consensus report
Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)
1
1 3
Österreichischer
Konsensus zur Definition und
Therapie der Portalen Hypertension und ihrer
Komplikationen (Billroth II)
Zusammenfassung Im November 2004 hielt die Öster-
reichische Gesellschaft für Gastroenterologie und He-
patologie (ÖGGH) den ersten Konsensus über die De-
finitionen und die Therapie der Portalen Hypertension
und ihrer Komplikationen im Billroth-Haus in Wien,
Österreich ab (Billroth I Meeting). Diesem Treffen ging
ein internationales Expertenmeeting über die Portale
Hypertension mit einigen wichtigen Proponenten der
Baveno Konsensus-Konferenzen vorraus (http://www.
oeggh.at/videos.asp). Der Konsensus selber basiert auf
dem Baveno III Konsensus im Hinblick auf die portal-
hypertensive Blutung und den Vorschlägen des Interna-
tional Ascites Club in Hinblick auf die Therapie des As-
zites. Deren Aussagen wurden mit neuen Erkenntnissen
aus der rezenten Literatur und auch entsprechend der
praktischen Erfahrung der Teilnehmer des Konsensus-
Treffens modifiziert. Im Oktober 2001 organisierte die
ÖGGH das zweite Konsensus Treffen über die porta-
le Hypertension und ihrer Komplikationen (Billroth II
Meeting). Die Billroth II Leitlinien über die Definitionen
und die Therapie der Portalen Hypertension und ihrer
Komplikationen lassen die Entwicklungen der letzten
7 Jahre inklusive des Baveno V Updates und etlicher
Schlüsselpublikationen mit einfließen und stellen den
neuen Standard im Management der Portalen Hyper-
tension in Österreich dar.
Schlüsselwörter: Aszites, Varizenblutung, TIPS, Hepa-
torenales Syndrom, Hepatopulmonales Syndrom,
Portopulmonale Hypertension, Budd-Chiari Syndrom,
Somatostatin, Terlipressin, Carvedilol
Wiener klinische Wochenschrift
The Central European Journal of Medicine
Wien Klin Wochenschr
DOI 10.1007/s00508-013-0337-z
Austrian consensus on the definition and treatment of
portal hypertension and its complications (Billroth II)
Markus Peck-Radosavljevic, Bernhard Angermayr, Christian Datz, Arnulf Ferlitsch, Monika Ferlitsch,
Valentin Fuhrmann, Michael Häfner, Ludwig Kramer, Andreas Maieron, Berit Payer, Thomas Reiberger,
Rudolf Stauber, Rudolf Steininger, Michael Trauner, Siegfried Thurnher, Gregor Ulbrich, Wolfgang Vogel,
Heinz Zoller, Ivo Graziadei
Received: 10 September 2012 / Accepted: 15 February 2013
© Springer-Verlag Wien 2013
For the Austrian Society of Gastroenterology and Hepatology
(ÖGGH)
M. Peck-Radosavljevic, MD () · A. Ferlitsch, MD ·
M. Ferlitsch, MD · V. Fuhrmann, MD · B. Payer, MD ·
T. Reiberger, MD · M. Trauner, MD
Klinische Abteilung für Gastroenterologie und Hepatologie,
Universitätsklinik für Innere Medizin III, Medizinische Universität
Wien, Währinger Gürtel 18–20, 1090 Vienna, Austria
e-mail: markus.peck@meduniwien.ac.at
B. Angermayr, MD
2. Medizinische Abteilung, Landesklinikum St. Pölten, St. Pölten,
Austria
C. Datz, MD
Abteilung Innere Medizin, Krankenhaus Oberndorf, Oberndorf bei
Salzburg, Austria
M. Häfner, MD
Krankenhaus St. Elisabeth, Vienna, Austria
L. Kramer, MD · G. Ulbrich, MD
1. Medizinische Abteilung mit Gastroenterologie, Krankenhaus
Hietzing, Vienna, Austria
A. Maieron, MD
4. Interne Abteilung, Krankenhaus St. Elisabeth, Linz, Austria
R. Stauber, MD
Klinische Abteilung für Gastroenterologie und Hepatologie,
Medizinische Universität Graz, Graz, Austria
R. Steininger, MD
Universitätsklinik für Chirurgie, Medizinische Universität Wien,
Vienna, Austria
S. Thurnher, MD
Klinische Abteilung für Radiologie und Nuklearmedizin,
Krankenhaus Barmherzige Brüder Wien, Vienna, Austria
W. Vogel, MD · H. Zoller, MD · I. Graziadei, MD
Universitätsklinik für Innere Medizin (Gastroenterologie
und Hepatologie), Medizinische Universität Innsbruck,
Innsbruck, Austria
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Austrian consensus on the definition and treatment of portal hypertension and its complications (Billroth II)
consensus report
1 3
Summary In November 2004, the Austrian Society of
Gastroenterology and Hepatology (ÖGGH) held for
the first time a consensus meeting on the definitions
and treatment of portal hypertension and its complica-
tions in the Billroth-Haus in Vienna, Austria (Billroth
I-Meeting). This meeting was preceded by a meeting of
international experts on portal hypertension with some
of the proponents of the Baveno consensus conferences
(http://www.oeggh.at/videos.asp). The consensus it-
self is based on the Baveno III consensus with regard
to portal hypertensive bleeding and the suggestions of
the International Ascites Club regarding the treatment
of ascites. Those statements were modified by new
knowledge derived from the recent literature and also
by the current practice of medicine as agreed upon by
the participants of the consensus meeting. In October
2011, the ÖGGH organized the second consensus meet-
ing on portal hypertension and its complications in Vi-
enna (Billroth II-Meeting). The Billroth II-Guidelines on
the definitions and treatment of portal hypertension and
its complications take into account the developments of
the last 7 years, including the Baveno-V update and sev-
eral key publications.
Keywords: Ascites, Variceal bleeding, TIPS, Hepatorenal
syndrome, Hepatopulmonary syndrome, Portopulmo-
nary hypertension, Budd-Chiari Syndrome, Somatosta-
tin, Terlipressin, Carvedilol
Abbreviations
AVB
Acute variceal bleeding
BCS
Budd-Chiari syndrome
CSPH
Clinically significant portal hypertension
FCB
Failure to control bleeding
FFP
Fresh frozen plasma
GAVE
Gastric antral vascular ectasia
GOV
Gastro oesophageal varices
HCC
Hepatocellular carcinoma
HE
Hepatic encephalopathy
HPS
Hepatopulmonary syndrome
HRS
Hepatorenal syndrome
HVPG
Hepatovenous pressure gradient
IGV
Isolated gastric varices
ISMN
Isosorbidmononitrate
NSBB
Nonselective beta-blockers
PPHTN
Portopulmonary hypertension
PTFE
Polytetrafluoroethylene
PHG
Portal hypertensive gastropathy
TIPS
Transjugular intrahepatic portosystemic stent
SBP
Spontaneous bacterial peritonitis
Introduction/background
In November 2004, the Austrian Society of Gastroenter-
ology and Hepatology (ÖGGH) held for the first time a
consensus meeting on the definitions and treatment of
portal hypertension and its complications in the Billroth-
Haus in Vienna, Austria (Billroth I-Meeting). This meet-
ing was preceded by a meeting of international experts on
portal hypertension with some of the proponents of the
Baveno consensus conferences (http://www.oeggh.at/
videos.asp). The consensus itself is based on the Baveno
III consensus with regard to portal hypertensive bleed-
ing [
1
] and the suggestions of the International Ascites
Club regarding the treatment of ascites [
2
]. Those state-
ments were modified by new knowledge derived from the
recent literature and also by the current practice of medi-
cine as agreed upon by the participants of the consensus
meeting. The section on TIPS-placement was based on
the consensus statement of the Vienna TIPS Study Group
(VTSG) [
3
].
In October 2011, the ÖGGH organized the second
consensus meeting on portal hypertension and its com-
plications in Vienna (Billroth II-Meeting). The Billroth
II-Guidelines on the definitions and treatment of portal
hypertension and its complications take into account the
developments of the last 7 years, including the Baveno-V
update [
4
] and several key publications.
An effort was made to develop a practical guideline to
everyday medical practice. In order to reduce the areas
without specific recommendations for treatment to an
absolute minimum, we included treatment recommen-
dations even in case of insufficient or contradictory data
through consensus of the participating physicians. The
evidence was graded according to a modified established
grading system [
5
]:
Grade definition
I
Randomized controlled trials
II-1 Controlled trials without randomization
II-2 Cohort or case-control analytic studies
II-3 Multiple time series, dramatic uncontrolled
experiments
III
Opinions of respected authorities, descriptive
epidemiology
Criteria and definition of portal hypertension
1. Clinically significant portal hypertension (CSPH) is
defined as an increase of the hepatovenous pressure
gradient (HVPG) to a threshold above 10 mmHg [
6
] (I).
2. The presence of varices, variceal hemorrhage, and/or
ascites (in the absence of significant cardiac, perito-
neal, or renal comorbidities) is indicative of the pres-
ence of CSPH (I).
3. Measurement of the HVPG or endoscopic assessment
of esophageal varices is sufficient for diagnosis of
CSPH (I).
4. The accuracy of noninvasive tests for diagnosis of
CSPH (e.g., transient elastography, Doppler ultra-
sound, various indices containing dynamics in plate-
lets or other parameters) should be further evaluated.
They are currently of limited use in daily clinical prac-
tice (III).