Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis (2007)

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 pressure, which act as internal zeroes. The resultant 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 pressure, 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 pressure, 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. 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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