MODERN METHODS AND PREVENTION OF STOPPING BLEEDING FROM VARICOSE VEINS OF THE ESOPHAGUS COMPLICATED BY CIRRHOSIS OF THE LIVER

ABSTRACT

Background: Variceal bleeding from the esophagus is a severe and potentially fatal complication of portal hypertension in liver cirrhosis. Despite therapeutic advances, early mortality and recurrence remain critical challenges.

Objective: This study aimed to evaluate the effectiveness of modern treatment methods—endoscopic and pharmacologic—in the control and prevention of esophageal variceal bleeding in cirrhotic patients.

Materials and Methods: A retrospective analysis was conducted on 71 patients with liver cirrhosis treated at City Clinical Hospital №4 (Almaty, Kazakhstan) between 2022 and 2024. Data included clinical parameters, endoscopic findings, treatment modalities, and outcomes. Statistical significance was determined using the Student’s t-test and Pearson correlation (p < 0.05).

Results: The majority of patients were male (69.01%), with a peak bleeding incidence in the 31–50 age group (59.16%). Endoscopic variceal ligation was the most frequently used hemostatic method (53.52%) and demonstrated a high success rate (92.11%). Conservative therapy with terlipressin, beta-blockers, and octreotide showed overall effectiveness of 95.94%, with terlipressin yielding the highest hemostatic efficacy (88.7%). Statistically significant improvements in hemoglobin, hematocrit, and RBC counts were recorded (p < 0.01). Rebleeding occurred in only 4.22% of cases; mortality was 4.22%.

Conclusion: A combined approach involving endoscopic ligation and vasoactive pharmacotherapy is highly effective in managing acute variceal bleeding. Preventive strategies, including regular surveillance and beta-blocker use, are essential to reduce recurrence and improve survival. Our results support the integration of EVL and terlipressin into standard protocols, with ongoing evaluation of adjunctive methods such as clipping and TIPS in complex cases.

АННОТАЦИЯ

Актуальность: Кровотечение из варикозно расширенных вен пищевода — одно из наиболее опасных осложнений портальной гипертензии при циррозе печени. Несмотря на развитие методов лечения, смертность и частота рецидивов остаются высокими.

Цель: Оценить эффективность современных эндоскопических и медикаментозных методов лечения в остановке и профилактике кровотечений из варикозно расширенных вен пищевода у пациентов с циррозом печени.

Материалы и методы: Проведен ретроспективный анализ 71 случая госпитализированных пациентов с циррозом печени, проходивших лечение в ГКБ №4 г. Алматы в период с 2022 по 2024 год. Проанализированы клинические, лабораторные, инструментальные данные, результаты эндоскопии и проводимых методов лечения. Статистическая обработка включала t-критерий Стьюдента и корреляционный анализ (р < 0,05).

Результаты: Преобладали мужчины (69,01%), наибольшая частота кровотечений зафиксирована в возрастной группе 31–50 лет (59,16%). Наиболее часто применяемым методом остановки кровотечения являлось эндоскопическое лигирование варикозных вен (53,52%), эффективность составила 92,11%. Консервативная терапия (терлипрессин, β-блокаторы, октреотид) показала общую эффективность 95,94%, при этом терлипрессин оказался наиболее действенным (88,7%). Достоверное повышение уровня гемоглобина, гематокрита и эритроцитов отмечено к моменту выписки (р < 0,01). Рецидивы кровотечения наблюдались у 4,22% пациентов, летальность составила 4,22%.

Выводы: Современный комбинированный подход, включающий эндоскопическое лигирование и применение вазоактивных препаратов, обеспечивает высокий уровень эффективности в лечении острых кровотечений. Профилактика рецидивов требует регулярного наблюдения, применения β-блокаторов и своевременной эндоскопической диагностики. Полученные результаты подтверждают целесообразность включения лигирования и терлипрессина в стандартные протоколы лечения пациентов с циррозом печени и портальной гипертензией.

Keywords: cirrhosis of the liver, varicose veins of the esophageal veins, bleeding, complications, hepatology.

Ключевые слова: цирроз печени, варикозное расширение вен пищевода, кровотечение, осложнения, гепатология.

Introduction

Liver cirrhosis (LC) is a chronic, progressive disease resulting from sustained hepatic inflammation and fibrosis. It represents the advanced stage of liver fibrosis and constitutes the final common pathway of numerous chronic liver diseases. Once decompensation occurs, the average life expectancy drops to less than three years. Over the past two decades, the global burden of liver cirrhosis has increased significantly. Worldwide, liver diseases account for approximately 2 million deaths annually—1 million of which are attributed to complications of cirrhosis, and the other 1 million to viral hepatitis and hepatocellular carcinoma (HCC) [1, p.3; 2, p.4].

Currently, cirrhosis ranks as the 11th leading cause of death globally, while liver cancer occupies the 16th position [3, p.2]. Approximately 2 billion people worldwide consume alcohol, and over 75 million individuals are diagnosed with alcohol use disorders, placing them at high risk for developing alcohol-related liver diseases. Moreover, nearly 2 billion adults are overweight or obese, and more than 400 million are diagnosed with diabetes mellitus—both recognized risk factors for the development of non-alcoholic fatty liver disease (NAFLD) and hepatocellular carcinoma [3, p.4; 4, p.2].

In Kazakhstan, the incidence of liver cirrhosis has been rising in recent years. According to World Health Organization (WHO) data (Figure 1), the number of patients diagnosed with liver cirrhosis in 2021 was 53 per 100,000 population, compared to 51 per 100,000 in 2020—a 3.77% increase [1, p.5]. Currently, 49,175 adult patients in Kazakhstan are officially registered with a diagnosis of viral hepatitis, including 23,233 with hepatitis C, 22,977 with hepatitis B, and 1,252 with hepatitis D. A total of 5,976 patients are registered with liver cirrhosis [2, p.3].

Figure 1а. Prevalence of liver cirrhosis in Kazakhstan per 100,000 population (2016–2021), according to WHO data [1, p.5]

Acute esophageal variceal bleeding (EVB) is a life-threatening complication of portal hypertension, associated with increased morbidity, mortality, and hospitalization costs. It occurs at an annual rate of 5–15% in patients with liver cirrhosis. Among patients with newly diagnosed esophageal varices, approximately 25% develop variceal hemorrhage within two years [3, p.4]. According to several authors, EVB accounts for up to 70% of all gastrointestinal (GI) bleeding episodes in cirrhotic patients [4, p.5; 5, p.3]. Therefore, in any cirrhotic patient presenting with GI bleeding, variceal hemorrhage should be suspected until ruled out by diagnostic endoscopy.

Over the past three decades, early mortality rates associated with EVB have declined from 42% to 15–24% [5, p.6]. A recent population-based study conducted in the United States reported a reduction in in-hospital mortality from 18% in 2010 to 11.5% in 2016 [6, p.4]. Nonetheless, early mortality remains significant and likely underestimated. Current data suggest that most EVB-related deaths are due to uncontrolled hemorrhage or rebleeding, while the remaining cases are attributed to liver failure, infections, or hepatorenal syndrome [6, p.4; 7, p.2]. As such, optimal management requires a comprehensive approach combining hemostatic therapy with preventive strategies targeting the aforementioned complications.

The control and prevention of esophageal variceal bleeding remain key priorities in modern hepatology, as timely and effective treatment can significantly improve patient survival. In recent years, advances in medical technologies have led to the development of several innovative treatment options. This article aims to analyze the most effective contemporary methods for controlling EVB secondary to liver cirrhosis and evaluate their clinical efficacy.

EVB can be managed using pharmacologic agents (somatostatin, octreotide, vasopressin, terlipressin), endoscopic therapy (sclerotherapy or band ligation), balloon tamponade, transjugular intrahepatic portosystemic shunt (TIPS), and other approaches [8–10].

The main treatment goals are: to achieve hemostasis, restore circulating blood volume, correct coagulopathy, prevent rebleeding, preserve hepatic function, and avoid bleeding-related complications (e.g., infections, hepatic encephalopathy) [12, p.3; 15, p.2; 17, p.4].

According to their mechanisms of action in reducing portal pressure, medications are classified into two major groups:

1. Venodilators – e.g., nitroglycerin, which lowers the hepatic venous pressure gradient by 40–44% (e.g., Perlinganit, isosorbide-5-mononitrate).

2. Vasoconstrictors:

a) Somatostatin analogues (e.g., stilamin, sandostatin, octreotide) – reduce portal pressure by 20–25%;

b) Vasopressin analogues (e.g., vasopressin, glipressin, terlipressin [Remestyp]) – reduce arterial flow to the portal system and lower portal pressure by 30–40%.

Endoscopic variceal ligation (EVL) is a modern method for both treatment and prevention of variceal bleeding due to cirrhosis or other liver diseases causing portal hypertension. This method involves the placement of specialized latex bands (Wilson-Cook Med 6 or 10) over varices. The band compresses the varix at its base, resulting in ischemia and necrosis. Within 5–7 days, the necrotic varix sloughs off. EVL achieves bleeding control in 90–95% of cases and significantly reduces rebleeding risk [20, p.4; 22, p.5].

Endoscopic sclerotherapy has two major techniques:

a) Intravascular sclerotherapy: the sclerosant (e.g., sodium tetradecyl sulfate, ethoxysclerol, or thrombovar) is directly injected into the variceal lumen. Doses per injection range from 1–3 mL, with a total volume of up to 10 mL. The agent induces inflammation, thrombosis, and fibrosis, leading to variceal obliteration.

b) Paravascular sclerotherapy: the sclerosant is injected into the submucosal space near the varix, producing a compressive effect through tissue edema. This method is preferred in cases of active bleeding when intravascular injection is impractical.

The sclerosing agent causes chemical injury to the vessel wall, followed by phlebitis, thrombosis, and eventual fibrosis. After 5–7 days, the treated vein is completely obliterated and replaced by scar tissue. However, due to a higher risk of complications (e.g., esophageal ulceration or stricture), sclerotherapy is usually reserved as an adjunct to EVL or as an alternative when ligation is not feasible [23–25].

Endovascular embolization is a minimally invasive technique involving catheter-guided delivery of embolic materials to occlude variceal lumens. It is particularly effective in patients with large varices or atypical vascular anatomy that complicates ligation. Embolic agents include N-butyl cyanoacrylate, coils, polyethylene particles, or microspheres. A follow-up angiogram is performed after material delivery to confirm occlusion, with technical success rates of 90–95% [26, p.2; 27, p.4].

Transjugular Intrahepatic Portosystemic Shunt (TIPS) involves the creation of a shunt between the portal and hepatic veins within the liver parenchyma, allowing decompression of the portal venous system. In studies by M.A. Nartaylakov and I.F. Mukhamedyanov, TIPS was shown to significantly reduce both mortality and rebleeding rates (from 18% to 6.7%) [28, p.6]. They concluded that TIPS is highly effective for managing elevated portal pressure and expands treatment options for patients with Child-Pugh class B or C cirrhosis. Furthermore, TIPS facilitates the resolution of stenosis and thrombosis.

Aim of the Study: To analyze modern effective methods for controlling esophageal variceal bleeding secondary to liver cirrhosis and to evaluate their clinical efficacy in real-world practice.

Materials and Methods. A retrospective clinical and statistical analysis was conducted on n = 71 patients who received inpatient treatment for liver cirrhosis in the Department of Surgery at Municipal Clinical Hospital №4 in Almaty, Kazakhstan, from January 1, 2022, to March 1, 2024.

Inclusion criteria: patients aged 18 to 90 years with a confirmed diagnosis of liver cirrhosis.

Exclusion criteria: patients with incomplete medical histories or those whose outcomes included death were excluded from the analysis.

For all enrolled patients, the following data were reviewed and analyzed: clinical symptoms, laboratory findings, instrumental diagnostics (including esophagogastroduodenoscopy, abdominal ultrasound, and computed tomography), and pathological-histological findings. The severity of bleeding episodes was assessed using standard clinical scoring systems.

Descriptive statistics were applied to analyze the collected data. Results are presented as mean ± standard deviation (M ± m). Statistical significance between means was determined using Student’s t-test. A p-value < 0.05 was considered statistically significant. Data processing and statistical analyses were performed using Microsoft Office Excel.

Results. Considering age as a potential risk factor, the analysis revealed that the mean age of patients was 53.77 ± 11.09 years (Table 1). The majority of the patients were male (n = 49; 69.01%) with a mean age of 55.35 ± 12.62 years, whereas females comprised n = 22; 30.99% with a mean age of 52.19 ± 10.56 years. The gender-based age difference was statistically significant (p < 0.01), with a mean age gap of 3.16 ± 2.06 years.

Table 1.

Age distribution of patients by gender (%)

Note: BMI – Body Mass Index (kg/m²)

Variceal bleeding in individuals under the age of 18 accounts for approximately 5–10% of all cases, as this age group is typically affected by congenital hepatic disorders such as biliary atresia, Caroli syndrome, thrombophlebitis, or portal vein thrombosis leading to portal hypertension. Among patients aged 18–40 years, the incidence is estimated at 10–20%, with the most common etiological factors being viral hepatitis (types B and C) and autoimmune liver diseases [5, p.3; 8, p.4].

Patients in this younger cohort typically present with compensated liver cirrhosis, and therefore the risk of variceal bleeding is generally lower compared to older individuals. In the 40–60 year age group, bleeding events account for approximately 50–60% of all cases, most often associated with chronic liver conditions such as alcoholic liver disease, viral hepatitis, and non-alcoholic steatohepatitis (NASH).

The highest frequency of variceal bleeding is observed in patients over 60 years of age, with incidence rates reaching 70–80%. This is largely attributable to advanced decompensation, presence of multiple comorbidities (e.g., diabetes mellitus, cardiovascular disease), impaired hepatic function, and a higher risk of coagulopathy [5, p.3; 8, p.4; 13, p.2].

In our study, we evaluated the incidence of variceal bleeding across age groups based on the classification recommended by the World Health Organization (WHO) (Figure 2). The highest frequency of EVB was observed in patients aged 31–50 years — n = 37 (59.16%). This was followed by the 18–30 year group (15.5%), the 51–70 year group (19.72%), and the ≥71 year group (5.62%). The differences were statistically significant (p < 0.01) (Figure 1).

Figure 1. Age Distribution of Patients (%)

All patients admitted to the hospital (100%) underwent esophagogastroduodenoscopy (EGD). Endoscopic findings of variceal bleeding were assessed using the Paquet classification (1983) and the Japanese classification proposed by N. Soehendra and K. Binmoeller (1997). According to the Paquet classification, Grade I varices were observed in n = 8 patients (11.23%), Grade II in n = 26 (36.62%), and the most frequently identified, Grade III varices—in n = 37 patients (52.11%), indicating a predominance of severe forms (p < 0.01) (Table 2).

Table 2.

Endoscopic Classification According to the Paquet Scale (%)

Based on the Soehendra–Binmoeller classification (Figjres 2A, B), variceal diameter ranged from 5–10 mm in n = 31 patients (43.66%), and exceeded 10 mm in n = 28 cases (39.44%). Smaller varices, measuring less than 5 mm, were noted in n = 12 patients (16.9%), also showing statistically significant differences (p < 0.01) (Table 3).

Table 3.

Endoscopic Findings According to the Soehendra–Binmoeller Classification (%)

Figure 2A and 2B. Patient Zh., 57 years old, post-endoscopic band ligation status

With regard to hematologic parameters, upon admission, the hemoglobin (HGB) level was 82.73 ± 20.14 g/L, which improved during hospitalization to 93.45 ± 11.06 g/L at the time of discharge. Hematocrit (HCT) increased from 24.73 ± 9.08% to 30.05 ± 10.15%, and red blood cell (RBC) count rose from 3.26 ± 1.32 × 10¹²/L to 3.93 ± 2.01 × 10¹²/L, all showing statistically significant improvement (p < 0.01) (Figure 3).

Indications for blood transfusion (HGB <70 g/L) were identified in n = 23 patients (32.33%), and transfusions were administered according to blood type compatibility.

Additionally, in n = 70 patients (98.56%), successful placement of the Sengstaken–Blakemore tube was achieved.

Bleeding severity was assessed using validated clinical scoring systems: the Rockall score averaged 0.86 ± 0.34 points, while the Glasgow-Blatchford score averaged 13.04 ± 4.73 points (Figure 4).

Note: 1 – Hemoglobin (g/L), 2 – Hematocrit (%), 3 – Red Blood Cells (×10¹²/L)

Figure 3. Dynamics of Red Blood Cell Parameters (x)

Figure 4. Clinical Assessment Based on Scoring Systems (x)

Patients admitted with signs of gastrointestinal bleeding underwent endoscopic hemostasis procedures. Among the interventions performed, the most frequently utilized method was endoscopic variceal band ligation using latex rings, applied in n = 38 patients (53.52%). Endoscopic sclerotherapy was performed in n = 9 patients (12.67%), demonstrating statistically significant preference for band ligation (p < 0.01) (Figure 5).

Figure 5. Distribution of Treatment Modalities (%)

Terlipressin demonstrated the highest efficacy in achieving hemostasis (88.7%), followed by octreotide (77.5%) and somatostatin (70.4%), though both were less effective than terlipressin (Table 4). Beta-blockers were highly effective in preventing rebleeding (83.1%) and play a key role in long-term management. The overall treatment efficacy reached 95.94%, confirming the high success rate of a multimodal therapeutic approach. Statistical analysis (Pearson r and p-values) revealed a strong positive correlation between the selected treatment modalities and their clinical effectiveness (p < 0.05).

Table 4.

Indicators of Conservative Therapy in Patients (%)

For conservative therapy specifically, a Pearson correlation coefficient of r = 0.95 with p = 0.002 indicates a strong positive relationship between the use of conservative measures and treatment success (Table 5). The efficacy of endoscopic band ligation was slightly lower (r = 0.001, p = 0.89), while the lowest effectiveness was observed in patients undergoing sclerotherapy, highlighting the limited potential of this method (r = 0.004, p = 0.91).

Table 5.

Effectiveness of Primary Therapeutic Interventions in Patients (%)

However, rebleeding occurred in n = 3 patients (4.22%) following endoscopic hemostasis. Gastrotomy was required in n = 2 patients (2.81%), while mortality due to multi-organ failure was recorded in n = 3 patients (4.22%), all of which were statistically significant (p < 0.01) (Table 6).

Table 6.

Frequency of Complications in Patients (%)

Discussion. Management of esophageal variceal bleeding (EVB) in patients with liver cirrhosis has advanced significantly, with contemporary strategies focusing on endoscopic and pharmacological interventions. Effective treatment approaches are critical for improving patient outcomes and reducing EVB-related mortality.

According to the 2024 guidelines of the American Association for the Study of Liver Diseases (AASLD), non-selective beta-blockers (NSBBs)—such as carvedilol, propranolol, and nadolol—remain the cornerstone of therapy. Notably, carvedilol has demonstrated superior efficacy in reducing portal pressure (PP) compared to other NSBBs. The recommended regimen begins with 6.25 mg daily, with titration to 12.5 mg/day after 2–3 days (either as a single or divided dose) [29, p.2].

In addition, AASLD recommends novel pharmacologic agents for the prevention and treatment of EVB. Among them, statins have shown promising outcomes. As HMG-CoA reductase inhibitors, statins significantly reduce portal pressure and have demonstrated improved survival when simvastatin is added to standard secondary prophylaxis following acute variceal bleeding. These findings, supported by several clinical trials, highlight the expanding role of statins in cirrhotic patients [29, p.3].

Rehman H., Rehman S.T. and et. al. (2024) published a study evaluating outcomes in patients treated with either terlipressin or octreotide following endoscopic intervention [30, p.2]. Their findings confirmed that terlipressin significantly reduced the need for blood transfusion and was associated with improved survival rates. The authors concluded that terlipressin was more effective than octreotide in lowering variceal pressure, recommending it as a first-line agent, with octreotide or somatostatin as second-line options.

However, the difference in mortality rates between the terlipressin and octreotide groups was not statistically significant.

Sridharan K., Sivaramakrishnan G. (2019) reported that the risk of mortality was reduced by 34% following terlipressin therapy [31, p.3].

Meanwhile, Huaringa-Marcelo J. and  at.al. (2021) highlighted octreotide as the safest vasoactive agent, citing the lowest rates of adverse events (9.1%) and no serious adverse events (0.0%) in their study [32, p.4].

In a randomized clinical trial, Kuma M., Venishetty S., and et.al. (2024) evaluated 600 patients with decompensated esophageal variceal bleeding (EVB) in the setting of Child-Turcotte-Pugh class B or C liver cirrhosis, who were randomly assigned to receive either tranexamic acid (n = 300) or placebo (n = 300). By day 5, the incidence of bleeding cessation was significantly higher in the tranexamic acid group (6.3%, 19/300) compared to the placebo group (13.3%, 40/300; p = 0.006). At 5–6 weeks, rebleeding occurred in 4.9% of patients receiving tranexamic acid (11/222) versus 12.0% in the placebo group (27/225; p = 0.005). However, mortality rates at 5 days and 6 weeks were comparable between the two groups. The authors concluded that tranexamic acid does not prevent early bleeding but significantly reduces late rebleeding rates [33, p.2–3].

As for endoscopic approaches, endoscopic variceal ligation (EVL) remains the preferred method for primary prophylaxis of variceal bleeding [20, 22].

In a study by Deng Y., Jiang Y. at.al. (2024), outcomes were compared in 100 patients undergoing EVL or endoscopic injection (EI) between January 2017 and December 2022 at Zunyi Medical University (Tables 9a–9c) [34, p.2]. While overall treatment efficacy was similar between the EVL group (96.1%) and the EI group (94.1%) (χ² = 7.713, p < 0.05), post-treatment fibrosis was significantly more frequent in the EVL group (80.4%) compared to the EI group (35.3%). Moreover, late rebleeding rates (6 months to 1 year post-procedure) were markedly lower in the EVL group (11.8%) than in the EI group (45.1%, p < 0.01). Postoperative pain and infection rates were similar between groups, and no cases of perforation were reported (p > 0.05). The authors concluded that EVL is safer and more effective than EI [34, p.3].

Samsonyan E.Kh., Kurganov I.A. et al. (2018) reported findings from 48 patients who underwent EVL for acute EVB [35]. Mean hospitalization duration was 13.2 ± 2.7 days, with no intraoperative complications. Rebleeding on day 3 occurred in 4.3%, while hyperthermia (8.7%), dysphagia (8.7%), and chest pain (13.0%) were noted. Mortality was 4.7%. These results demonstrate the efficacy of EVL as a frontline intervention for achieving endoscopic hemostasis in ongoing bleeding [35, p.2].

Similar findings were reported by Gabriel S.A., Guchetl A.Y., et.al. (2017), who retrospectively analyzed 338 cirrhotic patients treated between 2009 and May 2016, during which a total of 511 EVL procedures were performed. EVL was successful in 98.2% (n = 502), and unsuccessful in only 1.8% (n = 9). The authors emphasized EVL as a cost-effective, efficacious treatment and preventive strategy for variceal bleeding [36, p.3].

In another retrospective study spanning 8 years (2013–2020), Razafindrazoto C.I., Randriamifidy N., et.al. (2023) evaluated 57 patients who underwent EVL as primary treatment or prophylaxis. The overall success rate was 94.7%, with rebleeding in 17.5% (n = 10) (HR: 1.34; CI: 1.01–1.80; p = 0.041) and mortality in 1.8% (n = 1) (HR: 37.18; CI: 0.14–18.4; p = 0.009). However, dysphagia (73.7%) and chest pain (78.9%) were commonly reported [37, p.2].

There is growing interest in endoscopic clipping for EVB, a method more commonly applied to peptic ulcers or colonic diverticular bleeding [11, 23, 37]. Randomized studies show that active bleeding is controlled in 90–95% of cases, with rebleeding rates of 5–15%, largely influenced by the severity of portal hypertension and the degree of hepatic decompensation. Combining clipping with pharmacologic or ligation therapy can reduce rebleeding to 3–5% [11, 23]. Nevertheless, larger trials and standardized protocols are needed to validate the broader application of this technique. Table 7 summarizes the effectiveness, advantages, and limitations of various methods reported in these studies.

Table 7.

Comparative Effectiveness of Commonly Used Methods in Clinical Studies (%)

Conclusion. Thus, modern approaches for managing esophageal variceal bleeding (EVB) in patients with liver cirrhosis include endoscopic interventions (ligation, sclerotherapy) and pharmacological therapy (vasopressors, somatostatin analogs). These strategies effectively control active bleeding, reduce recurrence rates, and improve patient survival.

1. Based on a review of national and international studies, endoscopic variceal ligation remains the gold standard for controlling acute variceal bleeding. Conservative therapy (non-selective beta-blockers, terlipressin, or octreotide) has also demonstrated high effectiveness in reducing the risk of rebleeding and preventing complications.

2. In this study, male patients predominated (69.01%) with a mean age of 55.35 ± 12.62 years. The highest incidence of EVB occurred in the 31–50 age group (59.16%). Endoscopic ligation was successfully performed in 92.11% of patients. With up to 95% success, ligation showed the highest hemostatic efficacy in initial bleeding and was associated with a significant reduction in rebleeding risk.

3. The key to prevention lies in early detection of portal hypertension, routine endoscopic screening, and prophylactic use of non-selective beta-blockers in high-risk patients. A comprehensive approach based on timely diagnostics, therapeutic, and preventive measures can significantly reduce recurrence rates, mortality, and enhance the quality of life in cirrhotic patients.

Key Recommendations for Clinical Practice:

1. Endoscopic methods such as clipping and band ligation should be implemented as adjunctive tools alongside pharmacologic therapy for optimal bleeding control.

2. Training of endoscopists in the proper technique of clip placement is crucial to enhancing its clinical efficacy.

3. Protocol development: Include endoscopic clipping in clinical algorithms for specific indications, such as massive bleeding or complex anatomy where ligation is technically challenging.

4. Further research: Well-designed comparative clinical trials are needed to assess the efficacy of clipping versus ligation and other methods, especially in emergency scenarios or as part of combination therapy.

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