Advances in portal hypertension management: Evolution of the Baveno guidelines

Table 1 Criteria for exclusion, suspicion, and diagnosis of compensated advanced chronic liver disease and indications for endoscopy based on non-invasive diagnostic tests according to Baveno VI and VII

	Baveno VI[20], 2015	Baveno VII[1], 2022
Exclusion of cACLD	TE1 < 10 kPa and absence of clinical symptoms of disease	TE1 < 10 kPa and absence of clinical and imaging signs of disease
Suspicion of cACLD	TE1 10-15 kPa	TE1 10-15 kPa
High suspicion of cACLD	TE1 > 15 kPa	TE1 > 15 kPa
Diagnosis of cACLD	Advanced fibrosis or cirrhosis in histopathological examination; Esophageal varices; HVPG > 5 mmHg	Definition of cACLD based on liver stiffness measurement
Exclusion of CSPH in cACLD	No recommendation	TE1 ≤ 15 kPa and PLT ≥ 150000/μL
Confirmation of CSPH in cACLD	HVPG ≥ 10 mmHg; TE1 ≤ 20-25 kPa alone or in combination with PLT and spleen size assessment (in the etiology of viral liver disease); Imaging studies showing collateral circulation	TE1 ≥ 25 kPa (applies to patients with cACLD related to virus and/or alcohol and/or NASH without obesity)
Indications for endoscopy	TE1 ≥ 20 kPa or PLT ≤ 150000/μL	TE1 ≥ 20 kPa or PLT ≤ 150000/μL
SSM	No recommendation	It can be used in chronic viral hepatitis to exclude CSPH (< 21 kPa) and diagnose CSPH (> 50 kPa); In individuals with SSM ≤ 40 kPa, endoscopy can be omitted

¹Liver fibrosis assessed using transient elastography.

cACLD: Compensated advanced chronic liver disease; CSPH: Clinically significant portal hypertension; HVPG: Hepatic venous pressure gradient; NASH: Non-alcoholic steatohepatitis; PLT: Platelet count; SSM: Spleen stiffness measurement; TE: Transient elastography.

Table 2 Prevention of first variceal bleeding

Baveno version (reference) - year of publication	NSBBs indications	Carvedilol	EBL
I[8], 1992	Recommended for high-risk varices, but not for small varices	Not mentioned	Not recommended
II[16], 1996	NSBBs confirmed as primary therapy for large varices	Not mentioned	Potentially valuable but role unclear
III[17], 2000	First-line treatment for large varices, but not indicated for small varices	Not mentioned	Alternative to NSBBs for large varices, but role uncertain
IV[18], 2005	Expanded to include small varices with high-risk features	First mentioned as a possible alternative to traditional NSBBs	Recommended for patients intolerant to NSBBs, but long-term benefits uncertain
V[19], 2010	Further expanded to all small varices, even without high-risk signs	Suggested to have potential advantages over propranolol/nadolol	Recommended for medium/Large varices
VI[20], 2015	Confirmed for all small varices to prevent progression and bleeding	More effective than traditional NSBBs in reducing HVPG	Recommended for medium/Large varices
VII[1], 20221	Recommended for CSPH to prevent decompensation	Preferred for compensated cirrhosis	Recommended for high-risk varices in NSBB-intolerant patients

¹This recommendation should be considered in addition to the Baveno VI.

CSPH: Clinically significant portal hypertension; EBL: Endoscopic band ligation; HVPG: Hepatic venous pressure gradient; NSBBs: Non-selective beta-blockers.

Table 3 Evolution for the management of acute bleeding across Baveno guidelines

Baveno version (reference), year of publication	Endoscopic treatment	Pharmacological treatment	Balloon tamponade	TIPS	Antibiotic prophylaxis	Failure to control bleeding criteria
I[8], 1992	ASAP; AEVB: No consensus, sclerotherapy proposed as the primary treatment	Vasoactive drugs for gastric variceal bleeding	If continued bleeding (or rebleeding within 24-36 hours) despite treatment	No recommendations	No recommendations	No consensus
II[16], 1996	Endoscopic techniques were the treatment of choice for AEVB; Tissue adhesives and thrombin suggested for AGVB	Terlipressin and somatostatin shown to be effective; Insufficient data on octreotide	Reserved for emergency cases	Rescue option if endoscopic and pharmacological treatments fail	No recommendations	Two failure timeframes: < 6 hours and > 6 hours; rebleeding defined > 48 hours
III[17], 2000	ASAP (within 12 hours); EBL established as superior to sclerotherapy for AEVB; Insufficient data on tissue adhesives and EBL for AGVB	Vasoactive drugs recommended in suspected AEVB; ASAP (before endoscopy); Use to 5 days; In combination with endoscopic techniques; Vasoactive drugs suggested for bleeding from PHG	Reserved for massive bleeding as a bridge to definitive treatment	TIPS or shunt surgery for PHG if pharmacological therapy fails	No recommendations	As above
IV[18], 2005	ASAP (within 12 hours); EBL preferred for AEVB (sclerotherapy as an alternative); Tissue adhesive is recommended for AGVB	Vasoactive drugs (terlipressin, somatostatin, vapreotide, octreotide) recommended in suspected AEVB; ASAP (before endoscopy); Use to 5 days; In combination with endoscopic techniques	As above	TIPS with PTFE-covered stents recommended in case of treatment failure	No recommendations	Fresh hematemesis 2 hours after treatment, 3 g drop in Hb without transfusion, increased blood transfusion requirement1, death
V[19], 2010	ASAP (within 12 hours); EBL preferred, sclerotherapy as an alternative; Tissue adhesive is recommended for AGVB from IGV and GOV2; EBL or tissue adhesive can be used in AGVB from GOV1	As above	As above	Early TIPS within 72 hours for high-risk patients; TIPS with PTFE-covered stents recommended in case of treatment failure	Antibiotic prophylaxis became an integral part of therapy in with cirrhosis	As above
VI[20], 2015	Requirement for 24/7 availability of an endoscopist proficient in hemostasis; ASAP (within 12 hours); EBL recommended for AEVB; Tissue adhesive is recommended for AGVB from IGV and GOV2; EBL or tissue adhesive can be used in AGVB from GOV1	As above, but vapreotide was not mentioned	Only in refractory esophageal bleeding, as a temporary ‘‘bridge’’ (for a maximum of 24 hours)	Early TIPS within 72 hours for high-risk patients (further specification of indications); TIPS with PTFE-covered stents recommended in case of treatment failure	As above	No changes
VII[1], 2022	As above; but patients with suspected AEVB should undergo upper endoscopy within 12 hours, If the patient is unstable, endoscopy should be performed as soon as safely possible; APC, radio-frequency ablation or EBL for PHG and GAVE bleeding	As above	As above but self-expandable metal stents self-expandable metal stents preferred due to safety	As above	As above	Absence of control of bleeding or by rebleeding within the first 5 days

¹Special definition.

AEVB: Acute esophageal variceal bleeding; AGVB: Acute gastric variceal bleeding; APC: Argon plasma coagulation; ASAP: As soon as possible; EBL: Endoscopic band ligation; GAVE: Gastric antral vascular ectasia; PHG: Portal hypertensive gastropathy; TIPS: Transjugular intrahepatic portosystemic shunt; PTFE: Polytetrafluoroethylene; GOVs: Gastroesophageal varices; IGVs: Intragastric varices.

Table 4 Prevention of recurrent bleeding from varices

Baveno version (reference), year of publication	First-line therapy	Alternative therapy	Rescue therapy (failure of first-line)	Gastric varices	Special considerations
I[8], 1992	Traditional NSBBs or sclerotherapy	No specific recommendation	Sclerotherapy, NSBBs, surgical shunt, and liver transplantation	Traditional NSBBs	Risk assessment debated
II[16], 1996	Traditional NSBBs or EBL	Combined therapy proposed but untested	TIPS or surgical shunts	No specific recommendation	Consider transplantation for advanced cirrhosis
III[17], 2000	Traditional NSBBs or EBL	EBL preferred in NSBB-intolerant patients; Combined therapy should be further investigated	TIPS or surgical shunts	No specific recommendation	Consider transplantation for advanced liver disease
IV[18], 2005	Traditional NSBBs + EBL	EBL preferred in NSBB-intolerant patients	TIPS or surgical shunts for Child-Pugh A/B patients; Liver transplantation for Child-Pugh B/C patients	IGV1, GOV2: N-butyl-cyanoacrylate, TIPS or NSBBs; GOV1: N-butyl-cyanoacrylate, EBL, NSBBs	Start prophylaxis by day 6
V[19], 2010	Traditional NSBBs + EBL	EBL preferred in NSBB-intolerant patients; The addition of ISMN to NSBBs for hemodynamic non-responders; Those who are unable or unwilling to be treated with EBL: NSBBs + ISMN	TIPS preferred; Surgical shunt in Child-Pugh A and B pts if TIPS is unavailable; Transplantation should be considered	IGV1, GOV2: N-butyl-cyanoacrylate or TIPS; GOV1: N-butyl-cyanoacrylate, EBL, NSBBs	TIPS as bridge to transplantation
VI[20], 2015	Traditional NSBBs + EBL	NSBB monotherapy if EBL contraindicated; EBL monotherapy only if intolerance/contraindications to NSBB	TIPS preferred	No specific recommendation	PHG has to be distinguished from GAVE because treatments are different
VII[1], 2022	Traditional NSBBs (including carvedilol) + EBL	Any therapy alone if intolerance the combination therapy	TIPS preferred	No specific recommendation	Argon plasma coagulation or hemospray were introduced for recurrent bleeding in PHG

APC: Argon plasma coagulation; EBL: Endoscopic band ligation; GAVE: Gastric antral vascular ectasia; GOVs: Gastroesophageal varices; IGVs: Intragastric varices; ISMN: Isosorbide mononitrate; NSBBs: Non-selective beta-blockers; PHG: Portal hypertensive gastropathy; TIPS: Transjugular intrahepatic portosystemic shunt.