The first Australian consensus on the diagnosis and management of portal hypertension in cirrhosis aims to upskill gastroenterologists managing an increasing number of patients with chronic liver disease.

Developed by the Gastroenterological Society of Australia (GESA), the consensus statement, which has been published as a special article in the journal Hepatology Communications [link here], provides 52 evidence-based recommendations on portal hypertension specific to the Australian context.

More than 40 health care professionals specialising in the area contributed to its development.

Associate Professor Avik Majumdar.

Melbourne-based hepatologist Associate Professor Avik Majumdar, who co-chaired the project, said a main driver for the document had been the “alarming” worsening of the chronic liver disease health burden, which had been highlighted by recently published statistics.

He pointed to the Australian Institute of Health and Welfare’s Burden of Disease Study 2024 [link here], which showed chronic liver disease was now the third leading cause of premature death – measured by years of life lost – in the 50-59 age group, and the fourth leading cause across all other age groups from 35-70.

For Indigenous Australians, the standardised death rate from chronic liver disease was almost 3-fold higher than in non-Indigenous Australians.

He also told the limbic that Australia’s patient profiles and care delivery differed from other countries and couldn’t be entirely captured in the European and American guidelines – which were often used by Australian clinicians, highlighting the need for local standardised practice.

“One of the things that happens in Australia is that hepatologists are largely concentrated in metropolitan teaching hospitals, whereas the care for these patients are provided by general gastroenterologists or general physicians in the community as well. It’s very hard for a general gastroenterologist to keep on top of everything that’s happening internationally,” said Associate Professor Majumdar, who is a transplant hepatologist at the Victorian Liver Transplant Unit at Austin Health and Clinical Associate Professor at the University of Melbourne.

“This is a resource that will enable earlier identification for patients at risk of events and then the standard-of-care management that can prevent outcomes and start addressing this increasing risk of premature death.”

Key recommendations from the consensus statement 

The guideline covers nine domains and includes clinical algorithms, which are “quite unique” and useful for the general gastroenterologist, said Associate Professor Majumdar.

The domains include:

• Diagnosis, risk stratification, and prevention of decompensation
• Portal hypertension–related bleeding
• Ascites and renal impairment
• Hepatic encephalopathy
• Sarcopenia, nutrition, and frailty
• Thrombosis in cirrhosis
• Cardiopulmonary complications
• Surgery
• Pregnancy

An algorithm for assessing and managing clinically significant portal hypertension in patients with compensated cirrhosis suggests using liver stiffness measurement by transient elastography combined with platelet count to rule in or out a diagnosis, with carvedilol listed as the preferred non-selective beta-blocker for management and propranolol a suggested alternative.

The algorithm for managing variceal bleeding, which has a high mortality risk, stresses early consideration of transjugular intrahepatic portosystemic shunt (TIPS) implantation (ideally within 72 hours of acute bleeding), which was “something that could save lives”, Associate Professor Majumdar said.

He said other unique aspects of the guideline include a recommendation for the use of continuous terlipressin infusions for patients who are transplant-eligible – an effective therapy that has been used particularly in Victoria, as well as a recommendation for albumin infusion – which has preceded the globally-recognised Baveno guidelines. Albumin infusion will be included in the Baveno VIII guidelines, Associate Professor Majumdar added.

The Australian document recommends against spontaneous bacterial peritonitis (SBP) prophylaxis, due to a lack of efficacy and increasing concerns about multi-drug-resistant organisms in patients with decompensated cirrhosis.

However, SBP prophylaxis with norfloxacin 400 mg daily or trimethoprim–sulfamethoxazole 800 mg/160 mg daily remains recommended.

The document is the first portal hypertension guideline to focus on sarcopenia, with suggestions to increase muscle mass with an exercise program and to consider testosterone replacement in men, which has been based on local research. It also incorporates recommendations on surgery and pregnancy.

Associate Professor Majumdar suggested the recommendations were cutting-edge globally.

“Having just returned from the Baveno meeting, which is a five-yearly portal hypertension meeting where the agenda is set internationally, our points are quite up-to-date and mirror what was discussed, which was really good to see.”

The consensus document has been developed in parallel with two other major documents: the more technical Australian best practice recommendations for transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension: a consensus statement [link here] and GESA’s Cirrhosis Care Bundle [link here].

The full guidance will be available on the GESA website later this year and will be regularly revised to ensure recommendations remain current.