Systematic Reviews
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Mar 16, 2022; 14(3): 163-175
Published online Mar 16, 2022. doi: 10.4253/wjge.v14.i3.163
Endoscopic management and outcome of non-variceal bleeding in patients with liver cirrhosis: A systematic review
Georgios Demetriou, Aikaterini Augoustaki, Evangelos Kalaitzakis
Georgios Demetriou, Aikaterini Augoustaki, Evangelos Kalaitzakis, Department of Gastroenterology, University Hospital of Heraklion, Heraklion 71500, Greece
Author contributions: Kalaitzakis E conceived the idea of the topic and designed the project with Demetriou G; Demetriou G and Augoustaki A searched and screened the titles and abstracts of all relative studies and then full text of the most relevant ones for eligibility criteria; any disagreement was resolved by means of consensus with all authors; all authors contributed to the selection of the studies and interpretation of the results; Demetriou G and Kalaitzakis E wrote the manuscript while Augoustaki A aided in revision; all authors discussed the results and made comments on the manuscript.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
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: Georgios Demetriou, Doctor, Department of Gastroenterology, University Hospital of Heraklion, Panepistimiou, Voutes, Heraklion 71500, Greece.
Received: June 30, 2021
Peer-review started: June 30, 2021
First decision: September 29, 2021
Revised: October 8, 2021
Accepted: February 10, 2022
Article in press: February 10, 2022
Published online: March 16, 2022

Acute non-variceal bleeding accounts for approximately 20% of all-cause bleeding episodes in patients with liver cirrhosis. It is associated with high morbidity and mortality therefore prompt diagnosis and endoscopic management are crucial.


To evaluate available data on the efficacy of endoscopic treatment modalities used to control acute non-variceal gastrointestinal bleeding (GIB) in cirrhotic patients as well as to assess treatment outcomes.


Employing PRISMA methodology, the MEDLINE was searched through PubMed using appropriate MeSH terms. Data are reported in a summative manner and separately for each major non-variceal cause of bleeding.


Overall, 23 studies were identified with a total of 1288 cirrhotic patients of whom 958/1288 underwent endoscopic therapy for acute non-variceal GIB. Peptic ulcer bleeding was the most common cause of acute non-variceal bleeding, followed by portal hypertensive gastropathy, gastric antral vascular ectasia, Mallory-Weiss syndrome, Dieaulafoy lesions, portal hypertensive colopathy, and hemorrhoids. Failure to control bleeding from all-causes of non-variceal GIB accounted for less than 3.5% of cirrhotic patients. Rebleeding (range 2%-25%) and mortality (range 3%-40%) rates varied, presumably due to study heterogeneity. Rebleeding was usually managed endoscopically and salvage therapy using arterial embolisation or surgery was undertaken in very few cases. Mortality was usually associated with liver function deterioration and other organ failure or infections rather than uncontrolled bleeding. Endoscopic treatment-related complications were extremely rare. Lower acute non-variceal bleeding was examined in two studies (197/1288 patients) achieving initial hemostasis in all patients using argon plasma coagulation for portal hypertensive colopathy and endoscopic band ligation or sclerotherapy for bleeding hemorrhoids (rebleeding range 10%-13%). Data on the efficacy of endoscopic therapy of cirrhotic patients vs non-cirrhotic controls with acute GIB are very scarce.


Endotherapy seems to be efficient as a means to control non-variceal hemorrhage in cirrhosis, although published data are very limited, particularly those comparing cirrhotics with non-cirrhotics and those regarding acute bleeding from the lower gastrointestinal tract. Rebleeding and mortality rates appear to be relatively high, although firm conclusions may not be drawn due to study heterogeneity. Hopefully this review may stimulate further research on this subject and help clinicians administer optimal endoscopic therapy for cirrhotic patients.

Keywords: Liver cirrhosis, Non-variceal gastrointestinal hemorrhage, Gastrointestinal endoscopy, Endoscopic therapy, Patient outcomes, Peptic ulcer, Mallory Weiss syndrome, Gastric antral vascular ectasia

Core Tip: Acute non-variceal gastrointestinal bleeding (ANVGIB) is not uncommon in cirrhotic patients. Survival of these patients has improved in recent years due to the evolution of both endoscopic and pharmacologic treatment. However data on most sources of ANVGIB and the efficacy of endoscopic therapy in cirrhosis are very limited, while similar data on acute bleeding from the lower gastrointestinal tract are almost non-existent in this group of patients. We herein present endoscopic modalities used to control ANVGIB and post-treatment outcomes in patients with liver cirrhosis. Our review highlights that endoscopic therapy seems to be effective in these patients, although comparative data with non-cirrhotic patients are very few.