variceal hemorrhage

A novel scheme for non-invasive drug delivery with a magnetically controlled drug delivering capsule endoscope

There is a lack of effective means for precise drug delivery of gastrointestinal diseases. Herein we report a novel magnetically controlled drug delivering capsule endoscope (MDCE) to achieve precision drug delivery for gastrointestinal diseases. MDCE integrates a drug delivery system into conventional capsule endoscope. It can carry 0.5 ml of liquid medication, which can be sprayed onto the target area using an electric pump upon detecting lesions by convolutional neural network (CNN)-model. Additionally, with the aid of an external magnet, the operator can adjust the posture and drug delivery direction of the capsule endoscope to enhance the accuracy of drug release. This adjustment process is monitored in real-time through the camera at the front of the capsule endoscope. To validate the clinical efficacy of the MDCE, we established porcine intestinal epithelial injury and bleeding models, and we demonstrated that MDCE could accurately deliver drugs under magnetic control through direct visualization. MDCE could significantly reduce injury area by delivering organoids to porcine injury sites after 7 days compared to the control group (48 mm2vs. 21 mm2, p = 0.018). MDCE could significantly reduce bleeding time by spraying norepinephrine to porcine intestinal bleeding site compared to the control group (731 s vs. 418 s, p = 0.007). These demonstrate that MDCE could actively accurately release drugs under magnetic control through direct visualization in a non-invasive manner. This opens a new chapter for the precision treatment of gastrointestinal diseases and provides a novel approach for oral drug administration for systemic diseases.

Hemodynamic profile of terlipressin and octreotide in patients with cirrhosis and portal hypertension: a randomized, single-blind clinical trial

Background & Aims

Continuous infusion of terlipressin may result in a more sustained reduction in portal pressure with fewer adverse effects than administered as a bolus. This study aimed to compare the hepatic and cardiopulmonary hemodynamic effects and safety profiles of bolus vs. terlipressin continuous infusion.

Methods

This is a single-center, single-blinded, double-dummy, parallel-group, clinical trial in which 38 patients with cirrhosis and portal hypertension were randomized to receive the following: 1 mg bolus of terlipressin + continuous infusion of placebo (TERLBOL, n = 12), a bolus of placebo + continuous infusion of terlipressin (2 or 4 mg/day if <10% reduction in hepatic venous pressure gradient [HVPG] at 30 min of infusion) (TERLINF, n = 14), or a bolus of octreotide (50 μg) + continuous infusion of octreotide (50 μg/h) (OCTR, n = 12) as an additional control group. HVPG, cardiopulmonary pressures, and cardiac output were measured at baseline and after 30, 60, and 120 min.

Results

Sixty-eight percent of patients were male, with a median age of 59 years. There were no significant differences in baseline characteristics. In the TERLBOL group, there was a nonsignificant reduction in HVPG (at 120 min, -4.9%; p = 0.14). However, cardiopulmonary and mean arterial pressures significantly increased, whereas cardiac output and heart rate significantly decreased. In the TERLINF group, there were nonsignificant changes in cardiopulmonary hemodynamics or HVPG (NS) despite doubling the infusion dose after 30 min in 13/14 patients. In the OCTR group, there was a nonsignificant reduction in HVPG (at 120 min, -4.9%; p = 0.08), and pulmonary capillary pressure significantly decreased. All treatments were well tolerated, and no adverse events were observed.

Conclusions

There were nonsignificant reductions in HVPG with the three therapeutic strategies. Further investigations are warranted to determine the optimal dosing strategy for continuous infusion of terlipressin in patients with cirrhosis and portal hypertension.

Impact and implications

The results of our study do not show a significant reduction in portal pressure, at least in the first 2 h after the selected dose. Although the study was not performed in the setting of acute variceal bleeding and terlipressin was used as a standard therapy, these results do not support the treatment strategy of terlipressin infusion alone at the doses studied for the management of acute variceal bleeding, where a quick reduction in portal pressure is thought to play a major role controlling variceal bleeding. It is important to highlight that the continuously infused terlipressin regimen is better tolerated and appears to have a better cardiopulmonary safety profile. Other treatment strategies of continuous terlipressin infusion, such as initial bolus administration or higher infusion doses, should be evaluated to support its use in managing variceal bleeding.

Clinical trial identifier

EudraCT No. 2019-004328-39.

The current applications and future directions of terlipressin

Terlipressin is a vasopressin analog with potent splanchnic vasoconstrictor properties. It has an established role in managing portal hypertensive bleeding and hepatorenal syndrome-acute kidney injury, with a growing body of evidence demonstrating improved safety and efficacy with continuous infusion-based administration compared to bolus dosing. We discuss previously reported adverse effects of terlipressin and evidence-based strategies to maximize the safety of administration. We also review the literature surrounding emerging indications for terlipressin in decompensated cirrhosis, particularly in the management of refractory ascites. Furthermore, we present data on novel ambulatory programs utilizing long-term continuous terlipressin infusion as bridging therapy for liver transplant candidates with recurrent hepatorenal syndrome-acute kidney injury, diuretic-refractory ascites, or hydrothorax.

Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Centre for Liver and Digestive Diseases (CIBERehd)

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd)

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Effectiveness of Adjunctive Drug Therapy to Endoscopic Stenting in Liver Cirrhosis Complicated by Refractory Variceal Bleeding

AIM OF THE STUDY. Comparative clinical analysis of the efficacy of terlipressin and octreotide as additional drug therapy to mechanical hemostasis with nitinol stent in patients with liver cirrhosis complicated by bleeding from esophageal varices refractory to endoscopic treatment.

MATERIAL AND METHODS. Thirty-one patients with liver cirrhosis complicated by esophageal variceal bleeding refractory to endoscopic treatment , in whose complex treatment program, as a first-line life­saving measure, hemostasis with a self-expanding hemostasis was performed nitinol stent were randomly assigned to two groups. In group A, 20 patients were treated with terlipressin as an adjuvant to mechanical hemostasis, and in group B, 11 patients were treated with octreotide. Unpaired Student’s t-test was used for statistical analysis of the results. Graphs for assessing the survival function of patients for 8 weeks after the end of treatment were constructed using the Kaplan-Meier method.

RESULTS. In the acute observation period terlipressin and octreotide were equally effective in treating refractory variceal bleeding. In the subacute observation period, the administration of octreotide was generally accompanied by a greater number of side effects (54.5%) than terlipressin (30.0%) (p=0.453). In the remote observation period, 8-week survival in the group of patients receiving terlipressin was higher than in the group of patients receiving octreotide.

CONCLUSION. Terlipressin is as effective as octreotide as an adjunct to endoscopic stenting in drug therapy for liver cirrhosis complicated by esophageal variceal bleeding refractory to endoscopic treatment. At the same time, terlipressin has a greater effect than octreotide on reducing 8-week mortality, which approaches statistical significance. In this regard, terlipressin may be the vasoactive drug of choice in acute refractory variceal bleeding.

Outcomes in Variceal Bleeding Associated With Continuous Octreotide in Patients With Delayed Endoscopy

Background: Variceal hemorrhage treatment includes endoscopy within 12 hours of admission and octreotide therapy for 2-5 days post-endoscopy. Duration of pre-endoscopy octreotide can be prolonged when intervention is delayed. Objective: This study aimed to evaluate the impact of extended pre-endoscopy octreotide on rebleeding after endoscopy when comparing short vs long durations of post-endoscopy octreotide. Methods: This was a single center, retrospective cohort evaluating adult cirrhotic patients with esophageal variceal hemorrhage admitted between July 1, 2017 and June 30, 2020. Study groups included patients receiving octreotide ≥12 hours prior to endoscopy followed by ≤ 48 (short course) or >48 hours (standard course) after endoscopy. The primary outcome was post-endoscopy rebleeding, defined as hemoglobin decrease of ≥2 g/dL from baseline or the requirement of ≥1 unit of packed red blood cells. Results: Of the 169 patients included, 88 patients received short course octreotide after endoscopy, and 81 patients received standard course octreotide after endoscopy. Twenty-nine (33%) patients in the short course group and 43 (53.1%) in the standard course group experienced the primary endpoint (OR 2.3, 95% CI 1.24 - 4.29; P = .008). Conclusion: Extended pre-endoscopy octreotide may be beneficial in preventing rebleeding when intervention is delayed. Further studies are needed to determine the necessary octreotide duration in delayed endoscopy and varying bleeding risk.

Management of Portal Hypertension in the Older Patient

PURPOSE OF THIS REVIEW

Aging is a process of physiological slowing, reduced regenerative capacity and inability to maintain cellular homeostasis. World Health Organisation declared the commencement of population aging globally, largely attributed to improvement in the healthcare system with early diagnosis and effective clinical management. Liver ages similar to other organs, with reduction in size and blood flow. In this review we aim to evaluate the effect of aging in liver disease.

RECENT FINDINGS

Aging causes dysregulation of major carbohydrate, fat and protein metabolism in the liver. Age is a major risk factor for liver fibrosis accelerated by sinusoidal endothelial dysfunction and immunological disharmony. Age plays a major role in patients with liver cirrhosis and influence outcomes in patients with portal hypertension. Transient elastography may be an useful tool in the assessment of portal hypertension. Hepatic structural distortion, increased vascular resistance, state of chronic inflammation, associated comorbidities, lack of physiological reserve in the older population may aggravate portal hypertension in patients with liver cirrhosis and may result in pronounced variceal bleed. Cut-offs for other non-invasive markers of fibrosis may differ in the elderly population. Non-selective beta blockers initiated at lower dose followed by escalation are the first line of therapy in elderly patients with cirrhosis and portal hypertension, unless contraindicated. Acute variceal bleed in the elderly cirrhotic patients can be life threatening and may cause rapid exsanguination due to poor reserve and associated comorbidities. Vasoactive drugs may be associated with more adverse reactions. Early endoscopy may be warranted in the elderly patients with acute variceal bleed. Role of TIPS in the elderly cirrhotics discussed. Management of portal hypertension in the older population may pose significant challenges to the treating clinician.

Pharmacologic Treatment of Portal Hypertension

Portal hypertension is the key mechanism driving the transition from compensated to decompensated cirrhosis. In this review, the authors described the pathophysiology of portal hypertension in cirrhosis and the rationale of pharmacologic treatment of portal hypertension. We discussed both etiologic and nonetiologic treatment of portal hypertension and the specific clinical scenarios how nonselective beta-blocker can be used in patients with cirrhosis. Finally, the authors summarized the evidence for emerging alternatives for portal hypertension in patients with cirrhosis.

Microarray analysis demonstrates up-regulation of the endothelin-1 gene with compensatory down-regulation of the ETA receptor gene in human portal vein

High blood pressure in the portal vein, portal hypertension (PH), is the final common pathway in liver cirrhosis regardless of aetiology. Complications from PH are the major cause of morbidity and mortality in these patients. Current drug therapy to reduce portal pressure is mainly limited to β-adrenergic receptor blockade but approximately 40% of patients do not respond. Our aim was to use microarray to measure the expression of ∼20,800 genes in portal vein from patients with PH undergoing transplantation for liver cirrhosis (PH, n=12) versus healthy vessels (control, n=9) to identify potential drug targets to improve therapy. Expression of 9,964 genes above background was detected in portal vein samples. Comparing PH veins versus control (adjusted P-value < 0.05, fold change > 1.5) identified 548 up-regulated genes and 1,996 down-regulated genes. The 2,544 differentially expressed genes were subjected to pathway analysis. We identified 49 significantly enriched pathways. The endothelin pathway was ranked the tenth most significant, the only vasoconstrictive pathway to be identified. ET-1 gene (EDN1) was significantly up-regulated, consistent with elevated levels of ET-1 peptide previously measured in PH and cirrhosis. ETA receptor gene (EDNRA) was significantly down-regulated, consistent with an adaptive response to increased peptide levels in the portal vein but there was no change in the ETB gene (EDNRB). The results provide further support for evaluating the efficacy of ETA receptor antagonists as a potential therapy in addition to β-blockers in patients with PH and cirrhosis.

Severe Hyponatremia Associated With Terlipressin Use in Esophageal Variceal Bleeding

Terlipressin is an analogue of vasopressin that is indicated as first-line therapy for variceal hemorrhage and hepatorenal syndrome. Hyponatremia is an uncommon complication of terlipressin because it has less effect on vasopressin V2 receptors located in the kidneys. Profound hyponatremia related to terlipressin use is a rare complication that needs to be aware of. We described a 35-year-old previously healthy man, who was admitted for esophageal variceal bleeding that was attributed to hepatitis B-related liver cirrhosis. He had a normal baseline sodium level (Na 139 mmol/L) and developed severe hyponatremia 119 mmol/L (euvolemic, hypo-osmolar) at 72 hours of terlipressin therapy. After holding the medication, the hyponatremia corrected rapidly to 135 mmol/L within 24 hrs. Terlipressin was given again as therapy for overcorrection of hyponatremia and the sodium level decreased before being stabilized without neurological consequences. Severe hyponatremia is an uncommon complication of terlipressin therapy; however, our case emphasizes the importance of sodium monitoring during terlipressin therapy in all patients to prevent this complication, and more importantly, to avoid rapid correction that could happen after holding it.

New sights in ectopic varices in portal hypertension

Ectopic varices and associated bleeding, although rare, pose a significant risk to patients with portal hypertension, carrying a relatively high mortality rate. These varices can occur in various anatomical regions, excluding the gastroesophageal region, which is typically associated with portal vein drainage. The limited data available in the literature, derived mostly from case reports and series, make the diagnosis and treatment of ectopic variceal bleeding particularly challenging. Furthermore, it is crucial to recognize that ectopic varices in different sites can exhibit variations in key decision-making factors such as aetiology and vascular anatomy, severity and bleeding risk and hepatic reserve. These factors significantly influence treatment strategies and underscore the importance of adopting individualized management approaches. Therefore, the objective of this review is to provide a comprehensive overview of the fundamental knowledge surrounding ectopic varices and to propose site-oriented, stepwise diagnosis and treatment algorithms for this complex clinical issue. A multidisciplinary treatment approach is strongly recommended in managing ectopic varices. In addition, to enhance clinical reference, we have included typical case reports of ectopic varices in various sites in our review, while being mindful of potential publication bias.

Octreotide versus Terlipressin as Adjuvant to Endoscopic Variceal Band Ligation in Bleeding Oesophageal Varices: A Systematic Review and Meta-Analysis

Background: Acute variceal bleeding (AVB) is a critical complication of portal hypertension, contributing significantly to mortality worldwide. Pharmacological interventions, including terlipressin and octreotide, have evolved to manage AVB, yet consensus on their comparative effectiveness remains elusive. This study conducts a comprehensive systematic review and meta-analysis of randomized control trials (RCTs) comparing terlipressin and octreotide in the management of AVB, aiming to provide insights into their relative benefits. Methods: This study included RCTs with head-to-head comparisons of terlipressin and octreotide. The search strategy covered PubMed, Scopus, and Cinahl databases, and the included studies involved adult patients with confirmed AVB undergoing endoscopic variceal band ligation (EVBL). Results: Seven RCTs meeting inclusion criteria were included in the meta-analysis. The assessed outcomes were: achieving haemostasis within 24 h, rebleeding rate, and mortality rate. The pooled analysis revealed no statistically significant differences between terlipressin and octreotide in achieving haemostasis (OR: 1.30, p = 0.23), rebleeding rates at 5 days (OR: 0.7, p = 0.23), and mortality at 42 days (OR: 0.9, p > 0.5). Conclusion: This meta-analysis suggests that terlipressin and octreotide exhibit similar efficacy in reducing bleeding, rebleeding rates, and mortality when used as adjuvants to EVBL in AVB. Clinicians are encouraged to consider individual patient characteristics and the broader clinical context when choosing between these agents. Future research should focus on addressing existing evidence gaps and enhancing understanding of variables influencing EVBL outcomes.

Assessment, Resuscitation and Medical Management of Variceal and Nonvariceal Gastrointestinal Bleeding

Upper gastrointestinal bleeding (UGIB) continues to be an important cause for emergency room visits and carries significant morbidity and mortality. Early resuscitative measures form the basis of the management of patients presenting with UGIB and can improve the outcomes of such patients including lowering mortality. In this review, using an evidence-based approach, we discuss the initial assessment and resuscitation of patients presenting with UGIB including identifying clues from history and physical examination to confirm UGIB, preendoscopic risk assessment tools, the role of early fluid resuscitation, utilization of blood products, use of pharmacologic interventions, and the optimal timing of endoscopy.

Real-world comparison of terlipressin vs. octreotide as an adjuvant treatment in the management of variceal bleeding

Variceal bleeding is a major complication and the leading cause of death in patients with cirrhosis and portal hypertension. This study aims to compare the efficacy and safety of terlipressin vs octreotide as an adjuvant to endoscopic management of patients with esophageal variceal bleeding in a real-time scenario. We reviewed the medical records of patients with esophageal variceal bleeding from January 2005 to December 2020 at our tertiary care Aga Khan University Hospital. Mortality was assessed after 6 weeks. A total of 842 patients with variceal bleed were evaluated. 624 patients (74.1%) and 218 patients (25.9%) received Terlipressin and Octreotide respectively. On multiple regression analysis, cardiac events during hospital stay (OR: 11.22), presence of Porto-systemic encephalopathy (OR: 3.79), and elevated bilirubin levels at the time of presentation were found to be independent risk factors for increased six weeks mortality. Moreover, cardiac events during hospital stay (OR: 3.26), Porto-systemic encephalopathy at presentation (OR: 3.06), and octreotide administration (OR: 1.80) were identified as independent risk factors for increased length of hospital stay. Terlipressin and Octreotide have similar outcomes in terms of control of bleeding, hospital stay, mortality, and side effects when used as adjuvant therapy for the management of variceal bleeding.

Comparison of 1-day versus 3-day intravenous terlipressin in cirrhosis patients with variceal bleeding: A pilot randomised controlled trial

BACKGROUND

In cirrhosis patients with acute variceal bleeding (AVB), the optimal duration of vasoconstrictor therapy after endoscopic haemostasis is unclear.

AIMS

We aimed to compare efficacy of 1-day versus 3-day terlipressin therapy in cirrhosis patients with AVB post-endoscopic intervention. The primary objective was to compare rebleeding at 5 days between the two arms. Secondary objectives included rebleeding and mortality rates at 6 weeks.

METHODS

In this open-label, randomised controlled trial, cirrhosis patients with AVB were randomised to either 1-day or 3-day terlipressin therapy.

RESULTS

A total of 150 cirrhosis patients with AVB were recruited to receive either 1 day (n = 75) or 3 days (n = 75) of terlipressin therapy. One patient from 1-day arm was excluded. Modified intention-to-treat analysis included 149 patients. Baseline characteristics were comparable between the two groups. Rebleeding at 5 days: 3 (4.1%; 95% confidence interval [CI]: 0.4-9.0) versus 4 (5.3%; 95% CI: 2.0-10.0), risk difference (RD) p = 0.726 and 5-day mortality rates: 1 (1.4%; 95% CI: 0-7.3) versus 1 (1.3%; 95% CI: 0.2-7.0), RD p = 0.960 were similar. Rebleeding at 42 days: 9 (12.2%; 95% CI: 7.0-20.0) versus 10 (13.3%; 95% CI: 7.0-20.0), RD p = 0.842 and mortality at 42 days: 5 (6.8%; 95% CI: 3.0-10.0) versus 4 (5.3%; 95% CI: 2.0-10.0), RD p = 0.704 were also similar. Patients in the 1-day terlipressin therapy arm experienced significantly fewer adverse effects compared with those receiving 3 days of terlipressin therapy: 28 (37.8%) versus 42 (56%), p = 0.026.

CONCLUSIONS

Our results suggest that 1 day of terlipressin therapy is associated with similar 5-day and 42-day rebleeding rates, 42-day mortality and an overall superior safety profile compared with 3-day of terlipressin therapy. These findings require to be validated in double-blinded, larger, multiethnic and multicentre studies across the various stages of cirrhosis (CTRI/2019/10/021771).

[Gastrointestinal bleeding in old age]

Gastrointestinal bleeding is a frequent symptom, with increasing age as a risk factor. Upper, middle and lower gastrointestinal bleeding are differentiated depending on the location, whereby only upper and lower gastrointestinal bleeding are elucidated in this article. The symptomatology varies depending on the localization of the bleeding. German and international clinical guidelines currently exist for the preclinical and clinical management of gastrointestinal bleeding. The main focus of the article is on pre-endoscopic management of upper gastrointestinal nonvariceal and variceal bleeding, including the risk stratification, transfusion and coagulation management as well as the initial pharmacological treatment. In addition, current developments in endoscopic and interventional treatment of gastrointestinal bleeding are highlighted.

[Gastrointestinal bleeding in old age]

Gastrointestinal bleeding is a frequent symptom, with increasing age as a risk factor. Upper, middle and lower gastrointestinal bleeding are differentiated depending on the location, whereby only upper and lower gastrointestinal bleeding are elucidated in this article. The symptomatology varies depending on the localization of the bleeding. German and international clinical guidelines currently exist for the preclinical and clinical management of gastrointestinal bleeding. The main focus of the article is on pre-endoscopic management of upper gastrointestinal nonvariceal and variceal bleeding, including the risk stratification, transfusion and coagulation management as well as the initial pharmacological treatment. In addition, current developments in endoscopic and interventional treatment of gastrointestinal bleeding are highlighted.

Managing a Prospective Liver Transplant Recipient on the Waiting List

The management of a patient in the peri-transplantation period is highly challenging, and it is even more difficult while the patient is on the transplantation waitlist. Keeping the patient alive during this period involves managing the complications of liver disease and preventing the disease's progression. Based on the pre-transplantation etiology and type of liver failure, there is a difference in the management protocol. The current review is divided into different sections, which include: the management of underlying cirrhosis and complications of portal hypertension, treatment and identification of infections, portal vein thrombosis management, and particular emphasis on the management of patients of hepatocellular carcinoma and acute liver failure in the transplantation waitlist. The review highlights special concerns in the management of patients in the Asian subcontinent also. The review also addresses the issue of delisting from the transplant waitlist to see that futility does not overtake the utility of organs. The treatment modalities are primarily expressed in tabular format for quick reference. The following review integrates the vast issues in this period concisely so that the management during this crucial period is taken care of in the best possible way.

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.

CURRENT PHARMACOLOGICAL MANAGEMENT IN UPPER GASTROINTESTINAL BLEEDING

Upper gastrointestinal bleeding is a common reason for presentation to the hospital. Appropriate resuscitation followed by endoscopic assessment and endotherapy for high-risk lesions (active bleeding or non-bleeding with visible vessels) forms the cornerstone of management. Pharmacological therapies are utilised at each stage of management in both variceal and non-variceal bleeding. Proton pump inhibitors and prokinetic agents can be administered pre-endoscopically with vasoactive medication and antibiotics utilised in suspected variceal bleeding. Epinephrine may be used as a temporising measure to improve visualisation during endoscopy but should not applied as a single agent. Topical endoscopic therapies have also shown promise in achieving haemostasis. Following endoscopy, a high dose of proton pump inhibitor should be given to patients who require endotherapy and vasoactive medications, and antibiotics continued in confirmed variceal bleeds. The timing of resumption of antithrombotic medication is dependent on the agent utilised and underlying thrombotic risk.

Terlipressin in the management of liver disease

INTRODUCTION

Terlipressin is a synthetic vasopressin analog which has been recently approved in the United States by the Food and Drug Administration for the treatment of hepatorenal syndrome. Terlipressin stimulates vasopressin receptors located on the smooth muscle vasculature of the splanchnic circulation and renal tubules which results in splanchnic vasoconstriction with improved renal perfusion and antidiuretic activity, respectively.

AREAS COVERED

In this review, we discuss available data regarding the FDA approved use of terlipressin, safety, and tolerability, as well as highlight alternative uses in chronic liver disease currently still under investigation.

EXPERT OPINION

Terlipressin is more efficacious compared to other vasoactive agents including midodrine octreotide and norepinephrine in reversal of hepatorenal syndrome and improves short-term survival. Other potential applications of terlipressin's vasoconstrictor actions reported in the literature include management of variceal hemorrhage and other complications of portal hypertension.

Acute-On-Chronic Liver Failure: Current Interventional Treatment Options and Future Challenges

Acute-on-chronic liver failure (ACLF) is a frequent complication in patients with liver cirrhosis that has high short-term mortality. It is characterized by acute decompensation (AD) of liver cirrhosis, intra- and extrahepatic organ failure, and severe systemic inflammation (SI). In the recent past, several studies have investigated the management of this group of patients. Identification and treatment of precipitants of decompensation and ACLF play an important role, and management of the respective intra- and extrahepatic organ failures is essential. However, no specific treatment for ACLF has been established to date, and the only curative treatment option currently available for these patients is liver transplantation (LT). It has been shown that ACLF patients are at severe risk of waitlist mortality, and post-LT survival rates are high, making ACLF patients suitable candidates for LT. However, only a limited number of patients are eligible for LT due to related contraindications such as uncontrolled infections. In this case, bridging strategies (e.g., extracorporeal organ support systems) are required. Further therapeutic approaches have recently been developed and evaluated. Thus, this review focuses on current management and potential future treatment options.

Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV)

The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.

Pathophysiology and management of liver cirrhosis: from portal hypertension to acute-on-chronic liver failure

Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic encephalopathy. Additionally, the severity of portal hypertension is the central driver for further advanced complications of hyperdynamic circulation, hepatorenal syndrome, and cirrhotic cardiomyopathy. The management of these individual complications has specific nuances which have undergone significant developments. In contrast to the classical natural history of cirrhosis and its complications which follows an insidious trajectory, acute-on-chronic failure (ACLF) leads to a rapidly downhill course with high short-term mortality unless intervened at the early stages. The management of ACLF involves specific interventions, which have quickly evolved in recent years. In this review, we focus on complications of portal hypertension and delve into an approach toward ACLF.

Intensive Care Unit Care of a Patient with Cirrhosis

Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.

Liver Cirrhosis and Portal Hypertension

The understanding of pathogenesis of portal hypertension in patients with liver cirrhosis continues to evolve. In addition to progressive fibrosis, cirrhosis is characterized by parenchymal extinction and vascular remodelling, causing architectural distortion. Existence of prothrombotic state and more recently, intestinal bacterial dysbiosis are recently described in the pathogenesis of portal hypertension. Clinically significant portal hypertension (CSPH) is an important prognostic milestone in patients with liver cirrhosis. This is a pre-symptomatic phase that predicts the development of varices, ascites and importantly increased risk of Hepatocellular carcinoma (HCC). CSPH is associated with significantly reduced survival. Endoscopic surveillance is necessary in these patients. Non-selective Beta-blocker is the preferred therapy for primary prophylaxis in the management of portal hypertension. Patients with acute variceal bleed should be resuscitated appropriately, followed by vasoactive drugs and endoscopic therapy. Early TIPS should be considered in those with refractory bleed or in endoscopic treatment failure. Application of artificial intelligence and machine learning may be useful in future for identifying patients at risk of variceal hemorrhage.

Emerging Therapeutic Targets for Portal Hypertension

Purpose of Review

Portal hypertension is responsible of the main complications of cirrhosis, which carries a high mortality. Recent treatments have improved prognosis, but this is still far from ideal. This paper reviews new potential therapeutic targets unveiled by advances of key pathophysiologic processes.

Recent Findings

Recent research highlighted the importance of suppressing etiologic factors and a safe lifestyle and outlined new mechanisms modulating portal pressure. These include intrahepatic abnormalities linked to inflammation, fibrogenesis, vascular occlusion, parenchymal extinction, and angiogenesis; impaired regeneration; increased hepatic vascular tone due to sinusoidal endothelial dysfunction with insufficient NO availability; and paracrine liver cell crosstalk. Moreover, pathways such as the gut-liver axis modulate splanchnic vasodilatation and systemic inflammation, exacerbate liver fibrosis, and are being targeted by therapy. We have summarized studies of new agents addressing these targets.

Summary

New agents, alone or in combination, allow acting in complementary mechanisms offering a more profound effect on portal hypertension while simultaneously limiting disease progression and favoring regression of fibrosis and of cirrhosis. Major changes in treatment paradigms are anticipated.

The influences of timing of urgent endoscopy in patients with acute variceal bleeding: a cohort study

BACKGROUND

There has always been a debate on the optimal timing of endoscopy in patients with acute variceal bleeding (AVB).

OBJECTIVE

This study aimed to examine the relation between the timing of endoscopy and the short-term outcomes of patients with AVB.

METHODS

Patients with AVB who underwent endoscopy within 24 h after admission at our tertiary care center from 2014 to 2022 were evaluated retrospectively. The primary outcomes were the 6-week mortality and re-bleeding. The secondary outcomes included the total number of blood units transfused, the length of hospital stay, and the need for salvage therapy. We used Cox proportional hazards model to analyze the predictors of 6-week mortality in all patients as well as in those who were at high risk of further bleeding or death.

RESULTS

A total of 312 patients were enrolled. Among them, 170 patients (54.49%) underwent urgent endoscopy (< 6 h), and 142 patients (45.51%) underwent early endoscopy (6-24 h). There were no significant differences between the urgent-endoscopy group and the early-endoscopy group, regarding the 6-week mortality (16.47% vs. 10.56%; P value = 0.132) and 6-week re-bleeding rate (11.2% vs. 16.2%; P value = 0.196). In multivariate analysis, time to endoscopy was independent of 6-week mortality (P value = 0.170), but the time between the beginning of bleeding and endoscopy (within 12 h) was significantly associated with low 6-week mortality (OR: 0.16; 95% CI: 0.06-0.46; P value = 0.001). Time to endoscopy was still not associated with 6-week mortality in patients at high risk for further bleeding or death (Glasgow-Blatchford score ≥ 12, n = 138, P value = 0.902).

CONCLUSIONS

Endoscopy performed within 6 h of admission, rather than within 6 to 24 h, did not improve six-week clinical outcomes in patients in stable condition with AVB and even those who were at high risk of further bleeding and death.

Saner F, Stark K, Mayerle J, M. Lange C. Platelet Aggregation Inhibitors and Anticoagulants in Gastroenterological and Visceral Surgical Procedures

BACKGROUND

The proper management of patients being treated with platelet aggregation inhibitors or anticoagulant drugs is a common clinical problem for both elective and emergency procedures in gastroenterology and visceral surgery. The essential matters that must be kept in mind in this situation are the hemorrhagic risk of the procedure, the indication for anticoagulation, and the pharmacology of anticoagulant drugs and platelet aggregation inhibitors.

METHODS

This review is based on publications retrieved by a selective search in PubMed and on the guidelines of the relevant specialist societies.

RESULTS

Nearly all procedures in gastroenterology and visceral surgery can be performed under monotherapy with acetyl - salicylic acid. Other platelet aggregation inhibitors, such as clopidogrel or prasugrel, or anticoagulant drugs generally do not need to paused before diagnostic endoscopic procedures with a low risk of bleeding (<1.5%), but they must be paused before procedures in gastroenterology and visceral surgery where the risk of bleeding is high (≥ 1.5%). Bridging with heparin is reserved for patients with a very high risk of thromboembolism ( ≥ 5%).

CONCLUSION

Knowledge of the current recommendations on the management of anticoagulants before gastroenterological and visceral surgical procedures gives the clinician a well-founded means of dealing with this complex and common clinical situation.

Investigation report on endoscopic management of esophagogastric variceal bleeding by Chinese endoscopists

BACKGROUND

Esophagogastric variceal bleeding (EGVB) is a potentially life-threatening complication of portal hypertension. Endoscopic treatment combined with pharmacotherapy remains the mainstay in the management of acute variceal bleeding.

AIM

This article intends to highlight the potential differences in the endoscopic management of EGVB in China.

METHODS

A cross-sectional descriptive study was conducted. Endoscopists from 85 hospitals in 62 cities from 26 provinces were contacted by email. The items in questionnaire involved academic experience, screening, esophagogastric varices (EGV) classification, emergency treatment, and primary and secondary prophylaxis of EGVB by endoscopists with different lengths of experience.

RESULTS

A total of 85 questionnaires were collected. There was no statistical difference in the selection of items (P < .05 indicated statistical significance). The majority of endoscopists (95.29%) offered EGV screening for patients with liver cirrhosis. The location, diameter, and risk factor classification was selected by 82.35% of endoscopists. Endoscopy + medication was preferred (42.35%) for the primary prophylaxis of moderate-to-severe EGVs. There was no statistical difference in emergency intervention time for active EGVB (P > .05). The response "patients receive emergency endoscopic intervention within 12 hours" was selected by 61.2% of the endoscopists. The preferred emergency treatment for EGVB was combination treatment (40%). Tissue adhesive embolization was selected for the treatment of gastric variceal bleeding by 74.12% of endoscopists; transjugular intrahepatic portosystemic stent shunt/percutaneous transhepatic variceal embolization were selected as remedial measures by 48.23% to 52.94% of endoscopists. In addition, 67.06% of endoscopists elected to perform secondary prophylaxis and treatment within 1 week after hemostasis. Endoscopy and endoscopy + medication were selected by 44.71% and 49.41% of endoscopists, respectively, for secondary prophylaxis. The choice of laboratory indicators did not differ with length of experience.

CONCLUSIONS

There was no statistical difference in the endoscopic management of EGVB among Chinese endoscopists. The selection of diagnosis/treatment schemes was mainly based on guidelines and physician experience.

Improvement of gut-vascular barrier by terlipressin reduces bacterial translocation and remote organ injuries in gut-derived sepsis

Gut-vascular barrier (GVB) serves as the last barrier to limit the migration of intestinal toxins into the blood circulation. The efficacy of terlipressin (a vasopressin V1 receptor agonist) in reducing GVB and multiple organ damage in gut-derived sepsis is unknown. In this study, we hypothesized that, besides other intestinal barriers, GVB play a key role in gut-derived sepsis and terlipressin improve GVB damage and then reduce bacterial translocation and organ injuries. In vivo, a cecal ligation and puncture mouse model was established. The mice were subjected to examine the damage of GVB determined by intestinal plasmalemma vesicle-associated protein-1(PV-1) and vascular endothelial-cadherin. And the intestinal permeability was assessed by translocation of intestinal bacteria and macromolecules. In vitro, transendothelial electrical resistance (TER) during interleukin (IL)-1β stimulation was measured on endothelial cells with or without small interfering RNA targeting β-catenin (si β-catenin). Terlipressin significantly improved GVB damage and reduced translocation of intestinal macromolecules and bacteria by activating PI3K signaling. Of note, intestinal PV-1 expression was significantly correlated with translocation of macromolecules, and dramatic increase of macromolecules was observed in intestinal tissues whereas fewer macromolecules and bacteria were observed in blood, liver and lung following terlipressin treatment. In vitro, terlipressin restored TER during IL-1β stimulation and si β-catenin transfection blocked the changes delivered by terlipressin. Collectively, terlipressin alleviated GVB damage and subsequent bacterial translocation via blood vessels after sepsis challenge, resulting in reduced distant organ injuries and the responsible mechanisms may involve the activation of PI3K/β-catenin pathway.

Update on the management of upper gastrointestinal bleeding

Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.

Somatostatin plus Gastroscopic Administration of Omeprazole for the Treatment of Acute Upper Gastrointestinal Bleeding: An Exploration of a Promising Alternative

Objective

To analyze the efficacy and safety of somatostatin combined with gastroscopic administration of omeprazole in the treatment of acute upper gastrointestinal bleeding.

Methods

Eligible 112 patients with acute upper gastrointestinal bleeding treated in our hospital from May 2019 to July 2020 were randomized at a ratio of 1 : 1 either to the control group (somatostatin) or observation group (somatostatin combined with omeprazole gastroscope administration). The treatment efficacy, the average hemostasis time, rebleeding rate, average length of hospital stay, and the incidence of adverse reactions were compared.

Results

The study group demonstrated significantly higher total effective rate than the control group (96.45% vs. 80.36%, <0.05). The study group demonstrated superior performances compared to the control group with respect to the average hemostasis time ((14.17 ± 2.53 h) vs. (28.84 ± 4.07 h)), rebleeding rate (3.57% vs. 14.28%), and average length of hospital stay ((5.86 ± 1.26 d) vs. (9.74 ± 1.07 d)) (all p < 0.05). The chi-square test revealed a remarkably lower total incidence of adverse reactions in the study group vs. control group which was (4 (7.14%) vs. 12 (21.43%)) (p < 0.05).

Conclusion

The combination of somatostatin and gastroscopic administration of omeprazole might be a promising alternative for the treatment of acute upper gastrointestinal bleeding. It improves the clinical treatment effect and controls the symptoms of patients, with a good safety profile.

Management of Portal Hypertension

Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.

Efficacy of Endoscopic Intervention plus Growth Inhibitor and Patient Self-Management in the Treatment of Esophagogastric Variceal Bleeding in Cirrhosis

Objective

To assess the efficacy of endoscopic intervention plus growth inhibitor and patient self-management in the treatment of esophagogastric variceal bleeding.

Methods

Between January 2019 and December 2021, 60 patients with esophagogastric variceal bleeding treated in our hospital were assessed for eligibility and randomly recruited. They were concurrently and randomly assigned at a ratio of 1 : 1 to receive either endoscopic intervention plus growth inhibitor (control group) or endoscopic intervention plus growth inhibitor and patient self-management (observation group). The endpoint is clinical efficacy.

Results

All eligible patients showed a similar time of hemostasis, success rate of hemostasis, rebleeding rate, and disappearance rate of varicose veins (P > 0.05). Endoscopic intervention plus growth inhibitor and patient self-management were associated with a lower incidence of complication (6.67%, including 1 (3.34%) case of ulcer and 1 (3.34%) case of fever) than endoscopic intervention plus growth inhibitor (26.67%, including 3 (10.00%) cases of ulcer, 2 (6.67%) cases of retrosternal pain, and 3 (10.00%) cases of fever) (P < 0.05). Patients in the observation group had significantly higher life satisfaction scores (25.17 ± 4.28 and 23.68 ± 5.17) than those in the control group (22.13 ± 2.24 and 18.12 ± 3.28) (P < 0.05). A decrease in life satisfaction scores was observed at 6 months after treatment, and the patients given patient self-management showed a higher satisfaction (P < 0.05).

Conclusion

Endoscopic intervention plus growth inhibitor and patient self-management yielded remarkable clinical efficacy in the treatment of esophagogastric variceal bleeding as it reduces the incidence of complication and enhances the life satisfaction of patients, and so it is worthy of clinical promotion.

Management of varices and variceal hemorrhage in liver cirrhosis: a recent update

Cirrhosis consists of two main stages: compensated (asymptomatic) and decompensated, the latter with a higher mortality. Variceal hemorrhage, together with ascites or encephalopathy, or both, are events that define cirrhosis decompensation and are driven by portal hypertension. The approach and management of patients with compensated cirrhosis has been mostly focused on preventing variceal hemorrhage in those who have high-risk varices on endoscopy. Recent studies suggest a paradigm shift aimed at preventing all decompensating events, not only variceal hemorrhage, in patients with cirrhosis and clinically significant portal hypertension identified via noninvasive measures such as liver stiffness and platelet count. In these patients, nonselective beta-blockers have been shown to prevent ascites (the most common decompensating event) and variceal growth. Variceal hemorrhage has a high mortality rate and even though advances in diagnostic approach and standard of care over the past decades have led to a decrease in mortality, it is still high with a 6-week mortality rate of 15-20%. Survival has improved with the preemptive placement of the transjugular intrahepatic portosystemic shunt in patients at high risk of failing standard therapy. In this review, we provide an overview of the pathophysiology and bases for therapy of portal hypertension and varices, the diagnostic approach and management of compensated cirrhosis with clinically significant portal hypertension, and the management of acute variceal hemorrhage as well as prevention strategies for variceal hemorrhage recurrence.

Update on the management of gastric varices

Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Although less frequent than oesophageal varices (EV), bleeding from gastric varices (GV) is generally more severe and associated with higher mortality and a greater risk to rebleed. According to Sarin's classification, GVs are categorized into four types based on their location within the stomach and relationship with EV. Currently, treatment options for the management of GV include beta-blockers, endoscopic band ligation, endoscopic cyanoacrylate injection, EUS-guided coil/cyanoacrylate injection, transjugular intrahepatic portosystemic shunts and balloon-occluded retrograde transvenous obliteration. The best treatment strategy of GV remains controversial because of the heterogeneity of GV, lack of high-quality data and suboptimal trial design of the studies available. The proper treatment algorithm may require adequate endoscopic and imaging evaluation by a multidisciplinary team with multiple treatment options available. This review describes the hemodynamic features of GV, pharmacological, endoscopic and interventional radiological treatment options for GV.

Liver Diseases in the Parturient

Sundaram S, Giri S. Liver Diseases in the Parturient. Indian J Crit Care Med 2021;25(Suppl 3):S248-S254.

Management of Decompensated Cirrhosis and Associated Syndromes

Patients with cirrhosis account for 3% of intensive care unit admissions with hospital mortality exceeding 50%; however, improvements in survival among patients with acutely decompensated cirrhosis and organ failure have been described when treated in specialized liver transplant centers. Acute-on-chronic liver failure is a distinct clinical syndrome characterized by decompensated cirrhosis associated with one or more organ failures resulting in a significantly higher short-term mortality. In this review, we will discuss the management of common life-threatening complications in the patient with cirrhosis that require intensive care management including neurologic, cardiovascular, gastrointestinal, pulmonary, and renal complications.

Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding

Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.

Progress in new hemostasis techniques for acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding (AUGIB) is one of the most common acute and critical illnesses in the emergency department. It mainly refers to gastrointestinal bleeding above the Treitz ligament, and the mortality rate is about 2%-10%. The main clinical manifestations are hematemesis and/or hematochezia. The diagnosis is mainly based on clinical manifestations combined with laboratory and imaging findings. Due to the rapid onset and severe nature of the condition, there are various treatment methods according to different causes. This article reviews the diagnosis and treatment of acute upper gastrointestinal bleeding.

[Diagnosis and Management of Esophageal and Gastric Variceal Bleeding: Focused on 2019 KASL Clinical Practice Guidelines for Liver Cirrhosis]

Varices are a frequent complication of liver cirrhosis and a major cause of mortality in patients with liver cirrhosis. Patients with decompensated cirrhosis complications have a poor prognosis and require careful management. Portal hypertension is the most common complication of liver cirrhosis, which is the key determinant for varices development. Increased intrahepatic vascular resistance to portal flow leads to the development of portal hypertension. Collateral vessels develop at the communication site between the systemic and portal circulation with the progression of portal hypertension. Varices are the representative collaterals, develop gradually with the progression of portal hypertension and may eventually rupture. Variceal bleeding is a major consequence of portal hypertension and causes the death of cirrhotic patients. The present paper reviews the latest knowledge regarding the diagnosis and management of esophageal and gastric variceal bleeding.

Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis

Portal hypertension (PH), a common complication of liver cirrhosis, results in development of esophageal varices. When esophageal varices rupture, they cause significant upper gastrointestinal bleeding with mortality rates up to 20% despite state-of-the-art treatment. Thus, prophylactic measures are of utmost importance to improve outcomes of patients with PH. Several high-quality studies have demonstrated that non-selective beta blockers (NSBBs) or endoscopic band ligation (EBL) are effective for primary prophylaxis of variceal bleeding. In secondary prophylaxis, a combination of NSBB + EBL should be routinely used. Once esophageal varices develop and variceal bleeding occurs, standardized treatment algorithms should be followed to minimize bleeding-associated mortality. Special attention should be paid to avoidance of overtransfusion, early initiation of vasoconstrictive therapy, prophylactic antibiotics and early endoscopic therapy. Pre-emptive transjugular intrahepatic portosystemic shunt should be used in all Child C10-C13 patients experiencing variceal bleeding, and potentially in Child B patients with active bleeding at endoscopy. The use of carvedilol, safety of NSBBs in advanced cirrhosis (i.e. with refractory ascites) and assessment of hepatic venous pressure gradient response to NSBB is discussed. In the present review, we give an overview on the rationale behind the latest guidelines and summarize key papers that have led to significant advances in the field.