Systematic strategies for preventing and treating esophagogastric variceal rebleeding (EVRB) are currently inadequate. This systematic review aimed to update this critical gap by searching contemporary studies from major guideline websites, databases, and professional associations focused on EVRB prevention in cirrhosis patients. Key findings highlight evaluation methods, risk management, preventive measures, health education, and follow-up strategies. Notably, a hepatic venous pressure gradient exceeding 18 mmHg is identified as a reliable predictor of gastroesophageal varices (GOV) rebleeding. Effective management of primary diseases is crucial, with methods including antiviral and anti-fibrotic therapies, alcohol avoidance, vaccination, and careful medication management. The combination of nonselective β-blockers (NSBBs) and endoscopic variceal ligation (EVL) is established as the gold standard for secondary EVRB prevention. For patients experiencing recurrent bleeding despite NSBBs and EVL, transjugular intrahepatic portosystemic shunt (TIPS) therapy is recommended. Surgical options, such as surgical shunt and devascularization, are advised for those unsuitable for endoscopic therapy or TIPS, particularly in Child-Pugh A and B patients unresponsive to treatment. Additionally, traditional Chinese medicine options, such as Fufang Biejia Ruangan Tablets, Fuzheng Huayu Capsules, and Anluo Huaxian Pills, have shown promise in improving hepatic fibrosis and GOV in cirrhotic patients. This review offers a comprehensive overview of current prevention and treatment strategies for EVRB, providing valuable insights for clinicians and healthcare professionals.

Department of Nursing The 1st Affiliated Hospital Zhejiang University School of Medicine Hangzhou 310003 China

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Ginès P, Krag A, Abraldes JG, Solà E, Fabrellas N, Kamath PS. Liver cirrhosis. Lancet 2021;398(10308):1359-76. PubMed DOI

Hu Z, Zhang D, Swai J, Liu T, Liu S. Risk of rebleeding from gastroesophageal varices after initial treatment with cyanoacrylate; a systematic review and pooled analysis. BMC Gastroenterol 2020;20(1):181. PubMed DOI

Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015;64(11):1680-704. PubMed DOI

Albillos A, Zamora J, Martínez J, Arroyo D, Ahmad I, De-la-Peña J, Garcia-Pagán JC, Lo GH, Sarin S, Sharma B, Abraldes JG, Bosch J, Garcia-Tsao G. Stratifying risk in the prevention of recurrent variceal hemorrhage: Results of an individual patient meta-analysis. Hepatology 2017;66(4):1219-31. PubMed DOI

Wang AJ, Wang J, Zheng XL, Liao WD, Yu HQ, Gong Y, Gan N, You Y, Guo GH, Xie BS, Zhong JW, Hong JB, Liu L, Shu X, Zhu Y, Li BM, Zhu X. Second-look endoscopy-guided therapy under sedation prevents early rebleeding after variceal ligation for acute variceal bleeding. J Dig Dis 2020;21(3):170-8. PubMed DOI

Baiges A, Hernández-Gea V. Management of Liver Decompensation in Advanced Chronic Liver Disease: Ascites, Hyponatremia, and Gastroesophageal Variceal Bleeding. Clin Drug Investig 2022;42(Suppl 1):25-31. PubMed DOI

Xie HF, Feng M, Cao SM, Jia YY, Gao P, Wang SH. Evidence summary for nonsurgical prevention and management of parastomal hernia in patients with enterostomy. Am J Transl Res 2021;13(11):13173-82.

Lilova R, Dubin J, Hameed D, Pettijohn WA, Bains SS, Reich J, Moore MC, Delanois RE. Assessment of the AAOS guidelines using the AGREE II instrument: An update. J Orthop 2023;46:83-9. PubMed DOI

Ramakrishnan VM, Yim K, Wollin DA. Is the AGREE II framework the appropriate tool to evaluate global urolithiasis guidelines? Transl Androl Urol 2023;12(9):1366-7. PubMed DOI

Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, Moher D, Tugwell P, Welch V, Kristjansson E, Henry DA. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Bmj 2017;358:j4008. PubMed DOI

Zhang FY, Shen AM, Zeng XT, Qiang WM, Jin YH. Interpretation of AMSTAR2, a methodological quality assessment tool for systematic reviews. Chinese Journal of Evidence-Based Cardiovascular Medicine 2018;10(1):14-8. doi: 10.3969/j.issn.1674-4055.2018.01.03 (In Chinese) DOI

Hu Y, Hao YF. Evidence-based nursing. 2nd Edition. Beijing: People's Medical Publishing House; 2018. (In Chinese)

Pap R, Lockwood C, Stephenson M, Simpson P. Development and testing of Australian prehospital care quality indicators: study protocol. BMJ Open 2020;10(7):e038310. PubMed DOI

Wang Y, Xiang LJ, Luo YS, Cao M, Song XM, Hong J, Zhang XM. Evidence summary on nutrition management for post-stroke dysphagia. Am J Transl Res 2022;14(11):8252-62.

European Association for the Study of the Liver. EASL Clinical Practice Guidelines on nutrition in chronic liver disease. J Hepatol 2019;70(1):172-93. PubMed DOI

(AISF) IAftSotL. Portal Hypertension and Ascites: Patient-and Population-centered Clinical Practice Guidelines by the Italian Association for the Study of the Liver (AISF). Dig Liver Dis 2021;53(9):1089-104. PubMed DOI

Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017;65(1):310-35. PubMed DOI

Xu X, Ding H, Jia J. Guidelines for the prevention and treatment of esophagogastric varices bleeding in portal hypertension with liver cirrhosis. J Prac Hepatol 2016;19(5):641-56. doi: 10.3969/j.issn.1672-5069.2016.05.036 (In Chinese) DOI

Qing Q, Yuan DF, Xie Y, Yu JL, Mao H, Zhang SH. Dietary strategies and the relationships with prognosis after endoscopic treatments of gastroesophageal varices in patients with cirrhosis: a systematic review. Journal of Parenteral and Enteral Nutrition 2020;27(2):84-88. doi: 10.16151/j.1007-810x.2020.02.005 (In Chinese) DOI

de Franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63(3):743-52. PubMed DOI

Yang LY, Bai XL. Expert consensus on the diagnosis and treatment of esophagus and fundus variceal bleeding in cirrhosis with portal hypertension (2019 edition). Zhongguo Shiyong Waike Zazhi 2019;39(12):1241-7. doi: 10.19538/j.cjps.issn1005-2208.2019.12.01 (In Chinese) DOI

Chang Y, Liu X, Gao Y, Wang H, Zhang L. Analysis of the influencing factors of portal hypertension complicated with upper gastrointestinal bleeding in liver cirrhosis. Journal of Vascular and Endovascular Surgery 2021;7(10):1222-6. doi: 10.19418/j.cnki.issn2096-0646.2021.10.17 (In Chinese) DOI

Shen Y, Zhao ZB, Li X, Chen L, Yuan H. Risk factors and construction of a nomogram model for cirrhotic portal vein thrombosis combined with esophagogastric variceal bleeding. Chin J Hepatol 2023;31(10):1035-42. doi: 10.3760/cma.j.cn501113-20220712-00377 (In Chinese) PubMed DOI

Li L, Zhang SB, Zhang YN, Ding HG. Application and status of digestive endoscopy in the overall management of portal hypertension-related esophagogastric variceal bleeding. Chin J Hepatol 2020;28(9):732-6. doi: 10.3760/cma.j.cn501113-20200602-00287 (In Chinese) PubMed DOI

Ding HG, Zhang SB, Li L, Li P, Zhang YN, Wang ZB. Endoscopic diagnosis and treatment of esophagogastric varices in liver cirrhosis: from guidelines to clinical practice. Journal of Clinical Hepatol 2017;33(3):454-7. doi: 10.3969/j.issn.1001-5256.2017.03.011 (In Chinese) DOI

Guidelines for the diagnosis and treatment of liver fibrosis with integrated traditional Chinese and Western medicine (2019 edition). Chin J Hepatol 2019;27(07):494-504. doi: 10.3760/cma.j.issn.1007-3418.2019.07.005 (In Chinese) PubMed DOI

Jansen C, Thiele M, Verlinden W, Krag A, Francque S, Trebicka J. Prediction of presence of oesophageal varices just by shear-wave elastography of the liver and spleen. Liver Int 2017;37(9):1406-7. PubMed DOI

Stefanescu H, Allegretti G, Salvatore V, Piscaglia F. Bidimensional shear wave ultrasound elastography with supersonic imaging to predict presence of oesophageal varices in cirrhosis. Liver Int 2017;37(9):1405. PubMed DOI

Lo GH. Letter to the Editor: Could Variceal Screening Stratified by Liver/Spleen Stiffness Replace the Role of Endoscopy? Hepatology 2020;71(3):1133. PubMed DOI

Han XJ, An WM, Cao QT, Liu CC, Shang SF, Zhao LQ. Noninvasive evaluation of esophageal varices in cirrhotic patients based on spleen hemodynamics: a dual-energy CT study. Eur Radiol 2020;30(6):3210-16. PubMed DOI

Jhang ZE, Wu KL, Chen CB, Chen YL, Lin PY, Chou CT. Diagnostic value of spleen stiffness by magnetic resonance elastography for prediction of esophageal varices in cirrhotic patients. Abdom Radiol (NY) 2021;46(2):526-533. PubMed DOI

Agarwal S, Sharma S, Anand A, Gunjan D, Saraya A. Liver stiffness assessment as an alternative to hepatic venous pressure gradient for predicting rebleed after acute variceal bleed: A proof-of-concept study. JGH Open 2021;5(1):73-80. PubMed DOI

Liu H, Liu GY, Zhou JL. Advances in imaging studies of esophageal varices and bleeding risk in liver cirrhosis. Chin J Magn Reson Imag 2021;12(09):109. doi: 10.12015/issn.1674-8034.2021.09.028 (In Chinese) DOI

Lv SC, Gao YH, Wang L, Zhang K. Expert consensus on multidisciplinary diagnosis and treatment of portal hypertension in liver cirrhosis (based on hepatic venous pressure gradient). Journal of Clinical Hepatol 2021;37(09):2037-44. doi: 10.3969/j.issn.1001-5256.2021.09.008 (In Chinese) DOI

Expert consensus on clinical application of hepatic venous pressure gradient in China (2018 edition). Journal of Clinical Hepatol 2018;34(12):2526-36. doi: 10.3969/j.issn.1001-5256.2018.12.008 (In Chinese) DOI

Zanetto A, Shalaby S, Feltracco P, Gambato M, Germani G, Russo FP, Burra P, Senzolo M. Recent Advances in the Management of Acute Variceal Hemorrhage. J Clin Med 2021;10(17):3818. doi: 10.3390/jcm10173818 PubMed DOI

Jakab SS, Garcia-Tsao G. Evaluation and Management of Esophageal and Gastric Varices in Patients with Cirrhosis. Clin Liver Dis 2020;24(3):335-50. PubMed DOI

Mousa N, Abdel-Razik A, Sheta T, A GD, Habib A, Diasty M, Eldesoky A, Taha A, Mousa E, Yassen A, Fathy A, Elgamal A. Endoscopic management of acute oesophageal variceal bleeding within 12 hours of admission is superior to 12-24 hours. Br J Biomed Sci 2021;78(3):130-4. PubMed DOI

Chen Y, Ma XM, Zhang XF, Luo J, An LJ, Zhang Y, Chang XJ, Dong Z, Zhang W, Kong HF, Zhao J, Ding HG, Liu FQ, Yang YP. Prevention of variceal rebleeding in cirrhotic patients with advanced hepatocellular carcinoma receiving molecularly targeted therapy: a randomized pilot study of transjugular intrahepatic portosystemic shunt versus endoscopic plus β-blocker. Hepatol Int 2022;16(6):1379-89. PubMed DOI

Tapper EB. Building Effective Quality Improvement Programs for Liver Disease: A Systematic Review of Quality Improvement Initiatives. Clin Gastroenterol Hepatol 2016;14(9):1256-65. PubMed DOI

Schillie S, Vellozzi C, Reingold A, Harris A, Haber P, Ward JW, Nelson NP. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018;67(1):1-31. PubMed DOI

Kleiner DE. Drug-induced Liver Injury: The Hepatic Pathologist's Approach. Gastroenterol Clin North Am 2017;46(2):273-96. PubMed DOI

Lewis JH, Stine JG. Review article: prescribing medications in patients with cirrhosis - a practical guide. Aliment Pharmacol Ther 2013;37(12):1132-56. PubMed DOI

Sauerbruch T, Wong F. Treatment of Oesophageal Varices in Liver Cirrhosis. Digestion 2019;99(4):261-6. PubMed DOI

Liu JC, Shi Q, Xiao SP, Zhou C, Zhou BQ, Yuan F, Zheng CS, Lin S, Qian K, Feng GS, Xiong B. Using transjugular intrahepatic portosystemic shunt as the first-line therapy in secondary prophylaxis of variceal hemorrhage. J Gastroenterol Hepatol 2020;35(2):278-83. PubMed DOI

Ueno M, Fujiwara T, Tokumasu H, Mano T, Kayahara T, Takabatake H, Morimoto Y, Matsueda K, Fukuoka T, Mizuno M. Real-world efficacy of antibiotic prophylaxis for upper gastrointestinal bleeding in cirrhotic patients in Japan. J Gastroenterol 2023;58(8):766-77. PubMed DOI

Zhou GP, Sun LY, Wei L, Qu W, Zeng ZG, Liu Y, Jiang YZ, Zhu ZJ. Comparision between portosystemic shunts and endoscopic therapy for prevention of variceal re-bleeding: a systematic review and meta-analysis. Chin Med J (Engl) 2019;132(9):1087-99. PubMed DOI

Huo F, Chen JX, Zheng YJ, Tan XY. The role and status of liver transplantation in the treatment of portal hypertension and issues that need attention. Chinese Journal of Digestive Surgery 2018;17(10):976-80. doi: 10.3760/cma.j.issn.1673-9752.2018.10.002 (In Chinese) DOI

Wang XC. Therapeutic effect of KangFuXin oral liquid applied to preventing early rebleeding after endoscopic ligation in patients with cirrhosis esophageal varices. Master's thesis, Hebei North University 2020. (In Chinese)

Edelson J, Basso JE, Rockey DC. Updated strategies in the management of acute variceal haemorrhage. Curr Opin Gastroenterol 2021;37(3):167-72. PubMed DOI

Ley D, Austin K, Wilson KA, Saha S. Tutorial on adult enteral tube feeding: Indications, placement, removal, complications, and ethics. JPEN J Parenter Enteral Nutr 2023;47(5):677-85. PubMed DOI

Zhang ZL, Peng MS, Chen ZM, Long T, Wang LS, Xu ZL. Effect of aluminum phosphate gel on prevention of early rebleeding after ligation of esophageal variceal hemorrhage. World J Gastrointest Surg 2021;13(12):1651-9. PubMed DOI

Jiang HM, Liu JG, Yang J. Preventive effect of early oral nutrition solution on rebleeding of esophagogastric varices in cirrhosis after endoscopic treatment. Journal of Practical Hepatology 2016;19(04):490-1. doi: 10.3969/j.issn.1672-5069.2016.04.030 (In Chinese) DOI

Xu LM, Liu P, Shen XZ, Wu YY, Ping J. Guidelines for the diagnosis and treatment of liver fibrosis with integrated traditional Chinese and Western medicine (2019 edition). Journal of Clinical Hepatology 2019;35(07):1444-9. doi: 10.3969/j.issn.1001-5256.2019.07.007 (In Chinese) DOI

Wang X, Luo JN, Liu C, Liu YN, Wu XY, Zheng FP, Wen ZF, Tian H, Wei XQ, Guo YW, Li JZ, Chen XL, Tao J, Qi XL, Wu B. Impact of variceal eradication on rebleeding and prognosis in cirrhotic patients undergoing secondary prophylaxis. Ann Transl Med 2021;9(7):540. PubMed DOI

Ying XH. Treatment and prognosis of esophageal variceal bleeding in liver cirrhosis. Master's thesis, Ningbo University 2019. (In Chinese)