Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management

Abstract

Background and Aims: Portal hypertension (PHT) and HCC are 2 major complications of cirrhosis that often coexist in the same patient and impact the prognosis, especially in patients with acute variceal bleeding. In this review, we aim to discuss the best strategy for PHT screening and primary prophylaxis, as well as the management of acute variceal bleeding, to improve the management of PHT in HCC patients. Results: Recent therapeutic advances observed in the management of HCC, notably through the advent of immunotherapy, have led to a clear improvement in the survival of patients. The prevention of complications related to underlying cirrhosis, such as PHT and acute variceal bleeding, is now part of the management of HCC patients. The Baveno VII conference recently redefined screening and prophylaxis in patients with cirrhosis. However, data regarding the applicability of these criteria in patients with HCC have been sparse. From our point of view, the Baveno criteria are not appropriate to exclude high-risk esophageal varices (EV) in HCC patients, and endoscopy should be performed except in HCC patients with a liver stiffness measurement (LSM) ≥25 kPa, who should benefit from nonselective beta-blockers (NSSBs) without performing endoscopy. We are also in favor of using NSBBs as primary prophylaxis in patients with EV regardless of the size and with gastric varices since these patients display clinically significant PHT. Conclusions: Appropriate evaluation and treatment of PHT remain major issues in improving the outcomes of HCC patients. Many questions remain unanswered, opening the field to many areas of research.

Reply: Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management

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We thank Tripathi and colleagues for their interest in our review about the evidence gaps for the prevention and management of portal hypertension (PHT) and acute variceal bleeding in patients with HCC. [1] We agree that we are facing a lack of strong evidence regarding the use of nonselective beta-blockers (NSBB) in HCC patients with a liver stiffness measurement ≥ 25 kPa. However, we believe that NSBB might present beneficial properties, as NSBB prevents acute variceal bleeding, are associated with a lower liver cancer mortality rate and may reduce HCC occurrence.

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“…So, we are not in favor of prescribing NSBB without endoscopy, only in patients with baseline HVPG ≥ 10 mm Hg. Other techniques need to be developed, such as spleen stiffness measurement or imaging score for the proper diagnosis of PHT in HCC patients.Although Tripathi et al [5] raised pertinent questions about the uncertainty of the literature regarding the use of NSBB in HCC patients, we still believe that the use of NSBB in patients with liver stiffness measurement of ≥ 25 kPa might improve their outcome and to date, no performant technique exists to diagnose PHT in this population of patients who appears as a major research issue.…”

“…Although Tripathi et al [5] raised pertinent questions about the uncertainty of the literature regarding the use of NSBB in HCC patients, we still believe that the use of NSBB in patients with liver stiffness measurement of ≥ 25 kPa might improve their outcome and to date, no performant technique exists to diagnose PHT in this population of patients who appears as a major research issue.…”

Letter to the Editor: Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management

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To the editor, We read with interest the article by Allaire and Thabut on the management of portal hypertension (PH) in patients with HCC. [1] We would like to clarify some important aspects of the Baveno VII recommendations [2] for starting nonselective beta-blockers (NSBBs).The authors correctly mentioned that Baveno VII focuses on clinically significant portal hypertension (CSPH) to select patients with compensated advanced chronic liver disease for NSBB regardless of varices. [3,4] Evidence supports using liver stiffness measurement (LSM) ≥ 25 kPa through vibrationcontrolled transient elastography as a CSPH surrogate in patients with hepatitis C or hepatitis B infection, or alcohol-associated liver disease, and nonobese NASH-but not for other etiologies or for obese NASH.

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“…To the editor, We read with interest the article by Allaire and Thabut on the management of portal hypertension (PH) in patients with HCC. [1] We would like to clarify some important aspects of the Baveno VII recommendations [2] for starting nonselective beta-blockers (NSBBs).…”