EUS-Guided Cyanoacrylate Injection With Balloon-Compression Sclerotherapy Versus Band Ligation for Gastroesophageal Varices: A Randomized Trial.

For acute variceal hemorrhage in cirrhosis, resuscitate conservatively with a restrictive RBC transfusion strategy targeting hemoglobin 7-8 g/dL, start a vasoactive agent as soon as bleeding is suspected and before endoscopy (terlipressin, somatostatin, or octreotide; octreotide is the agent available for this indication in US practice) and continue it 2-5 days, and give empiric IV ceftriaxone 1 g every 24 hours in patients with advanced cirrhosis. Perform upper endoscopy within 12 hours of presentation once resuscitated, or as soon as safely possible if the patient is unstable, with band ligation for esophageal varices and for GOV1 (which is treated as an esophageal varix); cardiofundal varices (GOV2 and IGV1) are treated with cyanoacrylate injection, with EUS-guided coil placement with or without cyanoacrylate increasingly used as first-line where expertise exists, and TIPS or BRTO as alternatives or salvage. PPIs started empirically should be stopped immediately after endoscopy unless there is a separate strict indication. Evaluate every patient at presentation for pre-emptive (early) TIPS with a PTFE-covered stent, placed within 72 hours and ideally within 24 hours, in high-risk patients defined as Child-Pugh class C with score under 14 (that is, 10-13) or Child-Pugh class B with score above 7 who have active bleeding at initial endoscopy despite vasoactive drugs; the decision is individualized and multidisciplinary, weighing age, frailty, comorbidity, heart failure, HCC, portal vein thrombosis, and transplant candidacy. For uncontrolled bleeding, a self-expanding covered esophageal metal stent is as effective as balloon tamponade and is the safer option; both are a bridge to definitive therapy (PTFE-covered TIPS) and neither is definitive therapy. Balloon tamponade must NOT be left in place for more than 24 hours, 24 hours is the ceiling, not a range: Baveno VI states it "should only be used in refractory oesophageal bleeding, as a temporary bridge (for a maximum of 24 h) with intensive care monitoring and considering intubation, until definitive treatment can be instituted", because severe esophageal injury/necrosis, perforation and aspiration rise sharply beyond that point. The 72-hour figure in this standard belongs to the pre-emptive TIPS window and must not be read as a permissible tamponade duration. Secondary prophylaxis is mandatory in all survivors and is combination therapy: a nonselective beta-blocker, either a traditional NSBB (propranolol or nadolol) or carvedilol, which Baveno VII endorses as an equivalent rather than clearly superior option in this specific indication, plus serial EVL every 2 to 8 weeks until variceal eradication, with surveillance endoscopy thereafter. TIPS is the treatment of choice for patients who rebleed despite NSBB plus EVL.