Endoscopic treatment of variceal upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline

Authors: John Gásdal Karstensen, Alanna Ebigbo, Purnima Bhat, Mario Dinis-Ribeiro, Ian Gralnek, Claire Guy, Olivier Le
Moine, Peter Vilmann, Giulio Antonelli, Uche Ijoma, Gideon Anigbo, Mary Afiheni, Babatunde Duduyemi, Hailemichael Desalegn, Roberto De Franchis, Thierry Ponchon, Cesare Hassan, Lars Aabakken

Introduction

Patients with variceal gastrointestinal bleeding are encountered daily in endoscopic departments around the world. Risk factors include infectious diseases such as hepatitis B and C virus and schistosomiasis, as well as alcohol consumption and metabolic syndrome with development of nonalcoholic fatty liver disease [1]. Globally, prevalence and incidence of chronic liver disease and cirrhosis varies markedly between countries [2]. High-quality epidemiological data from the majority of African countries are lacking; nevertheless, development of cirrhosis and related consequences are a major burden for public health systems in the continent [2–4]. In Africa, mortality from cirrhosis is estimated at 12.9 to 24.2 per 100,000 person-years range and prevalence of hepatitis B virus is among the highest in the World at 6,100 per 100,000 inhabitants [5, 6].

The latest update of the Baveno guideline describes in detail how to prevent and manage variceal bleeding, as well as how to avoid recurrent bleeding [7]. The majority of recommendations in the guideline are based on high levels of evidence and many years of practice. However, some of the recommendations are resource-sensitive and may be unavailable in low-resource settings due to factors such as extensive costs, lack of sufficient health professional training and logistical limitations.

The European Society of Gastrointestinal Endoscopy (ESGE) has implemented a cascade methodology in a joint effort with the World Endoscopy Organization (WEO), aiming to adapt existing guidelines to make them applicable to resource-limited regions (including some African countries) [8]. Previously, two cascade guidelines have been published focusing on endoscopic management of non-variceal upper gastrointestinal bleeding and upper gastrointestinal obstruction, respectively [8–10]. This ESGE cascade guideline aims to standardize endoscopic management of patients with variceal gastrointestinal bleeding.