Top tips:
- Patients with compensated cirrhosis and fibroscan based liver stiffness <20 kPa AND platelet count >150,000 OR those who are already on carvedilol or a non-selective beta blocker, do not need endoscopy to screen for varices
- All patients with a suspected variceal bleed should receive antibiotic prophylaxis (ceftriaxone, 1 g i.v. daily for 7 days or until discharge whichever occurs sooner)
- After a variceal bleed, prevention of re-bleeding includes a combination of variceal ligation and non-selective beta-blockers (in the absence of contraindications)
- Intolerance to one beta-blocker can often be overcome by switching to a different beta-blocker
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General Cirrhosis Admission and Discharge Order Sets
*Add specific panels to general admission orders as appropriate*
For adults with cirrhosis requiring hospital admission
Cirrhosis Adult Admission Orders
For adults with cirrhosis requiring hospital discharge
Cirrhosis Adult Discharge Orders
Check out the bottom of the page for short videos from Dr. Abraldes!
Compensated Cirrhosis
Defined by: the absence of ascites, hepatic encephalopathy, variceal bleeding or jaundice (see more info)
Decompensated Cirrhosis
Defined by: the presence of ascites, hepatic encephalopathy, variceal bleeding or jaundice (see more info)
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Management of Rectal Varices
A Practical Approach to Rectal Varices
- Management of Ectopic varices, including rectal varices requires a multidisciplinary approach. No randomized trials have been conducted so far to guide management
- CT scan with venous phase essential to define the anatomy of the portal systemic collaterals feeding the rectal varices
- Endoscopic treatment for rectal varices with either banding ligation or sclerotherapy is controversial, since it is associated with high rate of complications
- A better initial approach might be transhepatic embolization of the rectal varices. This achieves hemostasis without recurrence in a high number of patients
- In case of recurrence, TIPS can be attempted if no contraindications
Introducing Dr. Abraldes!
Video 1 – The top things that may be useful for you to know about this page as a family physician including: Do all patients need to be screened for varices? and How to titrate up non-selective beta blockers.
Video 2 – How I use the Fibroscan and platelet count to determine if my patient needs to be screened for varices. What to do if there are delays with scopes (e.g. COVID)?
Video 3 – Practical tips for managing a variceal bleed in cirrhosis – how I do it!
Video 4 – Transjugular intrahepatic portosystemic shunt (TIPS) for cirrhosis and variceal bleeding – indications and cautions.
Downloadable content:
You can download these to print or view offline:
AASLD guidelines
Video Links:
See relevant videos:
Placement of a Sengstaken blakemore v1
References:
This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors: Dr. Juan Abraldes, Dr. Guadalupe Garcia-Tsao, Dr. Kelly Burak, Dr. Puneeta Tandon
References:
- EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018 Aug;69(2):406-460 PMID 29653741
- de Franchis R et al. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015 Sep; 63(3):743-52 PMID 26047908
- Villanueva C et al. β-blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo-controlled, multicentre trial PMID 30910320
- Garcia-Tsao G et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. Hepatology 2017 Jan;65(1):310-335. PMID 27786365
- Burak KW HepAPPtology.
Last reviewed November 3, 2022