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

Shiv Kumar Sarin, Ashish Kumar, Peter W. Angus, Sanjay Saran Baijal, Soon Koo Baik, Yusuf Bayraktar, Yogesh Kumar Chawla, Gourdas Choudhuri, Jin Wook Chung, Roberto De Franchis, H. Janaka De Silva, Hitendra Garg, Pramod Kumar Garg, Ahmed Helmy, Ming Chih Hou, Wasim Jafri, Ji Dong Jia, George K. Lau, Chang Zheng Li, Hock Foong LuiHitoshi Maruyama, Chandra Mohan Pandey, Amrender S. Puri, Rungsun Rerknimitr, Peush Sahni, Anoop Saraya, Barjesh Chander Sharma, Praveen Sharma, Gamal Shiha, Jose D. Sollano, Justin Wu, Rui Yun Xu, Surender Kumar Yachha, Chunqing Zhang

Research output: Contribution to journalReview article

52 Citations (Scopus)

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.

Original languageEnglish
Pages (from-to)607-624
Number of pages18
JournalHepatology International
Volume5
Issue number2
DOIs
Publication statusPublished - 2011 Jun 1

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Hemorrhage
Liver
Portal Hypertension
Guidelines
Clinical Trials
Melena
Hematemesis
Venous Pressure
Antibiotic Prophylaxis
Therapeutics
Endoscopy
Ligation
Hospitalization
Emergencies
Pediatrics
Mortality
Wounds and Injuries
Pharmaceutical Preparations

All Science Journal Classification (ASJC) codes

  • Hepatology

Cite this

Sarin, Shiv Kumar ; Kumar, Ashish ; Angus, Peter W. ; Baijal, Sanjay Saran ; Baik, Soon Koo ; Bayraktar, Yusuf ; Chawla, Yogesh Kumar ; Choudhuri, Gourdas ; Chung, Jin Wook ; De Franchis, Roberto ; De Silva, H. Janaka ; Garg, Hitendra ; Garg, Pramod Kumar ; Helmy, Ahmed ; Hou, Ming Chih ; Jafri, Wasim ; Jia, Ji Dong ; Lau, George K. ; Li, Chang Zheng ; Lui, Hock Foong ; Maruyama, Hitoshi ; Pandey, Chandra Mohan ; Puri, Amrender S. ; Rerknimitr, Rungsun ; Sahni, Peush ; Saraya, Anoop ; Sharma, Barjesh Chander ; Sharma, Praveen ; Shiha, Gamal ; Sollano, Jose D. ; Wu, Justin ; Xu, Rui Yun ; Yachha, Surender Kumar ; Zhang, Chunqing. / Diagnosis and management of acute variceal bleeding : Asian Pacific Association for study of the Liver recommendations. In: Hepatology International. 2011 ; Vol. 5, No. 2. pp. 607-624.
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title = "Diagnosis and management of acute variceal bleeding: Asian Pacific Association for study of the Liver recommendations",
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.",
author = "Sarin, {Shiv Kumar} and Ashish Kumar and Angus, {Peter W.} and Baijal, {Sanjay Saran} and Baik, {Soon Koo} and Yusuf Bayraktar and Chawla, {Yogesh Kumar} and Gourdas Choudhuri and Chung, {Jin Wook} and {De Franchis}, Roberto and {De Silva}, {H. Janaka} and Hitendra Garg and Garg, {Pramod Kumar} and Ahmed Helmy and Hou, {Ming Chih} and Wasim Jafri and Jia, {Ji Dong} and Lau, {George K.} and Li, {Chang Zheng} and Lui, {Hock Foong} and Hitoshi Maruyama and Pandey, {Chandra Mohan} and Puri, {Amrender S.} and Rungsun Rerknimitr and Peush Sahni and Anoop Saraya and Sharma, {Barjesh Chander} and Praveen Sharma and Gamal Shiha and Sollano, {Jose D.} and Justin Wu and Xu, {Rui Yun} and Yachha, {Surender Kumar} and Chunqing Zhang",
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Sarin, SK, Kumar, A, Angus, PW, Baijal, SS, Baik, SK, Bayraktar, Y, Chawla, YK, Choudhuri, G, Chung, JW, De Franchis, R, De Silva, HJ, Garg, H, Garg, PK, Helmy, A, Hou, MC, Jafri, W, Jia, JD, Lau, GK, Li, CZ, Lui, HF, Maruyama, H, Pandey, CM, Puri, AS, Rerknimitr, R, Sahni, P, Saraya, A, Sharma, BC, Sharma, P, Shiha, G, Sollano, JD, Wu, J, Xu, RY, Yachha, SK & Zhang, C 2011, 'Diagnosis and management of acute variceal bleeding: Asian Pacific Association for study of the Liver recommendations', Hepatology International, vol. 5, no. 2, pp. 607-624. https://doi.org/10.1007/s12072-010-9236-9

Diagnosis and management of acute variceal bleeding : Asian Pacific Association for study of the Liver recommendations. / Sarin, Shiv Kumar; Kumar, Ashish; Angus, Peter W.; Baijal, Sanjay Saran; Baik, Soon Koo; Bayraktar, Yusuf; Chawla, Yogesh Kumar; Choudhuri, Gourdas; Chung, Jin Wook; De Franchis, Roberto; De Silva, H. Janaka; Garg, Hitendra; Garg, Pramod Kumar; Helmy, Ahmed; Hou, Ming Chih; Jafri, Wasim; Jia, Ji Dong; Lau, George K.; Li, Chang Zheng; Lui, Hock Foong; Maruyama, Hitoshi; Pandey, Chandra Mohan; Puri, Amrender S.; Rerknimitr, Rungsun; Sahni, Peush; Saraya, Anoop; Sharma, Barjesh Chander; Sharma, Praveen; Shiha, Gamal; Sollano, Jose D.; Wu, Justin; Xu, Rui Yun; Yachha, Surender Kumar; Zhang, Chunqing.

In: Hepatology International, Vol. 5, No. 2, 01.06.2011, p. 607-624.

Research output: Contribution to journalReview article

TY - JOUR

T1 - Diagnosis and management of acute variceal bleeding

T2 - Asian Pacific Association for study of the Liver recommendations

AU - Sarin, Shiv Kumar

AU - Kumar, Ashish

AU - Angus, Peter W.

AU - Baijal, Sanjay Saran

AU - Baik, Soon Koo

AU - Bayraktar, Yusuf

AU - Chawla, Yogesh Kumar

AU - Choudhuri, Gourdas

AU - Chung, Jin Wook

AU - De Franchis, Roberto

AU - De Silva, H. Janaka

AU - Garg, Hitendra

AU - Garg, Pramod Kumar

AU - Helmy, Ahmed

AU - Hou, Ming Chih

AU - Jafri, Wasim

AU - Jia, Ji Dong

AU - Lau, George K.

AU - Li, Chang Zheng

AU - Lui, Hock Foong

AU - Maruyama, Hitoshi

AU - Pandey, Chandra Mohan

AU - Puri, Amrender S.

AU - Rerknimitr, Rungsun

AU - Sahni, Peush

AU - Saraya, Anoop

AU - Sharma, Barjesh Chander

AU - Sharma, Praveen

AU - Shiha, Gamal

AU - Sollano, Jose D.

AU - Wu, Justin

AU - Xu, Rui Yun

AU - Yachha, Surender Kumar

AU - Zhang, Chunqing

PY - 2011/6/1

Y1 - 2011/6/1

N2 - 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.

AB - 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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