Consensus report
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consensus report Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II) 15 1 3
Staging of severity Severity of HPS will be staged according to criteria men- tioned below [ 101
] (III): 1. Mild HPS: AaDO 2 ≥ 15 mmHg, PaO 2 ≥ 80 mmHg 2. Moderate HPS: AaDO 2 ≥ 15 mmHg, PaO 2 < 80 mmHg– ≥ 60 mmHg 3. Severe HPS: AaDO 2 ≥ 15 mmHg, PaO 2 < 60 mmHg– ≥ 50 mmHg 4. Very severe HPS: AaDO 2 ≥ 15 mmHg, PaO 2 < 50 mmHg (< 300 mmHg on 100 % oxygen) Diagnosis HPS positive patients should undergo lung perfusion scan- ning for intrapulmonary shunt quantification and should have pulmonary function testing and pulmonary imag- ing (chest x-ray and thoracic computed tomography) for exclusion of other structural pulmonary diseases. Pulmo- nary artery catheterization should be performed at least in patients with severe and very severe HPS for assessment of intrapulmonary shunting, cardiac index, and exclusion of additional portopulmonary hypertension (III). Therapy
Patients with mild and moderate HPS should have con- trol blood gas analysis at regular intervals as HPS is a pro- gressive disease [ 124
] (II-2). Long term oxygen therapy (LTOT) should be started in patients with severe and very severe HPS (PaO 2
< 60 mmHg). Oxygen supply should be adjusted to raise PaO
2 > 60 mmHg (III). Patients with severe HPS should be listed for liver transplantation only due to the severity of gas exchange abnormality as transplantation is the only proven ther- apy of HPS. They should receive an exceptional posi- tion ranking comparable to patients with hepatocellular carcinoma (III). Evaluation for liver transplantation in patients with very severe HPS should be based on an individualized risk–benefit assessment as the cardiopul- monary complication rate has significantly increased in these patients following transplantation [ 101 ] (III).
Appendix Participants “Billroth II”, 2. ÖGGH-Consensus Confer- ence “Portal Hypertension”, Palais Clam Gallas, Vienna 011011
Dr. Bernhard Angermayr Landesklinikum St. Pölten, 2. Medizinische Abteilung Dr. Eva Brownstone KA Rudolfstiftung, 4. Medizinische Abteilung Theresa Bucsics Univ.-Klinik für Innere Medizin III, AKH Prim. Dr. Christian Datz Krankenhaus Oberndorf, Abteilung Innere Medizin Dr. Arnulf Ferlitsch Univ.-Klinik für Innere Medizin III, AKH PD Dr. Valentin Fuhrmann Univ.-Klinik für Innere Medizin III, AKH Univ.-Prof. Dr. Ivo Graziadei Klinische Abteilung für Gastroenterologie und Hepatologie, Medizinische Universität Innsbruck Dr. Evelyn Grilnberger Otto Wagner Spital Prim. Dr. Michael Häfner KH St. Elisabeth, Interne Abteilung Dr. Birgit Heinisch Univ.-Klinik für Innere Medizin III, AKH Dr. Sadia Hoppe KH Hietzing, I. Medizinische Abteilung Dr. Thomas Horvatits Univ.-Klinik für Innere Medizin III, AKH Prim. Dr. Andreas Kirchgatterer V. Interne Abteilung, Klinikum Wels Prim. Dr. Peter Knoflach Klinikum Wels-Grieskirchen, Abteilung für Innere Medizin I Dr. Andreas Kopecky Thermenklinikum Baden, Interne Abteilung Dr. Peter Kotlan Ordination Markt Priestling Prof. Dr. Ludwig Kramer Krankenhaus Hietzing, 1. Medizinische Abteilung mit Gastroenterologie Dr. Anna Kreil Otto Wagner Spital Waltraud Leiss Univ.-Klinik für Innere Medizin III, AKH Dr. Simone Luszczak Landesklinikum St. Pölten, 2. Medizinische Abteilung Prim. Dr. Christian Madl KA Rudolfstiftung, 4. Medizinische Abteilung Dr. Andreas Maieron Krankenhaus St. Elisabeth Linz, 4. Interne Abteilung Dr. Ilona Marszalek Ordination Dr. Biowski-Frotz, Wien Prof. Dr. Christian Müller Univ.-Klinik für Innere Medizin III, AKH Dr. Roland Nömeyer Klinikum Wels-Grieskirchen, Abteilung für Innere Medizin I Dr. Julia Palkovits Krankenhaus Hietzing, 1. Medizinische Abteilung mit Gastroenterologie Dr. Berit Anna Payer Univ.-Klinik für Innere Medizin III, AKH Prof. Dr. Markus Peck- Radosavljevic Univ.-Klinik für Innere Medizin III, AKH Prim. Dr. Johann Pidlich Thermenklinikum Baden, Interne Abteilung Dr. Csilla Putz-Bankuti Universitätsklinik für Innere Medizin, LKH Graz
Dr. Thomas Reiberger Univ.-Klinik für Innere Medizin III, AKH Dr. Birgit Reinhart Dr. Karoline Reinhart Univ.-Klinik für Innere Medizin III, AKH
16 Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II) consensus report 1 3
Acknowledgments We would like to thank Ms. Alexandra Weisgram for the coordination of the meeting and the editorial assistance during the consensus meeting and Ms. Andrea Reichel for her assistance during the consensus meeting.
A. Ferlitsch: Consultant for Pejcl Medizintechnik, Austria; Boston Scientifc: Travel expenses; Boston Scientific, Cook Medical, Ferring: Sponsoring of dedicated meetings. V. Fuhrmann: Forschungsunterstützung von den Fir- men Actelion, Air Liquide und Vivisol. T. Reiberger: Roche (speaking/teaching, travel grant), MSD (speaking/teaching, research grant), Phenex Phar- ma (research grant), Gilead Sciences (research grant, travel grant), Janssen (research grant). Rest of the authors declare that there are no actual or potential conflicts of interest in relation to this article. References 1. de Franchis R. Updating consensus in portal hypertension: report of the Baveno III consensus workshop on defini- tions, methodology and therapeutic strategies in portal hypertension. J Hepatol. 2000;33:846–52. 2. Moore KP, Wong F, Gines P, Bernardi M, Ochs A, Salerno F, Angeli P, et al. The management of ascites in cirrhosis: report on the consensus conference of the International Ascites Club. Hepatology. 2003;38:258–66. 3. Angermayr B, Cejna M, Peck-Radosavljevic M. Manage- ment von Patienten vor und nach Implantation eines tran- sjugulären intrahepatischen portosystemischen Shunts (TIPS) – Bericht der Vienna TIPS Study Group. Journal für Gastroenterologische und Hepatologische Erkrankungen. 2003;1:11–4. 4. de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodol- ogy of diagnosis and therapy in portal hypertension. J Hep- atol. 2010;53:762–8. 5. EASL. EASL clinical practice guidelines: management of hepatitis C virus infection. J Hepatol. 2011;55:245–64. 6. Bosch J, Garcia-Pagan JC. Complications of cirrhosis. I. portal hypertension. J Hepatol. 2000;32:141–56. 7. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Bur- roughs AK, Planas R, Escorsell A, et al. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med. 2005;353:2254–61. 8. Garcia-Tsao G, Groszmann RJ, Fisher RL, Conn HO, Atter- bury CE, Glickman M. Portal pressure, presence of gas- troesophageal varices and variceal bleeding. Hepatology. 1985;5:419–24. 9. D’Amico G, Pagliaro L, Bosch J. Pharmacological treat- ment of portal hypertension: an evidence-based approach. Semin Liver Dis. 1999;19:475–505. 10. Tripathi D, Ferguson JW, Kochar N, Leithead JA, Ther- apondos G, McAvoy NC, Stanley AJ, et al. Randomized controlled trial of carvedilol versus variceal band ligation for the prevention of the first variceal bleed. Hepatology. 2009;50:825–33. 11. Imperiale TF, Chalasani N. A meta-analysis of endoscopic variceal ligation for primary prophylaxis of esophageal var- iceal bleeding. Hepatology. 2001;33:802–7. 12. Merkel C, Bolognesi M, Sacerdoti D, Bombonato G, Bell- ini B, Bighin R, Gatta A. The hemodynamic response to medical treatment of portal hypertension as a predictor of clinical effectiveness in the primary prophylaxis of variceal bleeding in cirrhosis. Hepatology. 2000;32:930–4. 13. Abraldes JG, Tarantino I, Turnes J, Garcia-Pagan JC, Rodes J, Bosch J. Hemodynamic response to pharmacological treatment of portal hypertension and long-term prognosis of cirrhosis. Hepatology. 2003;37:902–8. 14. Tripathi D, Hayes PC. The role of carvedilol in the manage- ment of portal hypertension. Eur J Gastroenterol Hepatol. 2010;22:905–11. 15. Bosch J. Carvedilol for portal hypertension in patients with cirrhosis. Hepatology. 2010;51:2214–8. 16. Turnes J, Garcia-Pagan JC, Abraldes JG, Hernandez- Guerra M, Dell’Era A, Bosch J. Pharmacological reduc- tion of portal pressure and long-term risk of first variceal bleeding in patients with cirrhosis. Am J Gastroenterol. 2006;101:506–12. 17. D’Amico G, Garcia-Pagan JC, Luca A, Bosch J. Hepatic vein pressure gradient reduction and prevention of variceal bleeding in cirrhosis: a systematic review. Gastroenterol- ogy. 2006;131:1611–24. 18. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217–31. 19. Banares R, Moitinho E, Matilla A, Garcia-Pagan JC, Lamp- reave JL, Piera C, Abraldes JG, et al. Randomized compari- son of long-term carvedilol and propranolol administration in the treatment of portal hypertension in cirrhosis. Hepa- tology. 2002;36:1367–73.
Dr. Petra Salzl Univ.-Klinik für Innere Medizin III, AKH Dr. Monika Schmid Univ.-Klinik für Innere Medizin III, AKH Dr. Christiane Schrutka KA Rudolfstiftung, 4. Medizinische Abteilung Dr. Bernhard Stadler Klinikum Wels-Grieskirchen Prof. Dr. Rudolf Stauber Medizinische Universität Graz, Abteilung Gastroenterologie und Hepatologie Dr. Philipp Steininger Krankenhaus St. Elisabeth Wien, Interne Abteilung Prof. Dr. Rudolf Steininger Universitätsklinik für Chirurgie, Medizinische Uni Wien Prim. Dr. Siegfried Thurnher Krankenhaus Barmherzige Brüder Wien, Radiologie und Nuklearmedizin Prof. Dr. Michael Trauner Univ.-Klinik für Innere Medizin III, AKH Prof. Dr. Barbara Tribl Univ.-Klinik für Innere Medizin III, AKH Dr. Gregor Ulbrich Krankenhaus Hietzing, 1. Medizinische Abteilung mit Gastroenterologie Prim. Prof. Dr. Wolfgang Vogel Klinische Abteilung für Gastroenterologie und Hepatologie, Medizinische Universität Innsbruck Dr. Martina Wichlas KH Barmherzige Brüder, II. Medizinische Abteilung Dr. Afrodite Zendeli KH Barmherzige Brüder, II. Medizinische Abteilung Prof. Dr. Heinz Zoller Klinische Abteilung für Gastroenterologie und Hepatologie, Medizinische Universität Innsbruck
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