Thread by @Dr_ACaballero_

🔦Endoscopic Diagnosis & Management of Esophagogastric Variceal Hemorrhage
🗒️ESGEGuidelines2022

16 Keys:

1⃣Pts w compensated advanced CLD & >10mmHg portalHT➡️NSBB (carvedilol) therapy💊

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🧵👇

2⃣ Patients unable to receive NSBB therapy with a screening upper endoscopy 🔦that demonstrates high risk esophageal varices ➡️ endoscopic band ligation (EBL). Repeat after 2-4 weeks until eradication
🕵️‍♂️Surveillance every 6 months in the first year

3⃣ In hemodynamically stable patients with acute upper GI hemorrhage and no ❤️ disease ➡️Restrictive red blood cell transfusion strategy:

🕑When? ▶️ Hemoglobin threshold ≤ 70 g/L
🎯Post Transfusion target: 70–90 g/L

4⃣ Patients with ACLD presenting with suspected acute variceal bleeding:
▶️Stratify risk with Child and MELD scores 🗒️
▶️GI endoscopy 🔦

5⃣ Iniciate vasoactive agents💉: terlipressin, octreotide, or somatostatin when suspected acute variceal bleeding 🩸. Continue up to 5 days

6⃣ Antibiotic prophylaxis using ceftriaxone 1 g/day 💊 for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage🩸

7⃣ IV💉erythromycin 250 mg be given 30–120 minutes prior to upper GI endoscopy🔦 in patients with suspected acute variceal hemorrhage🩸

8⃣Suspected variceal hemorrhage➡️endoscopic evaluation🔦: within 12 hours 🕑from the time of patient presentation. Previously: hemodynamic resuscitation.

9⃣ EBL for the treatment of acute esophageal variceal hemorrhage🩸

1⃣0⃣If high risk for recurrent esophageal variceal bleeding 🩸following endoscopic 🔦hemostasis (Child C  ≤ 13 or Child B > 7 with active EVH at the time of 🔦 despite vasoactive agents💉, or HVPG > 20mmHg)➡️pre-emptive TIPS within 72h (preferably 24h) must be considered🤔

1⃣1⃣Persistent esophageal variceal bleeding despite 💉vasoactive pharmacological and endoscopic 🔦therapy ➡️ urgent rescue TIPS 🕑should be considered

1⃣2⃣Endoscopic 🔦💉cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.

1⃣3⃣Endoscopic 💉🔦cyanoacrylate injection or EBL in patients with GOV1-specific bleeding🩸.

1⃣4⃣Urgent rescue TIPS / balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when failure of 🔦💉endoscopic hemostasis or early recurrent bleeding🩸

1⃣5⃣Patients with EBL for acute EVH ➡️ scheduled for follow-up EBLs at 1-4 weeks intervals to eradicate esophageal varices (2ªprophylaxis)

1⃣6⃣Use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy🔦 for secondary prophylaxis in EVH in patients with ACLD

Thanks for sharing!

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