Baveno portal hypertension

 Baveno 7

 

1)    Portal hypertension = HVPG >5 mm hg

2)    In viral & alcoholic hepatitis – CSPH = HVPG >=10

3)    In PBC, CSPH likely develops at lower HVPH, due to (unmeasured) component of pre-sinusoidal PH

4)    Similarly, in NASH, CSPH may develop at HVPG < 10

 

 

Reduction in HVPG secondary to Betablockers predicts clinical response!

 

In patients undergoing TIPS, HVPG <12 affords near-complete protection from PH complications

 

 

Compensated advanced chronic liver disease (cACLD) (a.k.a cirrhosis)

<10 kPa = unlikely cACLD      (<1% 3-year risk of decompensation or liver-related death)

>15 Kpa = highly likely cACLD

 

 

Clinically significant reduction in LSM defined as either:

1)    20% reduction, such that LSM <20 Kpa

2)    Or LSM <10 Kpa

 

CSPH (based on LSM)

LSM <15 + Platelet >150 – unlikely CSPH (>90% negative predictive value)

LSM >25 – Definite CSPH

 

Baveno indications for Gastroscopy

LSM >20 or Plt <150

 

Other Meds:

1)    Statins – In patients with cirrhosis, the use of Statins Should be encouraged, as this may reduce portal pressure & improve OS

CP-A – Statins as usual

CP-B – Lower dose statins – for eg Simvastatin up to 20mg daily

CP-C – No evidence of use of statins (too late)

2)    Aspirin – Aspirin can be continued – it likely has anti-HCC effect and likely reduces liver-related complications and death

3)    Anticoagulation­ – can be continued. Likely improves liver-related complications & death

DOACs – use in CP-A & B as usual

                 Use in CP-C – only in trials

 

 

 

 

Pearls:

- Minimal ascites (detected radiologically), mild overt bleeding secondary to PHG and minimal overt encephalopathy ­are not synonymous with Liver decompensation (as they don’t hold same prognostic implications as gross symptoms of decompensation)

 

 

 

Carvedilol – Is superior to propranolol or nadolol

1)    Greater portal pressure reduction than other NSBB

2)    Better side-effect profile

3)    Improves mortality in patients with compensated Cirrhosis with CSPH

 

Indications for starting carvedilol

1)    Patients with CSPH (any of following)

Symptoms: Gross ascites / Encephalopathy

Gastroscopy: Oesophageal varices

LSM > 25

 

 

 

 

Acute variceal bleeding-

1)    Vasoactive drugs – for 2-5 days

Look out for hyonatraemia with Terlipressin

(Terlipressin is synthetic vasopressin analogue which causes mesenteric vasoconstriction, thereby reducing portal flow & portal pressures. Octreotide is a synethetic somatostatin anaologue which reduces hormone secretion, such as glucagon, which in turn leads to reduced mesenteric vasodilation and reduced portal flow (indirectly slow compared to terlipressin).

2)    PPI – STOP immediately after endoscopy unless good indication to continue

3)    Antibiotics – Ceftriaxone 1g IV daily

4)    Pre-emptive TIPS(note – encephalopathy should not be considered a contraindication)

Ideally within 24 hrs (or up to 72 hours) for:

·      No active bleeding at endoscopy – if CPC 10-13

·      Active bleeding at endoscopy – if CPB 8-9 or CPC 10-13

TIPS is likely Futile in CPC 14-15 OR MELD-30+Lactate12 unless liver tx in short term is an option

5)    In refractory variceal bleed, SEMS are as efficacious, and safe compared to SB tube

6)    Rapid removal of blood from GI tract is important to prevent encephalopathy. Use Lactulose oral or enemas)

Lactulose enema is given as 300 ml of lactulose + 700 ml of NS as retention enema every 8-12 hrs

 

TAL-p (terlipressin, antibiotics, laxatives, consider pre-emptive tips)

 

Variceal bleeding is DUE to portal hypertension, and NOT due to coagulation abnormality. There is NO evidence that FFP, platelet transfusion or correction of fibrinogen is correlated with risk of re-bleeding or failure to control bleeding. However, in case of failure to correct bleeding, consider correction of ROTEM on case-by-case basis.

 

 

Recurrent ascites: Needing LVP >3x a year should be considered for TIPS (irrespective of absence of varices)

 

In patients with large varices, carvedilol is preferred over banding for secondary prevention

 

 

Discontinue betablockers (temporarily, and re-trial again after improvement) if

1)    SBP <90 or MAP <65

2)    HRS-AKI

 

 

PHG:

1)    To prevent recurrent bleeding from PHG, use beta-blockers (carvedilol)

2)    APC can be used to treat PHG

3)    TIPS can be considered for transfusion dependent PHG despite beta-blockers & endoscopic treatment.

 

 

Indiactions for TIPS

1)    Pre-emptive for variceal bleeding

2)    Transfusion dependent PHG despite betablocker & endotherapy

3)    Ascites >3LVP a year