Treatment of portal hypertension

Table 1 Portal hypertension consensus conferences in the last two decades

Title	Year	Venue
21st meeting of the European association for the study of liver	1986	Groningen, The Netherlands
Definitions, methodology and therapeutic strategies in portal hypertension. A consensus development workshop	1990	Baveno, Italy
Developing consensus in portal hypertension	1995	Baveno, Italy
Portal hypertension and variceal bleeding. AASLD single topic symposium	1996	Virginia, United States
Updating consensus in portal hypertension. Reports of the Baveno III consensus workshop on definitions, methodology and therapeutic strategies in portal hypertension	2000	Baveno, Italy
Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension	2005	Baveno, Italy
Portal hypertension and variceal bleeding-unresolved issues. Summary of an AASLD and European association for the study of the liver single-topic conference	2007	Atlanta, United States
Revising consensus in portal hypertension: Report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension	2010	Baveno, Italy

AASLD: American association for the study of liver diseases.

Table 2 Primary prophylaxis and secondary prophylaxis of variceal hemorrhage

Therapy	Starting dose	Therapy goals	Maintenance/follow-up
Propranolol	(1) 20 mg orally twice a day; (2) Adjust every 2-3 d until treatment goal is achieved; (3) Maximal daily dose should not exceed 320 mg	(1) Maximum tolerated dose; (2) Aim for resting heart rate of 50-55 beats per minute	(1) At every outpatient visit make sure that patientis appropriately β-blocked; (2) Continue indefinitely; (3) No need for follow-up EGD
Nadolol	(1) 40 mg orally once a day; (2) Adjust every 2-3 d until treatment goal is achieved; (3) Maximal daily dose should not exceed 160 mg	As for propranolol	As for propranolol
EVL	Every 2-4 wk until the obliteration of varices	Obliteration of varices; Eradication of new varices following initial obliteration	First EGD performed 1-3 mo after obliteration and every 6-12 mo thereafter
Propranolol	(1) 20 mg orally twice a day; (2) Adjust every 2-3 d until treatment goal is achieved; (3) Maximal daily dose should not exceed 320 mg	(1) Maximum tolerated dose; (2) Aim for resting heart rate of 50-55 beats per minute	(1) At every outpatient visit make sure that patient is appropriately β-blocked; (2) Continue indefinitely
Nadolol	(1) 40 mg orally once a day; (2) Adjust every 2-3 d until treatment goal is achieved; (3) Maximal daily dose should not exceed 160 mg	As for propranolol	As for propranolol
ISMN	(1) Only to be used in conjunction with propranolol or nadolol; (2) 10 mg orally at night every day; (3) Adjust every 2-3 d by adding 10 mg in am and then pm; (4) Maximal dose is 20 mg twice a day	(1) Maximal tolerated dose; (2) Systolic blood pressure remains over 95 mmHg	Continue indefinitely
EVL	Every 2-4 wk until the obliteration of varices	Obliteration of varices; Eradication of new varices following initial obliteration	First EGD performed 1-3 mo after obliteration and every 6-12 mo thereafter

Either one of the three therapies shown in the table are recommended. EGD: Esophagogastroduodenoscopy; EVL: Endoscopic variceal ligation; ISMN: Isosorbide-5-mononitrate.

Table 3 Vasoactive agents used in the management of acute hemorrhage

Drug	Standard dosing	Duration	Mechanism of action
Somatostatin	Initial iv bolus 250 μg (can be repeated in the first hour if ongoing bleeding); continuous iv infusion of 250 to 500 μg/h	Up to 5 d	Inhibits vasodilator hormones like glucagon causing splanchnic vasoconstriction and reduced portal blood flow
Octreotide (somatostatin analogue)	Initial iv bolus of 50 μg (can be repeated in first hour if ongoing bleeding); continuous iv infusion of 50 μg/h	Up to 5 d	Same as somatostatin, longer duration of action
Vapreotide (somatostatin analogue)	Bolus: 50 μg; continuous iv infusion of 50 μg/h	Up to 5 d	Similar to somatostatin with higher metabolic stability
Vasopressin + nitroglycerine	0.2-0.4 units/min continuous iv infusion intravenously, may titrate to a maximum of 0.8 units/min; always use in combination with nitroglycerine	Maximum of 24 h at lowest effective dose	Causes direct vasoconstriction on splanchnic circulation resulting in decreased portal blood flow
Terlipressin (vasopressin analogue)	Initial 48 h: 2 mg iv every 4 h until control of bleeding; maintenance: 1 mg iv every 4 h to prevent re-bleeding	Up to 5 d	Splanchnic vasoconstriction; the active metabolite lysine-vasopressin is gradually released over several hours thus decreasing typical vasopressin side effects