Thread by @AnilcheswinK

✨ APASL 2025 AVB Guidelines vs 2011 ✨

1️⃣ Refined definitions & risk stratification → “Home-to-door” 🏠➡️🏥, APASL Bleed Severity Score, HVPG, AI 🧠
2️⃣ Expanded rescue therapies → SEMS, early-TIPS, EUS-guided glue/thrombin, BRTO/CARTO/PARTO 💉
3️⃣ Personalized pharmacology → region-specific antibiotics 💊, tailored vasoactives
4️⃣ Standardized endoscopy → EVL = gold standard 👑 + anesthesia/risk guidance
5️⃣ Greater clinical focus → practical, Asia-Pacific-specific 🌏

👉 More precise, dynamic & practice-ready for better #AVB outcomes ✅

#Hepatology #GI #Liver #Cirrhosis #VaricealBleed #APASL2025 #Guidelines

link.springer.com/article/10.100…

📘 New APASL Definitions (2025)

🔴 Acute Variceal Bleeding (AVB):
➡️ Hematemesis within last 48h 🩸
➡️ Ongoing melena (last stool ≤24h) in suspected/known PHT

🔄 Re-bleeding (post AVB control):
⏰ Very early: 48–120h
🗓 Early: 120h – 42 days
📅 Late: >42 days

⏱️ ‘Home-to-door’ time – new in APASL 2025 AVB Guidelines

➡️ Time = onset of bleed 🏠 → hospital 🏥

✅ Ideal: within 2h
✅ Acceptable: ≤4h (mild cases)
⚠️ Delay >4–6h → ↑ mortality (uncontrolled bleed, hepatic ischemia, organ failure)

👉 Applies the “golden hour” principle to variceal bleeding 🔑🩸

🔷 Severity assessment in AVB

🩸 Blood loss severity = based on hemodynamics & clinical signs (tachycardia, orthostatic hypotension, shock).

📊 APASL AVB Severity Score (0–7 points):
✅ SBP & postural drop
✅ Child–Turcotte–Pugh class
✅ Platelet count
✅ Infection
✅ Active bleeding at endoscopy

💊 Pharmacological Therapy in AVB

⚡ Start vasoactives ASAP (<30 min): terlipressin, somatostatin, octreotide

💉 Terlipressin infusion (4–6 mg/24h) > bolus (ECG baseline advised)

⏳ Stop vasoactives after 24–48h once controlled ➕ start NSBB (if no contraindication)

🩸 Tranexamic acid → may ↓ post-EVL re-bleeding

🦠 Antibiotics (ceftriaxone 5d, can shorten to 2d) → not needed in Child-Pugh A

🌐 PPI only for non-variceal UGIB

🚫 Factor VIIa not routinely recommended

🔷 Role of Endoscopy in AVB

First line : Vasoactive drugs + endoscopic therapy

✅ “Door-to-scope”: ideally <6h, latest 24h
🔹 EVL (banding) = gold standard
🔹 GV glue → attending/well-trained fellow

⚠️ Preparation: SBP >70, avoid routine intubation, extubate early
💊 Pre-scope: vasoactives + prokinetics (erythromycin/metoclopramide)

🛑 Rescue Therapies (APASL 2025)

🎈 Balloon tamponade → immediate but high re-bleed, ≤24h only

🧩 SEMS → safer & more effective, controls bleed ~90%, bridge to TIPS

⏳ SEMS can stay 5–7d vs 24h balloon

🔑 Role of TIPS in AVB

⚡ Pre-emptive TIPS = 1st line in high-risk cirrhosis (CTP C<14, CTP B>7 + active bleed,
HVPG>16) → ↑ survival

🩸 Salvage TIPS: uncontrolled bleed despite drugs + endotherapy (prefer 8mm stent)

🚑 Emergency TIPS <8h → better survival

⚠️ Poor outcomes: MAP↓, AKI, active spurter

❌ Futility: CTP ≥14, MELD >30, lactate >12 (unless for transplant)

🔷 Gastric Variceal Bleeding (GVB)

💥 Severe, rapid, profuse bleeds (esp. GOV2/IGV1)
🧪 1st line: Endoscopic glue (cyanoacrylate)
2️⃣ 2nd line: Banding/thrombin
🔄 If recurrent: repeat glue, EUS-embolization
🛠 Rescue: TIPS / BRTO / PARTO
📉 BRTO/PARTO → ↓ re-bleed & encephalopathy vs TIPS
➕ CARTO / Combo (TIPS+embolization) → further ↓ recurrence

🔷 Acute Variceal Bleed in NCPH

🩺 Clinical clues vs cirrhosis → splenomegaly, no ascites/jaundice/encephalopathy

📉 Natural history → low mortality

📑 Definitions & timelines → same as cirrhosis

💊 1st line: vasoactive drugs + EVL > sclerotherapy

🚫 Antibiotics NOT recommended unless ANC <1000

🧬 Coagulopathy uncommon → correction not needed

🛠 Rescue: TIPS, BRTO/PARTO, surgery (portal decompression > non-shunt)

✅ TIPS complications less frequent (better liver function preserved)

Difference APASL 2025 vs BAVENO VII

@UnrollHelper