Vancouver IM LMR

Our very own Dr. Victoria Chen (PGY2 Internal Medicine) presented a fantastic noon report on the changing landscape of how we approach diagnosis and treatment of portal hypertension and cirrhosis, based on the Baveno VII consensus workshop (2021) as well as new AASLD guidelines. There are some practice-changing changes that we should all be updated on!

See her comprehensive slide deck here.

Key takeaway points:

• “Cirrhosis”: pathology based
• “Advanced Chronic Liver Disease (ACLD)”: suspected on basis of non-invasive testing (e.g. tissue elastography, transient elastography i.e. TE)
  • Clinically significant portal hypertension (CSPH) is diagnosed if liver stiffness measurement (LSM) via non-invasive testing is > 25
  • CSPH is highly probable if LSM 20-25 and PLT < 150
  • CSPH is probable if LSM 15-20 and PLT < 110
• Compensated cirrhosis:
  • CPSH should be treated with NSBBs
    • Carvedilol is the preferred NSBB in compensated chronic ACLD (better hepatic venous pressure gradient lowering, does not need titration to HR 55-60)
  • Variceal screening endoscopy is not needed for patients with compensated cirrhosis on NSBBs (monitor with yearly TE and PLTs), but patients with compensated cirrhosis and highly probable CSPH who are not candidates for NSBBs should undergo screening endoscopy
• Decompensated cirrhosis:
  • Consider for liver transplant or TIPS
  • NSBBs should be used in those with ascites, varices, or prior variceal bleeds (but preference for carvedilol is not emphasized)
    • NSBBs preferred over EVL for primary variceal bleed prophylaxis in ascites + high risk varices
    • NSBBs = EVL for secondary bleed prophylaxis
    • Trend towards preference to continue NSBBs long term after resolution of SBP, HRS, hypotensive episodes etc
  • Variceal screening endoscopy should be done in patients with ascites who are not on NSBBs (?utility of screening endoscopy in decompensated patients on NSBBs – no specific statement)