Advances in portal hypertension management: Evolution of the Baveno guidelines

Table 3 Evolution for the management of acute bleeding across Baveno guidelines

Baveno version (reference), year of publication	Endoscopic treatment	Pharmacological treatment	Balloon tamponade	TIPS	Antibiotic prophylaxis	Failure to control bleeding criteria
I[8], 1992	ASAP; AEVB: No consensus, sclerotherapy proposed as the primary treatment	Vasoactive drugs for gastric variceal bleeding	If continued bleeding (or rebleeding within 24-36 hours) despite treatment	No recommendations	No recommendations	No consensus
II[16], 1996	Endoscopic techniques were the treatment of choice for AEVB; Tissue adhesives and thrombin suggested for AGVB	Terlipressin and somatostatin shown to be effective; Insufficient data on octreotide	Reserved for emergency cases	Rescue option if endoscopic and pharmacological treatments fail	No recommendations	Two failure timeframes: < 6 hours and > 6 hours; rebleeding defined > 48 hours
III[17], 2000	ASAP (within 12 hours); EBL established as superior to sclerotherapy for AEVB; Insufficient data on tissue adhesives and EBL for AGVB	Vasoactive drugs recommended in suspected AEVB; ASAP (before endoscopy); Use to 5 days; In combination with endoscopic techniques; Vasoactive drugs suggested for bleeding from PHG	Reserved for massive bleeding as a bridge to definitive treatment	TIPS or shunt surgery for PHG if pharmacological therapy fails	No recommendations	As above
IV[18], 2005	ASAP (within 12 hours); EBL preferred for AEVB (sclerotherapy as an alternative); Tissue adhesive is recommended for AGVB	Vasoactive drugs (terlipressin, somatostatin, vapreotide, octreotide) recommended in suspected AEVB; ASAP (before endoscopy); Use to 5 days; In combination with endoscopic techniques	As above	TIPS with PTFE-covered stents recommended in case of treatment failure	No recommendations	Fresh hematemesis 2 hours after treatment, 3 g drop in Hb without transfusion, increased blood transfusion requirement1, death
V[19], 2010	ASAP (within 12 hours); EBL preferred, sclerotherapy as an alternative; Tissue adhesive is recommended for AGVB from IGV and GOV2; EBL or tissue adhesive can be used in AGVB from GOV1	As above	As above	Early TIPS within 72 hours for high-risk patients; TIPS with PTFE-covered stents recommended in case of treatment failure	Antibiotic prophylaxis became an integral part of therapy in with cirrhosis	As above
VI[20], 2015	Requirement for 24/7 availability of an endoscopist proficient in hemostasis; ASAP (within 12 hours); EBL recommended for AEVB; Tissue adhesive is recommended for AGVB from IGV and GOV2; EBL or tissue adhesive can be used in AGVB from GOV1	As above, but vapreotide was not mentioned	Only in refractory esophageal bleeding, as a temporary ‘‘bridge’’ (for a maximum of 24 hours)	Early TIPS within 72 hours for high-risk patients (further specification of indications); TIPS with PTFE-covered stents recommended in case of treatment failure	As above	No changes
VII[1], 2022	As above; but patients with suspected AEVB should undergo upper endoscopy within 12 hours, If the patient is unstable, endoscopy should be performed as soon as safely possible; APC, radio-frequency ablation or EBL for PHG and GAVE bleeding	As above	As above but self-expandable metal stents self-expandable metal stents preferred due to safety	As above	As above	Absence of control of bleeding or by rebleeding within the first 5 days

¹Special definition.

AEVB: Acute esophageal variceal bleeding; AGVB: Acute gastric variceal bleeding; APC: Argon plasma coagulation; ASAP: As soon as possible; EBL: Endoscopic band ligation; GAVE: Gastric antral vascular ectasia; PHG: Portal hypertensive gastropathy; TIPS: Transjugular intrahepatic portosystemic shunt; PTFE: Polytetrafluoroethylene; GOVs: Gastroesophageal varices; IGVs: Intragastric varices.