Main recommendations

Summary

Non-invasive tests are increasingly being used to improve the diagnosis and prognostication of chronic liver diseases across aetiologies. Herein, we provide the latest update to the EASL Clinical Practice Guidelines on the use of non-invasive tests for the evaluation of liver disease severity and prognosis, focusing on the topics for which relevant evidence has been published in the last 5 years.

Main recommendations

1  ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.
Strong recommendation, moderate quality evidence.

2 ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2–4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3–6 months in the first year following eradication.
Strong recommendation, moderate quality evidence.

3 ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70–90 g/L is desired.
Strong recommendation, moderate quality evidence.

4 ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child–Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.
Strong recommendation, high quality of evidence.

5 ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.
Strong recommendation, high quality evidence.

6 ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.
Strong recommendation, high quality evidence.

7 ESGE recommends, in the absence of contraindications,intravenous erythromycin 250mg be given 30–120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.
Strong recommendation, high quality evidence.

8 ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.
Strong recommendation, moderate quality evidence.

9 ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).
Strong recommendation, high quality evidence.

10 ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child–Pugh C ≤ 13 or Child–Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.
Strong recommendation, high quality evidence.

11 ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).
Strong recommendation, moderate quality evidence.

12 ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.
Strong recommendation, high quality evidence.

13 ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.
Strong recommendations, moderate quality evidence.

14 ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.
Weak recommendation, low quality evidence.

15 ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).
Strong recommendation, moderate quality evidence.

16 ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.
Strong recommendation, high quality evidence.

Introduction

This is the second European Crohn’s and Colitis Organisation [ECCO] evidence-based consensus on extraintestinal manifestations [EIMs] of inflammatory bowel disease [IBD] and anaemia. Up to 50% of patients with IBD will develop at least one EIM, which may impact each body system; hence they are a source of considerable morbidity, or even mortality in the case of primary sclerosing cholangitis [PSC] or venous thromboembolic events [VTE]. Broadly, EIMs can be categorized as classical, arising from inflammatory pathology at distant sites, the consequences of systemic inflammation and treatment, or wider associations. The underlying pathophysiology of extraintestinal inflammation is not fully understood. Potential driving forces include extension of the immune-mediated response from the inflamed gut to other organs, with shifts in leukocyte trafficking, changes to the intestinal microbiota, and underlying predisposing genetic factors. The systemic consequences of IBD lead to broader associations, including VTEs and anaemia. Whether these are strictly EIMs is of debate, but they are included within this guideline as they incur a considerable health burden to patients with IBD.

Abstract

Background

Variation exists in practice pertaining to bowel preparation before minimally invasive colorectal surgery. A survey of EAES members prioritized this topic to be addressed by a clinical practice guideline.

Objective

The aim of the study was to develop evidence-informed clinical practice recommendations on the use of bowel preparation before minimally invasive colorectal surgery, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.

Methods

This is a collaborative project of EAES, SAGES, and ESCP. We updated a previous systematic review and performed a network meta-analysis of interventions. We appraised the certainty of the evidence for each comparison, using the GRADE and CINeMA methods. A panel of general and colorectal surgeons, infectious diseases specialists, an anesthetist, and a patient representative discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost, and use of resources, moderated by a GIN-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.

Results

The panel suggests either oral antibiotics alone prior to minimally invasive right colon resection or mechanical bowel preparation (MBP) plus oral antibiotics; MBP plus oral antibiotics prior to minimally invasive left colon and sigmoid resection, and prior to minimally invasive right colon resection when there is an intention to perform intracorporeal anastomosis; and MBP plus oral antibiotics plus enema prior to minimally invasive rectal surgery (conditional recommendations); and recommends MBP plus oral antibiotics prior to minimally invasive colorectal surgery, when there is an intention to localize the lesion intraoperatively (strong recommendation). The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/LwvKej.

Conclusion

This guideline provides recommendations on bowel preparation prior to minimally invasive colorectal surgery for different procedures, using highest methodological standards, through a structured framework informed by key stakeholders.

Guideline registration number PREPARE-2023CN045.

Keywords: Bowel preparation, Colorectal surgery, Minimally invasive surgery, Laparoscopic surgery, Guidelines