Consensus report

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).

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    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). 

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