Search for a command to run...
This guideline has been approved by the American Association for the Study of Liver Diseases and the American College of Gastroenterology and represents the position of both associations. These recommendations provide a data-supported approach to the management of patients with varices and variceal hemorrhage. They are based on the following: (1) formal review and analysis of the recently published world literature on the topic (Medline search); (2) several consensus conferences among experts; (3) the American College of Physicians' Manual for Assessing Health Practices and Designing Practice Guidelines1; (4) guideline policies, including the American Association for the Study of Liver Diseases' Policy Statement on Development and Use of Practice Guidelines and the American Gastroenterological Association's Policy Statement on the Use of Medical Practice Guidelines2; and (5) the authors' years of experience caring for patients with cirrhosis and varices. Intended for use by healthcare providers, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care. As with other practice guidelines, this guideline is not intended to replace clinical judgment but rather to provide general guidelines applicable to the majority of patients. They are intended to be flexible, in contrast to standards of care, which are inflexible policies designed to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the quality of evidence supporting recommendations, the Practice Guidelines Committee of the AASLD requires a class (reflecting benefit versus risk) and level (assessing strength or certainty) of evidence to be assigned and reported with each recommendation (Table 1, adapted from the American College of Cardiology and the American Heart Association Practice Guidelines3, 4). When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical considerations may justify a course of action that differs from these recommendations. These recommendations are fully endorsed by the American Association for the Study of Liver Diseases and the American College of Gastroenterology. Portal hypertension is a progressive complication of cirrhosis. Therefore, the management of the patient with cirrhosis and portal hypertensive gastrointestinal bleeding depends on the phase of portal hypertension at which the patient is situated, from the patient with cirrhosis and portal hypertension who has not yet developed varices to the patient with acute variceal hemorrhage for whom the objective is to control the active episode and prevent rebleeding. Practice guidelines for the diagnosis and treatment of gastroesophageal variceal hemorrhage, endorsed by the American Association for the Study of Liver Diseases (AASLD), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and American Society of Gastrointestinal Endoscopy (ASGE), were published in 1997.5 Since then, a number of randomized controlled trials have advanced our approach to managing variceal hemorrhage. Three international consensus conferences have been held (Baveno III in 2000, Baveno IV in 2005, and an AASLD/EASL single topic conference in 2007) in which experts in the field have evaluated the changes that have occurred in our understanding of the pathophysiology and management of gastroesophageal hemorrhage.6, 7 In this updated practice guideline we have reviewed the randomized controlled trials and meta-analyses published in the last decade and have incorporated recommendations made by consensus. Cirrhosis, the end stage of any chronic liver disease, can lead to portal hypertension. Portal pressure increases initially as a consequence of an increased resistance to flow mostly due to an architectural distortion of the liver secondary to fibrous tissue and regenerative nodules. In addition to this structural resistance to blood flow, there is an active intrahepatic vasoconstriction that accounts for 20%-30% of the increased intrahepatic resistance,8 and that is mostly due to a decrease in the endogenous production of nitric oxide.9, 10 Portal hypertension leads to the formation of porto-systemic collaterals. However, portal hypertension persists despite the development of these collaterals for 2 reasons: (1) an increase in portal venous inflow that results from splanchnic arteriolar vasodilatation occurring concomitant with the formation of collaterals11; and (2) insufficient portal decompression through collaterals as these have a higher resistance than that of the normal liver.12 Therefore, an increased portal pressure gradient results from both an increase in resistance to portal flow (intrahepatic and collateral) and an increase in portal blood inflow. The preferred, albeit indirect, method for assessing portal pressure is the wedged hepatic venous pressure (WHVP) measurement, which is obtained by placing a catheter in the hepatic vein and wedging it into a small branch or, better still, by inflating a balloon and occluding a larger branch of the hepatic vein. The WHVP has been shown to correlate very closely with portal pressure both in alcoholic and non-alcoholic cirrhosis.13 The WHVP is always corrected for increases in intraabdominal pressure (e.g., ascites) by subtracting the free hepatic vein pressure (FHVP) or the intraabdominal inferior vena cava which as The pressure is the hepatic venous pressure gradient which is with the use of a balloon with a is very and Since it is a of the be in intrahepatic of portal as but be normal in of portal as portal vein The normal is The and changes in that have for the development of the of variceal the development of of portal and are in the of both and are to to and of liver to the use of are the of and to guidelines that and as as varices are the relevant porto-systemic collaterals results in variceal hemorrhage, the complication of cirrhosis. and variceal hemorrhage are the of cirrhosis that from portal hypertension. with cirrhosis and gastroesophageal varices have an of at varices are in of patients with cirrhosis. with the of liver (Table of patients have are in of with cirrhosis may varices and variceal hemorrhage in the course of the in the of has been shown that of patients with and have varices at a of and the for development of varices in with cirrhosis who have no varices at the of is an with small varices large varices at a of cirrhosis alcoholic and of as on the variceal at the of are the with the from small to large hemorrhage at a of and the of hemorrhage is the of with the of hemorrhage occurring in patients with large of hemorrhage are cirrhosis and the of bleeding from varices in to of and despite in the last it is with a of at at with an of variceal have been as at a higher for bleeding the of or to control bleeding and a higher to with in of mostly years of the is the that variceal is of the of variceal an a large a small not of the of variceal is the pressure the which is to the Therefore, a in lead to a decrease in variceal the of variceal hemorrhage not the is to has been shown that the of with in than from to or at from not have a of variceal but have a of and varices are than varices and are in of patients with portal hypertension with a reported of bleeding of in 2 with a higher bleeding for for variceal hemorrhage the of varices as and class and of variceal as or on the of a varices are based on with varices as as in the varices are an of varices and are into 2 The are which the They are of varices and be 2 varices the and to be and more varices in the of varices and are into 2 are in the and to be and and 2 are in the or the The of varices requires the of vein The in the diagnosis of varices is In a consensus it that the be as as in 2 and by or by with a of with large varices than When varices are in or in by a small varices as the varices as than of the and large varices as more than of the recommendations for varices are the as for large this is were in As shown prevent bleeding in more than of patients with or large varices. Therefore, it is that patients with cirrhosis for varices at the of Since the of varices is the majority of not have varices or have varices that not in to the of varices by studies have evaluated of varices in patients with as the portal vein and However, the of is and large prospective studies of are is the of assessing for the of have for patients with or for patients with and for patients with of these a that not prevent the development of varices and are with variceal as an prospective studies these is the The of in patients with no or small varices depends on be the diagnosis of cirrhosis is In patients with cirrhosis who have no varices on the be in In who have small the be in In the of be at is and requires can be in patients with cirrhosis who are on for other (e.g., hypertension. In on a for other to a be that may replace is studies that is a and to to be may a in for varices larger studies the method for variceal The diagnosis of variceal hemorrhage is made of the following: active bleeding from a a a a or varices with no other of for the diagnosis of and varices is the diagnosis of cirrhosis is made varices be as small or large with the varices are The or of or on varices be for the management of varices for the management of hemorrhage and on portal venous portal and portal pressure are in of splanchnic and and and by splanchnic vasoconstriction and portal venous inflow. by intrahepatic However, (e.g., have a and the decrease in portal pressure to be more to a decrease in rather than a decrease in The of a and a has a portal as or variceal are that have no on portal flow or intrahepatic or by the of increased portal pressure by the of increased large to a benefit of in the of varices in patients with cirrhosis who portal hypertension at but not yet developed The that patients who a in of from a development of and that a larger of patients on this in to on larger number of patients with or were in the to the occurred in patients in the and in patients in the These results not the use of in the of consensus have that be every years in these and in the of In patients with cirrhosis who not have be to prevent development In patients who have cirrhosis and no varices on the it be in years there is evidence of hepatic be at that and of trials in the of variceal hemorrhage the results of trials that patients with small In this the of variceal hemorrhage 2 and it with 2 this not studies have the of in the of small with In the the of patients with large varices larger in the to the However, the patients with no and small varices and a of the patients were to large but that patients with small varices with a to large varices at than patients who were randomized to at with no in The of variceal bleeding in patients who treatment with varices were small at with patients who large varices were at However, this benefit to the patients in a of given that large varices developed and patients were with the of bleeding very to other a higher of patients on to be from the of to patients on with be in patients with small varices who are at a for that with advanced liver and the of on patients with small varices can to prevent variceal benefit has not been In who not to consensus have that be every 2 and in the of In patients with cirrhosis and small varices that have not but have for increased of hemorrhage or of on be for the of variceal hemorrhage In patients with cirrhosis and small varices that have not and have no for increased of can be benefit has not been In patients with small varices that have not and who are not be in 2 years there is evidence of hepatic be at that and In patients with small varices who a is not of trials that patients versus treatment or in the of variceal hemorrhage that the of variceal bleeding in patients with or varices is by in in and that bleeding episode is for every 10 patients with is in the with the control and this has recently been shown to be a and that were the of portal pressure by more by splanchnic vasoconstriction portal blood are and are for of variceal hemorrhage. decrease in the of hemorrhage and from or from decrease the of variceal hemorrhage. In the majority of the published the of to decrease the from However, is not and a in not correlate with in the of is to is at a of a is is at a of a a randomized that the of bleeding treatment with is be of patients from trials have to the use of as of and The to in cirrhosis are and of of these with or treatment in of patients. in which have reported of than have not been variceal has been to in several randomized trials in patients with varices varices with or meta-analyses of these trials have been the trials and with with and the studies with with that is with a small but of variceal hemorrhage in The results are the fully published trials or trials are the has a of the are more and bleeding from in 10 patients 2 and in This last complication is to given the use of that the use of for In the of of the 10 patients on of 2 of the more studies in these meta-analyses to be the number of patients and a of analysis a higher number of treatment or a in the to the The of this is in that that bleeding were not and that in the have the In the 2 randomized and a more not in the have shown that is to or to in the variceal hemorrhage. review of the a consensus of experts that both and are in variceal hemorrhage and the be based on patient and and not for The of a and has a portal and be more than in variceal In a with a of hemorrhage in the with These results were of in However, 2 more larger trials were to these and a number of were in the Therefore, the use of a of a and be for there is of The of a and has been shown to portal pressure by and splanchnic blood has been recently in a The results suggest that the addition of not increase the of in the of variceal hemorrhage. The of of a and in the of variceal hemorrhage recently evaluated in a randomized but not in patients with and cirrhosis who were no in the of bleeding or and varices more in the were more in the the of in the be shown in to be as as in variceal However, of patients in this higher in patients than a may lead to a higher in these patients by the of the as shown in trials other as and In in a patients with varices and or to were randomized to or to there a and of variceal hemorrhage in the with no in were more in patients These results were in randomized of patients with Therefore, not be in patients with cirrhosis. trials have shown very in variceal hemorrhage, blood from the liver is by more and higher These results can be to the intrahepatic is the as that of of blood from the Therefore, or not be in the of variceal hemorrhage. trials have studies studies no and to be it the higher in the than in the not be for the of variceal hemorrhage. In patients with varices that have not but have a of hemorrhage or variceal on or may be for the of variceal hemorrhage In patients with varices that have not and are not at the of hemorrhage patients and no are preferred and be in patients with or or to a patient is on a it be to the is a patient is with it be every with the and every to for variceal or in with or not be in the of variceal hemorrhage is evidence that treatment for acute variceal hemorrhage, including general and have in an both in the and with acute variceal hemorrhage be to an for and including assessing the and venous be but with with the of and a of This recommendation is based on studies that that of blood leads to increases in portal pressure to higher than and to more and with be in addition to variceal hemorrhage, this can or the of or at other that of blood can or more may be for to in patients with concomitant hepatic The of and can be in patients with of in patients with gastrointestinal hemorrhage to a of analysis of a of and patients that of the of patients with to control variceal studies are needed this can be in patients with and variceal patients with bleeding have a of and other that are with of variceal hemorrhage and a patients with liver are at an increased of this is in with more liver and The use of in patients with cirrhosis and hemorrhage with or has been shown not to decrease the of but to increase This is to a decrease in the of in patients with variceal hemorrhage who Therefore, be practice in patients with cirrhosis and acute variceal The is at a of for 7 The the of a is the at of in the the of However, with of as be When is not can be In a in patients with advanced cirrhosis and hemorrhage, IV more than in mostly due to The of in the not and this have to the has the of applicable and of as as a diagnosis of variceal hemorrhage is to of trials and treatment or a with with that be treatment of variceal not be in the acute as decrease blood pressure and a increase in with is the splanchnic blood flow to splanchnic to a decrease in portal venous inflow and to a decrease in portal The clinical of is by which are to including and and and are by the addition of of are higher than with or it can be at the for a of to the development of is at a IV of that can be increased to a of always be by IV at a of which can be increased to a of to a blood pressure a of that has a and is in acute variceal hemorrhage and has been with a but is not yet in the is at an of 2 IV every and can be to IV every hemorrhage is and as and splanchnic vasoconstriction at it has been that this is due to an of the of studies suggest that has a The of and as and is that are and can be for or is in the and it has been mostly as an IV of followed by a of Use of of a IV followed by of is given as a IV followed by of However, results of meta-analyses of trials of are and a more of trials of in general a The may not be is has been with and a more to However, as shown to be as an to be the diagnosis of variceal hemorrhage is be as as (e.g., and be the variceal of hemorrhage is the a of 10 randomized controlled trials including patients an benefit of in the control of bleeding to of with a of In of the studies in the that increased both and it for the of the in the to by Therefore, by is the preferred of for acute variceal is in patients in whom is not of and is the approach in the treatment of acute variceal hemorrhage. The use of with to the which the of is the of trials to or the control of bleeding and in or variceal bleeding be controlled or in of patients. of has been shown to be of treatment or has clinical as for patients who to to or has reported control of bleeding and a with the of of of bleeding in patients a This approach has not been by other and is not a small has that of is with a in in patients as with an with acute variceal These results in a larger number of patients followed for a can be The of both and are on is very in bleeding with control of hemorrhage in of However, use is with as and of the with as as Therefore, it be to patients with bleeding for whom a more (e.g., is of is balloon is hemorrhage in a patient with cirrhosis is an that requires with and blood to a of 7 be in any patient with cirrhosis and hemorrhage or patients in whom is not is the In patients with advanced cirrhosis may be in with a of or and be as as variceal hemorrhage is and for diagnosis is be to the diagnosis and to variceal hemorrhage, with or is in patients in whom hemorrhage from varices be controlled or in whom bleeding despite and be as a in patients with bleeding for whom a more (e.g., or is The literature on the management of variceal hemorrhage is not as as that for variceal hemorrhage. there are controlled clinical trials, can be on guidelines for the management of varices. varices an of varices the of the Therefore, the approach to management be the as for varices the other there are very data the management of bleeding from are secondary to vein in which of to or variceal with tissue as or is more for acute variceal with better control of hemorrhage as as of large randomized variceal with versus in patients with acute variceal hemorrhage that control of active bleeding in both but that a of years occurred in the with an of In an an approved for in the has been as for and from Therefore, the use of these is preferred in the of varices. However, in the of these or the is with this of be studies the of for bleeding from varices with bleeding control of it been that bleeding from varices more to control with than bleeding from a prospective in patients with versus variceal bleeding and with control of hemorrhage in but patient in each The to for variceal hemorrhage is than for variceal hemorrhage and can be is not or a single of In patients who from variceal tissue as is preferred, is an be in patients in whom hemorrhage from varices be controlled or in whom bleeding despite and who an episode of acute variceal hemorrhage have a very of and The in is years of the hemorrhage, with a of is that patients who have from an episode of variceal hemorrhage and have no evidence of hemorrhage for at be on to prevent to from the who to control the acute episode not preventive these patients be to a are a or a or of variceal to patients with have a higher of However, there are better and the of a and has a portal and be more than has a the of and in patients with variceal This a benefit of but it not from randomized clinical trials that the in patients with is than that obtained with Therefore, the of in the of variceal is the of a and a However, this has to and is in clinical practice that patients end is the method of for variceal it has been shown to be to from randomized clinical trials a in patients with of are at to variceal which requires 2 to is every to to for variceal and for of in of but are The complication is and at the of each are the and may In a small randomized of IV followed by every for the number of at 10 the in both were in the not bleeding occurred in the These results the use of in patients with versus has been in randomized studies a benefit of a benefit of and a no treatment despite a in of These the of patient to be at in the of variceal with of is the approach to variceal and prevent variceal randomized trials the of versus in these 2 trials were and for to and for These results the use of to prevent a consensus conference or as in The a is in patients who variceal hemorrhage or on or a The of variceal is obtained in patients who are that patients in whom or leads to a in to or a from In patients who are it not be to use As the be to the to prevent variceal in the of this of the including the to the studies have the a of the and there is evidence that the of the in is with is very in rebleeding. However, it increases the of hepatic and has no on meta-analyses of trials that to as is with more and there is no in a than in it with and more in class with than Therefore, not be as a but as a for patients who have large of versus of and in patients with or cirrhosis who with a higher of in the both have the is on and to the and the trials have been The of that have been shown to have a and of may increase the for However, given results with it is that a not for secondary no be in the secondary of variceal hemorrhage. of trials which patients versus in the of variceal that the of variceal is by there were no in are and with and the number of needed to is than with suggest that is followed by a higher of variceal in with the no in variceal the of with in variceal has been 7 and a more no in or number of to variceal and a higher of in the Therefore, not be with with cirrhosis who an episode of active variceal hemorrhage to prevent of variceal hemorrhage of is the for secondary of variceal hemorrhage The be to the be every with the and every to for variceal be in patients who are or who experience variceal hemorrhage despite and In the is can be in patients who are be to a for that of varices of in the diagnosis of varices and variceal hemorrhage of in to with a on for varices and variceal hemorrhage In the decade the practice guidelines were a number of have our management of variceal hemorrhage. have been as a and have no in the of the development of varices but are the in the of variceal hemorrhage in patients with varices. variceal has been as an to for the of variceal hemorrhage. The of and variceal is the preferred approach to the management of acute variceal hemorrhage. is of as treatment of the acute bleeding and have been for the of variceal hemorrhage. of or are the the management of patients with varices may with the of that the intrahepatic more for and of liver This guideline in with the Practice Guidelines Committee of the American Association for the Study of Liver Diseases and the Practice Committee of the American College of Gastroenterology. These review of the of the AASLD Practice Guidelines Committee and of the Practice Committee and