Consensus report

consensus report

Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)   

7

1 3

Treatment for high-risk patients with failure of 

medical/endoscopic therapy in the prophylaxis  

of rebleeding

1.   TIPS implantation is recommended for selected high-

risk patients, in whom medical and endoscopic treat-

ment fails to prevent rebleeding (at least twice) (II-2).

2.   These patients should be considered for liver trans-

plantation (III). 

Portal hypertensive gastropathy (PHG), gastric 

antral vascular ectasia (GAVE)

Definitions

1.   PHG is defined as a macroscopically visible mosaic 

like pattern of the gastric mucosa. The prevalence of 

PHG in portal hypertension varies between 20 % and 

80 %. PHG should be differentiated into PHG with and 

without signs of bleeding [

29

]. Severe PHG is charac-

terized by red marks and associated with a higher risk 

of bleeding [

30

].

2.  GAVE is a distinct clinical, endoscopic, and histo-

pathologic entity endoscopically characterized by 

aggregates of red spots arranged in linear pattern or 

diffuse lesions (in this case they have to be confirmed 

by biopsy of the antrum). GAVE can be seen with other 

conditions than cirrhosis of the liver. The prevalence 

of GAVE in cirrhosis is low (about 2 %) [

31

].

3.   The incidence of acute PHG bleeding is low (less than 

3 % at 3 years).

4.   The incidence of chronic PHG bleeding is around 10–

15 % at 3 years.

5.   The lesions may change over time (fluctuate, worsen, 

or improve). 

Treatment of acute PHG bleeding

1.  Vasoactive drugs are used with a high success rate 

(70–100 %) in uncontrolled studies. Controlled studies 

are lacking but patients are managed in a similar way 

as acute variceal bleedings in many centers (III).

2.  Emergency transjugular intrahepatic porto-systemic 

shunt (TIPS; or shunt surgery in rare cases) should be 

regarded as rescue treatments in cases of failure of va-

soactive drugs (III). 

Treatment of chronic PHG bleeding

1.   Nonselective beta-blockers (II-1), and if needed iron, 

are the first-choice treatment.

2.   Beta-blockers and isosorbide-5-mononitrate, as well 

as other medical treatments (i.e., carvedilol, long-

acting somatostatin analogues), should be evaluated.

3.   Treatment should be continued indefinitely (III).

4.   TIPS is a rescue therapy in PHG-associated bleedings, 

which could respond to a decrease in HVPG (II-3). 

APC might be an additional therapeutic option for pa-

tients with refractory bleeding from PHG (III). 

Treatment of GAVE bleeding

1.   Argon plasma coagulation is an effective therapy in 

patients with mild to moderate bleedings (II-3).

2.   Multiple sessions are usually needed to control acute 

bleeding or to stop chronic blood loss, but no con-

trolled studies are available (III). 

Gastric varices

Definitions

1.   The classification of Sarin et al. should be used [

32

]; 

it distinguishes gastroesophageal varices type 1 and 2 

(GOV 1 and 2) and isolated gastric varices 1 and 2 (IGV 

1 and 2), which occur in 5–33 % of patients with portal 

hypertension.

2.   GOV2 and IGV1: the presence of red signs, large size, 

and Child Class B or C should be considered as risk 

factors for bleeding (Fig. 

1

).    

3.   GOV2, GOV1, and IGV1 are at the highest risk of bleed-

ing (bleeding risk 55–78 %), which has a high mortality 

rate [

32

, 

33

]. 

For therapy of bleeding gastric varices, the  

following approaches can be used

1.  Cyanoacrylate glue injection is the most effective 

therapy for acute fundal variceal bleeding [

34

–

37

] (I).

Fig. 1

  Gastroesophageal varices

Gastro-oesophageal varices (GOV)

GOV 1

GOV 2

IGV 1

IGV 2

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    Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)

consensus report

1 3

2.   One single injection should consist of 0.5 ml cyano-

acrylate and 0.5 ml lipiodol. Not more than 1.0 ml of 

the cyanoacrylate/lipodol mixture should be injected 

at each time to minimize the risk of embolization [

38

] 

(II-2).

3.  Endoscopic variceal sclerotherapy is no alternative 

(bleeding control of 60–100 % but rebleeding rate of 

up to 90 %) [

39

] (II-3).

4.   Vasoactive drugs could be used in combination with 

other treatments (III).

5.   Balloon tamponade can be used as a bridge in case of 

failure to control bleeding (III).

6.   Endoscopic band ligation is not an established thera-

py for bleeding varices GOV2, IGV 1 + 2 due to a lower 

rate of hemostasis and a higher rebleedings rate com-

pared to cyanoacrylate [

34

, 

36

] (I); GOV1 are consid-

ered extensions of esophageal varices and should be 

treated accordingly [

33

] (III).

7.  

Balloon-occluded retrograde transvenous oblitera-

tion (B-RTO) is a treatment option for gastric varices 

mostly used in Japan [

40

–

42

]. It shows promising re-

sults there but the efficacy in Caucasians populations 

has not adequately been documented. 

8. TIPS (rarely surgery) is indicated as rescue therapy 

(“emergency TIPS”: bleeding control rate up to 90 %) 

[

43

] for patients not responding to medical and en-

doscopic therapy [

44

] (II-3). TIPS might be a good 

first-line treatment option also for high-risk patients 

with gastric variceal bleeding (GOV2, IGV1 + 2; “early 

TIPS”) but has not been studied specifically in this 

patient population. Surgical devascularization is a 

rescue therapy in case of failure of medical and endo-

scopical treatment to prevent rebleeding in patients 

in whom neither a TIPS can be implanted nor shunt 

surgery can be performed.

For long-term therapy of fundal varices, there are 

no established and prospectively evaluated thera-

pies. Potential candidate therapies include

1.   Long-term cyanoacrylate glue application

2.   TIPS (rarely shunt surgery in patients with very good 

liver function)

3.   Medical therapy with NSBB (propranolol, carvedilol) 

and/or ISMN 

Management of ascites

Diagnostic approach in patients with ascites

1.   Ascites should be graded according to the International 

Ascites Club guidelines into uncomplicated (grade 1: 

only visible on ultrasound; grade 2: moderate ascites; 

grade 3: massive ascites), and refractory ascites (not 

responsive or intolerant to diuretic therapy even after 

paracentesis) [

2

].

2.   All patients presenting with ascites for the first time, 

with recurrence of ascites or deterioration of ascites, 

need investigation of their ascites. Substitution of co-

agulation factors or platelets is not indicated even in 

patients with severe coagulopathy, because paracen-

tesis rarely leads to serious bleeding complications  

[

1

, 

45

] (I).

3.   Investigation of ascites should include at least the de-

termination of the ascitic neutrophil count, protein 

concentration, and serum-ascites albumin gradient 

(I).

4.  Additionally, aerobic and anaerobic blood culture 

bottles should be inoculated with ascitic fluid for bac-

teriologic diagnosis of SBP (I).

Therapy of uncomplicated ascites

1.   For initial therapy of patients with mild ascites (grade 

1), sodium restriction (90  mmol NaCl/day, corre-

sponding to 5.2 g NaCl/day) is recommended(III).

2.   In patients with moderate ascites (grade 2), the initial 

therapy consists of sodium restriction and diuretic 

therapy (I).

3.  Diuretic therapy should be started with spironolac-

tone (100–200 mg). In case of insufficient ascites con-

trol or lack of effectiveness (< 1–2 kg weight reduction 

within 7 days), furosemide should be added. The daily 

dose of 400  mg spironolactone and 160  mg furose-

mide should not be exceeded. Alternatively, butizide 

in combination with spironolactone can be used in-

stead of or in combination with furosemide (I).

4.   In patients with tense ascites (grade 3), paracentesis 

is the treatment of choice and should be followed by 

diuretic therapy. Total paracentesis should be carried 

out as a single procedure, even when a large volume of 

ascites is present (I).

5.  Plasma volume expansion using albumin is recom-

mended in all patients undergoing paracentesis, 

especially if more than 5  L of ascites have been re-

moved; for prevention of hypovolemia and circulatory 

dysfunction. Albumin at a dose of 8 g/L of ascites re-

moved should be administered (I).

6.   Patients responsive to diuretics should primarily be 

treated with sodium restriction and diuretics and 

should not undergo serial paracentesis.

7.   In patients with hyponatremia< 120 mmol/L (or mM), 

diuretic therapy should be halted, since at these levels 

diuretics are ineffective and worsen hyponatremia. 

Substitution of concentrated NaCl solutions is not in-

dicated (II-1).

8.  Patients with moderate to severe ascites should be 

considered for liver transplantation.

9.  

The administration of nonsteroidal antiinflamma-

tory drugs (NSAID) in patients with decompensated 

cirrhosis and ascites can lead to renal failure and 

therefore should be avoided [

46

]. The same is true for 

angiotensin-converting enzyme inhibitors [

47

, 

48

] (I).

            

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