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.

OBJECTIVE: To investigate the association of computed tomography (CT) imaging features and severity of portal hypertension (PH) and develop a nomogram to predict high-risk PH in cirrhotic patients with gastroesophageal variceal hemorrhage (GVH).
METHODS: The study retrospectively enrolled 158 cirrhotic patients with a history of endoscopic treatment for GVH. Hepatic vein pressure gradient (HVPG) was measured and the patients were classified into high-risk (HVPG > 16 mmHg) or low-risk (HVPG ≤ 16 mmHg) PH group. Pre-treatment CT features, including cavernous transformation of portal vein (CTPV), hilar periportal space (a distance between right portal vein and posterior edge of segment IV of the liver), and depth of right posterior hepatic notch sign (a sharp indentation in the right medial posterior liver surface), were evaluated. Risk factors associated with high-risk PH were analyzed, and a nomogram based on the imaging features was developed.
RESULTS: High-risk PH group showed a higher rebleeding rate after treatment than that of the low-risk (P = 0.029). Multivariate analysis indicated that larger hilar periportal space (P < 0.001), less frequencies of CTPV (P = 0.044) and deeper right posterior hepatic notch (P < 0.001) were independent risk factors associated with high-risk PH. A nomogram based on the three CT imaging features was established to predict high-risk PH with an excellent discrimination (c-statistic 0.854).
CONCLUSIONS: The nomogram based on CT features of hilar periportal space, depth of right posterior hepatic notch and CTPV can help to distinguish cirrhotic patients with high-risk PH, who are more vulnerable of variceal rebleeding after endoscopic treatment.

Variceal hemorrhage (VH) is a life-threatening complication of cirrhosis. An accurate VH risk evaluation is critical to determine appropriate prevention strategies. We aimed to develop an individualized prediction model to predict the risk of first VH in hepatitis B virus (HBV)-related cirrhotic patients.
A nomogram was developed based on a retrospective analysis of 527 consecutive HBV-related cirrhotic patients with gastroesophageal varices (GEVs). The nomogram evaluation was performed using the area under the receiver operating characteristic curve (AUC), concordance index (C-index), calibration plot, and decision curve analysis (DCA). The results were verified using an external cohort (n = 187).
We developed a nomogram based on clinical and endoscopic features, including the size of varices, red wale marks, ascites, spleen thickness, γ-glutamyltransferase, and hematocrit. The C-index of the nomogram in the derivation and validation cohort was 0.806 and 0.820, respectively, and the calibration plot fitted well. Compared with those of the North Italian Endoscopic Club (NIEC) and revised NIEC indexes, the AUC (derivation cohort: 0.822 vs. 0.653 vs. 0.713; validation cohort: 0.846 vs. 0.685 vs. 0.747) and DCA curves of this nomogram were better. Further, based on the risk scores, patients were classified into low-, medium-, and high-risk groups, and significant differences were noted in VH incidence among the three risk groups (P <0.001 for each cohort).
An effective individualized nomogram to predict the risk of first VH in HBV-related GEV patients was established, which can assist clinicians in developing more appropriate prevention strategies.

Background and Objectives: Portal hypertension (PH), as the main consequence of cirrhosis, leads to the development of gastroesophageal varices (GEVs). Variceal hemorrhage (VH) caused by the rupture of GEVs is a life-threatening emergency. Thus, the prediction of VH risk is considerably important. Our pilot study aimed to identify the risk factors of variceal hemorrhage (VH) in cirrhosis. Materials and Methods: Cirrhotic patients were prospectively included and divided into two groups according to the presence or absence of VH. Conventional ultrasound and shear wave dispersion (SWD) imaging were conducted to detect the portal vein diameter, spleen diameter, ascites, liver stiffness (LS) and shear wave dispersion slope (SWDS). The laboratory tests were recorded, including platelets (PLT), alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL) and albumin (ALB). The risk factors of VH were screened using univariate analyses and identified using multivariate logistic regression. The ROC curves were used to assess diagnostic accuracy. Comparisons between AUCs were performed using the Delong method. Results: Sixty-five patients with 22 VHs were finally included. The SWDS, spleen diameter and ascites were identified as independent risk factors for VH. The SWDS showed good performance for diagnosing VH (AUC = 0.768, 95% CI: 0.647−0.864), and sensitively identified 95.5% (95% CI: 77.2%−99.9%) of patients with VH. Including the three risk factors in multivariate logistic regression, we obtained a formula for diagnosing VH: −20.749 + 0.804 × SWDS + 0.449 × spleen diameter + 1.803 × ascites (no ascites = 0, ascites = 1). Comparison of AUCs revealed that the formula (AUC = 0.900, 95% CI: 0.800−0.961) performed better than LS, SWDS, and spleen diameter in diagnosing VH (p < 0.001; p < 0.05; p < 0.05). Conclusions: SWDS is a sensitive parameter for assessing the risk of VH. Combining the SWDS, spleen diameter and ascites resulted in good diagnostic accuracy.

UNASSIGNED: Esophagogastric variceal bleeding is a serious complication of decompensated cirrhosis. Transjugular intrahepatic portal shunt (TIPS) is a salvage treatment with clear hemostatic results. However, various complications may occur after TIPS, including postoperative liver failure, and the prognosis is very poor once occurs. Liver failure is a common symptom of severe liver disease with a high mortality rate. This study investigated the incidence of liver failure after TIPS treatment for varicose bleeding.
UNASSIGNED: We analyzed the data of patients admitted to the First Affiliated Hospital of Soochow University between January 2013 and December 2018 with portal hypertension with an episode of acute gastroesophageal variceal bleeding. A total of 121 patients were referred to the regional liver unit for TIPS. Hepatic venous pressure gradient (HVPG) and clinical data were collected. Patients with incomplete data were excluded, and 93 patients were ultimately enrolled in the study. Primary outcomes were morbidity and hospital mortality within 4 weeks of surgery. The data were retrospectively and consecutively collected and evaluated by univariate and multivariate analyses to identify risk factors of liver failure.
UNASSIGNED: The patients included 58 males (62.37%) and 35 females (37.63%), and the mean age was 58.43±11.85 years. The main cause was hepatitis B virus (HBV), which was found in 50.54% of patient. The overall surgical success rate was 83.87% (78/93). Of 15 treatment-failure patients, 9 (9.68%) died in hospital. Four patients died of liver failure, accounting for 44.44% of postoperative all-cause deaths. Univariate logistic regression analysis showed that only hepatic venous pressure gradient (HVPG) was an independent risk factor for post-TIPS morbidity [relative risk (RR) 1.156; 95% confidence interval (CI): 1.041 to 1.283; P=0.006]. In addition, HVPG was an independent risk factor for hospital mortality within 4 weeks (RR 1.133; 95% CI: 1.021 to 0.539; P=0.016).
UNASSIGNED: Post-TIPS liver failure is a serious complication in patients with cirrhosis. Pre-TIPS HVPG level may be used as a predictor of potential short-term postoperative adverse events.

OBJECTIVE: This study aimed to establish a non-invasive model based on the virtual portal pressure gradient (vPPG) to predict the first variceal hemorrhage (VH) in patients with cirrhosis.
METHODS: This single-center study prospectively enrolled cirrhotic patients as the training and validation cohorts during different time periods. The PPG-detection software (PPGS 1.0) was used to perform vPPG calculation, which involves 2 steps including three-dimensional (3D) reconstruction of portal vein tree and subsequent application of computational fluid dynamics. All patients were given standard primary prophylaxis against VH and followed up for 2 years. Data from the training cohort were assessed using univariate and multivariate Cox regression and Kaplan-Meier analyses, by which a nomogram with its dynamic form was developed to estimate the probability of VH.
RESULTS: In the training cohort (n = 128), 37 (28.9%) experienced VH during 2-year follow-up. Four variables including vPPG ≥ 10.5 mmHg (p < 0.001), PLT < 56 × 109/L (p = 0.048), albumin < 32 g/L (p < 0.001) and INR ≥ 1.2 (p = 0.022) were identified as independent risk factors of VH, among which vPPG showed the best diagnostic performance (AUC 0.875). Subsequently, these predictors were incorporated into the nomogram, of which C-indexes were 0.891 and 0.926 for the training and validation cohorts, respectively. Calibration curves demonstrated a great calibration ability of the model. At the threshold probabilities of 0.1-0.6 (1 year) and 0.1-1.0 (2 years), this nomogram could offer more net benefits in decision curve analysis.
CONCLUSIONS: The vPPG-based nomogram could be used for risk stratification of the first VH in patients with cirrhosis.

BACKGROUND: Endoscopic therapy has been widely applied to prevent variceal rebleeding, but data addressing the effect of endoscopic variceal eradication (VE) are lacking. We aimed to clarify the clinical impact of VE and reveal the long-term incidence and mortality of gastrointestinal rebleeding.
METHODS: This prospective study included 228 cirrhotic patients who underwent secondary prophylaxis for variceal bleeding and achieved VE through a systematic procedure we proposed as endoscopic sequential therapy (EST). Rebleeding rates before and after VE were compared and cumulative incidence of rebleeding and mortality were calculated using the Kaplan-Meier method. A logistic regression model and P for trend were used to investigate the optimal time limit for VE.
RESULTS: During a median (interquartile range) follow-up duration of 33.0 (23.0-48.75) months, rebleeding was identified in 28 patients (12.3%) after VE and in 27 patients (11.8%) during endoscopic sessions. The cumulative incidence of rebleeding before and after VE was 8.4% and 1.8% at 6 months, and 14.9% and 4.0% at 1 year respectively (P<0.001). The long-term incidence of all-cause/variceal rebleeding following VE was 10.4%/9.1%, and 31.5%/23.5% at 2 and 5 years respectively. Eleven patients (4.8%) died and the 5-year mortality was 9.3%. VE achieved within 6 months was associated with fewer rebleeding events compared to VE achieved after 6 months (5.5% vs. 20.0%, P=0.002), while logistic regression revealed an overall increasing trend in the odds ratio of rebleeding (vs. patients with VE time ≤6 months) for patients with 6< VE time ≤12 months and VE time >12 months (P for trend <0.001).
CONCLUSIONS: VE further reduces rebleeding based on routine endoscopic prophylaxis and improves long-term prognosis. VE within 6 months seems to be the optimal timing and should therefore be advocated.

OBJECTIVE: To evaluate the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) and non-TIPS therapy (endoscopy and/or nonselective beta-blockers [NSBB]) in patients with cirrhosis and active variceal hemorrhage who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis.
METHODS: Medical records of cirrhotic patients who did not respond to high-dose vasoactive drugs and required balloon tamponade for hemostasis at five university hospitals in China between January 2011 and December 2018 were reviewed. Treatment outcomes were compared between the TIPS and the non-TIPS groups.
RESULTS: Treatment failure of variceal hemorrhage within 5 days was reported in six patients of the non-TIPS group (N = 70) and none of the TIPS group (N = 66) (P = .028). The TIPS group had a higher 1-year variceal rebleeding-free rate compared with the non-TIPS group (95.5% vs 60.0%, P < .001). One patient treated with TIPS and nine with non-TIPS therapy experienced rebleeding within 5 days and 6 weeks after the intervention (P = .009). The cumulative 1-year survival rate was higher in the TIPS group than in the non-TIPS group (93.9% vs 78.6%, P = .01). The TIPS group had a higher incidence of hepatic encephalopathy within one year compared with the non-TIPS group (18.2% vs 4.3%, P = .026).
CONCLUSIONS: For patients with cirrhosis and active variceal bleeding who do not respond to high-dose vasoactive agents and require a balloon tamponade for hemostasis, TIPS may be an appropriate treatment choice.

BACKGROUND: Portal vein velocity (PVV) has shown reasonable correlation with the presence of portal hypertension in patients with cirrhosis. This study aims to evaluate the value of PVV for diagnosing clinically significant portal hypertension (CSPH) and predicting the risk of variceal hemorrhage (VH) in patients with hepatitis B virus (HBV)-related cirrhosis.
METHODS: A cohort of 166 consecutive adult patients with HBV-related cirrhosis was recruited in this retrospective study from two high-volume liver centers in China between April 2015 and April 2017. The performance of PVV and other non-invasive parameters for diagnosing CSPH and predicting risk of VH were studied.
RESULTS: PVV demonstrated the best performance for diagnosing CSPH (defined as an HVPG ≥10 mmHg) in patients with HBV-related cirrhosis among the included noninvasive predictors with the area under the receiver operating characteristic curve (AUC), specificity, and sensitivity of 0.745, 50%, and 93.5%, respectively. Other noninvasive markers, including APRI, AAR, LS, FIB-4, and diameter of portal vein, did not show sufficient performance with the AUCs of 0.565, 0.560, 0.544, 0.529, and 0.474, respectively. With regard to predicting the risk of VH (defined as an HVPG ≥12 mmHg), PPV also exhibited a moderate performance with an AUC of 0.762, which was superior to that of the aforementioned markers. By using two cutoff values of PVV to rule-out (11.65 cm/s) and rule-in (20.20 cm/s) CSPH, 30 (33.7%) patients showed definite results categories, with 23 (76.7%) patients were well classified and 7 (23.3%) were misclassified. Fifty-nine (66.3%) patients were with indeterminate results. By using PVV values of 13.10 cm/s and 21.40 cm/s to rule-out and rule-in HVPG ≥ 12mmHg, 34 (38.2%) patients has definite results, among whom 26 (76.5%) were well classified and 8 (23.5%) were misclassified. And 55 (61.8%) patients required further evaluation.
CONCLUSIONS: PPV is not good enough to serve as a non-invasive parameter for identifying CSPH and predicting risk of VH in patients with HBV-related cirrhosis.

The predictors for gastroesophageal varices (GOV) and hemorrhage development have not been well studied in different liver diseases or different population. This study aimed to evaluate whether a new algorithm focusing on chronic hepatitis B (CHB) patients is also applicable to other chronic liver diseases (CLDs) in Chinese population.
We retrospectively analyzed 659 CHB patients and 386 patients with other CLDs. A total of 439 CHB patients were included in training set, the other 220 CHB patients and other patients with CLDs were included in validation set. A new algorithm for diagnosing GOV was established and its sensitivity and specificity for predicting the varices was verified.
Multivariable logistic regression revealed that the rough surface of the liver (p<0.001), splenic thickness (p<0.001), and liver stiffness (p=0.006) were independent predictors of GOV. The new algorithm was considered to be a reliable diagnostic model to evaluate the presence of varices. The AUROC was 0.94 (p<0.001) in CHB validation set and 0.90 (<0.001) in non-CHB validation set. When the cut-off value was chosen as -1.048, the sensitivity and specificity in diagnosing GOV in CHB population were 89.1% and 82.5%, respectively. Importantly, the new algorithm accurately predicted the variceal hemorrhage not only in CHB patients, but also in patients with other CLDs.
The new algorithm is regarded as a reliable model to prognosticate varices and variceal hemorrhage, and stratified not only the high-risk CHB patients, but also in patients with other CLDs for developing GOV and variceal bleeding.