To explore differences in the clinical practice of endoscopic treatment of EGVB, we obtained satisfactory responses from Chinese endoscopic physicians with different academic backgrounds, practice conditions, and clinical experience. Our questionnaire received a high response rate, which shows that the questions posed in the questionnaire received much attention. It is expected that the answers to these questionnaires will be of reference to readers, endoscopists, and researchers worldwide.
It is generally believed that the clinical practice of endoscopists may be influenced by many factors, such as personal experience, previous training, operational skills, guidelines, and academic publications. Through a comprehensive comparative analysis of 85 questionnaires (Table 1), we found that the responses to the questionnaire items did not significantly differ among endoscopists with different lengths of experience. The majority (95.29%) of endoscopists agreed with the statement that patients with cirrhosis should receive endoscopic screening for EGVs, which is consistent with the recommendations of consensus guidelines. The guidelines suggest that patients with compensated cirrhosis without varicose veins should undergo gastroscopy every 2 years; those with mild varicose veins should undergo gastroscopy every year, and those with decompensated cirrhosis should undergo gastroscopy every 0.5–1 year . For patients with compensated liver disease without EGVB, most participants in the 3 groups tended to recommend a screening interval of 2 years (38.25%, 53.19%, and 68.18% of endoscopists in the 5–10 years, 11–20 years, and ≥ 21 years groups, respectively). The risk of EGVB in cirrhosis is estimated to be 5–15% per year . Endoscopic screening of EGVs is essential in patients with cirrhosis complicated with venules or varicose veins, and the time interval of screening should be shortened. Therefore, the Expert Consensus on Diagnosis and Treatment of EGVB in Cirrhotic Portal Hypertension, Chinese Medical Association (2019)  recommended that patients with compensated cirrhosis without varicose veins be reexamined using endoscopy every 2–3 years; patients with compensated cirrhosis and mild varicose veins be reexamined using endoscopy every 1–2 years; and patients with liver hardness < 20 kPa and platelet count > 150 × 109/L be allowed to opt out of endoscopic screening.
In terms of the diagnosis and treatment criteria for EGVs, 82.35% of endoscopists chose the LDRf classification, which is in line with the eligibility of Chinese patients. The LDRf classification criteria  not only provide a basis for the diagnosis and prognosis of EGVs but also provide normative guidance for the selection of treatment timing and methods. According to statistics , the incidence rate of both the formation and aggravation of EGVs is approximately 7% per year. The incidence of hemorrhage from the first rupture of esophageal and gastric varices within 1 year is approximately 12%. The incidence of re-rupture bleeding is approximately 60%. The mortality rate within 6 weeks of esophageal and gastric variceal hemorrhage is 15–20% . Therefore, the screening, prevention, and treatment of EGVs are particularly important for patients with cirrhosis and portal hypertension, and endoscopic therapy and the combination of endoscopic and drug therapy remain the preferred choices over drug therapy alone (Fig. 6).
The purpose of primary prevention is to prevent the formation and progression of varicose veins in order to prevent moderate-to-severe varicose vein rupture and bleeding, and the occurrence of complications as well as to improve the survival rate. A prospective study  found that the incidence of bleeding during 1, 3, and 5 years of follow-up was 16%, 36%, and 44%, respectively. The same study reported that the annual bleeding rate for patients with Child-Pugh class A cirrhosis with small varicose veins and no red rash was 4%, while the rate for patients with Child-Pugh class C cirrhosis with large varicose veins and a red rash was 65%. Because GV bleeding is more serious and has a higher mortality rate than esophageal variceal bleeding, it is necessary to identify high-risk GV patients in time and intervene early to prevent large-diameter GV bleeding. Early intervention and bleeding prevention can improve not only the quality of life of these patients but also the survival rate of patients with cirrhosis. The guidelines recommend primary prevention for patients with moderate-to-severe varicose veins and high bleeding risk, and recommend the use of non-selective β-blockers or endoscopic variceal ligation (EVL) to prevent the first episode of bleeding from varicose veins . Portal shunt surgery, portal evascularization surgery, and TIPS cannot fundamentally change the hemodynamic status of portal hypertension, and are not recommended as measures to prevent the first episode of bleeding [6, 11]. Gastroendoscopy can identify the site of bleeding under direct vision and can simultaneously be used for hemostasis treatment, which has made it the preferred diagnostic/treatment method for EGVB . However, the timing of endoscopic diagnosis and treatment remains controversial [12, 13]. Endoscopic treatment for active bleeding at different sites achieved a high degree of uniformity among the different groups in our study, with consistent rates of 78.72–95.74% (Table 2). The first choice of emergency treatment for acute esophageal variceal bleeding was a combination of various methods (40%). GVs occur in approximately 50% of patients with liver cirrhosis, and is closely related to the severity of liver disease. The incidence of isolated GVs is 33.0–72.4%, and the incidence of bleeding within 2 years is approximately 25% . Because the gastric fundus veins are abundant and superficial, they are prone to varicosity. The venous blood flow at this site is abundant and fast. Once ruptured, fatal massive hemorrhage can occur. For the treatment of GV bleeding, 74.12% of endoscopists chose tissue adhesive embolization, because tissue adhesive has the characteristics of coagulation, rapid hemostasis, and definite effect; TIPS/PTVE was chosen by 48.23–60% of the endoscopists for patients with failed endoscopic treatment of EGVB.
The purpose of secondary prevention is to prevent rebleeding in patients who have already had a bleeding episode, and thereby reduce the rebleeding and mortality rates. In terms of the timing of secondary prevention and treatment of varicose veins, 67.06% of endoscopists chose endoscopic intervention within 1 week after hemostasis. Secondary prevention measures include drug therapy, endoscopic therapy, surgical treatment, and interventional therapy. EVL, endoscopic variceal sclerotherapy, and tissue adhesive embolization are the main measures used for secondary prevention. When choosing one of these treatment methods, endoscopists should take into account the location, diameter, and risk factors for varicose veins . Most authors believe that combination therapy is better than monotherapy [8, 14]. In terms of treatment options, endoscopic therapy and endoscopic-drug combination therapy were selected by 44.71% and 49.41% of endoscopists, respectively. In terms of the selection of laboratory indexes for secondary prevention, those with more than 20 years of experience did not have clear requirements for laboratory indexes, while those with less than 20 years of experience had certain requirements for these indexes and strove to be safe and effective (Fig. 7).
After the failure of emergency treatment or endoscopic treatment for primary and secondary prevention, TIPS was the preferred choice of treatment for most endoscopists. According to the guidelines in the literature [15, 16], TIPS was given priority after the failure of endoscopic and drug treatment for patients with Child-Pugh class A or B disease, and surgical shunts were considered when there was no sufficient treatment preparation for TIPS or when TIPS was contraindicated. Ectopic varices are varices outside the esophagus and stomach in patients with portal hypertension . Although rare, ectopic variceal bleeding accounts for 2–5% of variceal bleeding related to portal hypertension, and its mortality rate can be as high as 40% . The pathological characteristics of ectopic varicose veins are thinner venous walls and larger diameter, which can cause greater wall tension and lead to a high bleeding rate . In our study, 54.12% endoscopists chose tissue adhesive embolization for the treatment of ectopic variceal bleeding. Finally, 70.59% of the respondents offered endoscopic treatment for more than 50 cases of EGVs per, which reflects the wide application of the treatment methods and the consistency of treatment schemes. The choice of treatment-related indicators did differ among the study groups, but the differences were not statistically significant. The selection of treatment options was mainly based on the guidelines in the literature and personal experience (Fig. 8). In other words, Chinese endoscopists may gradually accumulate personal experience based on the guidelines in the literature, which are themselves based on evidence-based medicine.