BAVENO VI guideline for portal hypertension

selection of statements

Identification of patients with cACLD who can safely avoid screening
endoscopy (new)

-Patients with a liver stiffness <20 kPa and with a platelet count >150,000 have a very low risk of having varices requiring treatment, and can avoid screening endoscopy
-These patients can be followed up by yearly repetition of TE and platelet count
-If liver stiffness increases or platelet count declines, these patients should undergo screening esophagogastroduodenoscopy

Surveillance of oesophageal varices (changed from Baveno V)
-In compensated patients with no varices at screening endoscopy and with ongoing liver injury (e.g. active drinking in alcoholics, lack of SVR in HCV), surveillance endoscopy should be repeated at 2 year intervals

Patients with no varices or small varices
-There is no indication, at this time, to use beta blockers to prevent the formation of varices
-Patients with small varices with red wale marks or Child-Pugh C class have an increased risk of bleeding and should be treated with non-selective beta blockers (NSBB)
-Patients with small varices without signs of increased risk may be treated with NSBB to prevent bleeding

Patients with medium-large varices
-Either NSBB or endoscopic band ligation is recommended for the prevention of the first variceal bleeding of medium or large varices

Patients with gastric varices
-Although a single study suggested that cyanoacrylate injection is more effective than beta blockers in preventing first bleeding in patients with large gastroesophageal varices type 2 or isolated gastric varices type 1

Early TIPS placement
-An early TIPS with PTFE-covered stents within 72 h (ideally <24 h) must be considered in patients bleeding from EV, GOV1 and GOV2 at high risk of treatment failure (e.g. Child-Pugh class C <14 points or Child-Pugh class B with active bleeding) after initial pharmacological and endoscopic

Prevention of recurrent variceal haemorrhage
-First line therapy for all patients is the combination of NSBB (propranolol or nadolol) + EVL
-EVL should not be used as monotherapy unless there is intolerance/ contraindications to NSBB

-NSBB should be used as monotherapy in patients with cirrhosis who are unable or unwilling to be treated with EV
-Covered TIPS is the treatment of choice in patients that fail first line therapy (NSBB + EVL)
-Because carvedilol has not been compared to current standard of care, its use cannot be recommended in theprevention of rebleeding

Secondary prophylaxis in patients with refractory ascites
-In patients with cirrhosis and refractory ascites NSBB (propranolol, nadolol) should be used cautiously with close monitoring of blood pressure, serum sodium and serum creatinine
-Until randomized trials are available NSBB should be reduced/discontinued if a patient with refractory ascites develops any of the following events

  • Systolic blood pressure <90 mmHg
  • Hyponatremia (<130 mEq/L)
  • Acute kidney injury [17]