Paradigm Evolution of Endoscopic Management for Esophagogastric Variceal Bleeding in Cirrhosis

Abstract

Endoscopic therapy is a first-line modality for esophagogastric variceal bleeding(EGVB) in cirrhosis; however, its technical logic has long been constrained by the limitations of the "intraluminal perspective"—variceal ligation, sclerotherapy, and cyanoacrylate injection all target the variceal lumen, failing to address the pathological root of transmural feeding vessels driven by portal hypertension. In recent years, endoscopic ultrasound (EUS)-guided selective devascularization has shifted the therapeutic target from the intraluminal compartment to the vessel wall and extramural vasculature, marking a paradigm shift in endoscopic intervention from "passive tamponade" to "active devascularization." This article systematically reviews the indications, efficacy evidence, and inherent limitations of conventional techniques such as EVL, EIS, and ECI, with particular emphasis on research advances in EUS-guided precise devascularization regarding the localization of transmural feeding vessels, mitigation of ectopic embolism risk, and optimization of treatment burden; it further discusses controversies surrounding the timing of endoscopic therapy, reassessment of platelet thresholds, and rebalancing of combination strategies. The review posits that the core contradiction in endoscopic therapy has shifted from "whether hemostasis can be achieved" to "how to achieve radical devascularization with minimal trauma," and that EUS-guided targeted devascularization represents a technical breakthrough in this direction; however, its long-term survival benefit and precise positioning within the treatment algorithm remain to be defined by prospective studies.