<aside> 📘 Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy(ESGE) guideline (2022)

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Flowcharts

Management of acute esophageal variceal hemorrhage (EVH).
Management of acute gastric variceal hemorrhage (GVH).

Definition and abbreviation

Term	Definition/Description
ACLD	Advanced chronic liver disease
NSBB	non-selective beta-blocker
Compensated ACLD	Liver stiffness via transient elastography < 20 kPa and platelet count > 150 × 10^9/L
Decompensated ACLD	Liver stiffness via transient elastography ≥ 20 kPa or platelet count ≤ 150 × 10^9/L
Clinically significant portal hypertension	HVPG > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa

Screening for high risk esophagogastric varices and primary prophylaxis

Condition	High-risk varices (medium to large, red wale marking)	Plan
Compensated ACLD	Low probability	Screening can be avoided
Decompensated ACLD not receiving NSBB	High probability	Should be screened
Clinically significant portal hypertension	Probability for variceal bleeding	Should be screened. Should receive NSBB (preferably carvedilol), if no contraindications

Patient with high risk varices but cannot use NSBB

Esophageal varices	EBL should be done every 2-4 weeks until varices are eradicated.	Surveillance EGD should be performed every 3-6 months in the first year following eradication.
Gastric varices	Individualized approach (No treatment, cyanoacrylate injection alone, or EUS-guided coil plus cyanoacrylate injection)	There is currently a lack of definitive high-level evidence regarding specific eradication therapies for cardiofundal varices.

<aside> 💡 The evidence of NSBB NSBB therapy and EBL are equally effective in preventing the first variceal bleed. EBL has more serious side effects, but NSBBs are more often discontinued due to adverse events. NSBBs offer a survival advantage, possibly due to their effect on reducing portal hypertension. Carvedilol is the preferred NSBB for primary prophylaxis due to its superior portal pressure-lowering effect and better outcomes for nonresponders to propranolol.

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Pre-endoscopy management of acute EGVH

Hemodynamic resuscitation

Treatment	Recommendation	Strength of Recommendation	Quality of Evidence
Hemodynamic Assessment	Urgent assessment of the hemodynamic status	Strong	Low
Volume Replacement	Prompt, yet careful, intravascular volume replacement, initially using crystalloid fluids	Strong	Low
Fresh Frozen Plasma	Does not recommend as part of the initial management.	Strong	Low. Mohanty et al., in a retrospective study, FFP transfusion was associated with significantly increased mortality at 42 days.
Recombinant Factor VIIa	Does not recommend as part of the initial management of EGVH.	Strong	High. Bosch et al., RCT., 2008 did not find a significant benefit

Endotracheal intubation

Management	Recommendation	Strength of Recommendation	Quality of Evidence
Endotracheal Intubation	Suspected variceal hemorrhage and ongoing hematemesis, encephalopathy, and/or with agitation and inability	Weak	Low
Prophylactic Endotracheal Intubation	If prophylactic endotracheal intubation is performed, extubation should occur ASAP after upper GI endoscopy.	Strong	Very Low