Portal Hypertension IVProceedings of theFourth Baveno International Consensus Workshop

EDITED BY

ROBERTO DE FRANCHIS MDProfessor of GastroenterologyDepartment of Internal Medicine, University of Milan, andHead, Gastroenterology and Gastrointestinal Endoscopy Service,IRCCS Ospedale Maggiore Policlinico, Milan, Italy

Portal Hypertension IV

Portal Hypertension IVProceedings of theFourth Baveno International Consensus Workshop

EDITED BY

ROBERTO DE FRANCHIS MDProfessor of GastroenterologyDepartment of Internal Medicine, University of Milan, andHead, Gastroenterology and Gastrointestinal Endoscopy Service,IRCCS Ospedale Maggiore Policlinico, Milan, Italy

©2006 by Blackwell Publishing LtdBlackwell Publishing, Inc., 350 Main Street, Malden, Massachusetts 02148-5020, USABlackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UKBlackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia

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First published 2006

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Baveno International Consensus Workshop (4th : 2005)Portal hypertension IV : proceedings from the Fourth BavenoInternational Consensus Workshop / edited by Roberto de Franchis.p. ; cm.

Includes bibliographical references and index.ISBN-13: 978-1-4051-3940-3 (hardback : alk. paper)ISBN-10: 1-4051-3940-4 (hardback : alk. paper)1. Portal hypertension–Congresses. I. De Franchis, Roberto. II. Title. III. Title: Portal

hypertension 4. IV. Title: Portal hypertension four.[DNLM: 1. Hypertension, Portal–Congresses. 2. Gastrointestinal

Hemorrhage–complications–Congresses. 3. Liver Diseases–complications–Congresses.WI 720 B353p 2006]

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Contents

Contributors, ix

Preface, xvii

LECTUREWhat Have We Accomplished (and What Lies Ahead), 1Roberto de Franchis

SESSION 1Definition of Key Events – Last Attempt? 11Andrew K. Burroughs, Paul Calés, David Kravetz, Oliviero Riggio,Dominique Thabut, Henk R. van Buuren and Patrick S. KamathBAVENO IV CONSENSUS STATEMENTSAndrew K. Burroughs, Patrick S. Kamath (Chairpersons), PaulCalés, David Kravetz, Oliviero Riggio, Dominique Thabut andHenk R. van Buuren

LECTUREAbnormalities of Haemostasis Tests in Chronic Liver Disease:Clinically Relevant? 40Pier Mannuccio Mannucci

SESSION 2Predictive Models in Portal Hypertension, 47Guadalupe Garcia-Tsao, Gennaro D’Amico, Juan G. Abraldes,Filippo Schepis, Manuela Merli, W. Ray Kim and Erik Christensen

v

vi Contents

BAVENO IV CONSENSUS STATEMENTSGennaro D’Amico, Guadalupe Garcia-Tsao (Chairpersons),Juan G. Abraldes, Erik Christensen, Pere Ginès, W. Ray Kim,Manuela Merli and Filippo Schepis

SESSION 3Prevention of the Formation of Varices (Pre-Primary Prophylaxis), 103Roberto J. Groszmann, Carlo Merkel, Yasuko Iwakiri, Vijay Shah,BenjaminL. Shneider,MarcoZoli, Annalisa Berzigotti, JulioVorobioffand Alberto MorabitoBAVENO IV CONSENSUS STATEMENTSRoberto J. Groszmann, CarloMerkel (Chairpersons), Yasuko Iwakiri,Alberto Morabito, Benjamin L. Shneider, Vijay Shah, Julio Vorobioffand Marco Zoli

LECTUREPulmonary Vascular Complications of Liver Disease: Implications forDiagnosis and Treatment of Portal Hypertension, 152Michael B. Fallon

SESSION 4Primary Prophylaxis for Variceal Bleeding, 168Norman D. Grace, Juan Carlos Garcia-Pagan, Mario Angelico,RichardMoreau, AgustinAlbillos,Michael Schepke, ThomasD. Boyerand Naga ChalasaniBAVENO IV CONSENSUS STATEMENTSNorman D. Grace, Juan Carlos Garcia-Pagan (Chairpersons),Agustin Albillos, Mario Angelico, Thomas D. Boyer, Naga Chalasaniand Michael Schepke

LECTUREHepatorenal Syndrome: Current Concepts, 201Andrés Cárdenas and Pere Ginès

SESSION 5Treatment of the Acute Bleeding Episode, 217Loren Laine, Ramón Planas, Frederik Nevens, Rafael Bañares,David Patch and Jaime BoschBAVENO IV CONSENSUS STATEMENTSJaimeBosch, LorenLaine (Chairpersons), Rafael Bañares,NormanMarcon,Frederik Nevens, Christine Silvain, David Patch and Ramón Planas

Contents vii

LECTURESpontaneous Bacterial Peritonitis/Infections in Cirrhosis, 243Miguel Navasa and Juan Rodés

SESSION 6Prevention of Rebleeding, 262Brigitte Bernard-Chabert, Tilman Sauerbruch,Gin-HoLo,Arun J. Sanyal,J.MichaelHenderson,Gamal Shiha,Han-ChiehLin, CàndidVillanueva,Jean-Pierre Vinel and Didier LebrecBAVENO IV CONSENSUS STATEMENTSDidier Lebrec, Tilman Sauerbruch (Chairpersons), Brigitte Bernard-Chabert,J. Michael Henderson, Gin-Ho Lo, Han-Chieh Lin, Arun J. Sanyal,Gamal Shiha, Càndid Villanueva and Jean-Pierre Vinel

SESSION 7Noncirrhotic Portal Hypertension, 285Dominique-Charles Valla, Shiv K. Sarin, G. Barosi, Y.C. Chawla,Elwyn Elias, Harry Janssen, Massimo Primignani and Ian R. WanlessBAVENO IV CONSENSUS STATEMENTSDominique-Charles Valla, Shiv K. Sarin (Chairpersons),G. Barosi, Y. C. Chawla, Elwyn Elias, Harry Janssen, Massimo Prim-ignani and Ian R. Wanless

LECTUREQuality of Randomised Clinical Trials in Portal Hypertension andOther Fields of Hepatology, 328Christian Gluud, Sarah Louise Klingenberg and Lise Lotte Gluud

LECTUREValue and Limits of Evidence-Based Medicine (EBM), 345Luigi Pagliaro

SESSION 8Providing Scientific Evidence: RCTs and Beyond, 356Thorkild I.A. Sørensen, Antoine Hadengue, Francesco Salerno,FlemmingBendtsen, Jayant Talwalkar, JennyHeathcote, Andres T. Blei andJuan Rodés

viii Contents

BAVENO IV CONSENSUS STATEMENTSThorkild I.A. Sørensen, JuanRodés (Chairpersons), FlemmingBendtsen,Andres T. Blei, AntoineHadengue, JennyHeathcote, Francesco Salernoand Jayant Talwalkar

Index, 391

Contributors

JUAN G. ABRALDES md, Research Associate, Hepatic HemodynamicLaboratory, Hospital Clinic, IDIBAPS, Barcelona, Spain

AGUSTIN ALBILLOS md, Assistant Professor of Medicine, Department

of Gastroenterology, Hospital Ramon y Cajal, University of Alcalà, Madrid, Spain

MARIO ANGELICO md, Professor of Gastroenterology, Department ofPublic Health and Cellular Biology, Tor Vergata University Medical School, Rome,

Italy

RAFAEL BAÑARES md, Associate Professor of Medicine, Liver Unit,

Hospital General Universitario Gregorio Marañon, Madrid, Spain

G. BAROSI md,Director, Laboratory of Clinical Epidemiology, IRCCS Poli-clinico S Matteo, Pavia, Italy

FLEMMING BENDTSEN md, Dr Med.Sci., Head, Department of

Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark

BRIGITTE BERNARD-CHABERT md, Service d’Hépato-Gastro-entérologie, Centre Hôpitalier Universitaire Robert Debré, 51100 Reims, France

ANNALISA BERZIGOTTI md, Department of Internal Medicine,

Cardioangiology, Hepatology, University of Bologna, 40138, Bologna, Italy

ANDRES T. BLEI md,Division of Hepatology, Department ofMedicine,

Lakeside VA Medical Center and Northwestern University Feinberg School of

Medicine, Chicago, IL 60611, USA

ix

x Contributors

JAIME BOSCH md, Professor of Medicine, University of Barcelona, Senior

Consultant Hepatologist, Liver Unit, Chief of Hepatology Section, IMD, Hospital

Clinic, Barcelona, Spain

THOMAS D. BOYER md, John J Lee Professor ofMedicine, University

of Arizona, Liver Research Institute, Tucson, AZ 85724, USA

ANDREW K. BURROUGHS md, Liver Transplantation and Hepa-tobiliary Unit, Royal Free Hospital, London, UK

PAUL CALÈS md, CHU, University of Angers, 49933 Angers Cedex 9,

France

ANDRÉS CÁRDENAS md, mmsc, Liver Unit, Institut de Malalties

Digestives, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain

NAGA CHALASANI md, Associate Professor of Medicine, Division of

Gastroenterology/Hepatology, Division of Clinical Pharmacology, Indiana Univer-

sity School of Medicine, Indianapolis, IN, USA

Y.C. CHAWLA md, Head, Department of Hepatology, PGIMER, Chandi-

garh, India 160012

ERIK CHRISTENSEN md, Clinic of Internal Medicine I, Bispebjerg

University Hospital, Bispebjerg Bakke 23, DK-2400, Copenhagen NV, Denmark

GENNARO D’AMICO md, UO Gastroenterologia, Ospedale V

Cervello, 90146 Palermo, Italy

ROBERTO DE FRANCHIS md, Professor of Gastroenterology,

Department of Internal Medicine, University of Milan. Head, Gastroenterology and

Gastrointestinal Endoscopy Service, IRCCS Ospedale Maggiore Policlinico, Milan,

Italy

ELWYN ELIAS md, Liver Unit, Queen Elizabeth Hospital, Birmingham

B15 2TH, UK

MICHAEL B. FALLON md, Department of Medicine, Division of

Gastroenterology/Hepatology, University of Alabama at Birmingham, Birmingham,

AL, USA

Contributors xi

JUAN CARLOS GARCIA-PAGAN md, phd, Consultant in Hep-atology, Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS,

Barcelona, Spain

GUADALUPE GARCIA-TSAO md, Professor of Medicine, Yale

University, VA-CT Healthcare System, New Haven, CT, USA

PERE GINÈS md, Liver Unit, Institut de Malalties Digestives, Hospital

Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain

CHRISTIAN GLUUD md, Dr Med. Sci., Head of Department, The

Cochrane Hepatobiliary Group, The Copenhagen Trial Unit, Centre for Clinical

Intervention Research, Department 7102 Rigshospitalet, Copenhagen University

Hospital, Copenhagen, Denmark

LISE LOTTE GLUUD md, Dr Med. Sci., Senior Researcher, The

Cochrane Hepato-Biliary Group, The Copenhagen Trial Unit, Centre for Clini-

cal Intervention Research, Department 7102 Rigshospitalet, Copenhagen University

Hospital, Copenhagen, Denmark

NORMAN D. GRACE md, facp, facg, Professor of Medicine,

Tufts University School ofMedicine, Lecturer onMedicine, HarvardMedical School,

Director of Clinical Hepatology, Brigham and Womens Hospital, Boston, MA, USA

ROBERTO J. GROSZMANN md, frcp, Professor of Medicine,

VA Connecticut Healthcare System, Hepatic Hemodynamic Laboratory, West

Haven, CT, and Yale University School of Medicine, New Haven, CT, USA

ANTOINE HADENGUE md, Professor of Medicine, University of

Geneva, Head, Division of Gastroenterology and Hepatology, Geneva University

Hospitals, Hopital Cantonal, CH 1211, Geneva, Switzerland

JENNY HEATHCOTE md, Professor of Medicine, University of

Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario

M5T 2S8, Canada

J. MICHAEL HENDERSON md, Department of Surgery, The

Cleveland Clinic Foundation, Cleveland, OH, USA

xii Contributors

YASUKO IWAKIRI phd, Section of Digestive Diseases, Yale University

School of Medicine, New Haven, CT, USA

HARRY JANSSEN md,Department ofGastroenterology andHepatology,Erasmus MC University Hospital, Rotterdam, The Netherlands

PATRICK S. KAMATH md, Professor of Medicine, Mayo Clinic

College of Medicine, Rochester, MN 55905, USA

W. RAY KIM md, Associate Professor of Medicine, Division of

Gastro enterology and Hepatology, Mayo Clinic College of Medicine, Rochester,

MN 55905, USA

SARAH LOUISE KLINGERBERG cand. scient., Hand Search

Coordinator, The Cochrane Hepato-Biliary Group, The Copenhagen Trial Unit,

Centre for Clinical Intervention Research, Department 7102 Rigshospitalet,

Copenhagen University Hospital, Copenhagen, Denmark

DAVID KRAVETZ md, Staff Physician, Gastroenterology Division,

VA San Diego Healthcare System, Professor of Clinical Medicine, University of

California, San Diego, CA, USA

LOREN LAINE md, Professor of Medicine, Keck School of Medicine,

University of Southern California, Los Angeles, CA, USA

DIDIER LEBREC md, Laboratoire d’Hémodynamique Splanchnique et deBiologie Vasculaire, INSERM U-481, and Service d’Hépatologie, Hôpital Beaujon,

Clichy, France

FA-YAU LEE md, Division of General Medicine, Department of Medicine,

Taipei Veterans General Hospital, Taiwan

HAN-CHIEH LIN md, Professor of Medicine, Division of Gastroen-

terology, Department of Medicine, Taipei Veterans General Hospital and National

Yang-Ming University School of Medicine, Taipei, Taiwan

GIN-HO LO md, Chief, Division of Gastroenterology, Department of

Medicine, Kaohsiung Veterans General Hospital, Professor, National Yang-Ming

University, Taiwan, Kaohshiung, Taiwan

Contributors xiii

PIER MANNUCCIO MANNUCCI md, Professor of Medicine

Angelo Bianchi BonomiHemophilia andThrombosis Center, Department of Internal

Medicine and Dermatology, IRCCS Maggiore Hospital Mangiagalli and Regina

Elena Foundation and University of Milan, Italy

NORMAN MARCON md, Gastroenterologist, St. Michael’s Hospital,

University of Toronto, Toronto, Ontario, Canada

CARLO MERKEL md, Associate Professor of Medicine, Department of

Clinical and Experimental Medicine, University of Padua, Padua, Italy

MANUELA MERLI md, Associate Professor of Gastroenterology,

II Division of Gastroenterology, Department of Clinical Medicine, University of

Rome ‘La Sapienza’, Rome, Italy

ALBERTO MORABITO phd, Professor of Medical Statistics and

Biometrics, Department of Medicine, Surgery and Dentistry, University of Milan,

Milano, Italy

RICHARD MOREAU md, INSERMand ServiceD’Hèpatologie,Hôpital

Beaujon, 92118 Clichy, France

MIGUEL NAVASA md, Associate Professor of Medicine, Liver Unit,

IMDIM, IDIBAPS, Hospital Clinic, University of Barcelona, Barcelona, Spain

FREDERIK NEVENS md, Department of Liver and Pancreatic Disease,UZ Gasthuisberg KU Leuven, Leuven, Belgium

LUIGI PAGLIARO md, Professor of Medicine, University of Palermo,

Internal Medicine, V Cervello Hospital, Regional Referral Center for Chronic Liver

Diseases, Palermo, Italy

DAVID PATCH md, mbbs, frcp, Royal Free Hospital, London, UK

RAMÓN PLANAS md, Liver Unit, Gastroenterology Department,

Autonomous University of Barcelona, Unidad de Hepatologia. Servicio de Diges-

tivo, Hospital Germans Trias i Pujol, Badalona, Spain

xiv Contributors

MASSIMO PRIMIGNANI md, Department of Internal Medicine,

University of Milan, Gastroenterology and Gastrointestinal Endoscopy Service,

IRCCS Ospedale Maggiore Policlinico, Milan, Italy

OLIVIERO RIGGIO md, Associate Professor of Gastroenterology,

II Division of Gastroenterology, Department of Clinical Medicine, University of

Rome ‘La Sapienza’, Rome, Italy

JUAN RODÉS md, Professor of Medicine, University of Barcelona. Chief

Executive, Hospital Clinic i Provincial, Barcelona, Spain

FRANCESCO SALERNO md, Professor of Medicine, Department of

Internal Medicine, University of Milan, Policlinico S. Donato, Milan, Italy

ARUN J. SANYAL md, Professor of Medicine and Chairman, Division

of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth Univer-

sity Medical Center, Richmond, VA 23298-0341, USA

SHIV K. SARIN md, Department of Gastroenterology, G.B. Pant

Hospital, New Delhi, India

TILMAN SAUERBRUCH md, Department of Internal Medicine I,

University of Bonn, Bonn, Germany

FILIPPO SCHEPIS md,GastroenterologyUnit, University ofModena and

Reggio Emilia, Via Del Pozzo 71, 41100, Modena, Italy

MICHAEL SCHEPKE Department of Internal Medicine I, University of

Bonn, Bonn, Germany

VIJAY SHAH md, Advanced Liver Disease StudyGroup andGastroenterol-ogy Research Unit, Mayo Clinic, Rochester, MN, USA

GAMAL SHIHA md, Professor of Internal Medicine, Elmansoura Faculty

of Medicine, Liver and Gastroenterology Unit, Elmansoura University Hospital,

Egypt

BENJAMIN L. SHNEIDER md, Professor of Pediatrics, Chief,

Division of Pediatric Hepatology, Mount Sinai School of Medicine, New York,

NY, USA

Contributors xv

CHRISTINE SILVAIN md, Service d’Hepato-Gastroenterologie, CHULa Miletrie, 86021 Poitiers Cedex, France

THORKILD I.A. SØRENSEN md, Professor, Dr Med. Sci, Insti-

tute Director, Institute of Preventive Medicine, Centre for Health and Society,

Copenhagen University Hospital, Copenhagen, Denmark

JAYANT TALWALKAR md, Assistant Professor of Medicine, Mayo

Clinic College of Medicine, Consultant, Division of Gastroenterology/Hepatology,

Mayo Clinic and Foundation, Rochester, MN, USA

DOMINIQUE THABUT md, Hepato-gastroenterology Unit, Hôpital

Pitié-Salpetrière, Paris, France

DOMINIQUE-CHARLES VALLA md, Professor of Hepatology,

Service d’Hépatologie, Fédération Médico-Chirurgicale d’Hépatogastroentérologie,

Hôpital Beaujon, 92118 Clichy, France

HENK R. VAN BUUREN md, Department of Gastroenterology,

Erasmus MC University Hospital, Rotterdam, The Netherlands

CÀNDID VILLANUEVA md,Gastrointestinal BleedingUnit,Departmentof Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

JEAN-PIERRE VINEL md,Chef du Service d’Hépato-Gastroentérologie,Fédération Digestive de Purpan, Centre Hospitalier Universitaire Purpan, Toulouse

Cedex, France

JULIO VOROBIOFF md, Gastroenterology Department, University of

Rosario Medical School, and Fundaciòn Villavicencio, Rosario, Argentina

IAN R. WANLESS md, cm, frcpc, Professor of Pathology, Universityof Toronto, Staff Pathologist, Toronto General Hospital, Toronto, Ontario, Canada

MARCO ZOLI md, Professor of Medicine, Department of Internal

Medicine, Cardioangiology, Hepatology, University of Bologna, S Orsola-Malpighi

Hospital, 40138, Bologna, Italy

xvi Contributors

PARTICIPANTS

Argentina: J. VorobioffBelgium: F. NevensCanada: J. Heathcote, N. Marcon, I.R. WanlessDenmark: F. Bendtsen, E. Christensen, C. Gluud, T.I.A. SørensenEgypt: G. ShihaFrance: B. Bernard-Chabert, P. Calès, D. Lebrec, R. Moreau, C. Silvain,D. Thabut, D.C. Valla, J.P. VinelGermany: T. Sauerbruch, M. SchepkeIndia: Y.C. Chawla, S.K. SarinItaly: M. Angelico, G. Barosi, G. D’Amico, R. de Franchis, P.M. Mannucci,C. Merkel, M. Primignani, F. Salerno, F. Schepis, M. ZoliSpain: J.G. Abraldes, A. Albillos, R. Bañares, J. Bosch, J.C. Garcia-Pagan,P. Ginès, M. Navasa, R. Planas, J. Rodés, C. VillanuevaSwitzerland: A. HandengueTaiwan: F.Y. Lee, H.C. Lin, G.H. LoThe Netherlands: H. Janssen, H. van BuurenUK: A.K. Burroughs, E. Elias, D. PatchUSA: A.T. Blei, T.D. Boyer, N. Chalasani, M.B. Fallon, G. Garcia-Tsao,N.D. Grace, R.J. Groszmann, J.M. Henderson, Y. Iwakiri, P.S. Kamath,W.R. Kim, D. Kravetz, L. Laine, A.J. Sanyal, V. Shah, B.L. Shneider,J. Talwalkar

Preface

Portal hypertension is the haemodynamic abnormality associated withthe most severe complications of cirrhosis, including ascites, hepaticencephalopathy and bleeding from gastroesophageal varices. Since varicealbleeding is a medical emergency associated with significant morbidity andmortality, the evaluation of diagnostic tools and the design and conduct ofgood clinical trials for the treatment of this condition have always been dif-ficult. Awareness of these difficulties has led to the organisation of a seriesof meetings aimed at reaching consensus on the definitions of some keyevents related to portal hypertension and variceal bleeding, and at produc-ing guidelines for the conduct of trials in this field. Such meetings took placein Groningen, the Netherlands in 1986, in Baveno, Italy in 1990 (Baveno I)and in 1995 (Baveno II), in Milan, Italy in 1992, in Reston, United States,in 1996 and in Stresa, Italy in 2000 (Baveno III). All these meetings weresuccessful and produced consensus statements on some important points,although several issues remained unsettled.

Since the Baveno III meeting, new diagnostic tools, new drugs and newtreatment strategies for portal hypertension have been developed, whichmight lead to important changes in the management of this condition. Wethus felt that the time had come to evaluate the impact of these novelties onthe diagnostic and therapeutic strategies that we follow in managing patientswith portal hypertension. Therefore, with the help and encouragement of agroup of friends from 16 countries, many of whom had taken part in theprevious three Baveno meetings, we organised a Baveno IV workshop whichtook place on 28–29 April 2005.

The aims of the Baveno IV workshop were the same as in Baveno I, II andIII, that is to refine and extend the definitions of key events concerning thebleeding episode, in the light of the feedback we have received from studiescarried out since Baveno III, and to review and put into perspective the newdiagnostic tools and the new therapeutic strategies that have been proposed

xvii

xviii Preface

in the last five years. In addition, we continued the effort that was begun inGroningen and continued in the following workshops of producing updatedguidelines aimed at improving the quality of our future studies. We werevery fortunate in being able to bring to this workshop many of the expertsresponsible for most of the major achievements of the last five years in thisfield.

The structure of the Baveno IV workshop included eight sessions andseven lectures. The first session was devoted to verifying the appropriate-ness and practicality of the definitions of key events that had been given inBaveno I , II and III, and an attempt was made to develop consensus defi-nitions on points which were not addressed – or not agreed upon – in theprevious workshops. In each of sessions 2 to 6, the chairpersons and thepanellists reviewed an important topic related to the diagnosis or the treat-ment of portal hypertension. At the end of each session, the chairpersonsproposed a series of statements which were discussed within the panel andwith the other experts on the floor with the aim of reaching consensus onsome important diagnostic or therapeutic issues.

Session 7 focused on an emerging entity, that is non-cirrhotic portalhypertension, comparing experiences developed in the Eastern and Westernworld. Session 8 was devoted to assess ways of evaluating the scientificevidence above and beyond randomised controlled trials.

The seven lectures were different in scope. The first one summarised thepast history of the Baveno workshops, the impact of publications derivedfrom those workshops on the medical literature and gave a brief surveyof the new diagnostic tools, new drugs and new therapeutic strategies thathave been recently proposed and will have to be evaluated in the future. Thesecond lecture analysed the value and limits of evidence-based medicine;the third, fourth, fifth and sixth lecture addressed important clinical issues,that is the relationship between coagulation defects, fibrinolysis and portalhypertensive bleeding, the hepatopulmonary syndrome and portopulmonaryhypertension, hepatorenal syndrome, spontaneous bacterial peritonitis andinfections. The seventh lecture analysed the quality of trials in portal hyper-tension and other fields of hepatology, and was an update of a lecture on thesame topic that was given at Baveno III.

These proceedings follow closely the structure of the workshop. Theorder of lectures and sessions is the same, except for the lectures byDr Gluud and of Professor Pagliaro, which were moved close to session 8,as they are the ideal introductions to the latter. The consensus statementsthat were agreed upon at the end of each session are reported at theend of the pertinent chapters. The levels of available evidence and the

Preface xix

strength of the recommendations are graded according to theOxford System:(http://www.cebm.net/downloads/Oxford_EBM_Levels_5.rtf).

Our deepest thanks go to all the friends who accepted to give lecturesand to serve as chairpersons and panellists of the sessions, and who helpedus by working hard in the preparation of the workshop and of the chap-ters. We also wish to thank Sandra Covre and her staff of GPA Net,who managed brilliantly the organisation of the workshop, Jorge CuberoSotela, Alessandra Dell’ Era, Federica Fabris end Emanuele Rondonotti,who skilfully operated the computer-video projector systems throughoutthe workshop. In addition, we are grateful to the European Association forthe Study of the Liver (EASL), the Associazione Italiana per lo Studio delFegato (AISF), the Società Italiana di Gastroenterologia (SIGE), the SocietàItaliana di Endoscopia Digestiva (SIED) and the Associazione Italiana deiGastroenterologi ed endoscopisti Ospedalieri (AIGO) who endorsed themeeting, to the Companies who sponsored the workshop and especially toFerring Pharmaceuticals, who made the publication of this book possiblethrough a generous grant, to Tim Akroyd for his encouragement and co-operation in this project, and to Blackwell Publishing for the timely andexcellent production of this volume.

Roberto de FranchisOn behalf of the Baveno IV Scientific Committee

LECTURE

What Have We Accomplished(and What Lies Ahead)

Roberto de Franchis

INTRODUCTION

The idea of holding consensus meetings on portal hypertension was bornin 1986, when Andrew Burroughs organised the first such meeting inGroningen, the Netherlands [1]. After Groningen, other meetings followed,in Baveno, Italy in 1990 (Baveno I) [2] and in 1995 (Baveno II) [3,4], inMilan, Italy in 1992 [5], in Reston, United States [6] and in Stresa, Italy in2000 (Baveno III) [7,8]. This is the seventh meeting of this kind.

In this review, I will summarise the work previously done in the Bavenoworkshops I to III and outline the new diagnostic and therapeutic modalitiesthat are emerging and will have to be evaluated in the near future.

What we have done

1 Topics covered at the Baveno I, II and III meetings.2 Publications derived from the Baveno I, II and III workshops.3 Quantitative impact of the Baveno I, II and III consensus on the medicalliterature.4 Attendance at the Baveno workshops.

What lies ahead

1 New diagnostic tools.2 New drugs.3 New therapeutic strategies.

1

2 R. de Franchis

WHAT WE HAVE DONE

Topics addressed at the Baveno I, II and III workshops

• Definitions of key events.• Diagnostic evaluation of patients with portal hypertension.• Prognostic factors for first bleeding, rebleeding and survival.• Therapeutic strategies in patients with portal hypertension.• Methodological requirements of future trials.

Publications derived from the Baveno I, II and III workshops

• The Baveno I workshop was reported in the Journal of Hepatology in1992 [2].• A report of the Baveno II workshop was published in the Journal ofHepatology in 1996 [3].• The proceedings book of the Baveno II workshop was published byBlackwell Science in 1996 [4].• The Baveno III workshop was reported in the Journal of Hepatology in2000 [7].• The proceedings book of the Baveno III workshop was published byBlackwell Science in 2001 [8].

Impact of the Baveno consensus on the medical literature

Figure 1 shows the number of citations of the Baveno I–III reports in themedical literature between January 1993 and January 2005. Overall, thereports had more than 200 citations.

Attendance at the Baveno workshops

Two hundred and five participants took part in the Baveno I workshop; 81%of them were from Italy, 19% from other countries. Eighteen countries wererepresented.

The Baveno II workshop was attended by 252 participants, of which74% were from Italy and 26% from other countries. Eighteen countrieswere represented.

The attendance of the Baveno III workshop was 385, of which 49%were from Italy and 51% from other countries. Twenty-nine countries wererepresented.

WHAT HAVE WE ACCOMPLISHED 3

Four hundred and eighty five participants took part in the Baveno IVworkshop; 38% were from Italy, 62% from 39 other countries. Forty coun-tries were represented: Argentina, Australia, Austria, Belgium, Bulgaria,Canada, Chile, Costa Rica, Croatia, Czech Republic, Denmark, Egypt,Finland, France, Germany, Greece, Hong Kong, Hungary, India, Israel,Italy, Jordan, Korea, Malaysia, Mexico, Pakistan, Portugal, Romania,Saudi Arabia, Serbia-Montenegro, Slovakia, Slovenia, Spain, Sweden,Switzerland, Taiwan, Thailand, The Netherlands, United Kingdom andUnited States.

These data are shown graphically in Figs 2 and 3.

Baveno I

62

44

101

Baveno II

Workshop reports

Baveno III

25

50

75

100

Num

ber

of c

itatio

ns

0

125

Fig. 1 Citations of the Baveno I–III reports.

International

Italian

185

67

188

197

185

300

166

39

Atte

ndan

ce

200

400

0

600

Baveno I Baveno II Baveno III Baveno IV

Fig. 2 Attendance at the Baveno I–IV workshops.

4 R. de Franchis

18 18

29

40

10

20

30

40

Baveno I Baveno II Baveno III Baveno IV

Num

ber

of c

itatio

ns

0

50

Fig. 3 Countries represented at the Baveno I–IV workshops.

WHAT LIES AHEAD

New diagnostic tools

Oesophageal endoscopic capsule (PillCam Eso)

Traditionally, upper GI endoscopy (EGD) has been the mainstay for thediagnosis of portal hypertension. Current guidelines [7] recommend thatall cirrhotic patients be screened for oesophageal varices by endoscopy atthe time of the diagnosis of cirrhosis: those with no varices at screen-ing endoscopy should undergo endoscopic surveillance every 2–3 years;those with small varices at screening endoscopy should undergo endoscopicsurveillance every 1–2 years.

These recommendations represent a potentially large endoscopic burden.Their application is hampered by suboptimal patient acceptance of conven-tional EGD. The availability of a less invasive screening test could improvepatient acceptance and thus adherence to recommendations.

The recently developed oesophageal capsule endoscope (PillCamEso�) isa new, minimally invasive tool for the study of oesophageal lesions. Plate 1(facing p. 204) shows the appearance of oesophageal varices on PillCamEso� endoscopy. In a pilot study [9], the PillCam Eso� has been comparedwith conventional EGD for the diagnosis and surveillance of oesophagealvarices in cirrhotic patients. The study has shown a 96.9% agreementbetween PillCam Eso� and EGD for the diagnosis of the presence ofoesophageal varices. The sensitivity, specificity, positive and negative predic-tive values of PillCam Eso� were 100%, 89%, 96% and 100% respectively(Fig. 4). If these data are confirmed, the PillCam Eso� could become a first-line, minimally invasive tool to screen cirrhotic patients for the presence ofvarices.

WHAT HAVE WE ACCOMPLISHED 5

Capsuleendoscopy

100%

96%

89%

100%

NPV

PPV

Specificity

Sensitivity

32923

880–

24123+Capsuleendoscopy

–+

TraditionalEndoscopy

Positive likelihood ratio: 9.1

Negative likelihoodratio: 0.0

Overall agreement 96.9%

Fig. 4 Comparison of EGD and PillCam Eso� for the diagnosis of oesophagealvarices.

Nl. Liver HVPG

< 12 mmHG

Nl. Liver HVPG

> 12 mmHG

Fibrosis HVPG

<12 mmHg

Fibrosis HVPG

> 12 mmHg

Cirrhosis HVPG

< 12 mmHg

Cirrhosis HVPG

< 12 mmHg

0.25

0.5

0.75

Fib

rote

st

0

1

Fig. 5 Relationship between Fibrotest values and degree of portal hypertension inpatients with normal liver, liver fibrosis and cirrhosis.

Fibrotest and Fibroscan

Attempts at identifying the patients with oesophageal varices by non-invasivemeans, in order to restrict the performance of endoscopy to the patientswith a high probability of having varices have been disappointing so far[10]. It has been suggested that patients with varices could be identifiednon-invasively by a combination of biochemical tests [α-2-macroglobulin,haptoglobin, apolipoprotein A1, gamma-glutamyltranspeptidase and totalbilirubin (Fibrotest)] and/or by transient elastography (Fibroscan). A Frenchstudy [11] presented in 2004 at the AASLD meeting has shown that there isa good correlation between the values of Fibrotest and the presence of severeportal hypertension (Fig. 5). Another recent study [12] has shown a goodcorrelation between liver stiffness measured by transient elastography and

6 R. de Franchis

F1 F2

Correlation with varices

AUROC for the prediction of varices

• LSM = 0.89

•PG = 0.7820

40

60

80LS

M (

kPa)

0

100

Fo F3

Size of varices

Fig. 6 Relationship between liver stiffness measured by transient elastography andpresence and size of oesophageal varices (left panel). Comparison of the area underthe ROC curve (AUROC) for transient elastography (LSM) and portal pressuregradient (PG) (right panel).

the presence and size of oesophageal varices (Fig. 6). Further studies with theabove techniques should be carried out to define whether Fibroscan and/orFibrotest can be used to identify non-invasively the patients with oesophagealvarices.

New drugs

Interferon in the prevention of the progression of fibrosis

Attempts at preventing the development of oesophageal varices withβ-blockers have given disappointing results [13,14]. The recent demon-stration that interferon treatment may delay the development of varicesin patients with chronic hepatitis C and hepatitis C virus (HCV)-relatedcirrhosis [15] (Fig. 7) suggests that interferon treatment might have a role inpreventing the development of portal hypertension. this hypothesis deservesto be tested in appropriately designed studies.

Recombinant-activated factor VII (rFVIIa) in the treatment of acutevariceal bleeding

It has recently been shown that the administration of recombinant-activatedfactor VII (rFVIIa) normalises prothrombin time in bleeding cirrhoticpatients. The potential role of rFVIIa has been evaluated in a multicentreEuropean trial [16], including 245 bleeding cirrhotic patients who were

WHAT HAVE WE ACCOMPLISHED 7

Colchicine PEG-Intron Colchicine PEG-Intron

10 10%

0

20

%

20

0

2-year development of varices 2-year variceal bleeding

Fig. 7 Comparison between PEG-Interferon and colchicine in the prevention of thedevelopment of oesophageal varices and of variceal bleeding in patients withchronic hepatitis C and with HCV-related cirrhosis.

p = 0.72 p = 0.12 p = 0.03

Variceal

bleeders

Placebo rFVIIaPlacebo rFVIIa

p = 0.31 p = 0.10 p = 0.01

20

% w

ith fa

ilure

0

40

20

% w

ith fa

ilure

0

40

Variceal

bleeders

Failure to survive 5 days without

rebleeding

All patients Child B-C VB All patients Child B-C VB

Failure to control bleeding at 24 hours

Fig. 8 Randomised controlled trial of recombinant-activated factor VII (rFVIIa) asan adjunct to endoscopic and vasoactive treatment for acute variceal bleeding.

randomised to receive eight doses of rFVIIa, 100 μg/kg or placebo inaddition to combined endoscopic + pharmacological treatment. The pri-mary end point was a composite including failure to control bleeding at24 h, failure to prevent rebleeding between 24 h and 5 days and deathwithin 5 days. No significant effect was found when analysing the wholepatients population; however, an exploratory analysis showed that, in Child-Pugh B and C variceal bleeders, rFVIIa significantly reduced the occurrenceof the primary end point (from 23% in patients receiving placebo to 8%in patients receiving rFVIIa, p = 0.03), and improved bleeding control at24 h (from 88% to 100%, p = 0.03) (Fig. 8). These data are encouraging,but require confirmation by studies specifically targeted on the appropriatepatients.

8 R. de Franchis

Conclusions

All these exciting new developments will have to be carefully evaluatedto see whether they can be incorporated in the diagnostic/therapeuticarmamentarium for portal hypertension.

REFERENCES

1 Burroughs AK ed. Methodology and review of clinical trials in portal hyper-tension. Excerpta Medical Congress Service No 763. Amsterdam, New York,Oxford, 1987.

2 de Franchis R, Pascal JP, Ancona E et al. Definitions, methodology and ther-apeutic strategies in portal hypertension. A consensus development workshop.J Hepatol 1992;15: 256–261.

3 de Franchis R. Developing consensus in portal hypertension. J Hepatol 1996;25:390–394.

4 de Franchis R ed. Portal hypertension II. Proceedings of the second Bavenointernational consensus workshop on definitions, methodology and therapeuticstrategies. Oxford, Blackwell Science, 1996.

5 Spina GP, Arcidiacono R, Bosch J et al. Gastric endoscopic features in por-tal hypertension: final report of a consensus conference. J Hepatol 1994;21:461–467.

6 Grace ND, Groszmann RJ, Garcia-Tsao G et al. Portal hypertension and varicealbleeding: an AASLD single topic symposium. Hepatology 1998;28: 868–880.

7 de Franchis R. Updating consensus in portal hypertension: report of the BavenoIII consensus workshop on definitions, methodology and therapeutic strategiesin portal hypertension. J Hepatol 2000;33: 846–852.

8 de Franchis R (ed). Portal hypertension III. Proceedings of the third Bavenointernational consensus workshop on definitions, methodology and therapeuticstrategies. Oxford, Blackwell Science, 2000.

9 Eisen G, de Franchis R, Eliakim R. Evaluation of esophageal varices by PillCamEso as compared to upper endoscopy. In: Lewis BS, Rey JF, Seidman E (eds). 4thinternational conference on capsule endoscopy (ICCE) abstract book. Yoqneam,Israel, Given Imaging, 2005; 199.

10 de Franchis R. Incidental esophageal varices.Gastroenterology 2004;126: 1860–1867.

11 Thabut D, Imbert-Bismuth F, Cazals-Hatem D et al. Diagnostic value offibrosis biochemical markers (Fibrotest-Fibrosure) for the prediction of severeportal hypertension in patients with and without cirrhosis. Hepatology2004;40(suppl. 1): 203A.

12 Kazemi F Pinto E, N’Koutchou G, Ganne-Carrié N, Trinchet JC, Beaugrand M.In Patients with cirrhosis, liver stiffness measurement (LSM) predicts the presenceof oesophageal varices (OV)more accurately than portal gradient (PG). J Hepatol2005;42(suppl. 2): 82.

13 Calés P, Oberti F, Payen JL et al. Lack of effect of propranolol in the preventionof large oesophageal varices in patients with cirrhosis: a randomized trial. Eur JGastroenterol Hepatol 1999;11: 741–745.