Objective To investigate the basis for the selection of secondary prevention with endoscopy or transjugular intrahepatic portosystemic shunt(TIPS) after esophagogastric variceal bleeding and the value of hepatic venous pressure gradient(HVPG) in clinical decision-making. Methods A retrospective analysis was performed for 148 patients who had an HVPG of above 12 mm Hg after esophagogastric variceal bleeding and received secondary prevention with endoscopy or TIPS in The Fifth Medical Center of Chinese PLA General Hospital from January 2016 to February 2018. According to related guidelines,HVPG > 18 mm Hg was a high-risk factor for esophagogastric variceal rebleeding,and the patients were divided into medium pressure group(HVPG 12-18 mm Hg) with 78 patients and high pressure group(HVPG > 18 mm Hg) with 70 patients. Clinical features and endoscopic findings were summarized for both groups. The patients were further divided into four groups with an HVPG of 12-16 mm Hg, > 16-18 mm Hg, > 18-20 mm Hg,and > 20 mm Hg,respectively,and the four groups were compared in terms of the safety and efficacy of secondary prevention,with focuses on rebleeding and prognosis. The two-independent-samples t test was used for comparison of continuous data between groups,the chi-square test was used for comparison of categorical data between groups,the Kruskal-Wallis H test was used for comparison of ranked data between groups. Results Before secondary prevention,there were no significant differences between the medium pressure group and the high pressure group in hemoglobin,platelet,albumin,bilirubin,creatinine,blood ammonia,prothrombin time,Child-Pugh score,and Model for End-Stage Liver Diseasescore,and the medium pressure group had a significantly higher proportion of patients with opening of collateral circulation than the high pressure group(67. 95% vs 50. 00%,χ2= 11. 250,P = 0. 004). There was no significant difference in the LDRf type of esophageal and gastric varices between the two groups. The high pressure group had a significantly higher proportion of patients who selected TIPS than the medium pressure group(28. 57% vs 10. 26%,χ2= 8. 067,P = 0. 005). After secondary prevention,the mean follow-up time was 28. 66 ±11. 20 months,and no serious complications were observed. No patients experienced the progression of liver cirrhosis,and there was an improvement in ascites. Rebleeding rate within 1 year after secondary prevention with endoscopy tended to increase with the increase in HVPG,and 41. 03% of the patients with HVPG > 20 mm Hg underwent the preventive treatment for the second time within 1 year. Secondary prevention with endoscopy had a good clinical effect in the patients with an HVPG of 12-16 mm Hg,with a rebleeding rate of 14. 63% within1 year. The patients with an HVPG of > 20 mm Hg who underwent secondary prevention with TIPS had a significantly lower rebleeding rate within 1 year than those who underwent secondary prevention with endoscopy(10% vs 34. 48%). Conclusion It is recommended to select secondary prevention for variceal bleeding based on HVPG,develop a follow-up plan for patients with different HVPG values after secondary prevention,and give individualized treatment.
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