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
Research background

Non-variceal acute gastrointestinal bleeding (NVAGIB) accounts for approximately one fifth of the bleeding episodes in cirrhotic patients and can lead to catastrophic consequences with high morbidity and mortality. Available data and trials addressing the efficacy of endoscopic modalities used to treat NVAGIB are very limited.

Research motivation

Variceal bleeding is a well-known cause of decompensation in cirrhotic patients and endoscopic treatment and outcomes after such an episode have been well studied. Whether NVAGIB is related to decompensation and if it indicates worse prognosis in the natural history of cirrhotics still needs to be clarified. Knowledge of endoscopic treatment efficacy and outcomes is a prerequisite in answering these challenging questions. Addressing these issues can lead to future changes in treatment and follow up of these patients.

Research objectives

To analyse the different causes of NVAGIB and their frequency as well as the endoscopic modalities used to achieve haemostasis. To investigate if NVAGIB denotes worse prognosis in the natural history of cirrhotic patients, if endoscopic treatment is efficient and what are the rebleeding and failure rates of endotherapy. Data on these issues may stimulate future research, and assist clinicians in choosing the best endoscopic modality to treat NVAGIB in cirrhotics.

Research methods

A systematic review using the PRISMA statement for reporting systematic reviews and meta-analyses was conducted. The MEDLINE was searched through PubMed by two authors ( Demetriou G, Augoustaki A) independently for relevant studies from 01/01/1980 until 01/01/2021 using the following query: “Liver Cirrhosis” AND “Gastrointestinal Hemorrhage/therapy”. After applying exclusion/inclusion criteria 23 studies out of 2002 were chosen to be analyzed.

Research results

A total of 23 studies (15 retrospective and 8 prospective) included a total of 1288 patients with liver cirrhosis and NVAGIB of whom 958 underwent endoscopic treatment. Causes of NVAGIB in a decreasing frequency order were as follows; peptic ulcers, 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 NVAGIB accounted for 3.5% of cirrhotic patients who underwent endoscopic therapy while rebleeding and mortality rates varied among studies (2%-25% and 3%-40% respectively). Endoscopic treatment related complications were rare (n = 1).

Research conclusions

NVAGIB is an important cause of morbidity and mortality in patients with cirrhosis and prompt diagnosis and endoscopic management affect prognosis. Despite limited data it seems that endoscopic management for upper-and lower-NVAGIB is safe and efficacious. The relatively high rebleeding and mortality rates are probably due to study heterogeneity but firm conclusions may not be drawn.

Research perspectives

The assumption that NVAGIB may be related to decompensation of liver cirrhosis and poor prognosis still need to be addressed. Expectantly this review will motivate further research on this subject and assist in administering optimal endoscopic therapy to patients with liver cirrhosis.