Disorders of Hepatic and Mesenteric Circulation -ACG Guidelines

The American College of Gastroenterology (ACG) has announced the publication of a new ACG Clinical Guideline on Disorders of Hepatic and Mesenteric Circulation, which have been published online in The American Journal of Gastroenterology.

Disorders of the mesenteric, portal, and hepatic veins and mesenteric and hepatic arteries have important clinical consequences and may lead to acute liver failure, chronic liver disease, noncirrhotic portal hypertension, cirrhosis, and hepatocellular carcinoma. These common disorders play an important role as precipitating factors for the development and progression of complications in patients with existing chronic liver diseases.

The guidelines offer evidence-based recommendations on the following clinical challenges:

• bleeding and thrombotic risk in cirrhosis,


• portal and mesenteric vein thrombosis in patients with and without cirrhosis,


• Budd-Chiari Syndrome,


• mesenteric artery aneurysms, and


• hereditary hemorrhagic telangiectasia (HHT).

Key Recommendations are-

• We do not recommend FFP to improve thrombin generation in patients with cirrhosis at conventional doses (10 mL/kg). If sufficient volume is given (1–2 L) to lower a significantly prolonged INR, volume expansion increases portal pressure and may trigger variceal hemorrhage. Thus, in most situations, infusion of plasma prophylactically to decrease bleeding risk is futile and potentially risky (conditional recommendation, low level of evidence).


• We do not recommend prophylactic platelet transfusions before common procedures such as routine variceal banding or paracentesis outside of significant renal dysfunction (serum creatinine > 2.5 mg/dL) or sepsis. Existing data indicate a somewhat tenuous relationship between bleeding risk and platelet count. In vitro studies demonstrate adequate thrombin production with platelet levels ≥50,000/mL. Infusion of a single adult platelet dose does not improve thrombin generation. Higher platelet levels may be more appropriate for high-risk procedures such as removal of large polyps and major surgery, but will probably require higher doses of platelet infusions; if the procedure is elective, the use of TPO agonists may be more appropriate (conditional recommendation, very low level of evidence).


• We do not recommend antifibrinolytic agents such as epsilon aminocaproic acid and tranexamic acid to reduce bleeding in the absence of hyperfibrinolysis. These agents are not generally considered to induce a hypercoagulable state but require caution if pathological clot such as PVT is already present (conditional recommendation, very low level of evidence).


• We recommend Doppler ultrasound examination as the initial noninvasive modality for diagnosis of PVT. Contrast-enhanced CT or MRI scan is recommended to assess the extension of thrombus into the mesenteric veins and to exclude tumor thrombus among patients with cirrhosis who develop new portal and/or mesenteric vein thrombus (strong recommendation, very low level of evidence).


• We recommend anticoagulation for all noncirrhotic patients with acute symptomatic portal or mesenteric vein thrombosis in the absence of any contraindication (strong recommendation, low level of evidence).


• We suggest anticoagulation for patients with chronic PVT if there is (i) evidence of inherited or acquired thrombophilia, (ii) progression of thrombus into the mesenteric veins, or (iii) current or previous evidence of bowel ischemia (conditional recommendation, very low level of evidence).


• We suggest at least 6 months of anticoagulation in patients with portal or mesenteric vein thrombosis without a demonstrable thrombophilia and when the etiology of the thrombosis is reversible. Indefinite anticoagulation is recommended in patients with portal or mesenteric vein thrombosis and thrombophilia (conditional recommendation, very low level of evidence).


• We recommend nonselective beta-blockers for prevention of variceal bleeding in patients with high-risk varices and portal and/or mesenteric vein thrombosis requiring anticoagulation. Endoscopic variceal ligation may be performed if there are contraindications or intolerance to beta-blockers; however, anticoagulation may need to be interrupted in the periprocedural period (strong recommendation, low quality of evidence).


• We suggest either unfractionated heparin or LMWH be used once a decision is made to initiate anticoagulation for treatment of portal and/or MVT. However, pros and cons of either approach should be considered before initiating either regimen (conditional recommendation, very low level of evidence).


• We suggest either LMWH or warfarin be used. Although this field continues to evolve, there is currently only limited experience with DOAC, which includes Xa or thrombin inhibitors. Because absorption of these agents may be limited in the presence of intestinal edema, some monitoring of therapy is recommended. A normal thrombin time and aPTT for dabigatran and a normal prothrombin time or anti-Xa activity for apixaban and rivaroxaban rule out substantial drug effect. Pros and cons of all approaches including availability of reversal agents should be considered before deciding on the specific regimen (conditional recommendation, very low level of evidence).