Purpose <p>To investigate whether computed tomography (CT) imaging features can aid in identifying cirrhotic patients with poor response to endoscopic therapy for gastroesophageal variceal hemorrhage (GVH).</p> Methods <p>Cirrhotic patients with a history of endoscopic therapy for GVH were retrospectively enrolled (<i>n</i> = 158). Pre-endoscopic data, hepatic venous pressure gradient (HVPG), and endoscopic and CT imaging data were collected and analyzed. The cross-sectional area of skeletal muscle (SMA) at the level of the third lumbar vertebra was measured, and the skeletal muscle index (SMI) was calculated by dividing SMA by the square of the patient’s height. Spleen volume was measured using a semi-automatic segmentation tool.</p> Results <p>HVPG &gt; 16 mmHg (<i>p</i> = 0.033), SMI-related sarcopenia (<i>p</i> &lt; 0.001), and significant splenomegaly (defined as spleen volume ≥ 974.3&#xa0;cm³, <i>p</i> = 0.008) were identified as independent risk factors for variceal rebleeding after endoscopic therapy in these cirrhotic patients. The cumulative risk curve showed a higher probability of rebleeding in the sarcopenia group (<i>p</i> &lt; 0.001). Similarly, the rebleeding rate was significantly higher in the HVPG &gt; 16mmHg group compared to the HVPG ≤ 16mmHg group (<i>p</i> = 0.029). And patients with significant splenomegaly demonstrated a significantly higher rebleeding probability (<i>p</i> = 0.021).</p> Conclusion <p>CT imaging features, particularly SMI-related sarcopenia and significant splenomegaly, in combination with HVPG, are risk factors associated with gastroesophageal variceal rebleeding after endoscopic therapy. Early identification of cirrhotic patients with poor response to endoscopic therapy is crucial for implementing more aggressive interventions to prevent variceal rebleeding.</p>