Published online Jun 7, 2019. doi: 10.3748/wjg.v25.i21.2665
Peer-review started: February 18, 2019
First decision: March 5, 2019
Revised: March 13, 2019
Accepted: March 24, 2019
Article in press: March 25, 2019
Published online: June 7, 2019
Baveno VI Consensus addresses management of patients without baseline oesophageal varices, or with small varices, in whom aetiological factor has been removed. No recommendation is given in those under betablockers. Main Liver Associations Guidelines on this topic simply refer to Baveno.
Future research in this field should confirm our results in a larger number of patients. Alternative aetiologies, not only hepatitis C virus (HCV) cirrhosis, should be explored.
We tried to satisfy a real-life, unmet situation: how to manage betablockers in our patients after sustained virological response (SVR).
All our study patients were recruited from our clinic. Baseline data [before direct-acting antivirals (DAA) treatment] were collected and checked against evolutionary data after SVR. As a novelty, endoscopy variceal size was confronted to hepatic venous pressure gradient having in mind endoscopy has been advocated by some authors to be a reliable tool after SVR. Transient elastography was also challenged in this SVR setting.
After more than one year of SVR, 39% of our patients evolved below the oesophageal bleeding threshold. The only predictable factor of this favourable evolution was a drop of at least 1 point in Model for End-Stage Liver Disease score. Transient elastography and endoscopy did not confidently detect this change. In those patients below 12 mmHg, permanently stopping betablockers was safe as no bleeding episode has appeared after more than one year of follow-up. Main remaining problem is the evolution of those patients still above 12 mmHg. Portal hypertension regression seems to be a dynamic condition after SVR. Therefore, some of them could still evolve satisfactorily in future evaluations but others could have reached a point of no return.
After more than one year of SVR, 39% of patients with baseline HCV cirrhosis and oesophageal varices under prophylactic betablockers are below the bleeding threshold. Transient elastography and endoscopy are unreliable in this setting. Permanently stopping betablockers seems to be safe in those below 12 mmHg. Evolution of portal hypertension after SVR in the subgroup of patients under betablocker treatment. Unreliability of transient elastography and endoscopy in this setting. Safety of permanently stopping betablockers in those below 12 mmHg. Portal hypertension can regress even in those with the more severe condition, making prophylaxis with betablockers unnecessary. Several studies recently characterize portal hypertension evolution in the new scenario of easy-to-reach SVR after interferon-free DAA treatment. Data on the evolution of portal hypertension and its management in those patients with the more severe condition (i.e., under betablockers) were lacking. Betablockers can be permanently stopped in those below 12 mmHg after SVR. Non-invasive assessment of post-SVR bleeding threshold is not reliable. Portal hypertension in those with the more severe condition is a dynamic regressive process with a clinical benefit for patients. Severe portal hypertension regresses in some patients and betablockers can be safely stopped. Endoscopy and transient elastography are not reliable assessing post-SVR bleeding risk. Betablockers can be safely discontinued in those below 12 mmHg.
Do not trust non-invasive assessment of bleeding risk after SVR. Reliable tools for non-invasive assessment of bleeding risk after removal of aetiological factor. We presume combinatory algorithm with liver and spleen elastographies. Perhaps ultrasound-based contrast-enhanced arrival time to hepatic vein.