consensus report
Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)
5
1 3
Time management of endoscopic treatment
1. Endoscopic treatment should be performed as soon
as possible after hemodynamic stabilization (at the
latest 12 h after admission, ideally during the first 6 h),
especially in patients with clinically significant bleed-
ing or in patients with suspected cirrhosis (III).
2. In patients with mild bleeding not causing hemody-
namic changes and not requiring transfusions, endos-
copy can be performed electively (III).
Blood volume restitution
1. Blood volume restitution should be done cautiously
and conservatively, using packed red cells to maintain
the hemoglobin between 7–8 g/dL (unless comorbidi-
ties/active bleeding mandate more aggressive sub-
stitution) (I), and substitution of fluids sufficient to
maintain hemodynamic stability. Targets for systolic
blood pressure are 90–100 mmHg, and for heart rate
100 bpm or less.
2. Further data from prospective studies are required
to determine the need for treating coagulopathy
and thrombocytopenia. In patients with severe co-
agulation disorders (PT < 30 %) or thrombocytopenia
(< 30,000/µL), substitution therapy using fresh frozen
plasma (FFP) or platelets should be considered (III).
3. Therapy with prothrombin-complex containing clot-
ting-factor concentrates should be omitted (III).
Antibiotic prophylaxis to prevent bacterial
infections/spontaneous bacterial peritonitis
Antibiotic prophylaxis is an integral part of the therapy
of variceal bleeding, which should be started before
endoscopic therapy. Broad-spectrum antibiotics should
be administered either orally or intravenously [
23
]. All
patients should be screened for the presence of a bacte-
rial infection (I).
Prevention/therapy of hepatic encephalopathy
1. Lactulose can be administered either orally or by a
nasogastric tube or by enema to prevent hepatic en-
cephalopathy, even though its therapeutic efficacy is
unproven for acute variceal bleeding (III).
2. In case of overt hepatic encephalopathy, L-ornithin-
L-aspartat should be given intravenously in combina-
tion with sufficient volume substitution for the first
24–48 h. Later it should be given orally on demand.
Alternatively, rifaximin might be used for long-term
prophylaxis (I).
3. For none of these above interventions, controlled data
on their efficacy are available.
Assessment of prognosis
HVPG of > 20 mmHg, active bleeding at endoscopy, and
Child-Pugh Class C are associated with an increased fail-
ure to control bleeding and early mortality [
24
] (II-2).
Use of balloon tamponade
1. Balloon tamponade should only be used in patients
with bleeding as a temporary “bridge” until definitive
treatment can be instituted, if other options such as
the bleeding stent are not available (I).
2. A better contemporary alternative to stop uncon-
trolled bleeding is the bleeding stent [
25
], which
should be preferred to ballon tamponade for esophe-
geal variceal bleeding if possible, even though con-
trolled data are still not available (II-2).
Pharmacological treatment
1.
In suspected variceal bleeding, vasoactive drugs
should be started as soon as possible, before diagnos-
tic endoscopy (I).
2. For vasoactive therapy, somatostatin (for continuous
intravenous application) and the vasopression-anal-
ogon terlipressin (application as a bolus) have proven
efficacy to control bleeding (I). They have similar ef-
ficacy and can be substituted one for the other. Terli-
pressin should not be used in patients with clinically
significant coronary heart disease, pAVK, higher grade
cardiac rhythm abnormalities, and severe grades of
asthma and COPD.
3. Drug therapy may be maintained for up to 5 days to
prevent early rebleeding (I). After this period, medical
therapy for secondary prophylaxis should be started
immediately (I).
Recommended drug doses
1. Somatostatin: initially a bolus of 500 µg, afterwards
500 µg/h (7 µg/kg/h) by continuous infusion. If the
patient does not bleed for 24 h, treatment with a dose
of 250 µg/h (3.5 µg/kg/h) should be continued for the
next 24 h up to 5 days.
2. Terlipressin: initially a bolus of 2 mg every 4 h. If the
patient does not bleed for 24 h under this regimen,
bolus administration of 1 mg every 4 h should be con-
tinued for the next 24 h up to 5 days.
Endoscopic therapy of esophageal variceal
bleeding
1. In acute bleeding, endoscopic ligation is the preferred
endoscopic method over endoscopic sclerotherapy(I).
6
Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)
consensus report
1 3
2. Endoscopic treatments are best used in association
with pharmacological therapy (vasoactive drugs + an-
tibiotics), which preferably should be started before
endoscopy (I).
3. Even when no active bleeding can be detected at en-
doscopy, endoscopic therapy of varices is highly rec-
ommended (I).
4. Cyanoacrylate is not a standard treatment for esopha-
geal varices but might be used as a rescue therapy of
refractory bleeding (II-3).
5. Erythromycin may improve visibility during endos-
copy while the impact on bleeding control is unclear
(III).
Early TIPS-placement
1. Recent data show that early TIPS-placement (within
72 h, even better within 24 h) can not only improve
FCB but also mortality in patients with high risk of
FCB [
26
,
27
] (I).
2. Early TIPS-placement should be performed in pa-
tients with acute variceal bleeding and either
– An HVPG ≥ 20 mmHg at the time of acute variceal
bleeding [
26
] or
– Child-Pugh C status at admission (but Child-Pugh
score < 14) or
– Child-Pugh B status with active bleeding at endos-
copy [
27
] despite treatment with vasoactive drugs
and antibiotics.
3. The decision for TIPS-implantation should consider
the standard exclusion criteria for TIPS-implantation
such as cardiac insufficiency (in particular right heart
failure) and technical contraindications (lack of vas-
cular connectability) (II-3).
4. Acute hepatic encephalopathy is not a contraindica-
tion for an early TIPS (III).
5. For Child-Pugh C patients with a score of ≥ 14, no evi-
dence for an improved outcome with an early TIPS is
available, since these patients were excluded from the
trials.
Prevention of variceal rebleeding (secondary
prophylaxis)
Standard therapy
1. Secondary prophylaxis should be started as soon as
possible, ideally at day 5 after the acute variceal epi-
sode (or whenever vasoactive therapy is discontin-
ued) (III).
2.
Combination of nonselective beta-blocker (NSBB)
(propranolol) therapy and endoscopic rubber band
ligation are the therapies of choice (I). Data from pri-
mary prophylaxis suggest that carvedilol might be at
least as effective as propranolol for lowering portal
pressure in cirrhosis [
20
] but no data for secondary
prophylaxis of acute variceal bleeding are available:
they should be generated (III).
3. Medical therapy with (II-2) NSBB alone is a valid
choice if their effectiveness can be documented by
HVPG. NSBB nonresponders can be treated with a
combination of NSBB with ISMN under hemody-
namic monitoring (III). Nonresponders to combina-
tion medical therapy require endoscopy band ligation
(III).
4. Propranolol should be titrated to a daily dosage of
minimum 80 mg in 2–3 fractions, carvedilol should
be administered once or twice daily with a minimum
daily dosage of 12.5 mg (starting with 6.25 mg/day for
1 week) (III).
5. Endoscopic band ligation to prevent rebleeding is
continued at 2–3 week intervals until ideally complete
eradication of varices (small residual varices can be
accepted) (III).
6. Patients with advanced stage liver disease should be
evaluated for liver transplantation. In these patients,
endoscopic and/or medical therapy should be contin-
ued until transplantation (II-2).
Treatment of patients with contraindications to
beta-blockers or combination drug therapy
1. Band ligation is the preferred treatment to prevent
recurrent variceal hemorrhage in patients who have
a contraindication to beta-blocker or combination
therapy (III).
2. ISMN monotherapy is not considered an alternative
to beta-blocker therapy (II-2).
Treatment of low-risk patients (early stage liver
disease, sufficient tolerance of bleeding) with
failure of secondary prophylaxis
1. Variceal band ligation is the therapy of choice in vari-
ceal rebleeding (or insufficient decrease in HVPG) de-
spite medical therapy, although band ligation could
have moderate beneficial effects especially in these
patients [
28
] (II-2). It might also be warranted in situ-
ations with combination prophylaxis (NSSB), if band
ligation was incomplete or finished some time (> 12
months) ago (III).
2. TIPS implantation with PTFE (polytetrafluoroethyl-
ene) -covered stent grafts (very rarely also shunt sur-
gery) is a good treatment option for low-risk patients
in whom medical and endoscopic treatment have re-
peatedly failed (at least twice) (II-2).
3. Surgical devasculariziation is a rescue therapy in case
of failure of medical and endoscopic treatment to pre-
vent rebleeding in patients in whom neither a TIPS
can be implanted nor shunt surgery can be performed
(III).