Screening and management of portal hypertension and varices in cirrhosis: Expert perspectives.

Abstract

The prevalence of liver injury, fibrosis, and, in particular, cirrhosis in the United States is increasing in parallel to the current epidemic of metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease. As fibrosis advances, portal hypertension occurs, and when the pressure gradient meets or exceeds 10 mm Hg, the patient is at an increased risk for decompensating events such as esophageal varices. The risk of death also increases. Therefore, decreasing the risk of progression to decompensated cirrhosis is an important management goal. The American Association for the Study of Liver Diseases recently published a guidance document to "coalesce best practice recommendations for the identification of portal hypertension, for prevention of initial hepatic decompensation, for the management of acute variceal hemorrhage, and for reduction of the risk of recurrent variceal hemorrhage in chronic liver disease." In this updated guidance, the new terms "advanced chronic liver disease" and "clinically significant portal hypertension" have been proposed for routine use in clinical practice. Following recommendations for advanced chronic liver disease identification, which are largely defined by transient elastography measurements of liver stiffness, guidance is provided on the identification of clinically significant portal hypertension and early administration of nonselective beta-blocker therapy in clinically significant portal hypertension for prophylaxis. Optimal control of active bleeding, the role of preemptive TIPS, and gastric varices management are also addressed. Despite the wealth of information provided, the guidance can be difficult to put into practice, leaving non-liver-focused clinicians with an unmet need for a simplified approach to guidelines in general. To address this issue, a panel of hepatologists met to review and discuss the real-world implications of this new guidance and the result is this expert perspective review. This review aims to facilitate improvements in risk stratification and management of variceal bleeding, streamline controversial and complex issues in the recent guidance in a practical way for clinical use, and make recommendations on how to incorporate this important new guidance document into clinical practice.