Decision support only. This deliberately reflects GESA documents rather than reconciling them with Baveno, EASL or AASLD. Verify doses and local antimicrobial/TIPS pathways; use current aetiology-specific and HCC guidance alongside it.
1 The exam framework: stage the portal-hypertension syndrome
Cirrhosis and clinically significant portal hypertension are related but not interchangeable. The treatment question is whether the patient is compensated, whether CSPH is established, and whether a first or further decompensation is already happening.
Compensated, no CSPHno ascites, variceal bleed, overt HE or non-obstructive jaundice
Cirrhosis may be present without portal-hypertension complications. Establish aetiology and reserve; use direct evidence or validated non-invasive testing for CSPH.
Treat the cause and cofactors. Do not prescribe a portal-pressure drug or arrange routine variceal screening merely because the chart says “cirrhosis”.
Compensated + CSPHHVPG ≥10, varices/collaterals, or validated NIT rule
CSPH predicts first decompensation. GESA accepts direct evidence and the fasting VCTE/platelet “rule of five” in its validated populations.
Consider an NSBB to prevent decompensation and death. Carvedilol is preferred. Target-dose NSBB removes the need for routine screening endoscopy. GESA 2026
High-risk varices pathwaywhen CSPH is uncertain or NSBB cannot be used
LSM <20 kPa plus platelets ≥150 ×10⁹/L excludes high-risk varices with NPV >95%; otherwise use endoscopy or dedicated 100-Hz spleen stiffness where available.
If endoscopy finds high-risk varices: NSBB or EVBL. Repeat EVBL every 1–3 months until eradication, then continue surveillance.
Decompensatedascites, variceal bleeding, overt HE or non-obstructive jaundice
Search for infection, bleeding, alcohol/drugs, dehydration/AKI, constipation, PVT and HCC. Multiple precipitants commonly coexist.
Use the GESA care bundle within 6 hours. Tap ascites, treat suspected infection/bleeding promptly, protect perfusion and involve gastroenterology/liver. Assess transplant suitability early.
GESA’s NNT of 9 for NSBB therapy comes from PREDESCI, where CSPH was proven invasively. A borderline FibroScan is not permission to treat an uncertain phenotype.
GESA first-six-hour bundle: observations and glucose; FBC, EUC/creatinine, LFT/albumin, CRP, Ca/Mg/PO₄, INR/APTT/fibrinogen; urine/MSU, blood cultures, chest X-ray and liver ultrasound; diagnostic paracentesis whenever ascites is present. Record alcohol intake. If current intake is >40 g/day, give thiamine 300 mg IV daily and use the local withdrawal pathway unless encephalopathic. Give LMWH VTE prophylaxis unless there is clinically significant bleeding. GESA care bundle
2 Numbers worth knowing: GESA fasting VCTE rule of five
| LSM | GESA interpretation | Exam action |
|---|
| <5 kPa | Normal. | Reconcile discordant clinical or imaging evidence. |
| 5 to <10 | Cirrhosis unlikely. | Treat the underlying liver disease; reconsider an unsupported label. |
| 10 to <15 | Possible cirrhosis. | Corroborate with platelets, imaging and another NIT; biopsy only if residual uncertainty changes care. |
| 15 to <20 | Cirrhosis confirmed. | CSPH is not automatic; continue portal-hypertension assessment. |
| 20 to <25 | Cirrhosis + possible CSPH; CSPH confirmed if platelets <150 ×10⁹/L. | Platelets ≥150 leaves an indeterminate CSPH result. |
| ≥25 kPa | Cirrhosis + CSPH confirmed. | Consider carvedilol if perfusion permits. GESA 2026 |
Validity matters. These cut-offs apply to alcohol-related liver disease, viral hepatitis and non-obese MASLD (BMI <30 kg/m²), using fasting VCTE. In MASLD with BMI ≥30 use ANTICIPATE-NASH or specialist assessment. Acute hepatitis, cholestasis, congestion and food can raise stiffness; ARFI/2D-SWE thresholds are not interchangeable. If using LSM <20 + platelets ≥150 to avoid endoscopy, repeat both annually.
3 Prevent the first bleed; manage the acute bleed
Primary prevention
- CarvedilolStart 6.25 mg daily; titrate to 12.5 mg/day once or divided. GESA permits up to 25 mg/day if hypertensive.
- AlternativePropranolol, at least 40 mg BD, titrating toward HR ~60 while preserving perfusion.
- HoldAvoid/withhold NSBB with AKI, bradycardia, SBP <90 mmHg, MAP <65 mmHg or Na <130 mmol/L.
Suspected acute variceal bleeding
- ResuscitateRestrictive PRBC transfusion at about Hb <70 g/L; target 70–90 g/L. Activate massive-transfusion protocol for massive loss.
- Nowterlipressin 1.7 mg IV q4h plus ceftriaxone 1 g IV daily for 3–5 d; modify for contraindications and local resistance.
- ScopeEndoscopy within 12 hours after resuscitation. EVBL for oesophageal varices; GOV1 usually EVBL ± injection; GOV2/IGV1 glue, thrombin or EUS coiling by expertise.
Failure and early TIPS
- BridgeDanis oesophageal stent or balloon tamponade; stabilise and transfer urgently if TIPS is unavailable.
- SalvageUrgent TIPS for suitable patients with bleeding refractory to standard care. High · strong
- Pre-emptiveAfter haemostasis, discuss TIPS within 72 h for Child–Pugh C 10–13, Child B 8–9 with active bleeding, and/or MELD ≥19 at index endoscopy. High · strong
Do not chase the INR with FFP. Restrict blood products; FFP adds volume and portal pressure and is reserved for the massive-transfusion pathway. Stop an empiric PPI once variceal bleeding is confirmed. After haemostasis, cease IV vasoactive therapy and antibiotics after 2–5 days; if no TIPS, start an NSBB before discharge and continue EVBL to eradication. GESA 2026
4 Ascites, SBP, AKI and HRS
Ascites
- TapDiagnostic paracentesis in every admitted patient with ascites, irrespective of INR or platelets; send cell count/differential, culture in blood-culture bottles and albumin.
- DietNo-added-salt pattern, sodium ≤2300 mg/day. No routine water restriction for ascites alone.
- DiureticsSpironolactone up to 400 mg/day with furosemide up to 160 mg/day; monitor weight, Na, K and creatinine.
- LVPFor refractory/tense ascites. If >5 L removed, give 20 g albumin per 2 L drained above 5 L.
SBP
- DiagnoseAscitic PMN >250 ×10⁶/L in the GESA bundle; treat while excluding secondary peritonitis.
- Bundleceftriaxone 2 g IV daily plus 20% albumin 1.5 g/kg within 6 hours; adapt antibiotic to local exposure/resistance.
- Primary PPxNo longer routinely recommended by GESA because efficacy is uncertain and MDRO harm matters.
- Secondarynorfloxacin 400 mg daily or TMP–SMX 800/160 mg daily; review MDRO risk and local supply.
AKI / HRS-AKI
- AKICreatinine rise ≥26.5 µmol/L in 48 h, ≥50% from baseline in 7 d, or urine output <0.5 mL/kg/h for >6 h.
- ResetStop diuretics/nephrotoxins; restore volume. If creatinine >133 µmol/L, the care bundle uses 20% albumin 1 g/kg/day for 2 d. Aim MAP >80 mmHg and urine output >0.5 mL/kg/h; escalate if unmet at 6 h.
- HRS-AKIAKI without another cause and no response to adequate correction of hypovolaemia within 24 h.
- Treatterlipressin 0.85 mg IV q6h or 1.7–3.4 mg/day infusion + albumin; escalate at 48–72 h, maximum 14 d. Monitor perfusion, respiratory and ischaemic toxicity.
Refractory ascites or hydrothorax → TIPS assessment and transplant discussion. Avoid chronic pleural drains; long-term ascites catheters belong to selected palliative care. GESA allows NSBB continuation in refractory ascites only while SBP ≥90, Na ≥130 and no AKI.
5 Encephalopathy, nutrition and frailty
Hepatic encephalopathy
- DiagnoseClinical diagnosis. Search for infection, bleeding, constipation, dehydration/AKI, electrolytes, sedatives/opioids and alcohol withdrawal.
- AmmoniaDo not use routinely to diagnose or grade HE. A normal result should make the diagnosis less comfortable; a high result is non-specific.
- First-lineStart lactulose on clinical suspicion; the care bundle uses 30 mL PO QID, or NG/rectal treatment if required. Titrate clinically.
- Recurrencerifaximin 550 mg BD after another episode despite lactulose or if lactulose is not tolerated.
- RefractoryLook for a large spontaneous portosystemic shunt; consider embolisation and transplant assessment.
Feed muscle, do not restrict protein
- ScreenMalnutrition, sarcopenia and frailty predict mortality. BMI <18.5 or decompensation is high risk; otherwise use a rapid nutrition/frailty tool.
- Protein1.2–1.5 g/kg ideal body weight/day. Never use protein restriction to treat HE.
- PatternHigh-energy frequent meals, minimal fasting and a late carbohydrate/protein snack. Add oral supplements promptly if intake is inadequate.
- EscalateDietitian for decompensation/sarcopenia; consider ≥4 weeks enteral feeding if oral intake remains inadequate. Add low–moderate aerobic and resistance exercise when safe.
6 PVT, cardiopulmonary disease and procedures
Portal vein thrombosis
- Map itDefine branch versus main portal vein, percentage occlusion, splenic/SMV extension and intestinal ischaemia; ask whether transplantation is plausible.
- ObserveNon-transplant candidate with <50% branch occlusion: repeat imaging in 6–12 weeks is reasonable.
- Anticoagulate≥50% occlusion, main/large splanchnic extension, intestinal ischaemia or a transplant need to preserve portal anatomy.
- AgentDOACs can be used in Child–Pugh A/B with caution; apixaban is preferred in the GESA table. Child–Pugh C → specialist haematology input.
Cardiopulmonary complications
- CCMCirrhotic cardiomyopathy may declare itself during sepsis, TIPS or transplant. Echocardiography is routine before elective TIPS/transplant.
- PoPHConfirm by right-heart catheterisation; manage with a pulmonary-hypertension specialist. Moderate/severe disease usually contraindicates transplant unless therapy sufficiently lowers pressures.
- HPSPlatypnoea/orthodeoxia + intrapulmonary shunt on bubble echo or Tc-99m scan. Liver transplantation is the only effective treatment.
Surgery, TEE and pregnancy
- SurgeryCombine procedure/site, frailty and comorbidity with Child–Pugh, MELD and VOCAL-Penn; difficult or non-low risk → hepatology/surgery/anaesthesia MDT.
- TEEKnown varices alone do not justify routine pre-TEE endoscopy; observed bleeding risk is low.
- PregnancyPlan with an MDT. Endoscopy within 12 months before conception; if not done, scope in the second trimester. Suspected variceal bleeding can be scoped in any trimester.
- MELDPreconception MELD ≥10 predicts higher decompensation risk; MELD ≤6 predicts freedom from adverse liver outcomes in the cited cohort.
7 TIPS: indications, exclusions and follow-up
| Decision | GESA position | Exam detail |
|---|
| Consider / perform | Pre-emptive or salvage TIPS for acute variceal bleeding; recurrent bleeding despite medical/endoscopic therapy; selected refractory ascites or hydrothorax; gastric bleeding not controlled endoscopically; selected complete PVT/complex portal-mesenteric thrombosis. | HRS is not an absolute contraindication when another indication exists, but evidence is insufficient to offer TIPS for HRS-AKI itself. TIPS is not established for HPS. |
| Pre-work-up | MDT at an experienced centre; multiphasic CT/MRI, renal function, nutrition/frailty, overt + covert HE assessment and comprehensive cardiac review including echocardiography. | Cardiology review if RVSP >45 mmHg or TAPSE <1.6 cm. Portal cavernoma is difficult, not an absolute contraindication. Emergency salvage TIPS must not wait for echo. |
| Contraindications | Moderate–severe pulmonary hypertension; advanced heart failure; severe valvular insufficiency; severe/refractory overt HE except during acute bleeding; uncontrolled sepsis; prohibitive anatomy/extensive malignancy. | Unrelieved biliary obstruction and uncorrectable severe coagulopathy are relative contraindications. No single age cut-off. |
| Futility warning | Do not perform salvage TIPS when Child–Pugh >13, MELD >30 and lactate >12 mmol/L coexist, unless short-term liver transplantation is planned. | Moderate · strong This is a conjunction, not three independent exclusions. |
| After TIPS | Gastro/hepatology + interventional-radiology follow-up; monitor renal function and HE. Doppler at 1 week, 3 months, 6 months, then every 6 months. | Prior overt HE: rifaximin 550 mg BD begun within 14 days before elective TIPS and continued for 6 months may reduce post-TIPS HE. High · strong |
TIPS creates a new problem set. Overt HE occurs in roughly 25–50%. Refractory post-TIPS HE may require embolisation of large spontaneous shunts, stent reduction or closure. Abnormal Doppler flow or recurrent ascites/bleeding → venography, manometry and possible revision; routine venography is unnecessary.