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Liver pressure has 'come of age,' aids management of liver disease
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ORLANDO — Measuring hepatic pressure should be done by gastroenterologists and hepatologists because it can best direct treatment and outcomes, according to an international expert at the World Congress of Gastroenterology at ACG 2017.
“Liver pressure has come of age. Gastroenterologists and hepatologists besides endoscopy should learn to measure pressures, should use it in routine practice like blood pressure measurements,” Shiv Kumar Sarin, MD, DM, director of WHO Collaborative Center on Viral Hepatitis and Liver Diseases at the Institute of Liver and Biliary Sciences, New Delhi, India, said during the Bockus Lecture. “It is the core of liver diseases because it changes the outcome of your patient.”
Sarin explained that patients with pressure lower than 10 mm Hg are candidates for beta blocker control.
“We have to prevent liver hypertension and we need to intervene before pressure hits the sky and collaterals start developing,” Sarin said.
Response to beta blockers is defined as 20% reduction in baseline portal pressure in large varices or 8% to 10% reduction in small or no varices. In prophylaxis of large varices, Sarin explained that beta blockers can aid in the prevention of first bleed in the 30% of patients with cirrhosis and high varices who respond. He said these responders who have more than a 20% reduction in HVPG from baseline have a reduced first bleed and are less likely to rebleed.
“Can you have a la carte treatment for liver hypertension? Yes,” Sarin said. “First you give beta blockers ... bring down the pressures as the patient tolerates. Repeat the pressure once. If it has not come down, you can add another drug such as a statin or metformin. If there is no response, you go for band ligation.”
The goal is to keep pressure below 12 mm Hg and, more ideally, below 10 mm Hg, he said.
“Often the liver is too hard and therefore we have to work better to avoid a larger spleen or hypersplenism, avoid ascites, avoid variceal bleed, avoid decompensation and even jaundice,” Sarin said. “I would like a new era to start in liver diseases. ... I do hope portal pressure will be considered relevant by all of you.” – by Katrina Altersitz
Reference: Sarin SK. Bockus Lecture. Presented at: World Congress of Gastroenterology at American College of Gastroenterology Annual Scientific Meeting; Oct. 13-18, 2017; Orlando, FL.
Disclosures: Sarin reports no relevant financial disclosures.