Guideline sources The following summarized guidelines for the evaluation and management of liver cirrhosis are prepared by our editorial team based on guidelines from the United European Gastroenterology (UEG/ESPEN 2023), the European Association for the Study of the Liver (EASL/ILCA 2023), the European Association for the Study of the Liver (EASL 2022; 2018; 2016; 2010), the International Society on Thrombosis and Haemostasis (ISTH 2022), the American College of Gastroenterology (ACG 2022; 2020), the American Association for the Study of Liver Diseases (AASLD 2021; 2018; 2017; 2014), the British Association for the Study of the Liver (BASL/BSG 2021), the Advancing Liver Therapeutic Approaches Consortium (ALTA 2021), the American Gastroenterological Association (AGA 2021; 2017), the Society of Critical Care Medicine (SCCM 2020), the European Federation of Societies for Ultrasound (EFSU 2020), the European Society of Medical Oncology (ESMO 2018), the International Liver Transplantation Society (ILTS 2016), the British Society of Gastroenterology (BSG 2015), the Baveno VI Consensus Workshop (Baveno VI 2015), the American Society for Gastrointestinal Endoscopy (ASGE 2014), the European Association for the https://web.pathway.md/diseases/recLkjF4yC22VlND8 1/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Study of the Liver (EASL/AASLD 2014), and the American College of Gastroenterology (ACG/AASLD 2007). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Calculator Calculator Child-Pugh score for mortality in Mumtaz readmission risk score i Guidelines 1. Classification and risk stratification Risk stratification: As per AASLD 2017 guidelines, describe, analyze, and manage cirrhosis in two distinct clinical stages, compensated and decompensated, defined by the presence or absence of overt clinical complications of cirrhosis (ascites, variceal hemorrhage, and hepatic encephalopathy). E Show 2 more As per Baveno VI 2015 guidelines, classify patients with compensated cirrhosis into those with and without clinically significant portal hypertension because of different prognoses. B 2. Diagnostic investigations Evaluation of fibrosis (hepatitis C): Obtain vibration-controlled transient elastography with a cutoff of 12.5 kPa, B if available, rather than other nonproprietary, noninvasive serum tests, such as AST-to-platelet ratio index, FIB-4, or magnetic resonance elastography, B to detect cirrhosis in patients with chronic hepatitis C. B Consider obtaining post-treatment vibration-controlled transient elastography with a cutoff of 9.5 kPa to rule out advanced liver fibrosis in non-cirrhotic patients with hepatitis C achieved sustained virologic response after antiviral therapy. C Evaluation of fibrosis (hepatitis B): consider obtaining vibration-controlled transient elastography with a cutoff of 11.0 kPa, rather than other nonproprietary, noninvasive serum tests, such as AST- to-platelet ratio index, FIB-4, to detect cirrhosis in patients with chronic hepatitis B. C Evaluation of fibrosis (alcoholic liver disease): consider obtaining vibration-controlled transient elastography with a cutoff of 12.5 kPa to detect cirrhosis in patients with chronic alcoholic liver disease. C Evaluation of fibrosis (NAFLD): https://web.pathway.md/diseases/recLkjF4yC22VlND8 2/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Insufficient evidence regarding the role of vibration-controlled transient elastography for the diagnosis of cirrhosis in adult patients with nonalcoholic fatty liver disease. Consider obtaining magnetic resonance elastography, rather than vibration-controlled transient elastography, for the detection of cirrhosis in adults with nonalcoholic fatty liver disease and a higher risk of cirrhosis. C Evaluation of fibrosis (compensated cirrhosis): consider obtaining vibration-controlled transient elastography with a cutoff of 19.5 kPa to assess the need for upper gastrointestinal endoscopy to identify high-risk esophageal varices in patients with suspected compensated cirrhosis. C Evaluation of fibrosis (preoperative assessment): consider obtaining vibration-controlled transient elastography with a cutoff of 17.0 kPa to detect clinically significant portal hypertension to inform preoperative care in patients with suspected chronic liver disease undergoing elective non-hepatic surgery. C Evaluation of ascites: As per AASLD 2021 guidelines, perform diagnostic paracentesis in all patients with new-onset ascites accessible for sampling. E Show 5 more As per BSG 2021 guidelines, perform diagnostic paracentesis in all patients with new-onset ascites. B Show 6 more As per EASL 2018 guidelines, obtain the following as part of the initial evaluation of patients with ascites: history and physical examination abdominal ultrasound laboratory assessment of liver and renal functions, serum and urine electrolytes ascitic fluid analysis. Show 8 more Evaluation of portal hypertension: diagnose clinically significant portal hypertension based on the presence of gastroesophageal varices on endoscopy. E Show 2 more Evaluation of gastroesophageal varices: As per EASL 2018 guidelines, perform screening upper gastrointestinal endoscopy for gastroesophageal varices, if not previously diagnosed and treated, in patients with decompensated cirrhosis. B Show 2 more As per AASLD 2017 guidelines, perform screening endoscopy for the diagnosis of gastroesophageal varices when the diagnosis of cirrhosis is made. E Show 4 more As per BSG 2015 guidelines, perform screening endoscopy in all patients with cirrhosis at the time of diagnosis. A https://web.pathway.md/diseases/recLkjF4yC22VlND8 3/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Show 3 more As per ASGE 2014 guidelines, perform screening endoscopy in all patients with a diagnosis of cirrhosis, to assess for esophageal and gastric varices. A Show 3 more As per ACG 2007 guidelines, perform screening upper gastrointestinal endoscopy when a diagnosis of cirrhosis is made in order to assess for the presence of esophageal and/or gastric varices. B Show 2 more As per AASLD 2007 guidelines: Classify esophageal varices as small or large (> 5 mm) on upper gastrointestinal endoscopy, with the latter classification encompassing medium and large-sized varices when 3 grades (small, medium, large) are used. B Report the presence or absence of red signs on varices. B Evaluation of variceal hemorrhage: As per EASL 2018 guidelines: Perform upper gastrointestinal endoscopy within the first 12 hours after admission once hemodynamic stability has been achieved, to ascertain the cause of hemorrhage and to provide endoscopic therapy. B Consider administering pre-endoscopy erythromycin (250 mg IV 30-120 minutes before), in the absence of contraindications (QT prolongation), to facilitate the procedure. B As per AASLD 2017 guidelines, perform upper gastrointestinal endoscopy within 12 hours of admission, and once the patient is hemodynamically stable, in patients presenting with acute esophageal variceal bleeding. E As per BSG 2015 guidelines, perform upper gastrointestinal endoscopy in unstable patients with severe acute upper gastrointestinal bleeding immediately after resuscitation. B Obtain endoscopy within 24 hours of admission in all other patients with upper gastrointestinal bleeding. B As per ASGE 2014 guidelines: Perform urgent endoscopy within 12 hours of admission in patients with suspected acute variceal hemorrhage. B Consider intubating patients before endoscopy to prevent aspiration during the procedure, especially in patients with encephalopathy. C Evaluation of portal vein thrombosis: As per AASLD 2021 guidelines, exclude malignant venous obstruction attributable to HCC with appropriate contrast-enhanced imaging in patients with cirrhosis. E Show 2 more As per AGA 2021 guidelines, avoid obtaining routine screening for portal vein thrombosis in patients with cirrhosis. D As per ACG 2020 guidelines: https://web.pathway.md/diseases/recLkjF4yC22VlND8 4/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Obtain Doppler ultrasound as the initial noninvasive modality for diagnosis of portal vein thrombosis. B Obtain contrast-enhanced CT or MRI to assess the extension of thrombus into the mesenteric veins and to exclude tumor thrombus in patients with cirrhosis developing new portal and/or mesenteric vein thrombus. B Evaluation of deep vein thrombosis: recognize that the risk of deep vein thrombosis/PE is at least as high in patients with cirrhosis as in the general population. B Show 2 more Evaluation of spontaneous bacterial peritonitis: As per AASLD 2021 guidelines, perform diagnostic abdominal paracentesis to rule out SBP in patients with ascites due to cirrhosis emergently admitted to the hospital, even in the absence of symptoms/signs of infection. E Show 3 more As per BSG 2021 guidelines, perform diagnostic paracentesis without a delay to rule out SBP in all patients with cirrhosis and ascites on hospital admission. B Show 3 more As per EASL 2018 guidelines, obtain blood cultures in all patients with suspected SBP before antibiotic treatment initiation. B Show 6 more Evaluation of hepatopulmonary syndrome: As per EASL 2018 guidelines, evaluate patients with the hallmarks of chronic liver disease for hepatopulmonary syndrome in the presence of tachypnea and polypnea, digital clubbing, and/or cyanosis. B Show 4 more As per ILTS 2016 guidelines, obtain screening for hepatopulmonary syndrome, especially in liver transplant candidates, since its clinical presentation may be variable, adversely influencing the quality of life and survival. B Show 5 more Evaluation of portopulmonary hypertension: As per EASL 2018 guidelines: Obtain Doppler TTE to screen for portopulmonary hypertension in patients deemed potential recipients for TIPS or liver transplantation. Perform right heart catheterization in patients with a positive screening echocardiogram. B Obtain repeated echocardiography in patients with portopulmonary hypertension listed for transplantation. B As per ILTS 2016 guidelines, obtain Doppler transthoracic echocardiography to screen for portopulmonary hypertension in patients with portal hypertension being candidates for TIPS or liver transplantation. B Obtain repeated screening for portopulmonary hypertension in patients with portal hypertension while waiting for liver transplantation. B Show 6 more https://web.pathway.md/diseases/recLkjF4yC22VlND8 5/28 6/29/23, 5:53 AM Liver cirrhosis Pathway As per AASLD 2014 guidelines, exclude portopulmonary hypertension in liver transplant candidates by routine echocardiography. Perform right heart cardiac catheterization in patients with RV systolic pressure 45 mmHg. B Evaluation of renal impairment: As per EASL 2018 guidelines, differentiate between pre-renal AKI, hepatorenal syndrome, intrinsic, particularly acute tubular necrosis, and post-renal AKI. B Show 9 more As per EASL 2010 guidelines, exclude other common causes of renal failure (including hypovolemia, shock, parenchymal renal diseases, and use of nephrotoxic drugs) in patients with cirrhosis before a diagnosis of hepatorenal syndrome is made. B Show 3 more Evaluation of hepatic encephalopathy: diagnose hepatic encephalopathy by excluding other causes of brain dysfunction. Obtain a diagnostic workup considering other disorders able to alter brain function and mimic hepatic encephalopathy. A Show 7 more Evaluation of cardiac complications: obtain echocardiography with dynamic stress testing either pharmacologically, or through exercise, in the evaluation of patients with cirrhosis, given that systolic dysfunction may be masked by the hyperdynamic circulation and reduced afterload. View failure to increment cardiac output after physiological/pharmacological stress (and in the absence of influence of -blockade) as systolic dysfunction. B Show 5 more Evaluation of relative adrenal insufficiency: Diagnose relative adrenal insufficiency based on a delta serum total cortisol of < 248 nmol/L (9 g/dL) after 250 g corticotropin injection or a random total cortisol of < 276 nmol/L (< 10 g/dL). B Consider preferring salivary cortisol determination as serum free cortisol concentration can be influenced by the reduced serum levels of corticosteroid-binding globulin and albumin frequently seen in patients with cirrhosis. C Evaluation of sarcopenia and frailty: consider obtaining objective measures of muscle loss to assess the risk for poor outcomes in patients with cirrhosis. E Show 11 more Evaluation of malignancy: consider obtaining contrast-enhanced ultrasound as first-line imaging technique for characterizing focal liver lesions found in patients with liver cirrhosis to establish a diagnosis of malignancy (contrast-enhanced ultrasound LR-M) or, specifically, HCC (contrast- enhanced ultrasound LR-5); however obtain CT or MRI for accurate staging unless contraindicated. C Show 3 more 3. Medical management https://web.pathway.md/diseases/recLkjF4yC22VlND8 6/28 6/29/23, 5:53 AM Liver cirrhosis Pathway General principles: As per EASL 2018 guidelines, identify and treat etiological factors in patients with decompensated cirrhosis, particularly alcohol consumption and hepatitis B or C virus infection. B As per Baveno VI 2015 guidelines, treat the underlying liver disease to reduce the rate of portal hypertension and prevent complications in patients with established cirrhosis. Recognize that obesity worsens the natural history of compensated cirrhosis of all etiologies. B Show 2 more Management of ascites, diuretic therapy: As per AASLD 2021 guidelines, initiate diuretics (spironolactone with or without furosemide), along with moderate sodium restriction (2 g or 90 mmol/day), as first-line therapy in patients with cirrhosis and grade 2 ascites. E Show 2 more As per BASL/BSG 2021 guidelines, consider initiating spironolactone monotherapy (starting dose 100 mg, increased to 400 mg) in patients with the first presentation of moderate ascites. B Show 6 more As per EASL 2018 guidelines, initiate spironolactone (starting at 100 mg/day PO, with stepwise increases every 72 hours to a maximum of 400 mg/day if there is no response to lower doses) in patients with a first episode of grade 2 ascites. A Show 8 more Management of ascites, IV albumin: As per AASLD 2021 guidelines: Consider administering human albumin solution (20-40 g/week) in patients with severe muscle cramps. E Insufficient evidence to support the routine long-term infusion of human albumin solution in patients with cirrhosis and diuretic-responsive ascites. I As per BASL/BSG 2021 guidelines: Administer albumin (20% or 25% solution) after paracentesis of > 5 L is completed at a dose of 8 g albumin/L of ascites removed. A Consider administering albumin (20% or 25% solution) after paracentesis of < 5 L at a dose of 8 g albumin/L of ascites removed in patients with acute-on-chronic liver failure or high risk of post-paracentesis AKI. C Management of ascites, other agents: As per AASLD 2021 guidelines, consider administering baclofen (10 mg/day, with a weekly increase of 10 mg/day, up to 30 mg/day) in patients with severe muscle cramps. E As per EASL 2018 guidelines, insufficient evidence to support adding clonidine or midodrine to improve the efficacy of diuretic treatment. I Management of ascites, therapeutic paracentesis: https://web.pathway.md/diseases/recLkjF4yC22VlND8 7/28 6/29/23, 5:53 AM Liver cirrhosis Pathway As per AASLD 2021 guidelines, perform large-volume paracentesis as first-line therapy in patients with grade 3 ascites. Advise sodium restriction and initiate diuretics after paracentesis. E As per BASL/BSG 2021 guidelines: Consider using ultrasound guidance when available during large-volume paracentesis to reduce the risk of adverse events. C Do not obtain routine measurement of the PT and platelet count before therapeutic or diagnostic paracentesis and infusion of blood products. D As per EASL 2018 guidelines, perform large-volume paracentesis, removing ascites completely in a single session, as first-line therapy in patients with large ascites (grade 3 ascites), followed by plasma volume expansion to prevent post-paracentesis circulatory dysfunction. A Show 4 more Management of ascites, transjugular intrahepatic portosystemic shunt: As per BASL/BSG 2021 guidelines: Consider performing TIPS placement in patients with refractory ascites. B Be cautious when considering TIPS placement in patients with: age > 70 years serum bilirubin > 50 mcmol/L platelet count < 75 10 /L model for end-stage liver disease score 18 current hepatic encephalopathy active infection or hepatorenal syndrome. B As per EASL 2018 guidelines, evaluate patients with refractory or recurrent ascites for TIPS insertion. A Show 7 more Management of ascites, implantable peritoneal pump: As per BASL/BSG 2021 guidelines, consider placing an automated low-flow ascites pump only in special circumstances with robust arrangements of clinical governance, audit or research. C As per EASL 2018 guidelines, consider placing an implantable peritoneal pump in experienced centers in patients with refractory ascites not amenable to transhepatic intrajugular portosystemic shunt insertion. Obtain close monitoring because of the high risk of adverse events including renal dysfunction and technical difficulties. B Management of ascites, refractory ascites: As per AASLD 2021 guidelines, advise continued dietary sodium restriction (< 2 g/day) in patients with refractory ascites to reduce the rate of ascites accumulation. E Show 10 more As per BASL/BSG 2021 guidelines, do not view refractory ascites as a contraindication to nonselective -blockers. D Show 2 more https://web.pathway.md/diseases/recLkjF4yC22VlND8 8/28 6/29/23, 5:53 AM Liver cirrhosis Pathway As per EASL 2018 guidelines, diagnose refractory ascites based on the assessment of the response of ascites to diuretic therapy and salt restriction in stable patients without associated complications, such as bleeding or infection, after ascertaining patient compliance with treatment. B Show 6 more Management of bacterascites: Initiate antibiotics in patients with bacterascites (neutrophil count < 250/mm but positive bacterial culture) exhibiting signs of systemic inflammation or infection. B Perform a second paracentesis in patients with bacterascites as an alternative strategy to antibiotic therapy. Initiate treatment if the culture results come back positive again regardless of the neutrophil count. B Management of hepatic hydrothorax: As per AASLD 2021 guidelines, advise dietary sodium restriction and initiate diuretics plus thoracentesis as required as first-line therapy in patients with hepatic hydrothorax. E Show 3 more As per BSG 2021 guidelines: Consider performing TIPS placement in patients with hepatic hydrothorax, after discussion with the multidisciplinary team. B Consider offering alternative palliative interventions in patients with hepatic hydrothorax not undergoing TIPS placement and/or liver transplant evaluation. B As per EASL 2018 guidelines, exclude cardiopulmonary and primary pleural disease before diagnosing hepatic hydrothorax. B Show 6 more Management of portal hypertensive gastropahy: initiate nonselective -blockers and iron supplementation and/or administer blood transfusion when indicated as first-line therapy for chronic hemorrhage from portal hypertension gastropathy. A Show 2 more Prevention of gastroesophageal varices: As per EASL 2018 guidelines, follow the recommendations of esophageal varices for primary prevention of type 1 gastroesophageal varices. B As per AASLD 2017 guidelines, insufficient evidence to support the use of nonselective - blockers for the prevention of varices formation. I As per AASLD 2007 guidelines: Do not use nonselective -blockers to prevent the development of varices in patients with cirrhosis. D Aim to prevent the development of clinically significant portal hypertension and decompensated cirrhosis in patients with mild, compensated portal hypertension, rather than aiming to prevent the formation of varices. E Prevention of variceal hemorrhage, primary prevention: https://web.pathway.md/diseases/recLkjF4yC22VlND8 9/28 6/29/23, 5:53 AM Liver cirrhosis Pathway As per ALTA 2021 guidelines, insufficient evidence to recommend preoperative TIPS creation for the prevention of bleeding complications or the need for blood transfusion during or after invasive nontransplant surgical procedures in patients with portal hypertension requiring nontransplant surgery. I As per EASL 2018 guidelines, initiate primary prophylaxis upon detection of high-risk varices - small varices with red signs, medium or large varices irrespective of Child-Pugh classification, or small varices in Child-Pugh C patients - in patients with decompensated cirrhosis A , ascites, or an acute intercurrent condition. B Show 7 more As per AASLD 2017 guidelines, initiate nonselective -blockers for the prevention of first variceal hemorrhage in patients with small varices at high risk of bleeding (red wale sign or red spot). E Show 5 more As per BSG 2015 guidelines, initiate primary prophylaxis in patients with grade I varices and red signs or grade 2-3 varices, irrespective of the severity of the liver disease. A Show 6 more As per ASGE 2014 guidelines, perform endoscopic variceal ligation in patients with large esophageal varices unable to tolerate or having contraindications to nonselective -blockers. B Show 3 more Prevention of variceal hemorrhage, gastric varices: As per EASL 2018 guidelines, consider initiating nonselective -blockers for primary prevention of variceal hemorrhage from type 2 gastroesophageal varices or type 1 isolated gastric varices. C As per AASLD 2017 guidelines, consider initiating nonselective -blockers for the prevention of first variceal hemorrhage from type 2 gastroesophageal varices or type 1 isolated gastric varices. E Show 2 more As per BSG 2015 guidelines, consider initiating nonselective -blockers for primary prophylaxis in selected high-risk patients with large gastroesophageal varices type 2 after taking into account the patient's preferences and clinical judgment. C Show 7 more Prevention of variceal hemorrhage, secondary prevention: As per AASLD 2017 guidelines, initiate nonselective -blockers combined with endoscopic variceal ligation as first-line therapy for the prevention of rebleeding in patients with a history of variceal hemorrhage. E Show 4 more As per BSG 2015 guidelines, initiate nonselective -blockers (propranolol or nadolol) and variceal band ligation combination therapy for secondary prophylaxis in patients with variceal hemorrhage. A Show 9 more https://web.pathway.md/diseases/recLkjF4yC22VlND8 10/28 6/29/23, 5:53 AM Liver cirrhosis Pathway As per ASGE 2014 guidelines: Repeat endoscopy with endoscopic variceal ligation after treatment of the acute episode of variceal hemorrhage until varices have been eradicated. B Consider repeating endoscopy at 1- to 8-week intervals for endoscopic variceal ligation for secondary prophylaxis. C Management of variceal hemorrhage, pharmacotherapy: As per EASL 2018 guidelines, initiate prompt volume replacement with colloids and/or crystalloids to restore and maintain hemodynamic stability. B Do not use starch for volume replacement. A Show 4 more As per AASLD 2017 guidelines, administer vasoactive drugs (somatostatin, octreotide, vasopressin, or terlipressin) as soon as variceal hemorrhage is suspected. E Show 3 more As per BSG 2015 guidelines, administer vasoconstrictors, such as terlipressin or somatostatin, in all patients with variceal hemorrhage, starting as soon as variceal bleeding is suspected and continuing until hemostasis is achieved or for up to 5 days. Consider initiating octreotide if terlipressin or somatostatin is unavailable. A Show 2 more As per ASGE 2014 guidelines: Administer octreotide in patients with suspected variceal hemorrhage and continue for 3-5 days after endoscopy if variceal hemorrhage is confirmed. B Administer prophylactic antibiotics for 7 days in patients with cirrhosis presenting with variceal hemorrhage. A Management of variceal hemorrhage, blood product transfusion: As per EASL 2018 guidelines, use a restrictive transfusion strategy in most patients with a Hgb threshold for transfusion of 7 g/dL and a target range of 7-9 g/dL. A As per AASLD 2017 guidelines, administer packed RBC transfusion when the Hgb level reaches a threshold of around 7 g/dL, with the goal of maintaining Hgb 7-9 g/dL. E As per BSG 2015 guidelines, administer blood, platelets, and clotting factors in patients with massive bleeding in line with local protocols. B Show 7 more Management of variceal hemorrhage, endoscopic therapy: As per EASL 2018 guidelines: Perform variceal ligation within the same procedure when acute variceal bleeding is confirmed by endoscopy. A Combine vasoactive drugs and endoscopic ligation as the first therapeutic option in acute variceal bleeding. A As per AASLD 2017 guidelines, perform endoscopic variceal ligation if a variceal source for gastrointestinal bleeding is confirmed/suspected. E https://web.pathway.md/diseases/recLkjF4yC22VlND8 11/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Show 2 more As per BSG 2015 guidelines, perform variceal band ligation as the preferred method for endoscopic treatment. A As per ASGE 2014 guidelines: Perform endoscopic variceal ligation in patients with acute variceal hemorrhage or in patients with varices and stigmata of recent hemorrhage. B Consider performing endoscopic sclerotherapy if endoscopic variceal ligation is technically difficult to perform. C Management of variceal hemorrhage, transjugular intrahepatic portosystemic shunt: As per ALTA 2021 guidelines, perform preemptive TIPS creation in patients with acute variceal hemorrhage successfully banded but meeting high-risk criteria for rebleeding (Child-Turcotte- Pugh class C with 10-13 points or Child-Turcotte-Pugh class B > 7 points with active bleeding at endoscopy). Perform TIPS within 72 hours of admission in patients without contraindications to TIPS. B Show 4 more As per EASL 2018 guidelines: Consider performing early preemptive covered TIPS placement within 24-72 hours in selected high-risk patients, such as with Child class C with a score < 14. B Perform TIPS placement as the rescue therapy of choice in patients with persistent bleeding or early rebleeding despite treatment with vasoactive drugs plus variceal ligation, and prophylactic antibiotics. A As per AASLD 2017 guidelines, perform an early preemptive TIPS placement within 72 hours of endoscopy/endoscopic variceal ligation in patients at high risk of treatment failure or rebleeding, in the absence of contraindications for TIPS. E Show 4 more As per BSG 2015 guidelines, consider performing early covered TIPS (< 72 hours after index variceal bleed), after satisfactory hemostasis and depending on local resources, in selected patients with Child's B cirrhosis and active bleeding or Child's C cirrhosis with Child's score < 14. C As per ASGE 2014 guidelines, perform TIPS creation in patients failed combined endoscopic and pharmacological therapies. B Management of variceal hemorrhage (balloon-occluded retrograde transvenous obliteration): perform TIPS placement or balloon-occluded retrograde transvenous obliteration as first-line treatments in the prevention of rebleeding in patients recovered from type 2 gastroesophageal or type 1 isolated gastric variceal hemorrhage. E Management of variceal hemorrhage, balloon tamponade: As per EASL 2018 guidelines, perform balloon tamponade in patients with uncontrolled bleeding but with a prerequisite of expertise and as a temporary "bridge" until definitive treatment can be instituted and for a maximum of 24 hours. B Consider placing removable, covered, and self- expanding esophageal stents as an alternative to balloon tamponade. B https://web.pathway.md/diseases/recLkjF4yC22VlND8 12/28 6/29/23, 5:53 AM Liver cirrhosis Pathway As per ASGE 2014 guidelines, consider performing balloon tamponade when initial endoscopic therapy fails to control acute variceal hemorrhage, to temporarily control bleeding until more definitive therapy can be performed. C Management of variceal hemorrhage (Sengstaken-Blakemore tube): insert a Sengstaken- Blakemore tube if bleeding is difficult to control, until further endoscopic treatment, TIPS, or surgery is performed depending on local resources and expertise. B Management of variceal hemorrhage, gastric varices: As per ALTA 2021 guidelines: Decide on the initial management of patients with bleeding gastric-fundal varices based on center expertise. Consider performing variceal obliteration/embolization with or without TIPS in patients with bleeding gastric-fundal varices if unable to be managed endoscopically. B Perform variceal obliteration with or without TIPS creation in patients with rebleeding gastric- fundal varices after endoscopic therapy. B As per EASL 2018 guidelines, treat acute gastric variceal hemorrhage medically similar to esophageal variceal hemorrhage. Use cyanoacrylate as the endoscopic hemostatic treatment for cardiofundal varices (gastroesophageal varices type 2 or isolated gastric varices type 1). B Show 2 more As per BSG 2015 guidelines, treat patients with gastroesophageal varices type 1 as for patients with esophageal varices. B Show 4 more As per ASGE 2014 guidelines: Consider performing gastric variceal obturation with a cyanoacrylate-based compound for the treatment of acute gastric variceal hemorrhage at centers familiar with this technique. Otherwise, consider performing endoscopic variceal ligation. C Perform alternative interventions when gastric variceal hemorrhage cannot be controlled with endoscopic and pharmacological therapy. B Management of variceal hemorrhage, surveillance: As per ALTA 2021 guidelines: Obtain surveillance Doppler ultrasound 3 months after TIPS creation and every 6 months thereafter to monitor for post-TIPS stenosis or occlusion. B Consider obtaining TIPS venogram with pressure measurements with consideration of TIPS revision in patients with suspected TIPS stenosis/occlusion or rebleeding after TIPS creation. C As per AASLD 2017 guidelines, avoid monitoring changes in hepatic venous pressure gradient routinely. Recognize that noninvasive tests do not correlate well with changes in hepatic venous pressure gradient. D As per ASGE 2014 guidelines, obtain endoscopic surveillance every 3-6 months after endoscopic treatment of acute variceal hemorrhage. Treat recurrent varices with endoscopic variceal ligation. B https://web.pathway.md/diseases/recLkjF4yC22VlND8 13/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Management of coagulopathy: As per EASL 2022 guidelines, do not correct abnormal laboratory tests (INR, activated PTT, platelet count, fibrinogen) by administering blood products or factor concentrates with the aim of preventing spontaneous bleeding in patients with cirrhosis. D Show 7 more As per ACG 2020 guidelines, do not administer FFP to improve thrombin generation in patients with cirrhosis at conventional doses (10 mL/kg). D Show 2 more Management of portal vein thrombosis: As per AASLD 2021 guidelines, insufficient evidence regarding treatment indications for portal vein thrombosis in patients with cirrhosis without ischemic symptoms. Consider initiating treatment on a case-by-case basis. I Show 7 more As per AGA 2021 guidelines, consider initiating anticoagulation for the treatment of portal vein thrombosis in patients with cirrhosis and acute or subacute nontumoral portal vein thrombosis. C As per ACG 2020 guidelines, initiate anticoagulation in patients with cirrhosis and: acute complete main portal vein thrombosis mesenteric vein thrombosis extension of portal vein thrombosis into mesenteric veins. B Show 7 more As per EASL 2016 guidelines, implement adequate prophylaxis for gastrointestinal bleeding before initiation of anticoagulation in patients with cirrhotic portal vein thrombosis. A Show 3 more Prevention of deep vein thrombosis: As per EASL 2022 guidelines: Consider administering thromboprophylaxis with LMWH in patients with cirrhosis at risk of deep vein thrombosis/PE. C Consider administering thromboprophylaxis with direct OACs in patients with Child-Pugh class A and B cirrhosis at risk of deep vein thrombosis/PE. Do not use direct OACs in patients with Child-Pugh C cirrhosis. C As per ISTH 2022 guidelines: Do not vie thrombocytopenia and/or prolongation of PT/INR as absolute contraindications to anticoagulant thromboprophylaxis in patients with cirrhosis. D Consider administering anticoagulant thromboprophylaxis (in line with local protocols) with LMWH or fondaparinux over UFH in hospitalized patients with cirrhosis. Consider administering LMWH over UFH in patients with renal impairment. Consider administering thromboprophylaxis in critically ill patients (particularly with acute-on-chronic liver failure) on a case-by-case basis. C Management of deep vein thrombosis: https://web.pathway.md/diseases/recLkjF4yC22VlND8 14/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Be cautious when using vitamin K antagonists in patients with cirrhosis for the treatment of DVT/PE, as these patients can have baseline altered INR and the target INR remains unknown. Consider initiating LMWH and vitamin K antagonists as reasonable options in patients with Child-Pugh A. Initiate LMWH for the treatment of DVT/PE in patients with Child-Pugh B and Child-Pugh C cirrhosis, and UFH as the treatment of choice in patients with renal failure. B Recognize that there are no major concerns regarding the safety of direct OACs for the treatment of deep vein thrombosis/PE in patients with Child-Pugh class A cirrhosis. Be cautious when using direct OACs in patients with Child-Pugh class B cirrhosis and in patients with CrCl < 30 mL/min because of the possibility of accumulation. Do not use direct OACs in patients with Child-Pugh class C cirrhosis. B Prevention of spontaneous bacterial peritonitis, primary prevention: As per AASLD 2021 guidelines: Administer antibiotic prophylaxis for SBP in patients with cirrhosis and upper gastrointestinal hemorrhage. Administer IV ceftriaxone 1 g/24 hours as the antibiotic of choice for a maximum of 7 days. E Consider administering primary prophylaxis for SBP in selected patients with cirrhosis and low protein (< 1.5 g/L) ascites and renal dysfunction (serum creatinine level > 1.2 mg/dL, BUN level > 25 mg/dL or serum sodium level < 130 mEq/L) or liver failure (Child-Turcotte-Pugh score > 9 and bilirubin > 3 mg/dL). E As per BASL/BSG 2021 guidelines: Administer prophylactic antibiotic treatment (chosen based on local data) to prevent the development of SBP in patients presenting with gastrointestinal bleeding and underlying ascites due to cirrhosis. A Administer primary prophylaxis for SBP in high-risk patients, as defined by an ascitic protein count < 1.5 g/dL, with a discussion of potential risks and benefits and existing uncertainties with patients. B As per ACG/AASLD 2007 guidelines, administer short-term (maximum 7 days) antibiotic prophylaxis to prevent infectious complications, including SBP, in any patient with cirrhosis and gastrointestinal hemorrhage. A Show 2 more Prevention of spontaneous bacterial peritonitis, secondary prevention: As per AASLD 2021 guidelines, initiate long-term prophylaxis with daily norfloxacin in patients recovered from an episode of SBP. Consider initiating oral ciprofloxacin if norfloxacin is unavailable. E As per BASL/BSG 2021 guidelines, consider initiating norfloxacin (400 mg once daily), ciprofloxacin (500 mg once daily, PO), or co-trimoxazole (800 mg sulfamethoxazole and 160 mg TMP daily, PO) to prevent further episodes of SBP in patients recovered from an episode of SBP. C As per EASL 2018 guidelines: Initiate prophylactic norfloxacin (400 mg/day, PO) in patients recovered from an episode of SBP, also to prevent hepatorenal syndrome-AKI. A https://web.pathway.md/diseases/recLkjF4yC22VlND8 15/28 6/29/23, 5:53 AM Liver cirrhosis Pathway Insufficient evidence to support the use of rifaximin as an alternative to norfloxacin for secondary prophylaxis of SBP. I Management of spontaneous bacterial peritonitis, antibiotic therapy: As per AASLD 2021 guidelines, initiate empiric IV antibiotics in all patients with an ascites/pleural fluid polymorphonuclear count > 250/mm . E Show 3 more As per BASL/BSG 2021 guidelines: Initiate immediate empirical antibiotic therapy with due consideration of the context of SBP (community-acquired or healthcare-associated), the severity of infection, and local bacterial resistance profile. Guide the choice of an antibiotic agent by local resistance patterns and protocols. B Consider performing a second diagnostic paracentesis at 48 hours from the start of treatment to check the efficacy of antibiotic therapy in patients with apparent inadequate response or if secondary bacterial peritonitis is suspected. C As per EASL 2018 guidelines, initiate empiric IV antibiotics immediately after the diagnosis of SBP. B Show 6 more Management of spontaneous bacterial peritonitis, IV albumin: As per AASLD 2021 guidelines, administer IV albumin in addition to antibiotics (1.5 g/kg on day 1 and 1 g/kg on day 3) in patients with SBP, especially in the presence of AKI and/or jaundice at the time of SBP diagnosis. E As per BASL/BSG 2021 guidelines, administer albumin (1.5 g/kg infusion within 6 hours of diagnosis followed by 1 g/kg on day 3) in patients with SBP and increased or rising serum creatinine. B As per EASL 2018 guidelines, administer albumin (1.5 g/kg at diagnosis and 1 g/kg on day 3) in patients with SBP. A Management of spontaneous bacterial peritonitis, medications to avoid: As per AASLD 2021 guidelines: Avoid using aminoglycosides, wherever possible, for the treatment of bacterial infections in patients with cirrhosis and ascites. D Discontinue nonselective -blockers temporarily in patients with SBP developing hypotension (mean arterial pressure < 65 mmHg) or AKI. E As per EASL 2018 guidelines: Discontinue nonselective -blockers in patients with SBP. B Attempt reinitiating nonselective -blockers after recovery. B Restrict the use of PPIs to patients with a clear indication, since they may increase the risk of SBP in patients with prior SBP. B Management of other infections: recognize that infections other than SBP are frequent and associated with increased mortality in patients with cirrhosis. Assess and closely monitor https://web.pathway.md/diseases/recLkjF4yC22VlND8 16/28 6/29/23, 5:53 AM Liver cirrhosis Pathway hospitalized patients with cirrhosis for the presence of infections to enable early diagnosis and appropriate treatment. B Show 5 more Management of hepatopulmonary syndrome: As per SCCM 2020 guidelines, provide supportive care with supplemental oxygen in the management of patients with hepatopulmonary syndrome, pending possible liver transplantation. E As per EASL 2018 guidelines: