Endoscopic band ligation (EBL) standard therapy is traditionally performed with banding from the distal esophagus upwards. However, esophageal varices (EV) with stigma of recent bleeding are not consistently banded at the first attempt. We aimed to compare conventional banding in acute variceal bleeding (AVB) vs targeted banding of EV in patients with stigma of recent bleeding (white nipple sign).

This case-control study included patients treated in our hospital from December 2016 to September 2019 with endoscopic signs of recent variceal bleeding. The targeted technique involves deploying the first band at the recent bleeding stigmata and then completing the procedure with standard variceal banding technique. The conventional group included patients treated with standard EBL.

We analyzed 92 patients, 54 (58.7%) in conventional technique and 38 (41.3%) in the targeted group. Active bleeding during endoscopy occurred in 11 (20.0%) of conventional and two (6.5%) of the targeted group (p=0.021). Although procedure time was longer in the conventional group (24.3min SD 11.58) compared to the targeted group (21.52min SD 8.73) this difference was not significant. One detached band episode was documented in targeted group and none in the conventional group (p=0.418). TIPS were not used during this study due to health system policy. There were no significant differences in mortality, rebleeding or transfusion requirements between groups.

The targeted technique for EV with stigma of recent bleeding had a low band detachment incidence and fewer bleeding events during endoscopy, however, the limitations of the study should be considered.

To investigate the role of endoscopic ultrasonography (EUS) in the diagnosis and treatment of upper gastrointestinal bleeding of unknown origin in liver cirrhosis, focusing on patients with recurrent treatment of esophageal and gastric varices who failed to identify the bleeding site under direct endoscopy.

Esophagogastric variceal bleeding is one of the severe complications of decompensated liver cirrhosis, and serial endoscopic therapy can improve the long-term quality of life of patients. Most acute bleeding can be detected under direct endoscopy with thrombus or active bleeding, but there are still some patients with recurrent bleeding after repeated treatments, and it is difficult to find the bleeding site, especially in gastric variceal bleeding. Therefore, it is of great significance to identify the bleeding site.

A total of 88 patients with liver cirrhosis bleeding diagnosed and treated under EUS were collected in this study, including 26 patients who failed to identify the bleeding site under direct endoscopy. EUS was used to scan the bleeding site, and EUS-guided treatment was performed. The characteristics of the bleeding site under direct endoscopy and EUS and the follow-up results after surgery were analyzed.

Among the 26 patients, 16 patients (16/26, 61.5%) showed red color signs of gastric fundus mucosa under direct endoscopy, 5 patients (5/26, 19.2%) showed punctate erosion, and the remaining 5 patients (5/26, 19.2%) showed no abnormal mucosal manifestations. All patients could find anechoic blood vessels under EUS, and blood flow signals could be detected within. Among them, 23 patients (23/26, 88.5%) chose EUS-guided treatment, and no rebleeding occurred after surgery. Another 3 patients (3/26, 11.5%) were given endoscopic variceal ligation due to small esophageal and gastric varices and inability to perform intravascular injection. The median follow-up time was 86 days. Adverse reactions included 5 cases of retrosternal pain (5/23, 21.7%), and 1 case of fever (1/23, 4.3%).

EUS can detect submucosal varices in the gastric mucosa, and these bleeding sites may present as red color signs or punctate erosion under direct endoscopy.

The effectiveness of emergent endoscopy (EE), defined as endoscopy performed within six hours of admission, for improving outcomes in patients presenting with acute upper gastrointestinal bleeding (AUGIB) remains controversial. This study aimed to evaluate the impact of EE on 42-day rebleeding and mortality rates and identify subgroups of patients who benefit most from this approach.

We conducted a retrospective cohort study at a tertiary hospital with 24/7 endoscopy services. Eligible patients were aged ≥18 years, presented with AUGIB, and underwent endoscopy within 24 hours of admission. The exclusion criteria included prior interventions at other facilities, in-hospital bleeding for unrelated reasons, or loss to follow-up. All patients were managed under a standardized AUGIB protocol. The primary outcomes were 42-day rebleeding and mortality. The data were analysed via multivariate logistic regression and interaction analyses.

There were 651 patients with a median age of 58.6 years (18-92). The median time from admission to endoscopy was 4.8 hours (3.1-8.0). The 42-day rebleeding and mortality rates were 16.7% and 11.8%, respectively. EE was significantly associated with 42-day mortality but not rebleeding. Independent risk factors for mortality included hemodynamic instability, malignancy, NSAID use, and elevated serum creatinine. Interaction analysis revealed that EE was associated with reduced 42-day mortality in hemodynamically unstable patients (OR: 0.29, 95% CI: 0.145-0.579), a benefit not observed in patients with other risk factors for mortality.

EE appears to be associated with reduced 42-day mortality in patients presenting with hemodynamically unstable AUGIB.

Peptic ulcer bleeding (PUB) is a significant cause of morbidity and mortality, especially in geriatric patients. Risk stratification tools such as AIMS65, Glasgow Blatchford Score (GBS), T-score, and Age, Blood tests, and Comorbidities (ABC) score are frequently used to predict outcomes in PUB patients. This study aims to compare the predictive performance of these four scoring systems in geriatric patients with PUB.

This retrospective cohort study included patients aged 65 years and older who were diagnosed with PUB between January 1, 2019, and January 1, 2024, in a tertiary care hospital. Data collected included demographic information, clinical presentation, laboratory results, and comorbidities. AIMS65, GBS, T-Score, and ABC score were calculated for each patient. The primary outcome was in-hospital mortality.

A total of 315 patients were included in the study, with an overall in-hospital mortality rate of 7.9%. AIMS65 had the highest area under the curve (area under the receiver operating characteristic curve (AUROC): 0.829), followed by the ABC score (AUROC: 0.775). The GBS (AUROC: 0.694) and T-score (AUROC: 0.526) demonstrated lower predictive performance. Pairwise comparisons showed a statistically significant difference between the AIMS65 and GBS (p = 0.0214). AIMS65 was the most accurate predictor of in-hospital mortality in geriatric PUB patients.

The AIMS65 and ABC scoring systems are more effective in predicting in-hospital mortality in geriatric patients with PUB compared to the GBS and T-Score. Implementing these tools in clinical practice could improve risk stratification and decision-making processes in managing high-risk elderly patients.

Evaluation of the Australian Triage Scale in patients who present to the emergency department with upper gastrointestinal bleeding BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a common presentation to the emergency department (ED). Study aims were to evaluate the utility of the Australasian Triage Score (ATS) in patients presenting to the ED with UGIB.

This retrospective observational study included 356 patients over a 2-year period who presented to a metropolitan hospital ED. The ATS was categorised into three groups, ATS 1/2, ATS 3 and ATS 4/5. Primary outcomes explored the relationship between ATS and haemodynamic parameters. Secondary outcomes evaluated the proportion of patients with suspected variceal bleeding and allocated a non-life-threatening ATS category.

The study population were distributed by ATS 1/2 (28.7 %), ATS 3 (46.6 %) and ATS 4/5 (24.7 %). Over half of patients with some haemodynamic compromise were allocated an ATS 3 or 4/5. Additionally, 56 % with suspected variceal bleeding and 51 % with syncope were also allocated an ATS category (3 or 4/5).

The utility of the ATS recognises most patients presenting with UGIB at high-risk of adverse outcomes. Additional screening at triage maybe beneficial for those patients with a history of cirrhosis or varices, and UGIB-related syncope. Consideration of an ATS category of 2 for these patients may enable them to access earlier time-critical therapies.

There is a lack of consensus on the optimal management of fundal gastric varices (GVs) in patients with cirrhosis due to varied anatomy and hemodynamics. In this study, we evaluate the safety and efficacy of trans-splenic anterograde coil-assisted transvenous occlusion (TACATO) for preventing recurrent bleeding in fundal GVs associated with gastrorenal shunt (GRS).

In this 4-year study, patients with cirrhosis with GRS-associated GV bleeding, without prior esophageal variceal bleeding, ascites, or portal vein thrombosis, were eligible for TACATO. Trans-splenic access was achieved by puncturing a splenic venous branch using ultrasound/fluoroscopic guidance. A microcatheter was inserted into the varices for embolization with detachable microcoils and possibly N-butyl-cyanoacrylate-Lipiodol. Technical success was assessed by venography. All patients underwent follow-up endoscopy and decompensating events were recorded. A retrospective external control group of patients with cirrhosis and similar GRS-associated GVs treated by retrograde transvenous obliteration was enrolled as a comparative group.

Twenty patients with cirrhosis underwent TACATO (17 GOV2, 6 IGV1 - median GRS size 23 mm, range 15-32 mm). Median occlusion of the shunt was 90% (complete in 14/20); complications included local abdominal pain and partial splanchnic thrombosis in two patients. Over a median follow-up of 23 (range 10-31) months, no rebleeding or further decompensation occurred; liver function remained stable and endoscopy showed reduced or resolved fundal GVs without worsening esophageal varices in all patients. The comparative group (18 patients - median GRS diameter 14 mm, range 6-23 mm) reported no rebleeding but worsening varices in two and ascites progression in two.

TACATO is a viable option for secondary prophylaxis of bleeding from GVs associated with GRS and may reduce hepatic decompensation risk. Further studies are needed to validate these results and determine TACATO's broader role in GV management.

Gastric varices (GVs) affect 20% of patients with cirrhosis, with a 2-year bleeding risk of 25%. Fundal GVs, which account for 70% of cases, are associated with mortality rates of up to 55%, posing management challenges due to their complex anatomy and hemodynamics. Transjugular intrahepatic portosystemic shunt placement often fails to address fundal GV hemodynamics, leaving patients at a high risk of rebleeding. Balloon-occluded retrograde transvenous obliteration, while effective, is limited by complexity, logistical hurdles, and complications. TACATO (trans-splenic anterograde coil-assisted transvenous occlusion) provides effective secondary prophylaxis for fundal GV bleeding linked to gastrorenal shunts. It matches the efficacy of retrograde and anterograde techniques while offering faster execution, minimal side effects, and no need for specialized equipment or gastrorenal shunt size restrictions. Trans-splenic access ensured safe and straightforward access to the portal system and fundal GVs in all patients treated with TACATO.

Critically ill patients with liver cirrhosis exhibit complex alterations in coagulation that should be considered in clinical acute management. As routine laboratory tests (e.g., INR, aPTT, platelet count) cannot always adequately reflect the coagulation status of critically ill patients with liver cirrhosis, functional hemostatic tests, such as viscoelastic tests, should also be used to assess coagulation disorders in these patients. If invasive procedures are planned, hemostatic interventions to prevent bleeding and measures to stabilize coagulation disorders should be considered depending on the risk of procedure-associated bleeding, while a prophylactic routine correction of abnormal laboratory coagulation parameters should be avoided. If an acute bleeding complication manifests in critically ill patients with liver cirrhosis, an individualized correction of hemostatic changes is indicated in addition to prompt identification of the source of bleeding. This review article describes the pathophysiological changes underlying the altered hemostatic system in critically ill patients with liver cirrhosis and provides an overview of diagnostic and therapeutic options for hemostatic complications.

Bleeding from gastric varices is life-threatening, with significant rebleeding risk despite standard cyanoacrylate glue injection therapy. Our aim was to evaluate the efficacy and safety of endoscopic ultrasonography (EUS)-guided coil embolization with cyanoacrylate injection (Coil+CYA) compared with EUS-guided cyanoacrylate injection alone (CYA) for the treatment of gastric varices.

The study was conducted at a tertiary referral center in India, using a single-blinded, prospective, and parallel-group randomized design. A total of 50 patients were randomly assigned (1 : 1) to Coil+CYA or CYA. The primary outcome was clinical success (i.e. variceal obliteration). Secondary outcomes involved technical success, gastric variceal recurrence during follow-up, rebleeding episodes, reintervention, and survival.

Post-intervention, gastric variceal obliteration assessed by EUS was higher in the Coil+CYA group (100% vs. 92.3%; P = 0.49), with both groups achieving 100% technical success. Rebleeding episodes during 0-12 and 12-24 weeks were comparable in the two groups. At 12 weeks, on EUS, variceal reappearance was less common in the Coil+CYA group (12.5% vs. 19.2%; P = 0.70). Significantly fewer reinterventions were needed in the Coil+CYA group (20.8% vs. 53.8%; P = 0.03). The time to reintervention was significantly longer in the Coil+CYA group (P = 0.01), and the survival time was also longer (P = 0.04).

EUS-guided coil embolization with cyanoacrylate injection achieved superior clinical success, reducing the need for reintervention and resulting in improved survival compared with cyanoacrylate injection alone.

Ectopic Variceal Bleeding is a rare complication of portal hypertension, often difficult to manage and potentially life-threatening. However, established guidelines directing treatment are lacking. This report presents a 51-year-old female with hepatitis B-related cirrhosis, who experienced rare small intestinal bleeding due to varicose veins in the superior mesenteric vein and left ovarian vein. The bleeding was successfully resolved by Balloon-occluded Retrograde Transvenous Obliteration. This report discusses the feasibility of BRTO compared to Transjugular Intrahepatic Portosystemic Shunt for certain patients with EctVB.

The study aimed to develop machine learning (ML) models to predict the mortality of patients with acute gastrointestinal bleeding (AGIB) in the intensive care unit (ICU) and compared their prognostic performance with that of Acute Physiology and Chronic Health Evaluation II (APACHE-II) score.

A total of 961 AGIB patients admitted to the ICU of Renmin Hospital of Wuhan University from January 2020 to December 2023 were enrolled. Patients were randomly divided into the training cohort (n = 768) and the validation cohort (n = 193). Clinical data were collected within the first 24 h of ICU admission. ML models were constructed using Python V.3.7 package, employing 3 different algorithms: XGBoost, Random Forest (RF) and Gradient Boosting Decision Tree (GBDT). The area under the receiver operating characteristic (ROC) curve (AUC) was used to evaluate the performance of different models.

A total of 94 patients died with an overall mortality of 9.78% (11.32% in the training cohort and 8.96% in the validation cohort). Among the 3 ML models, the GBDT algorithm demonstrated the highest predictive performance, achieving an AUC of 0.95 (95% CI 0.90-0.99), while the AUCs of XGBoost and RF models were 0.89 (95% CI 0.82-0.96) and 0.90 (95% CI 0.84-0.96), respectively. In comparison, the APACHE-II model achieved an AUC of 0.74 (95% CI 0.69-0.87), with a specificity of 70.97% (95% CI 64.07-77.01). When APACHE-II score was incorporated into the GBDT algorithm, the ensemble model achieved an AUC of 0.98 (95% CI 0.96-0.99) with a sensitivity of 85.71% and a specificity up to 95.15%.

The GBDT model serves as a reliable tool for accurately predicting the in-hospital mortality for AGIB patients. When integrated with the APACHE-II score, the ensemble GBDT algorithm further enhances predictive accuracy and provides valuable insights for prognostic evaluation.

Previous studies have indicated that, in addition to the types of food consumed, eating habits are also associated with the risk of esophageal diseases. Some studies have suggested a possible link between breakfast skipping and esophageal tumors as well as gastroesophageal reflux disease. However, it remains unclear whether breakfast skipping has a causal relationship with esophageal diseases. To address this issue, this study aimed to investigate the potential causal relationship between breakfast skipping and esophageal diseases using a two-sample mendelian randomization (MR) approach.

We obtained data from genome-wide association studies (GWAS) involving 193,860 individuals from the UK Biobank on breakfast skipping. The summary statistics for the esophageal diseases were derived from the IEU open GWAS project. In this two-sample MR analysis, inverse variance weighted was used, supplemented with weighted median, simple mode and weighted mode methods.

The results revealed significant causal relationships between breakfast skipping and esophageal cancer (odds ratio (OR): 5.992, 95 % confidence interval (CI): 1.606-22.350, p = 0.008), Barrett's esophagus (OR: 4.041, 95 % CI: 1.837-8.889, p < 0.001), gastroesophageal reflux disease (OR: 2.463, 95 % CI: 1.995-3.041, p < 0.001), and esophageal varices (OR: 4.454, 95 % CI: 1.785-11.112, p = 0.001). All of the supplementary methods supported the findings.

Our research provides evidence for the association between breakfast skipping and esophageal diseases. Breakfast skipping could be a potential risk factor for esophageal cancer, Barrett's esophagus, gastroesophageal reflux disease and esophageal varices. For high-risk groups prone to these esophageal diseases, emphasizing the importance of regular breakfast and maintaining consistent dietary habits is crucial for esophageal health.

EUS-guided coil plus glue injection has emerged as a safe and effective modality for gastric varices (GVs). Very few studies have compared EUS embolization with the direct endoscopic glue injection (EGI) technique for its safety and effectiveness. In this systematic review and meta-analysis, we compared the outcomes of EUS-guided coil plus glue injection versus EGI.

MEDLINE, EMBASE, and Cochrane databases were searched for studies that compared EUS and EGI for GVs, and 1454 articles were screened following the Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol. Endpoints were pulmonary embolism, recurrent bleeding rate, reintervention rate, technical success, abdominal pain, and mortality rate. A restricted maximum likelihood random-effects model with odds ratios (ORs) and 95% confidence intervals (CIs) was used for binary endpoints. Heterogeneity was evaluated through Cochrane's Q statistic and Higgins and Thompson's I2 statistic. Significance was defined as P < .05.

We included 6 studies with 445 patients treated for GVs. Mean patient age was 49 years, and 43% were women. EUS was associated with a reduction in recurrent bleeding rate (OR, .22; 95% CI, .11-.45; P < .001; I2 = 0) and reintervention rate (OR, .29; 95% CI, .09-.89; P = .03; I2 = 49%) compared with EGI. There were no differences between groups in pulmonary embolism (OR, .34; 95% CI, .10-1.18; P = .09; I2 = 0%), mortality rate (OR, .78; 95% CI, .28-2.13; P = .63; I2 = 0%), technical success (OR, 3.50; 95% CI, .60-20.49; P = .16; I2 = 0%), fever (OR, 1.49; 95% CI, .42-5.21 days; P = .5; I2 = 0%), and abdominal pain (OR, .96; 95% CI, .31-2.95; P = .94; I2 = 32%).

In patients with GVs, EUS-guided coil plus glue injection is associated with lower recurrent bleeding and reintervention rates than EGI with no difference in pulmonary embolization rate, abdominal pain, technical success, and mortality rate.

Variceal upper gastrointestinal bleeding is a common cause of decompensation in patients with liver cirrhosis. While mortality data, which are from 10 to 15%, are available, there are no validated scales to predict in-hospital mortality in this patient population.

To determine whether the MELD-Lactate (MELD-LA) level is associated with in-hospital mortality in patients with chronic liver disease who are admitted for variceal bleeding.

A prospective, observational, and analytical study was conducted that included 120 patients. The MELD-LA cut-off point was obtained, and in-hospital mortality was obtained using conventional prognostic scales that had the highest sensitivity and specificity for comparison purposes. Additionally, a survival analysis was performed using the MELD-LA cut-off point obtained.

In our cohort, 6 (5.0%) patients died during hospitalization. Patients who died had a mean MELD-LA value of 20.0 (±4.97) as opposed to those who did not die, 13.62 (±3.29), (p<0.001). The MELD-LA cut-off point of >14.0, with a sensitivity of 100%, a specificity of 71.0%, a positive predictive value of 15.4%, a negative predictive value of 100.0%, and an AUC (area under the curve) of 0.886, was most well correlated with higher in-hospital mortality. Survival was 71.1% in patients with MELD-LA levels>14.0 versus 100.0% in those with lower levels (p=0.001) during hospitalization.

The measurement of MELD-LA at admission seems to be a good complementary marker for the evaluation and prognosis of in-hospital mortality in patients with liver cirrhosis, and variceal upper gastrointestinal bleeding.

To construct a nomogram combining CT varices vein evaluation and clinical laboratory tests for predicting the risk of esophageal gastric variceal bleeding (EGVB) in patients with noncirrhotic portal hypertension (NCPH).

A total of 315 NCPH patients with non-EGVB and EGVB were retrospectively enrolled and randomly divided into training and testing cohorts. Thirteen collateral vessels were identified and evaluated after CT portal vein system reconstruction. Multivariate binary logistic regression analysis was used to choose CT images and clinical predictors of EGVB. The varices score of each patient was calculated. A nomogram was built by combining the varices score with the selected clinical predictors of EGVB. The receiver operating characteristic (ROC) curve was used to evaluate the predictive performance of the nomogram.

Platelet count and prothrombin time were selected as clinical predictors; the esophageal vein, gastroepiploic vein and omental vein were selected as CT image predictors for predicting EGVB. A reduced platelet count, prolonged prothrombin time, severe esophageal and gastroepiploic vein tortuosity and less omental vein tortuosity were predictors of EGVB in NCPH patients. The specificity, sensitivity, negative predictive value, positive predictive value and AUC of the ROC of the nomogram were 0.82, 0.81, 0.89, 0.70, and 0.88 (95% CI: 0.84-0.93) in the training cohort and 0.87, 0.86, 0.88, 0.84, and 0.91 (95% CI: 0.84-0.97) in the testing cohort, respectively.

The nomogram combining CT images and clinical predictors could be useful to individualize and predict the risk of EGVB in NCPH patients.

Results showed that the nomogram combining CT-evaluated collateral vessels (varices score) and clinical laboratory tests could be used to realize personalized prediction of first-time EGVB in NCPH patients.

Practice guidelines recommend non-selective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) for primary prevention in cirrhosis patients with esophageal varices. However, there is no clear recommendation for primary prevention strategies for gastric varices, particularly GOV-2. Our objective is to investigate the incidence of initial bleeding and liver-related complications when NSBB and EVL are used for primary prevention in GOV-2.

A retrospective analysis was conducted on data from patients with GOV-2 gastric varices. Patients were divided into the NSBB group or the EVL group. Differences in the incidence of initial bleeding within 1 year, as well as the occurrence of complications such as hepatic encephalopathy and ascites, were compared between the two groups before and after adjustment for Inverse Probability of Treatment Weighting (IPTW). A Cox proportional hazards model was used to identify independent risk factors for the first bleeding event.

There were 60 patients in the NSBB group and 66 patients in the EVL group. Before IPTW adjustment, there were differences between the two groups in sex, portal hypertensive gastropathy, esophageal variceal diameter, red signs, FIB-4, and MELD scores. After IPTW adjustment, these differences were balanced, with standardized mean differences (SMDs) within acceptable ranges. Kaplan-Meier survival analysis showed no difference in bleeding rates between the two groups before or after IPTW adjustment. After IPTW adjustment, Cox regression analysis identified esophageal variceal diameter (HR:5.59 (2.03-15.39), p < 0.001) and MELD score (HR:1.17 (1.01-1.23), p = 0.042) were independent risk factors for bleeding. NSBB treatment did not reduce the incidence of liver-related complications within one year compared to EVL.

For primary prevention of bleeding in cirrhotic patients with GOV-2, EVL does not significantly reduce initial bleeding episodes or liver-related complications compared to NSBB.

Patient blood management (PBM) adherence in clinical practice is unclear. This real-world practice study assessed the management of patients with gastrointestinal (GI) bleeding after the implementation of the PBM strategy.

This was a nationwide multicenter and prospective study involving consecutive adults with GI bleeding between March 2019 and March 2021. Patients were examined according to hemoglobin (Hb) level at admission (<7 g/dl, n  = 93; 7-8 g/dl, n  = 47; 8-9 g/dl, n  = 61; and >9 g/dl, n  = 249). Study outcomes measures were morbidity and mortality during hospitalization and at 3- and 6-month follow-up. Appropriate anemia or iron deficiency management was considered when adherence to PBM policy was higher than 75%.

A total of 450 patients (57.6% men, median age: 74 years, interquartile range: 63-82) were included. Overall, 55.1% and 59.3% of patients received transfusion and iron supplementation, respectively. The rates of appropriate transfusion and iron supplementation adherence were 90.9% (range: 86.9-93.5%, P  = 0.109) and 81.8% (range: 78.5-85.1%, P  = 0.041), depending on Hb level, respectively. No associations were observed between adherence to the PBM strategy and length of stay ( P  = 0.263) or risk of further bleeding ( P  = 0.742). Patients who were transfused [hazard ratio (HR): 0.79, 95% confidence interval (CI): 0.27-0.85] and iron supplemented (HR: 0.91, 95% CI: 0.38-1.41), however, appropriately achieved a lower risk of death. Age (HR: 1.12, 95% CI: 1.12-1.25) and further bleeding (HR: 39.08, 95% CI: 4.01-181.24) were poor prognostic factors. No serious adverse events were reported.

In this nationwide study, there is a high level of adherence and safety of PBM for the treatment of GI bleeding. Adherence to the PBM strategy improved outcomes in patients with GI bleeding.

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 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.

This study aims to evaluate the outcomes of endoscopic sclerotherapy (EST) in the treatment of esophagogastric varices in cases of extrahepatic portal hypertension (EHPH) secondary to portal vein thrombosis.

Records of cases that underwent endoscopic sclerotherapy for esophagogastric varices between 1990 and 2022 in our clinic were retrospectively reviewed. The age, gender, symptomatology, etiology, clinical, laboratory, and radiological data of the patients, as well as treatment outcomes, were evaluated. Results were compared based on age groups, time periods, and etiological factors. The classification of the Japanese Portal Hypertension Research Society was used for variceal assessment. The absence of bleeding or bleeding not requiring transfusion within one year was considered a positive outcome.

Of the 126 cases that underwent endoscopy with a diagnosis of EHPH, 41 had varices at the F1-F2 level and were not subjected to sclerotherapy. In 21 cases, due to advanced varices, gastropathy findings, frequent bleeding episodes, and hypersplenism, surgical indication was established after the first endoscopy. The remaining 64 cases were included in the study. Positive outcomes were achieved in 44 cases with an average of 4.1 sessions. Desired outcomes were not achieved in 20 cases, and surgical procedures were performed. When the results were evaluated based on the periods 1990-2000, 2001-2010, and 2011-2022, the success rates were 60%, 44%, and 88.2%, respectively. Statistically significant more favorable results were obtained in the last decade.

EST is a safe and effective minimally invasive method for the elective treatment of esophagocardial varices in children with EHPH. More effective results have been achieved with increased experience and advancements in imaging technology.

Imaging remains an essential aspect in evaluating patients receiving liver transplants, especially in cases of complications such as portal vein thrombosis. Several imaging modalities are available to approach portal vein thrombosis, with portography as the gold standard. However, the development of noninvasive methods such as contrast-enhanced computed tomography (CECT) is preferred nowadays due to the fewer complications in nature. This case report presented a case of a giant varix of the portal vein with thrombus in a 20-year-old male receiving living-donor liver transplant, reliably visualized in both CECT and direct splenoportography. Detailed parameters and sequences required for accurate imaging in CECT are discussed in this study.

This review explores the pharmacokinetics, benefits, and risks of proton pump inhibitors (PPIs) in cirrhotic patients, focusing on the appropriateness of their use and potential adverse effects.

Recent studies highlight significant pharmacokinetic alterations in PPIs among cirrhotic patients, with marked increases in lansoprazole and pantoprazole exposure and relatively stable levels of esomeprazole. While effective for managing acid-related disorders and post-band ulcer rebleeding, evidence supporting PPI use for portal hypertension-related bleeding is lacking. Emerging research suggests potential adverse effects such as hepatic decompensation, spontaneous bacterial peritonitis, hepatic encephalopathy, and increased mortality, possibly linked to dysbiosis and bacterial translocation. PPI use in cirrhotic patients alters pharmacokinetics significantly, with esomeprazole potentially safer in advanced cirrhosis. The review advises caution in routine PPI use beyond acid-related conditions due to limited evidence and substantial risks. It underscores the need for careful risk-benefit assessments and exploration of alternative therapies. Future research should aim to identify safer management strategies for portal hypertension complications and to develop evidence-based guidelines for PPI use in patients with cirrhosis.

Esophageal variceal bleeding is a severe complication often associated with portal hypertension, commonly due to liver cirrhosis. Prevention and treatment of this condition are critical for patient outcomes. Preventive strategies focus on reducing portal hypertension to prevent varices from developing or enlarging. Primary prophylaxis involves the use of non-selective beta-blockers, such as propranolol or nadolol, which lower portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices. Endoscopic variceal ligation (EVL) may also be employed as primary prophylaxis to prevent initial bleeding episodes. Once bleeding occurs, immediate treatment is essential. Initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs such as octreotide or terlipressin to control bleeding. Endoscopic intervention is the cornerstone of treatment, with techniques such as EVL or sclerotherapy applied to directly manage the bleeding varices. In cases where bleeding is refractory to endoscopic treatment, transjugular intrahepatic portosystemic shunt may be considered to effectively reduce portal pressure. Long-term management after an acute bleeding episode involves secondary prophylaxis using beta-blockers and repeated EVL sessions to prevent rebleeding, complemented by monitoring and managing liver function to address the underlying disease. In light of new scientific evidence, including the findings of the study by Peng et al, this editorial aims to review available strategies for the prevention and treatment of esophageal varices.

This review addresses the peri-procedural bleeding risks in patients with cirrhosis, emphasizing the need for careful coagulation assessment and targeted correction strategies. Liver disease presents a unique hemostatic challenge, where traditional coagulation tests may not accurately predict bleeding risk, complicating the management of procedures like paracentesis, endoscopic therapy, and various interventional procedures. As such, this paper aims to provide a comprehensive analysis of current data, guidelines, and practices for managing coagulation in cirrhotic patients, with a focus on minimizing bleeding risk while avoiding unnecessary correction with blood products. The objectives of this review are threefold: first, to outline the existing evidence on bleeding risks associated with common invasive procedures in cirrhotic patients; second, to evaluate the efficacy and limitations of standard and advanced coagulation tests in predicting procedural bleeding; and third, to examine the role of blood product transfusions and other hemostatic interventions, considering potential risks and benefits in this delicate population. In doing so, this review highlights patient-specific and procedure-specific factors that influence bleeding risk and informs best practices to optimize patient outcomes. This review progresses through key procedures often performed in cirrhotic patients. The discussion begins with paracentesis, a low-risk procedure, followed by endoscopic therapy for varices, and concludes with high-risk interventions requiring advanced hemostatic considerations. Each chapter addresses procedural techniques, bleeding risk assessment, and evidence-based correction approaches. This comprehensive structure aims to guide clinicians in making informed, evidence-backed decisions in managing coagulation in cirrhosis, ultimately reducing procedural complications and improving care quality for this high-risk population.

Esophageal subepithelial lesions (ESELs) encompass a variety of diseases, including leiomyoma, granular cell tumors, hemangioma, lipoma, stromal tumors, leiomyosarcoma, schwannoma, neuroendocrine tumors and more. These lesions often present asymptomatically, leading to a generally low clinical diagnosis rate. Common imaging techniques for diagnosing ESELs include conventional endoscopy, spiral computed tomography, and endoscopic ultrasound (EUS). Among these, EUS is currently regarded as one of the most accurate methods for diagnosing ESELs. In recent years, EUS has increasingly been combined with advanced technologies such as artificial intelligence, submucosal saline injection, high-frequency impedance measurement, and enhanced imaging to improve diagnostic accuracy and reduce missed diagnoses. This article reviews the application and recent advancements of EUS in diagnosing esophageal submucosal lesions.

Esophageal-gastric variceal bleeding (EGVB) is a serious complication in patients with liver cirrhosis, characterized by high mortality and rebleeding rates. The effect of sequential endoscopic therapy on patient mortality and rebleeding rates remains unclear.

This study aimed to evaluate the effects of sequential endoscopic therapy on mortality and rebleeding rates in patients with EGVB.

In this single-center retrospective study, 373 hospitalized cases of EGVB caused by liver cirrhosis, collected between November 2019 and November 2023, were divided into four groups according to different treatment methods: a sequential endoscopy group, emergency endoscopy group, emergency endoscopy plus transjugular intrahepatic portosystemic shunt (TIPS) group and control group.

Mortality and rebleeding rates were compared among the four groups using statistical analyses.

The mortality and rebleeding rates of the sequential endoscopy group (3.7% and 19%, respectively) were significantly lower than those of the emergency endoscopy (22% and 36%, respectively), emergency endoscopy plus TIPS (33% and 28%, respectively), and control groups (33% and 51%, respectively) (p = 0.013 and p = 0.013, respectively).

Sequential endoscopic therapy may significantly reduce the mortality and rebleeding rates of patients with EGVB compared to other conventional treatment strategies. The findings of the study could help develop approaches benefiting EGVB treatment.

Direct oral anticoagulants (DOACs) are increasingly being used due to their improved efficacy/safety ratio and lower clinical and economic burden when compared to vitamin K antagonists. However, bleeding is still the most frequent complication associated with DOACs, and although rare, bleeding episodes can be life-threatening or critical. The impact of DOAC anticoagulation activity during a bleeding event must be evaluated according to patient clinical assessment, dosage and time from last intake, the presence of comorbidities (especially kidney and liver dysfunction), and, whenever possible, coagulation tests. Unfortunately, DOACs' anticoagulation activity is not easily or usually detectable in routine common coagulation testing. Specific DOAC tests allow for specific drug monitoring, but they are too time consuming, and are usually unavailable in routine emergency practice. If a clinically relevant DOAC plasma concentration is assumed or proven in a severe bleeding scenario, DOAC reversal is needed to restore hemostasis. This experts' consensus provides a narrative review about DOAC reversal and practical life-threatening bleeding management in several scenarios (trauma, intracranial hemorrhage and gastrointestinal bleeding), focusing on the selection of patients to whom specific reversal agents should be given.

We present the case of a 73-year-old male, recipient of a liver transplant a year ago, with migration of a "Be-Graft" stent used in a pre-transplant transjugular intrahepatic portosystemic shunt towards the pulmonary artery. The stent was incidentally discovered via imaging tests during hospitalization due to acute cholangitis.

Background: Acute variceal hemorrhage (AVH) is a frequent cause of upper gastrointestinal bleeding (UGIB) in liver cirrhosis. Most cases require urgent endoscopic intervention due to potentially life-threatening courses. Different endoscopic hemostasis techniques can be used, in particular endoscopic variceal ligation (EVL) and endoscopic sclerotherapy (EST), depending on the bleeding side (esophageal, fundal, and gastric) as well as radiological interventions (e.g., embolization and transjugular intrahepatic portosystemic shunt [TIPS]). This study aimed to investigate trends in incidence, treatment modalities, and outcome parameters, such as in-hospital mortality and adverse events in Germany. Methods: We evaluated the current epidemiological trends, therapeutic strategies, and in-hospital mortality of AVH in Germany based on the standardized hospital discharge data provided by the German Federal Statistical Office from 2010 to 2019. Results: A total of 65,357 AVH cases, predominately males (68.3%), were included in the analysis. The annual incidence rate (hospitalization cases per 100,000 persons) was 8.9. The in-hospital mortality was 18.6%. The most common underlying disease was alcohol-related liver cirrhosis (60.6%). The most common clinical complication was bleeding anemia (60.1%), whereas hypovolemic shock (12.8%) was the less frequent. In esophageal variceal hemorrhage (EVH), EVL was the most frequently performed endoscopic therapy, while in gastric variceal hemorrhage (GVH), EST and fibrin glue injection were the most commonly performed therapies. EVL showed the lowest in-hospital mortality (12.3%) in EVH, while EST showed favorable results (14% in-hospital mortality) in GVH. Combination therapies overall showed a higher in-hospital mortality and were more frequent in GVH. The presence of hypovolemic shock, AKI, sepsis, artificial ventilation, ARDS, bleeding anemia, hepatic encephalopathy, and male sex was associated with a significantly worse outcome. Conclusion: Our study provides detailed insight into the incidence, patient-related risk factors, endoscopic treatment, and in-hospital mortality in a sizeable AVH collective in Germany. These data might help improve risk stratification and treatment strategies for AVH patients in the future.

Esophagogastric variceal bleeding (EVB) is one of the main causes of cirrhosis-related deaths, and endoscopic therapy is the first-line treatment of choice. However, the efficacy of prophylactic endotracheal intubation (PEI) before endoscopy remains controversial.

Data were collected from 119 patients who underwent endoscopic confirmation of an EVB. Inverse probability of treatment weighting was applied to reduce bias between the two groups. The primary outcomes included rebleeding rates within 24 h and 6 weeks post-endoscopic surgery and 6-week mortality.

After endoscopic surgery, the rebleeding rate within 24 h in the PEI group was significantly lower than non-PEI group (1.2 % VS 12.6 %, P-value = 0.025). Although PEI did not reduce 6-week mortality, it significantly reduced the risk of rebleeding within 24 h (odds ratio [OR]: 0.89, 95 % confidence interval [CI]: 0.82-0.97, P = 0.008) and within 6 weeks (hazard ratio [HR]: 0.36, 95%CI: 0.14-0.90, P = 0.029). In multivariate regression analyses, maximum varices diameter >1.5 cm (OR: 1.23, 95 % CI: 1.09-1.37, P < 0.001) was independent risk factor for rebleeding within 24 h. Creatinine (HR: 1.01, 95 % CI: 1.01-1.02, P < 0.001) and international normalized ratio (HR: 2.99, 95 % CI: 1.99-4.65, P < 0.001) were independent risk factors for rebleeding within 6 weeks.

PEI before endoscopic surgery reduced the incidence of rebleeding within 24 h and 6 weeks after endoscopic surgery. However, PEI did not reduce the 6-week mortality rate after endoscopic surgery and might increase the length of hospital stay.

Patients with cirrhosis commonly undergo endoscopic cyanoacrylate injection for gastric and esophageal variceal bleeding. However, postoperative infections can increase the risk of rebleeding and mortality.

This study aimed to determine the risk of postoperative infections and its associated factors following cyanoacrylate injection treatment in these patients.

A retrospective analysis was conducted on 57 patients treated with ligation (ligation group), 66 patients treated with cyanoacrylate injection (injection group), and 91 patients treated with conservative treatment (control group) at the Nanchong Central Hospital.

The rate of postoperative infection was similar among the cyanoacrylate, ligation, and conservative treatment groups, with no significant statistical difference observed ( P  = 0.97). Multivariate analysis identified postoperative Child-Pugh score and renal insufficiency as two independent risk factors for postoperative infection. The rebleeding rate in the injection group was significantly lower than in the other groups ( P  = 0.01). Mortality was significantly higher in the control group compared with the ligation and injection groups ( P  = 0.01).

Cyanoacrylate combined with lauromacrogol injection did not significantly increase the risk of infection compared with ligation and conservative treatments, and it was more effective in reducing the risk of rebleeding. This method is safe, effective, and holds clinical value for broader application.

Factor XIII plays a key role within the coagulation cascade.

We aimed to investigate the relevance of factor XIII activity on the outcome of patients with gastrointestinal bleedings.

In this retrospective, single-center study patients with gastrointestinal bleeding and measurement of factor XIII activity were included. The primary endpoint was the number of red blood cell transfusions in patients with reduced factor XIII activity (< 70%) compared to patients with normal activity. Additionally, the influence of factor XIII substitution was assessed.

Ninety-seven patients (median age: 64 [IQR 55, 77] years, 31 (32%) females) were included in the analysis. Fifty-six (58%) patients suffered from an upper gastrointestinal bleeding. 66 (68%) patients had a factor XIII activity < 70% and 24 (36%) of those received factor XIII substitution. Patients with reduced FXIII activity needed significantly more red blood cell transfusions than patients with normal activity (9 [5, 12] vs. 4 [1, 8], p < 0.001). Patients receiving factor XIII substitution showed a trend toward a decreased need for transfusions after substitution (0 [0, 5] vs. 3 [1, 6], p = 0.066). Factor XIII activity correlated negatively with the INR (rs = -0.24, p = 0.018) and positively with hemoglobin levels (rs = 0.28, p = 0.006) and with thrombocyte counts (rs = 0.30, p = 0.003).

The present study shows an association of factor XIII activity with the requirement of blood transfusions in patients with gastrointestinal bleedings and indicates a potential benefit of factor XIII substitution. Factor XIII activity seems to be dependent from the amount of blood loss and the global coagulation parameters.

To assess the role of 4D flow MRI in the assessment of gastro-oesophageal varices and in the prediction of high-risk varices in patients with chronic liver disease.

Thirty-eight patients diagnosed with either oesophageal or gastric varices were included in this single-centre prospective study. 4D flow MRI was used to calculate peak flow, average flow and peak velocity at the portal vein confluence (PV1) and hilum (PV2), splenic vein hilum (SV1) and confluence (SV2), and superior mesenteric vein (SMV). PV and SV fractional flow changes were also measured.

ROC analysis revealed that both PV2 average flow and PV fractional average flow change had 100% sensitivity to predict high-risk patients with the PV fractional peak flow change having the widest area under the curve (AUC) and the highest specificity (92.3%). SV1 average flow, SV2 average flow, SV2 peak flow, and SV2 peak velocity increased significantly in patients with oesophageal compared to gastric varices included (p = 0.022, < 0.001, < 0.001 and 0.001, respectively).

Based on certain porto-mesenteric blood flow, velocity, and fractional flow change parameters, 4D flow MRI showed excellent performance in identifying high-risk patients and giving an idea about the grade and location of varices.

Variceal bleeding is a major consequence of unidentified risky upper GI varices. Thus, by identifying and locating high-risk varices early, either oesophageal or gastric, using a non-invasive method like MRI, adverse events might be avoided.

4D flow MRI can be used as a potential alternative for endoscopy to predict patients with high-risk varices. Based on portal vein fractional flow change, splenic flow and velocity, 4D MRI can predict and locate high-risk varices. Earlier identification of high-risk varices can allow for interventions to prevent adverse events.

Acute variceal bleeding in cirrhosis represents a critical clinical event that significantly impacts patient prognosis, with mortality rates increasing further after a second episode. This underscores the need for immediate intervention and optimal prophylaxis. The creation of a transjugular intrahepatic portosystemic shunt (TIPS) has been proven to be highly effective for managing esophageal variceal bleeding. However, the use of TIPS for managing cardiofundal gastric varices and ectopic varices remains debated due to their unique vascular anatomy and the limited data available. These varices, although less prevalent than esophageal varices, are complex and heterogeneous vascular shunts between the splanchnic venous system and the systemic veins. Indeed, while endoscopic therapy with tissue adhesives is widely endorsed for achieving hemostasis in active hemorrhage, there is no consensus regarding the optimal approach for secondary prophylaxis. Recent research emphasizes the efficacy of endovascular techniques over endoscopic treatments, such as TIPS and endovascular variceal embolization techniques. This review examines the use of TIPS in managing acute variceal bleeding in patients with cirrhosis, focusing specifically on cardiofundal gastric varices and ectopic varices, discussing optimal patient care based on the latest evidence, aiming to improve outcomes for this challenging subset of patients.

Esophageal varices, dilated submucosal veins in the lower esophagus, are commonly associated with portal hypertension, particularly due to liver cirrhosis. The high morbidity and mortality linked to variceal hemorrhage underscore the need for accurate diagnosis and effective management. The traditional method of assessing esophageal varices is esophagogastroduodenoscopy (EGD), which, despite its diagnostic and therapeutic capabilities, presents limitations such as interobserver variability and invasiveness. This review aims to explore the role of artificial intelligence (AI) in enhancing the management of esophageal varices, focusing on its applications in diagnosis, risk stratification, and treatment optimization.

This systematic review focuses on the capabilities of AI algorithms to analyze clinical scores, laboratory data, endoscopic images, and imaging modalities like CT scans.

AI-based systems, particularly machine learning (ML) and deep learning (DL) algorithms, have demonstrated the ability to improve risk stratification and diagnosis of esophageal varices, analyzing vast amounts of data, identifying patterns, and providing individualized recommendations. However, despite these advancements, clinical scores based on laboratory data still show low specificity for esophageal varices, often requiring confirmatory endoscopic or imaging studies.

AI integration in managing esophageal varices offers significant potential for advancing diagnosis, risk assessment, and treatment strategies. While promising, AI systems should complement rather than replace traditional methods, ensuring comprehensive patient evaluation. Further research is needed to refine these technologies and validate their efficacy in clinical practice.

Acute-on-chronic liver failure (ACLF) is a severe complication of advanced liver disease. A significant number of ACLF patients have not clear precipitating factors. The aim of the study was to investigate the role of alterations in porto-hepatic hemodynamics, especially non-forward portal flow (NFPF), in ACLF and liver-related mortality.

233 cirrhotic patients were included in the study with a median follow-up of 24 months. Color-Doppler ultrasound was used to assess portal vein patency, flow direction and significant porto-systemic collaterals (>8 mm). Patients with active cancer, both at baseline and during follow-up and severe non liver-related comorbidities were excluded. ACLF and liver-related mortality were recorded during follow-up.

Fifty-six patients (24%) developed ACLF; 24 (10,3%) had baseline NFPF. In survival analysis, NFPF, but not portal vein thrombosis, was independently associated with ACLF development (HR 2.85 95% C.I. [1.49-5.42], p = 0.001) and liver-related mortality (HR 2.24 95% C.I. [1.16-4.28], p = 0.015), even after adjustment for liver disease severity scores, age and etiology of liver disease.

NFPF is independently associated with ACLF development and liver-related mortality, regardless of etiology, severity disease scores and portal vein thrombosis. Although there is no specific measure to reverse NFPF, patients with NFPF should receive prompt intensive management and urgent prioritization for liver transplantation.

2730 CESC.

This trial was to shorten the duration of both vasoconstrictors and prophylactic antibiotics to only 2 days in the therapy of acute gastroesophageal variceal hemorrhage.

After successful endoscopic hemostasis of gastroesophageal variceal hemorrhage, eligible patients were randomized to receive terlipressin infusion 1 mg per 6 hours and ceftriaxone 1 g daily for 5 days (group A) or a similar regimen for 2 days (group B). Primary end points were very early rebleeding at 5 days, and secondary end points included 48-hour hemostasis, 42-day rebleeding, and hospitalization days.

Group A comprised 48 patients, and group B comprised 52 patients. Both groups were comparable in the severity of liver disease. Forty-eight-hour initial hemostasis was 95.8% in group A and 100% in group B ( P = 0.13). Very early rebleeding between 3 and 5 days occurred in 1 patient (2.1%) in group A and 2 patients (3.8%) in group B ( P = 0.60). The difference was 1.8% and the 95% confidence interval was -1.31% to 2.08%, which demonstrated noninferiority. Forty-two-day rebleeding occurred in 5 patients (10.4%) in group A and 4 patients (7.7%) in group B ( P = 0.63). The median hospitalization days were 8.5 ± 3.8 days in group A vs 5.6 ± 2.6 days in group B ( P < 0.001).

After successful endoscopic hemostasis of acute variceal bleeding, combination of 2-day terlipressin infusion and ceftriaxone therapy was not inferior to the 5-day regimen in terms of very early rebleeding, with the advantage of shortening hospitalization stay.

The aim of the present study was to conduct a meta-analysis for elucidating the effects of antibiotic prophylaxis on infection, rebleeding and mortality in patients who underwent endoscopic therapy for variceal hemorrhage. Articles on antibiotic prophylaxis and on-demand antibiotic administration following endoscopic therapy for acute variceal bleeding were searched on PubMed, Embase and Cochrane Library between January 1959 and February 2024, to elucidate whether the use of prophylactic antibiotics was necessary. The quality of randomized controlled trials (RCTs) was assessed using the Cochrane risk-of-bias assessment tool and RevMan software version 5.4.1 was used for meta-analysis of the data. The current meta-analysis included four RCTs and 322 patients with acute variceal bleeding who underwent endoscopic therapy. All included studies were of high quality according to the Cochrane risk-of-bias assessment tool. According to the results of the meta-analysis, the incidence of infection in the prophylactic antibiotic group was significantly lower than that in the on-demand group [odds ratio (OR), 0.31; 95% confidence interval (CI), 0.13-0.74; P=0.009]. The prophylactic antibiotic group also exhibited a lower incidence of rebleeding compared with that of the on-demand group (OR, 0.37; 95% CI, 0.19-0.72; P=0.003). No significant differences were noted in the incidence of mortality between the two groups (OR, 0.92; 95% CI, 0.45-1.92; P=0.83). In conclusion, the data indicated that antibiotic prophylaxis is recommended to be used in patients who have undergone endoscopic therapy for variceal hemorrhage.