7.5 Secondary prevention of variceal bleeding in cirrhosis Combination therapy with NSBB (propranolol) + VBL is recommended as secondary prevention. Combined with the patient’s will and clinical judgment, NSBB or VBL monotherapy can also be chosen as secondary prevention. How often should endoscopy be repeated in patients with liver cirrhosis? If varices are not found in the first endoscopy, it is recommended to repeat endoscopy every 2-3 years. If grade I varices are diagnosed, it is recommended to review endoscopy once a year. 8 New philosophy in treating patients with cirrhosis The current new philosophy in treating patients with cirrhosis lies in early preventive intervention to prevent disease progression and to avoid or delay the complications of cirrhotic decompensation and the need for liver transplantation. Early detection of liver problems is better recommended abroad. Although liver disease often progresses after decades, and despite many opportunities for intervention, about 3/4 of patients with cirrhosis are not diagnosed until they are hospitalized for end-stage liver disease, so there is a need for accurate predictive models of cirrhosis and hepatocellular liver cancer risk. Overseas, it is proposed that the diagnosis and treatment of complications of cirrhosis need to be advanced. We need to make changes in the management of cirrhosis, which are mainly reflected in three changes in perspective. In the case of hepatic encephalopathy, for example, in the past clinicians often focused only on the treatment of patients presenting to the clinic who already had significant impairment of consciousness. In contrast, there is now a growing clinical awareness of occult hepatic encephalopathy, and these patients are at increased risk of developing overt hepatic encephalopathy due to their poor quality of life, difficulty driving, and reduced ability to work. Another similar shift in understanding is for acute renal function in cirrhosis. The traditional concept of hepatorenal syndrome required the clear presence of significant renal impairment prior to diagnosis. In contrast, we have now begun to advance the diagnosis and treatment of renal dysfunction in this group of patients to an earlier stage in order to prevent disease progression. Another conceptual shift that has occurred is in the recognition and treatment of coagulation in liver disease. “Patients with cirrhosis do have a significant risk of thrombosis, particularly portal vein thrombosis, which worsens liver function and makes the patient’s prognosis worse, and we are currently considering whether anticoagulant therapy can enable a subset of patients to avoid thrombosis. The new shift allows clinicians to identify complications that affect patient survival and quality of life earlier. Advances in technological tools can also help physicians detect and manage patients with possible complications. “The Apple mobile app program has been able to help detect occult hepatic encephalopathy.” Recent foreign studies have found that regardless of the patient’s advancing age and more clinically complex cirrhosis, the improvement in survival of hospitalized patients is consistent. This suggests that the improvement in the level of treatment for cirrhosis exceeds the improvement in the level of treatment for the disease in general. The marked improvement in survival rates for cirrhosis has greatly encouraged patients and clinicians. Emphasis was placed on reducing cirrhosis-related hospital mortality and also on the subgroup of patients most in need (because of their very high risk of short-term complications). There will be a large number of future clinical trials to explore new treatment options to benefit the growing number of patients with cirrhosis.