Aggressive versus Conservative Endotherapy for Gastric Varices in Cirrhosis: A Randomized Controlled Trial

Background: Gastric variceal bleeding in cirrhosis remains a challenging clinical problem with variations in management strategies. This randomized controlled trial aimed to compare aggressive versus conservative cyanoacrylate therapy for gastric varices in cirrhotic patients presenting with their first variceal bleeding episode. Methods: Cirrhotic patients with large gastric varices (GOV1, GOV2, IGV1) and a first episode of variceal bleeding were randomized to receive aggressive endotherapy (Group A) or conservative endotherapy (Group B). In Group A, all visible gastric varices were obliterated using cyanoacrylate glue, whereas in Group B, only varices with stigmata of recent hemorrhage (SRH) or high-risk features were treated. The primary outcome was variceal rebleeding at 1 year, with all-cause mortality, variceal obliteration time, and adverse events as secondary endpoints. Results: A total of 145 patients were analyzed (Group A: 72; Group B: 73). At 1-year follow-up, the cumulative incidence of rebleeding was comparable between groups (18.2% vs. 15.0%). All-cause mortality at 1 year was also similar (22.2% vs. 32.9%), with a hazard ratio (HR) of 0.63 (95% CI: 0.33–1.18; p = 0.15), suggesting a non-significant 37% reduction in mortality risk with aggressive endotherapy. The time to obliteration of GOV1 varices was shorter in Group A, with a median (range) of 4 (4–20) weeks compared to 8 (4–116) weeks in Group B. Similarly, the number of endoscopic sessions required for GOV1 obliteration was fewer in Group A (1 [1–4] sessions vs. 2 [1–5] sessions). Adverse event rates were comparable across both groups. Conclusion: Aggressive endotherapy resulted in similar rebleeding and mortality rates compared to conservative therapy.

Publication History

Received: 20 December 2024

Accepted after revision: 17 June 2025

Accepted Manuscript online:
17 June 2025