Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jul 27, 2021; 13(7): 731-746
Published online Jul 27, 2021. doi: 10.4254/wjh.v13.i7.731
Clinical algorithms for the prevention of variceal bleeding and rebleeding in patients with liver cirrhosis
Nikolaus Pfisterer, Lukas W Unger, Thomas Reiberger
Nikolaus Pfisterer, Medizinische Abteilung für Gastroenterologie und Hepatologie, Klinik Landstraße/Krankenanstalt Rudolfstiftung, Vienna 1030, Austria
Nikolaus Pfisterer, Thomas Reiberger, Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna 1090, Austria
Lukas W Unger, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna 1090, Austria
Lukas W Unger, Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge CB2 0AW, United Kingdom
Thomas Reiberger, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna 1090, Austria
Thomas Reiberger, Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna 1090, Austria
Author contributions: Pfisterer N, Unger LW and Reiberger T performed literature review, prepared figures and tables, wrote the manuscript, contributed intellectually, critically revised the manuscript and approved the final version of the manuscript.
Supported by the Austrian Science Fund FWF, No. J4396; and the Christian Doppler Society/Boehringer Ingelheim.
Conflict-of-interest statement: Pfisterer N and Unger LW declare no conflicts of interest related to this manuscript. Reiberger T received grant support from Abbvie, Boehringer-Ingelheim, Gilead, MSD, Philips Healthcare, Gore; speaking honoraria from Abbvie, Gilead, Gore, Intercept, Roche, MSD; consulting/advisory board fee from Abbvie, Bayer, Boehringer-Ingelheim, Gilead, Intercept, MSD, Siemens; and travel support from Abbvie, Boehringer-Ingelheim, Gilead and Roche.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Lukas W Unger, MD, PhD, Doctor, Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria.
Received: February 11, 2021
Peer-review started: February 11, 2021
First decision: May 3, 2021
Revised: May 14, 2021
Accepted: July 7, 2021
Article in press: July 7, 2021
Published online: July 27, 2021

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.

Keywords: Portal hypertension, Endoscopy, Non-selective betablockers, Transjugular intrahepatic portosystemic shunt

Core Tip: Variceal bleeding is a severe, and often deadly, complication of portal hypertension. Screening for varices, effective bleeding prophylaxis and standardized management of bleeding is critical to improve clinical outcomes. While carvedilol seems to be the treatment of choice for primary prophylaxis in compensated cirrhosis, the use of hepatic venous pressure gradient measurements and safety of non-selective betablockers in advanced cirrhosis with refractory ascites is controversial. The pre-emptive use of transjugular intrahepatic portosystemic shunt within 72 h after variceal bleeding prevents rebleeding and mortality in Child C10-C13 patients.