Summary

AASLD 2024 Practice Guidance on risk stratification and management of portal hypertension and varices in cirrhosis updates the 2017 guidance and harmonizes with Baveno VII. Major changes include adoption of compensated advanced chronic liver disease (cACLD) as a noninvasive surrogate for cirrhosis, codification of noninvasive criteria (LSM + platelets, “Rule of Five”) to identify clinically significant portal hypertension (CSPH), and a paradigm shift toward early nonselective beta-blocker (preferably carvedilol) therapy in CSPH to prevent first decompensation. New sections address preemptive TIPS in high-risk acute variceal hemorrhage, cardiofundal gastric varices, portal hypertensive gastropathy, and endoscopy prior to TEE/antineoplastic therapy.

Key Recommendations

Use liver stiffness by transient elastography plus platelet count to noninvasively diagnose cACLD and CSPH; LSM <10 kPa rules out cACLD, ≥15 kPa rules it in.
Initiate nonselective beta-blocker (preferably carvedilol) in compensated cirrhosis with CSPH to prevent first decompensation, regardless of variceal status.
Carvedilol is the preferred NSBB; start 6.25 mg/day, titrate to 12.5 mg/day if tolerated and systolic BP ≥90 mm Hg.
Do not start NSBB in compensated cirrhosis without CSPH (mild PH, HVPG 6–9 mm Hg) — no benefit on variceal development or decompensation.
For AVH: ICU-level care, restrictive transfusion to hemoglobin ~7 g/dL, avoid FFP, start IV vasoactive (octreotide/somatostatin/terlipressin) and IV ceftriaxone 1 g daily, perform EGD within 12 hours, treat esophageal varices with EVL.
Place preemptive TIPS within 24–72 hours in high-risk AVH patients (CTP B with active bleeding on endoscopy or CTP C 10–13).
Secondary prophylaxis after AVH = combination NSBB + serial EVL every 2–4 weeks until variceal eradication; thereafter surveillance EGD every 6–12 months.
For bleeding cardiofundal varices (GOV2/IGV1), use endoscopic cyanoacrylate injection (± coiling) or BRTO; TIPS preferred when MELD-Na <20 with ascites/large esophageal varices, BRTO preferred with HE or MELD-Na >20.
In cACLD without CSPH, repeat LSM + platelets annually; Baveno VI criteria (LSM <20 kPa and platelets >150 K/mm3) safely avoid screening EGD.
NSBBs are safe in ascites/refractory ascites but down-titrate or switch from carvedilol to propranolol/nadolol if systolic BP <90 mm Hg.
Routine upper endoscopy before TEE is not required in patients with known varices.
Avoid liberal FFP and PPIs without clear indication during/after AVH; restart oral nutrition once hemostasis achieved.

Thresholds & Doses

PH defined as portocaval gradient >5 mm Hg (normal 1–5 mm Hg); CSPH = HVPG ≥10 mm Hg.
LSM by TE: <10 kPa rules out cACLD; ≥15 kPa rules in cACLD; >25 kPa rules in CSPH (in non-obese).
Rule of Five for CSPH: LSM >25 kPa OR LSM 20–25 kPa + platelets <150 K/mm3 OR LSM 15–20 kPa + platelets <110 K/mm3.
CSPH excluded: LSM <15 kPa AND platelets >150 K/mm3.
Baveno VI to avoid screening EGD: LSM <20 kPa AND platelets >150 K/mm3.
Spleen stiffness ≤46 kPa rules out varices needing treatment.
MRE: <3.5 kPa rules out cACLD; ≥5.0 kPa rules in cACLD; ~7.7 kPa cutoff for CSPH.
≥20% change in LSM considered clinically significant for monitoring.
Carvedilol dosing: start 6.25 mg/day, titrate to 12.5 mg/day; up to 25 mg/day if hypertensive; lower starting doses in CTP B/C.
Simvastatin: max 20 mg/day in decompensated cirrhosis or CTP B–C; avoid if bilirubin >3 mg/dL.
Atorvastatin: use low dose 10–20 mg in cirrhosis.
AVH management: hemoglobin transfusion target ~7 g/dL; vasoactive therapy for 2–5 days; IV ceftriaxone 1 g q24h up to 5 days.
IV erythromycin 125–250 mg 30–120 min pre-endoscopy to improve visualization.
Endoscopy within 12 hours of AVH presentation.
Preemptive TIPS within 24–72 hours for CTP B >7 with active bleeding or CTP C 10–13.
EVL repeated every 2–4 weeks until eradication, then EGD every 6–12 months.
HCC surveillance imaging every 6 months in all compensated cirrhosis.
EGD surveillance in cACLD without varices: every 2 years (active liver disease) or every 3 years (etiology controlled).
Variceal screening in pregnancy: EGD within 1 year before conception or early second trimester.
Maintain pulse ≥55 bpm and SBP ≥90 mm Hg during NSBB titration.
PHG prevalence: 49–80% in compensated cirrhosis; acute bleeding 2.5–5%, chronic bleeding 4–12%.

Citations

Purpose and Scope / Box 1 — major changes vs. 2017 guidance and harmonization with Baveno VII.
Section: Stages of cirrhosis — definitions of cACLD, CSPH, decompensation, further decompensation, and LSM cutoffs.
Section: Which is the optimal NSBB for PH? — carvedilol preferred, dosing protocol.
Section: Noninvasive detection of CSPH / Figure 3 — Rule of Five and Baveno VI criteria.
Section: Compensated cirrhosis with proven or likely CSPH — PREDESCI-based recommendation for NSBB to prevent decompensation.
Section: AVH initial bleed / Figure 4 / Table 5 — resuscitation, vasoactive drugs, antibiotics, endoscopy timing, preemptive TIPS criteria.
Section: Prevention of recurrent hemorrhage — secondary prophylaxis with NSBB + EVL.
Section: Gastric and ectopic varices — Sarin classification, ECI, BRTO, TIPS decision making.
Section: Portal gastropathy / Table 6 — Baveno III classification and propranolol for prevention of recurrent PHG bleeding.
Section: Endoscopy before TEE — routine pre-TEE EGD not recommended.