Patients with liver cirrhosis are at an increased risk of developing liver cancer,54 and routine screening (alpha-fetoprotein [AFP] and abdominal ultrasound) should be performed every 3–6 months; enhanced screening should be performed every 12 months (AFP, AFP-L3, protein induced by vitamin K deficiency or vitamin K antagonist-II protein (PIVKA) plus CT or magnetic resonance imaging [commonly known as MRI]) in patients who are at very high risk of liver cancer; precancerous lesions should be routinely examined every 1–3 months; and enhanced screening should be carried out every 6–12 months. Special examinations such as liver biopsy, liquid biopsy, and gadoxetate disodium (Gd-EOB-DTPA) enhanced MRI can be performed to improve the detection rate of early-stage liver cancer, as applicable.
Recommendation 5: EVB management strategies include (1) prevention of the first EVB (primary prevention); (2) control of AEVB; (3) prevention of the second EVB (secondary prevention); and (4) improvement of liver functional reserve (A1).
Recommendation 6: Attention should be paid to etiological treatment, as well as antiviral therapy and antihepatic fibrosis treatment (A1). TCMs such as Anluo Huaxian pills, Fuzheng Huayu capsules, and Fufang Biejia Ruangan tablets can be used to relieve liver fibrosis, liver cirrhosis, and GOV (B1).
Recommendation 7: In primary prevention, control of AEVB, and secondary prevention of liver cirrhosis, attention should be paid to serum albumin level of the patients, with timely supplementation of human serum albumin if necessary (B1).
Recommendation 8: NSBB is not recommended for primary prevention in patients without GOV (B1).
Recommendation 9: For mild GOV patients with Child-Pugh B and C, or positive RC sign, NSBB is recommended to prevent the first variceal bleeding (B1). In patients with mild GOV at low risk of bleeding, NSBB is not recommended (B2). For patients with mild GOV without NSBB, gastroscopy should be reviewed regularly (B1).
Recommendation 10: For patients with moderate or severe GOV and relatively high risk of bleeding (Child-Pugh B, C, or positive RC sign), NSBB or EVL is recommended to prevent the first variceal bleeding (A1). For those at low risk of bleeding, NSBB is the first-line choice. EVL is alternative for patients with contraindications or intolerance to NSBB or poor compliance (B2).
Recommendation 11: The initial dose of carvedilol is 6.25 mg/d, which can be increased to 12.5 mg after 1 week if the prior dose was well tolerated; the initial dose of propranolol is 10 mg twice a day, which can be gradually increased to the maximum tolerated dose; and the initial dose of nadolol is 20 mg per day, followed by escalation to a maximum tolerated dose. Response criteria: the resting heart rate decreased to 75% of basal heart rate or 50–60 beats/m (A1); HVPG ≤12 mmHg or decreased ≥10% from baseline (B2).
Recommendation 12: Nitrates alone or in combination with NSBB are not recommended for primary prevention (A2). ACEI/ARB drugs are not recommended for primary prevention (B2). Spironolactone is not recommended for primary prevention (C2).
Recommendation 13: Surgical procedures and TIPS are not recommended for primary prevention (A2). Concomitant use of EVL and NSBB for primary prevention is not recommended (C2).
Recommendation 14: NSBB can be used for primary prevention of gastric variceal bleeding (B2).
Recommendation 15: LDRf classification should be used to guide patient monitoring and timing of treatment. Rf 0, D0.3: (primary prevention) No treatment, follow-up with endoscopy once a year. D1.0: Elective EVL or follow-up with endoscopy every half year (B1). D1.5: Elective endoscopic injection sclerotherapy (EIS) for esophageal varices plus tissue glue injection for gastric cardia, or endoscopy every 3 months to half a year; tissue glue injection for varices located outside the esophagus or endoscopy every 3 months to half a year (C2). Rf 1, treatment in 3 months.