Introduction

The British Society of Gastroenterology (BSG) recognises that the current UK guideline on the management of variceal bleeding in cirrhotic patients (2015) requires updating. Recent updates to similar international guidance including the American Association for the Study of Liver Disease (AASLD), European Society of Gastrointestinal Endoscopy (ESGE) and Baveno VII, as well as updated NICE cirrhosis guidelines are acknowledged by the Clinical Guidelines Development (CGD) group. However, the CGD are also mindful of the large-scale, multi centre UK studies recently completed or currently in progress addressing both primary and secondary prophylaxis of variceal bleeding, with results expected to significantly influence UK best practice. Therefore, the CGD has opted to produce a position statement on the latest international guidance, while these data are pending. This decision is supported by the BSG Clinical Services (CS) committee. Furthermore, prioritising the identification of clinically significant portal hypertension (CSPH), rather than the management of varices alone, was felt to be an important shift in practice. On review, the CGD agreed that the AASLD guidance was most consistent with UK clinical practice. Therefore, the BSG endorses the interim use of the AASLD guidance in the UK, with some important caveats. The individual AASLD guidance statements are reproduced below, with necessary caveats added where applicable. These caveats primarily pertain to the recommendations for diagnosis of CSPH including the role of non-invasive tests (NITs), defining indications for non-selective beta-blockers (NSBB) and use of pre-emptive transjugular intrahepatic portosystemic shunt (pTIPSS) following acute oesophageal variceal bleeding (OVB).

As the evidence base is evolving, it is important to involve patients in decisions around their care and to ensure they are aware that there is still uncertainty around best practice and the implementation of the guidance. Individual patients’ circumstances (including likely concordance with medication, tolerability of medications and endoscopies) should be considered and they should be made aware that the guidance and approach may change with new emerging evidence. Patients should also be carefully counselled on how to recognise an acute variceal bleed. Vulnerable patients should be offered support to attend endoscopy/clinic appointments to facilitate engagement.