Summary of the 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
therapy
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]
Additional information about varices:
For more information on varices bleeding protocol click here
For more information about varices surveillance click here
References:
https://www.journal-of-hepatology.eu/article/S0168-8278(15)00349-9/pdf
Recent Comments