Professional Documents
Culture Documents
Received 9 June 2010; received in revised form 12 June 2010; accepted 14 June 2010 - Ht (or Hb) is measured at least every:
*
Address: Gastroenterology 3 Unit, IRCCS Ca Granda Ospedale Maggiore 6 h for the rst 2 days
Policlinico Foundation, Milan, Padiglione Beretta Est, Via F Sforza 35, 20122
12 h for days 35
Milan, Italy. Tel.: +39 02 5503 5331/2; fax: +39 02 5503 5271.
E-mail address: roberto.defranchis@unimi.it. - The transfusion target should be an haematocrit of 24% or a
1
The members of Baveno V Faculty given before references. haemoglobin of 8 g/dl.
- Failure to prevent re-bleeding is dened as a single episode Prevention of the rst bleeding episode
of clinically signicant re-bleeding from portal hyperten-
sive sources after day 5 (5;D). Patients with small varices
- Clinically signicant re-bleeding: recurrent melena or
hematemesis resulting in any of the following: - Patients with small varices with red wale marks or Child C
class have an increased risk of bleeding (1b;A) and should be
treated with nonselective beta-blockers (NSBB) (5;D).
1. hospital admission,
- Patients with small varices without signs of increased risk may
2. blood transfusion,
be treated with NSBB to prevent progression of varices and
3. 3 g drop in Hb,
bleeding (1b;A). Further studies are required to conrm their
4. death within 6 weeks.
benet.
Areas requiring further study (5;D)
Patients with medium-large varices
- Prospective validation of Baveno IV and V criteria and compar-
ison with Baveno II and III denitions. - Either NSBB or endoscopic band ligation (EBL) is recom-
- Interactions of time events with prognostic factors. mended for the prevention of the rst variceal bleeding of
- Denition and usefulness of a transfusion index for failure medium or large varices (1a; A).
criteria: - The choice of treatment should be based on local resources
Clinical applicability. and expertise, patient preference and characteristics, side
Appropriate for randomised trials. effects, and contra-indications (5;D).
- Studies evaluating the use of carvedilol. - Endoscopic therapy is recommended in any patient who pre-
- Studies evaluating novel therapeutic options. sents with documented upper GI bleeding and in whom
esophageal varices are the cause of bleeding (1a;A).
- Ligation (EVL) is the recommended form of endoscopic ther-
Treatment of acute bleeding from varices
apy for acute esophageal variceal bleeding, although sclero-
therapy may be used in the acute setting if ligation is
Blood volume restitution
technically difcult (1b;A).
- Endoscopic therapy with tissue adhesive (e.g. N-butyl-cyano-
- The goal of resuscitation is to preserve tissue perfusion. Vol-
acrylate) is recommended for acute bleeding from isolated
ume restitution should be initiated to restore and maintain
gastric varices (IGV) (1b;A) and those gastro-esophageal vari-
hemodynamic stability.
ces type 2 (GOV2) that extend beyond the cardia (5;D).
- PRBC transfusion should be done conservatively at a target
- EVL or tissue adhesive can be used in bleeding from gastro-
hemoglobin level between 7 and 8 g/dl., although transfusion
esophageal varices type 1 (GOV1) (5;D).
policy in individual patients should also consider other factors
such as co-morbidities, age, hemodynamic status and ongoing Early TIPS placement
bleeding (1b;A).
- Recommendations regarding management of coagulopathy - An early TIPS within 72 h (ideally 624 h) should be considered
and thrombocytopenia cannot be made on the basis of cur- in patients at high-risk of treatment failure (e.g. Child-Pugh
rently available data (5;D). class C <14 points or Child class B with active bleeding) after
- PT/INR is not a reliable indicator of the coagulation status in initial pharmacological and endoscopic therapy (1b;A).
patients with cirrhosis (1b;A).
Use of balloon tamponade
Antibiotic prophylaxis
- Balloon tamponade should only be used in massive bleeding
- Antibiotic prophylaxis is an integral part of therapy for as a temporary bridge until denitive treatment can be insti-
patients with cirrhosis presenting with upper gastrointestinal tuted (for a maximum of 24 h, preferably in an intensive care
bleeding and should be instituted from admission (1a;A). facility) (5;D).
- Oral quinolones are recommended for most patients (1b;A).
- Intravenous ceftriaxone should be considered in patients with Use of self-expandable metal stents
advanced cirrhosis (1b;A), in hospital settings with high prev-
alence of quinolone-resistant bacterial infections and in - Uncontrolled data suggest that self-expanding covered
patients on previous quinolone prophylaxis (5;D). esophageal metal stents may be an option in refractory
Treatment: bleeding
- For primary prophylaxis of variceal bleeding there is insuf- Conclusions
cient data on whether beta-blockers or endoscopic therapy
should be preferred. The purpose of the consensus denitions about the variceal
- For control of acute variceal bleeding, endoscopic therapy is bleeding episode is to use them in trials and other studies on por-
effective (2b;B). tal hypertension, as well as in clinical practice. This does not
- For secondary prophylaxis endoscopic therapy is effective mean that authors cannot use their own denitions, but they
(2a;B). There is preliminary evidence to suggest that beta- are encouraged to use and evaluate in parallel these Baveno V
blockers are as effective as endoscopic ligation therapy. consensus denitions. This should result in some measure of
- Decompressive surgery or interventional radiological proce- standardisation and increased ease of interpretation among dif-
dures should be considered for patients with failure of endo- ferent studies. Equally important, if there are uniformly dened
scopic therapy (5;D). end-points, meta-analyses will be based on more homogeneous
- Mesenteric-left portal vein bypass (Rex bypass) is preferred in studies, which is an essential pre-requisite of this methodology.
managing bleeding from paediatric patients with chronic It is desirable that future studies be reported using these deni-
EHPVO, if feasible (2b;B). tions as part of the evaluation. Change or renement can then
take place, as they have at Baveno V with respect to the previous
consensus meetings, to ensure that the consensus denitions do
Portal biliopathy-diagnosis
have clinical relevance and are easily applied in practice.
- Portal biliopathy is present in nearly all patients with EHPVO. Several denitions agreed upon in the previous Baveno work-
In the majority, it is asymptomatic. shops were taken for granted and not discussed in Baveno V. Inter-
- MRCP is the rst line of investigation. ested readers can refer to the Baveno IIV reports [24,710].
- ERCP is only recommended if a therapeutic intervention is The suggestions about the topics of future studies reect the
contemplated. opinions of the experts about the areas where new information
is most needed.
Portal biliopathy-treatment
As long as new diagnostic tools and new treatments appear,
Asymptomatic: No treatment (5;D).
they will have to be assessed in comparison with present-day
Symptomatic:
standards.
- Bile duct stones: Endoscopic therapy.
Common bile duct stricture: Endoscopic stenting; (3b;B) and
porto-systemic shunt surgery should be considered, whenever
possible, (3b;B). If not relieved by the above, hepatico-jejunos- Baveno V Faculty
tomy may be considered (3b;B).
The following were members of the Baveno V scientic committee
Chronic EHPVO in children: treatment
- Mesenteric-left portal vein bypass (Rex bypass) should be con- Jaime Bosch, Barcelona, Spain; Andrew K Burroughs, London, UK;
sidered in all children with complications of chronic EHPVO, Gennaro DAmico, Palermo, Italy; Roberto de Franchis, Milan,
who should be referred to centers with experience in treating Italy; Guadalupe Garcia-Tsao, West Haven CT, USA; Norman D
this condition (5;D). Grace, Boston, MA, USA; Roberto J Groszmann, West Haven, CT,
USA; Didier Lebrec, Clichy, France; Carlo Merkel, Padua, Italy;
Unresolved issues and future studies Massimo Primignani, Milan, Italy; Francesco Salerno, Milan, Italy;
- Prospective data on the frequency and clinical prole of recent Shiv K Sarin, New Delhi, India; Thorkild IA Srensen, Copenhagen,
and chronic EHPVO. Denmark.
- Natural history of EHPVO in children vs. adults; hepatic
dysfunction. The following chaired sessions or symposia
- Primary prophylaxis of variceal bleeding.
- Casecontrol studies on frequency of prothrombotic states in Jaime Bosch, Barcelona, Spain; Andrew K Burroughs, London, UK;
EHPVO (particularly in the East), identication of high-risk Juan Carlos Garcia-Pagn, Barcelona, Spain; Guadalupe Garcia-
population. Tsao, West Haven CT, USA; Roberto J Groszmann, West Haven,
- Usefulness of long-term anticoagulants, emergency TIPS, Rex CT, USA; Loren Laine, Los Angeles, CA, USA; Didier Lebrec, Clichy,
shunt surgery. France; Carlo Merkel, Padua, Italy; Shiv K Sarin, New Delhi, India;
- Assessment of factors associated with treatment failure, dis- Dominique Thabut, Paris, France; Dominique Valla, Clichy,
ease progression and thrombosis recurrence. France; Candid Villanueva, Barcelona, Spain.
- Experimental models of recent and chronic EHPVO.
- Management of ectopic varices. The following participated in the presentations and the discussion as
Panelists in the consensus sessions
Other issues
Argentina: Julio Vorobioff, Rosario; Belgium: Frederik Nevens, Leu-
In Baveno IV, a session was devoted to predictive models in por- ven; Denmark: Flemming Bendtsen, Copenhagen; France: Chris-
tal hypertension, during which classication stages of cirrhosis tophe Bureau, Toulouse, Paul Cals, Angers, Jean Pierre Vinel,