Updating Consensus in Portal Hypertension: Report of the Baveno III Consensus Workshop on definitions, methodology and therapeutic strategies in portal hypertension
Section snippets
Active bleeding
Active bleeding at endoscopy (defined as blood emanating from a varix) has prognostic value as a predictor of failure to control bleeding in the next few days. Future studies should ascertain whether the clinical or prognostic significance of active bleeding is the same with or without drug therapy, and whether active bleeding is related to mortality.
Failure to control bleeding
At Baveno II 3., 4., the definition of failure to control bleeding was divided into 2 time frames:
- 1.
Within 6 h: any of the following factors: a)
Definition of clinically significant portal hypertension (CSPH)
An increase in portal pressure gradient to a threshold above approximately 10 mm Hg. The presence of varices, variceal hemorrhage and/or ascites is indicative of the presence of CSPH.
Diagnostic tools to assess portal hypertension
The reliability of both the hepatic vein pressure gradient (HVPG) measurement and endoscopic assessment of esophageal varices for the diagnosis of CSPH is satisfactory. However, specific, simple guidelines might further improve reliability. The accuracy of non-invasive tests such as Doppler ultrasound and variceal
Pre-primary prophylaxis (prevention of the formation/growth of varices)
Every patient with cirrhosis without complications of portal hypertension ideally needs HVPG measurements in order to be included in a trial of pre-primary prevention. The sequence portal hypertension-collaterals-varices is an accepted one; collaterals can be diagnosed before the development of varices.
Portal pressure is predictive of varices formation, while the clinical importance of collaterals as predictors of more severe portal hypertensive complications should be further investigated.
“Low
Complications of pharmacological treatments
The following definitions were agreed upon
Fatigue. Inability to perform regular physical activities carried out before treatment.
Abdominal cramps. Abdominal pain starting after treatment that persists for more than 4 h after other major causes of abdominal pain (i. e. bacterial peritonitis) have been ruled out.
Severe bradycardia. Reduction of heart rate to a value below 50 b.p.m. during treatment, in the presence of symptoms.
Arterial hypertension. Systolic blood pressure >170 mmHg and/or
Methodological Requirements for Future Trials in Portal Hypertension
Randomized controlled trials in portal hypertension should: a) include a sufficient number of patients, based on appropriate sample size calculation; b) preferably be multicenter; c) preferably use stratified randomization/minimization; d) preferably report quality of life; e) preferably report health economics.
Conclusions
The purpose of the consensus definitions about the variceal bleeding episode and complications of treatments is to use them in trials and other studies on portal hypertension. This does not mean that authors cannot use their own definitions, but they are encouraged to use and evaluate in parallel these Baveno III consensus definitions. This should result in some measure of standardization and increased ease of interpretation among different studies. Equally important, if there are uniformly
Acknowledgements
The Baveno III workshop was endorsed and supported in part by an unrestricted educational grant of the European Association for the Study of the Liver (EASL).
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