Perceptions on the management of varices and on the use of albumin in patients with cirrhosis among GI specialists in Austria

Abstract

Summary Background Portal hypertension (PH) causes severe complications in patients with liver cirrhosis, such as variceal bleeding and ascites; however, data on the knowledge and perceptions on guideline recommendations for the management of varices and the use of albumin is scarce. Methods We designed two structured surveys on (i) the management of varices and (ii) the use of albumin for Austrian physicians of specialized Gastro-Intestinal (GI) centers. The interviewed physicians were confronted spontaneously and provided ad hoc responses to the questionnaire. Results In total, 158 surveys were completed. Interestingly, many specialists (30%) would recommend a follow-up gastroscopy after 1 year in patients with compensated cirrhosis without varices (i.e., overtreatment). For small varices, 81.5% would use non-selective beta blockers (NSBB) for primary prophylaxis (PP). For PP in patients with large varices, endoscopic band ligation (EBL) plus NSBB was preferred by 51.4% (i.e., overtreatment). Knowledge on the indication criteria for early TIPS (transjugular intrahepatic portosystemic shunt) was reported by 54.3%, but only 20% could report these criteria correctly. The majority (87.1%) correctly indicated a preference to use NSBB and EBL for secondary prophylaxis (SP). The majority of participating gastroenterologists reported no restrictions on the use of albumin (89.8%) in their hospitals. Of the interviewed specialists, 63.6% would use albumin in patients with SBP; however, only 11.4% would use the doses recommended by guidelines. The majority of specialists indicated using albumin at the recommended doses for hepatorenal syndrome (HRS-AKI, 86.4%) and for large volume paracentesis (LVP, 73.3%). The individual responses regarding albumin use for infections/sepsis, hyponatremia, renal impairment, and encephalopathy were heterogeneous. Conclusion The reported management of PH and varices is mostly adherent to guidelines, but endoscopic surveillance in patients without varices is too intense and EBL is overused in the setting of PP. Knowledge on the correct use of early TIPS must be improved among Austrian specialists. Albumin use is widely unrestricted in Austria; however, albumin is often underdosed in established indications.

Statins, metformin, and RAS inhibitors did not reduce variceal bleeding risk and mortality in a large, real-life cohort of patients with cirrhosis

“…Similarly, the rate of recommended NSBB use (26) was also low in our study, particularly in the context of secondary prophylaxis. This could be due to non-recorded contraindications or intolerance to NSBBs, but also to preferences of the respective treating physicians–as we have previously documented for Austria [ 42 , 43 ]. However, the impact of the synergistic effect of NSBB to individual co-medications (statin, metformin, or RASi) on bleeding has no significant effect (see Fig 5 ).…”

Endoscopic band ligation is safe despite low platelet count and high INR

“…Kaplan-Meier curves of procedure-related bleeding events according to A size of varices, B serum bilirubin, C international normalized ratio, and D platelet count within 30 days after EBL. n (total numbers), d (days), PLT (platelets count in 10 9 /L), INR (international normalized ratio), mg/dL (milligram per deciliter), HR (Hazard-Ratio; statistical comparisons were performed by log-rank tests) and found that 47.1% of the surveyed persons would use NSBB for primary prophylaxis and 87.1% would perform combined treatment with NSBB and EBL for secondary prophylaxis of variceal bleeding [41]. Thus, it seems that despite the recommendation to preferentially use NSBB for primary prophylaxis and the combination of NSBB and EBL in secondary prophylaxis, many physicians (or endoscopists) do not use NSBB according to their own preference.…”

Small varices in chronic liver diseases

“…[9]. Though there are controversies for the effects of NSBBs, 81.5% of the physicians would use NSBBs for primary prevention of small varices in a survey [104]. For the primary prevention of small varices with risk factors (red signs and/or with CTP B or C), NSBBs are recommended in many guidelines [11,102,105].…”