Purpose and scope of the guidance

This Practice Guidance from the American Association for the Study of Liver Disease (AASLD) intends to coalesce best practice recommendations for the identification of portal hypertension (PH), for prevention of initial hepatic decompensation, for the management of acute variceal hemorrhage (AVH), and for reduction of the risk of recurrent variceal hemorrhage in chronic liver disease. The document updates and expands on the most recent preceding Practice Guidance from the AASLD related to the management of PH and gastroesophageal varices that was published in 2017,1 itself an update on the initial multisociety guidelines on this topic from 2007.2 Since this latest AASLD Practice Guidance was published, the 7th Baveno consensus conference was convened in October 2021,3 at which international experts reviewed data related to several key randomized controlled trials (RCTs) and individual patient-data meta-analyses. Drawing from independent review of relevant studies as well as updated expert consensus, the most significant changes in the current Guidance (Box 1) therefore relate to (1) recognition of the concept of compensated advanced chronic liver disease (cACLD), a shift away from the requirement of a histological or radiological diagnosis of cirrhosis for initial patient risk stratification; (2) codification of methodology to use noninvasive assessments to identify clinically significant PH (CSPH); and (3) endorsement of a change in paradigm with the recommendation of early utilization of nonselective beta-blocker (NSBB) therapy when CSPH is identified in order to decrease the risk of cirrhosis decompensation.4 The updated guidance further explores potential future pharmacotherapy options for PH, clarifies the role of preemptive TIPS in AVH, discusses more recent data related to the management of cardiofundal varices, and addresses new topics such as portal hypertensive gastropathy (PHG) as well as endoscopy prior to transesophageal echocardiography (TEE) and antineoplastic therapy. The present guidance does not focus on ascites as a complication of PH because this was recently covered in the AASLD Practice Guidance on ascites and related complications5 and vascular causes of PH.6 The present guidance is also meant to harmonize with the recently updated AASLD Practice Guidance on the use of TIPS, Variceal Embolization, and Retrograde Transvenous Obliteration in the Management of Variceal Hemorrhage.7 The present guidance specifically addresses PH in adults with future guidance on the management of cirrhosis in children from the AASLD anticipated.