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Portal Hypertension Management - Baveno VIII

Portal Hypertension Management - Baveno VIII: Cirrhosis or cACLD (adults), no previous variceal bleed → Assess for CSPH → CSPH present, ruled out, or un...

Pathway Overview

18 steps

Algorithm Steps

18 total

  1. 01Start

    Cirrhosis or cACLD (adults), no previous variceal bleed

    Compensated advanced chronic liver disease: LSM ≥10 kPa or known cirrhosis. Not for acute GI bleeding: resuscitate and use the acute variceal bleeding pathway. Previous variceal bleed: secondary prophylaxis is NSBB plus EVL; use the variceal haemorrhage pathway. Pregnancy: hepatology and obstetric care.

  2. 02Action

    Assess for CSPH

    CSPH = HVPG ≥10 mmHg, or a non-invasive rule-in. Use fasting LSM by transient elastography (TE) and platelet count. Rare causes: HVPG or specialist advice.

    • Rule in: LSM ≥25 kPa (viral, alcohol or non-obese MASLD only), or ANTICIPATE CSPH risk ≥75%
    • Obese MASLD (BMI ≥30 kg/m2): LSM ≥25 kPa rule-in not valid. Rule in with ANTICIPATE-NASH ≥75% or HVPG
    • Rule out: LSM ≤15 kPa AND platelets ≥150 x10^9/L
    • Varices, portosystemic collaterals or spleen stiffness >55 kPa (100 Hz probe) also mean CSPH
    • Confirm an index LSM ≥10 kPa: repeat fasting, or add another validated fibrosis test
  3. 03Decision

    CSPH present, ruled out, or unclear?

  4. CSPH present
  5. 04Action

    CSPH present: NSBB to prevent decompensation

    Carvedilol preferred. A patient on NSBB for CSPH does not need screening EGD.

    • Aim: prevent ascites, variceal bleeding and encephalopathy
    • Start NSBB whether or not HVPG is available
  6. 05Warning

    Before NSBB: low BP, AKI, contraindications

    • Do not start, or reduce/stop, if SBP <90 mmHg, MAP <65 mmHg or HRS-AKI
    • Contraindicated: asthma, 2nd/3rd-degree AV block, sick sinus, symptomatic bradycardia, decompensated heart failure. Avoid with verapamil or diltiazem
    • If NSBB not possible: screening EGD, and EVL for high-risk varices
  7. 06Decision

    Can the patient take an NSBB?

  8. If Yes
    1. 07Action

      NSBB, adults: carvedilol preferred

      Reduce or stop if SBP <90 mmHg, MAP <65 mmHg or HRS-AKI. Restart or re-titrate when resolved. Continue long term if tolerated.

      • Carvedilol 6.25 mg once daily; after 1 week, 12.5 mg a day if tolerated
      • Carvedilol maximum 12.5 mg a day (up to 25 mg a day only with arterial hypertension)
      • Or propranolol: start 20-40 mg twice daily; increase every 2-3 days to HR about 60/min; target at least 40 mg twice daily
      • Propranolol maximum 160 mg twice daily; with ascites, maximum 80 mg twice daily
    2. 08End

      Ongoing care and surveillance

      Treat the cause (HCV SVR, HBV suppression, alcohol abstinence, weight and diabetes). HCC surveillance. Urgent review for ascites, bleeding or encephalopathy.

    If No
    1. 09Action

      Rule not met, or no NSBB possible: screening EGD

      Grade varices: small <5 mm, large ≥5 mm; note red signs and gastric varices.

      • No NSBB possible: EGD can be spared if LSM <20 kPa with platelets ≥150 x10^9/L, or spleen stiffness <40 kPa
      • Gastric varices (GOV2, IGV1) also mean CSPH: NSBB. If NSBB not possible, refer to an expert centre
    2. 10Decision

      Varices on EGD?

    3. None
    4. 11Action

      No varices: repeat EGD in 2 years

      3 years if the cause is removed (for example SVR or abstinence). Earlier if decompensation occurs.

    5. Path rejoins step 08Shared downstream outcome
    6. Small, low risk
    7. 12Action

      Small varices (<5 mm), no red signs, not Child-Pugh C

      Varices mean CSPH: NSBB to prevent decompensation, if no contraindication. No NSBB: repeat EGD in 1 year (2 years if the cause is removed).

    8. NSBB possible
    9. Path rejoins step 07Shared downstream outcome
    10. No NSBB
    11. Path rejoins step 08Shared downstream outcome
    12. High risk
    13. 13Action

      High-risk varices: large (≥5 mm), red signs, or Child-Pugh C

      Prevent a first bleed (no previous bleed). NSBB (carvedilol preferred). EVL only if NSBB is contraindicated or not tolerated.

      • With ascites: NSBB preferred over EVL
      • TIPS is not indicated for primary prophylaxis
    14. NSBB possible
    15. Path rejoins step 07Shared downstream outcome
    16. NSBB not possible
    17. 14Action

      NSBB not possible: EVL (band ligation)

      Repeat EVL every 1-3 months until varices are eradicated, then surveillance EGD.

      • EVL does not prevent ascites or encephalopathy
    18. Path rejoins step 08Shared downstream outcome
  9. Unclear
  10. 15Action

    CSPH unclear: not ruled in or out

    Repeat LSM and platelets in 12 months, or add spleen stiffness or HVPG. Screen for high-risk varices by the Baveno VI rule.

    • CSPH confirmed (HVPG ≥10 mmHg, varices, or, in viral, alcohol or non-obese MASLD, LSM 20-<25 kPa with platelets <150 x10^9/L per GESA): manage as CSPH present
    • Otherwise: use the Baveno VI rule for screening EGD
  11. 16Decision

    Baveno VI rule: LSM <20 kPa AND platelets ≥150 x10^9/L?

  12. If Yes
    1. 17Action

      Rule met: no screening EGD now

      Low risk of varices that need treatment. Repeat LSM and platelets every 12 months.

      • EGD if LSM rises to ≥20 kPa or platelets fall below 150 x10^9/L
    2. Path rejoins step 08Shared downstream outcome
    If No
    1. Path rejoins step 09Shared downstream outcome
  13. CSPH confirmed
  14. Path rejoins step 04Shared downstream outcome
  15. Ruled out
  16. 18Action

    CSPH ruled out: no NSBB

    NSBB has no role without CSPH. Treat the cause. Repeat LSM and platelets every 12 months.

  17. Path rejoins step 08Shared downstream outcome

Guideline Source

Baveno VIII - Advancing consensus in portal hypertension (Baveno VIII Faculty, J Hepatol 2026)

DOI: 10.1016/j.jhep.2026.07.030View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Primary prophylaxis only. Not for acute variceal bleeding, after a variceal bleed (secondary prophylaxis: NSBB plus EVL), non-cirrhotic portal hypertension (PSVD, portal vein thrombosis) or children.
  • Non-invasive CSPH rules are validated mainly in adults with viral, alcohol-related or MASLD cACLD. Other causes: use HVPG or specialist advice.
  • CSPH at LSM 20-<25 kPa with platelets <150 x10^9/L follows GESA 2026; Baveno VIII uses ANTICIPATE risk ≥75%.
  • HVPG may underestimate portal pressure in primary biliary cholangitis.

Contraindicated Populations

Children and adolescents under 18 yearsAcute variceal or GI bleeding (use the acute bleeding pathway)Previous variceal bleeding (secondary prophylaxis: use the variceal haemorrhage pathway)Non-cirrhotic portal hypertension (PSVD, portal or hepatic vein thrombosis)Pregnancy (specialist hepatology and obstetric care)

Applicable Regions

USAUUKEU

AU: GESA clinical practice guideline on portal hypertension in cirrhosis (Hepatol Commun 2026;10(4):e0934), aligned with Baveno VII. Carvedilol and propranolol are TGA-registered.

EU: Baveno VIII consensus (J Hepatol 2026)

UK: BSG variceal haemorrhage guideline (Tripathi 2015)

US: AASLD practice guidance on portal hypertension and varices

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Portal Hypertension Management - Baveno VIII?

The Portal Hypertension Management - Baveno VIII is a management clinical algorithm for Hepatobiliary Surgery. It provides a structured decision tree to guide clinical decision-making, based on Baveno VIII - Advancing consensus in portal hypertension (Baveno VIII Faculty, J Hepatol 2026).

What guideline is the Portal Hypertension Management - Baveno VIII based on?

This algorithm is based on Baveno VIII - Advancing consensus in portal hypertension (Baveno VIII Faculty, J Hepatol 2026) (DOI: 10.1016/j.jhep.2026.07.030).

What are the limitations of the Portal Hypertension Management - Baveno VIII?

Known limitations include: Primary prophylaxis only. Not for acute variceal bleeding, after a variceal bleed (secondary prophylaxis: NSBB plus EVL), non-cirrhotic portal hypertension (PSVD, portal vein thrombosis) or children.; Non-invasive CSPH rules are validated mainly in adults with viral, alcohol-related or MASLD cACLD. Other causes: use HVPG or specialist advice.; CSPH at LSM 20-<25 kPa with platelets <150 x10^9/L follows GESA 2026; Baveno VIII uses ANTICIPATE risk ≥75%.; HVPG may underestimate portal pressure in primary biliary cholangitis.. Individual patient factors may require deviation from these recommendations.

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