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Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations

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Abstract

Background

Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live.

Methods

The expert working party, predominantly from the Asia–Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted.

Results

AVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24 h of presentation, and/or ongoing melena, with last melanic stool within last 24 h. The time frame for the AVB episode is 48 h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (<30 min of hospitalization) and endoscopic variceal ligation (door to scope time <6 h) is accepted as first-line therapy. Rebleeding (48 h of T 0) is further sub-classified as very early rebleeding (48 to 120 h from T 0), early rebleeding (6 to 42 days from T 0) and late rebleeding (after 42 days from T 0) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of non-response to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients.

Conclusion

Management of acute variceal bleeding in Asia–Pacific region needs special attention for uniformity of treatment and future clinical trials.

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Conflict of interest

There is no conflict of interest to disclose by any of the authors.

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Authors and Affiliations

  1. Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, India

    Shiv Kumar Sarin, Ashish Kumar, Hitendra Garg & Praveen Sharma

  2. Department of Gastroenterology, Austin Health, Studley Rd, Heidelberg, 3084, Australia

    Peter W. Angus

  3. Department of Radiodiagnosis, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India

    Sanjay Saran Baijal

  4. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Wonju College of Medicine, Yonsei University, 162, Ilsan-dong, Wonju, 220-701, South Korea

    Soon Koo Baik

  5. Department of Gastroenterology, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara, Turkey

    Yusuf Bayraktar

  6. Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    Yogesh Kumar Chawla

  7. Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, UP, India

    Gourdas Choudhuri

  8. Department of Radiology, Institute of Radiation Medicine, Seoul National University College of Medicine, Clinical Research Institute, 28 Yongon-Dong, Chongno-Gu, Seoul, 110-774, South Korea

    Jin Wook Chung

  9. Department of Medical Sciences, University of Milan, Fondazione Ospedale IRCCS Maggiore Policlinico, Mangiagalli and Regina Elena, Milan, Italy

    Roberto de Franchis

  10. Department of Medicine, Faculty of Medicine, University of Kelaniya, P.O. Box 6, Thalagolla Road, Ragama, Sri Lanka

    H. Janaka de Silva

  11. Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India

    Pramod Kumar Garg & Anoop Saraya

  12. Section of Gastroenterology, Department of Medicine MBC: 46, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh, 11211, Saudi Arabia

    Ahmed Helmy

  13. Division of Gastroenterology, Department of Medicine, Taipei-Veterans General Hospital, No. 201 Sec. 2 Shih-Pai Road, Taipei, 11217, Taiwan, ROC

    Ming-Chih Hou

  14. Section of Gastroenterology, Department of Medicine, The Aga Khan University Hospital, Karachi, Pakistan

    Wasim Jafri

  15. Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People’s Republic of China

    Ji-Dong Jia

  16. Department of Medicine, 1838, Block K, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, People’s Republic of China

    George K. Lau

  17. Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, People’s Republic of China

    Chang-Zheng Li

  18. Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, 169608, Singapore

    Hock Foong Lui

  19. Department of Medicine and Clinical Oncology, Chiba University Graduate School of Medicine, Chiba, Japan

    Hitoshi Maruyama

  20. Department of Biostatistics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India

    Chandra Mohan Pandey

  21. Department of Gastroenterology, GB Pant Hospital, New Delhi, India

    Amrender S. Puri & Barjesh Chander Sharma

  22. Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10310, Thailand

    Rungsun Rerknimitr

  23. Department of Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India

    Peush Sahni

  24. GI and Liver Unit, Internal Medicine Department, Almansoura Faculty of Medicine, Almansoura, 35516, Egypt

    Gamal Shiha

  25. Section of Gastroenterology, University of Santo Tomas, España, Manila, The Philippines

    Jose D. Sollano

  26. Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street Shatin, Hong Kong, People’s Republic of China

    Justin Wu

  27. Department of Hepatobiliary Surgery, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510630, Guangdong, People’s Republic of China

    Rui Yun Xu

  28. Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226014, India

    Surender Kumar Yachha

  29. Department of Gastroenterology, Shandong Provincial Hospital, Jinan, 250021, Shandong, People’s Republic of China

    Chunqing Zhang

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  1. Shiv Kumar Sarin
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Asian Pacific Association for the Study of the Liver (APASL) Working Party on Portal Hypertension

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Correspondence to Shiv Kumar Sarin.

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Sarin, S.K., Kumar, A., Angus, P.W. et al. Diagnosis and management of acute variceal bleeding: Asian Pacific Association for Study of the Liver recommendations. Hepatol Int 5, 607–624 (2011). https://doi.org/10.1007/s12072-010-9236-9

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