New ACG Clinical Guideline on Disorders of Hepatic and Mesenteric Circulation
By Denise Baez
The American College of Gastroenterology has released a new guideline on disorders of hepatic and mesenteric circulation, published in the American Journal of Gastroenterology.
Disorders of the mesenteric, portal, and hepatic veins, and mesenteric and hepatic arteries, have important clinical consequences and may lead to acute liver failure, chronic liver disease, noncirrhotic portal hypertension, cirrhosis, and hepatocellular carcinoma. These disorders play an important role as precipitating factors for the development and progression of complications in patients with existing chronic liver diseases.
“Although literature in the field of vascular liver disorders is scant, these disorders are common in clinical practice, and general practitioners, gastroenterologists, and hepatologists may benefit from expert guidance and recommendations for management of these conditions,” wrote Douglas A. Simonetto, MD, Mayo Clinic, Rochester, Minnesota, and colleagues. “These guidelines represent the official practice recommendations of the American College of Gastroenterology and should be tailored to individual patients and circumstances in routine clinical practice.”
The guidelines offer evidence-based recommendations on clinical challenges, including bleeding and thrombotic risk in cirrhosis, portal and mesenteric vein thrombosis in patients with and without cirrhosis, Budd-Chiari Syndrome (BCS), mesenteric artery aneurysms, and hereditary hemorrhagic telangiectasia (HHT). Some recommendations from the guideline include:
● Use of Doppler ultrasound examination as the initial noninvasive modality for diagnosis of portal vein thrombosis (PVT). Contrast-enhanced CT or MRI scan is recommended to assess the extension of thrombus into the mesenteric veins and to exclude tumour thrombus among patients with cirrhosis who develop new portal and/or mesenteric vein thrombus (strong recommendation, very low level of evidence).
● Anticoagulation for all patients without cirrhosis with acute symptomatic portal or mesenteric vein thrombosis in the absence of any contraindication (strong recommendation, low level of evidence).
● Use of nonselective beta-blockers for prevention of variceal bleeding in patients with high-risk varices, with or without cirrhosis, and portal and/or mesenteric vein thrombosis requiring anticoagulation. Endoscopic variceal ligation may be performed if there are contraindications or intolerance to beta-blockers; however, anticoagulation may need to be interrupted in the periprocedural period (strong recommendation, low quality of evidence).
● Stepwise management from least to most invasive therapies for patients with BCS. Systemic anticoagulation is the initial treatment of choice. If medical therapy fails, as determined by worsening liver and/or renal function, ascites, or hepatic encephalopathy, then endovascular therapies such as angioplasty or transjugular intrahepatic portosystemic shunt (TIPS) are recommended. LT is reserved for TIPS failure and BCS presenting as fulminant liver failure (strong recommendation, moderate level of evidence).
● Surveillance for HCC is suggested with abdominal ultrasound and serum alpha-fetoprotein levels every 6 months in patients with chronic BCS. Diagnosis of HCC is challenging, and patients are best referred to centres of expertise for diagnosis (conditional recommendation, low level of evidence).
● Routine screening for liver vascular malformation (LVM) in patients with HHT is not recommended. There is no evidence to suggest that making a diagnosis in an asymptomatic patient has clinical benefits or prevents death. However, those with a liver bruit, hyperdynamic circulation, or liver test abnormalities should be further evaluated for LVMs. Of note, women with HHT and LVMs who become pregnant warrant special attention due to anticipated hemodynamic stress (strong recommendation, low level of evidence).
SOURCE: American College of Gastroenterology