Management of acute variceal bleeding: updated APASL guidelines

Acute variceal bleeding (AVB) is a common life-threatening complication of portal hypertension (PHT), having a six-week mortality of 10%-20%. Major advances in the hemodynamic management, risk stratification, pharmacotherapy, endoscopy techniques, hemostatic devices and radiological interventions have led to improved management and outcome of AVB patients in the recent past. Therefore, the APASL Portal Hypertension Working Party, chose a panel of experts, primarily from the Asia–Pacific region, to identify important developments and controversial areas in the field of AVB. They discussed through a pre-defined and structured process, advances in the field and proposed updates to the previous APASL AVB guidelines. These included emphasis on safe transportation, defining time frames for AVB episodes and re-bleeding, reporting of clinical outcomes, optimizing early intervention strategies, pharmacotherapy, medical management, endoscopic therapies, and salvage modalities, including TIPS and self-expanding metal stents. The current updates also cover variceal bleeding in special populations and situations, the skill sets required for managing AVB patients, and the research priorities in the field. The updated guidelines are based on the latest evidence and incorporate emerging trends to provide a contemporary template for management of AVB in both patients with cirrhosis and non-cirrhotic portal hypertension.