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Background Acute variceal bleeding (AVB) is a medical emergency and associated with a mortality of 20% at 6 weeks. Significant advances have occurred in the recent past and hence there is a need to update the existing consensus guidelines. There is also a need to include the literature from the Eastern and Asian countries where majority of patients with portal hypertension (PHT) live. MethodsThe expert working party, predominantly from the Asia-Pacific region, reviewed the existing literature and deliberated to develop consensus guidelines. The working party adopted the Oxford system for developing an evidence-based approach. Only those statements that were unanimously approved by the experts were accepted. Results AVB is defined as a bleed in a known or suspected case of PHT, with the presence of hematemesis within 24 h of presentation, and/or ongoing melena, with last melanic stool within last 24 h. The time frame for the 123Hepatol Int (2011( ) 5:607-624 DOI 10.1007 AVB episode is 48 h. AVB is further classified as active or inactive at the time of endoscopy. Combination therapy with vasoactive drugs (\30 min of hospitalization) and endoscopic variceal ligation (door to scope time \6 h) is accepted as first-line therapy. Rebleeding (48 h of T 0 ) is further sub-classified as very early rebleeding (48 to 120 h from T 0 ), early rebleeding (6 to 42 days from T 0 ) and late rebleeding (after 42 days from T 0 ) to maintain uniformity in clinical trials. Emphasis should be to evaluate the role of adjusted blood requirement index (ABRI), assessment of associated comorbid conditions and poor predictors of nonresponse to combination therapy, and proposed APASL (Asian Pacific Association for Study of the Liver) Severity Score in assessing these patients. Role of hepatic venous pressure gradient in AVB is considered useful. Antibiotic (cephalosporins) prophylaxis is recommended and search for acute ischemic hepatic injury should be done. New guidelines have been developed for management of variceal bleed in patients with non-cirrhotic PHT and variceal bleed in pediatric patients. Conclusion Management of acute variceal bleeding in Asia-Pacific region needs special attention for uniformity of treatment and future clinical trials.

HCC in young adults occurs mainly in hepatitis B carriers and is often diagnosed at an advanced stage. Their survival outcome is not different from that of older patients because the advanced disease at presentation offsets the advantages of better liver function and a higher resection rate. However, there is a distinct survival advantage for young patients diagnosed with early disease. These results support the importance of extending HCC surveillance to young hepatitis B carriers.

The haemodynamic effects of propranolol have been well studied. Lebrec et al. demonstrated a greater than 20% reduction in the hepatic venous pressure gradient (HVPG) following the acute administration of propranolol, 1 but up to one-third of patients do not exhibit a portal hypotensive response. 2 This may be explained by a portal hypertensive model demonstrating that a rise in the portocollateral resistance accompanies the reduction in portal blood¯ow, thus reducing the overall portal hypotensive response to propranolol. 3 Current evidence suggests that the goal of pharmacotherapy in reducing the risk of variceal haemorrhage is to achieve a fall in the HVPG to £ 12 mmHg 4 or a 20% 5 reduction from baseline values. The role of non-selective b-blockers in the primary prevention of variceal haemorrhage has been extensively studied. 6±14 Meta-analysis of these trials has clearly shown the bene®t of these drugs when compared with placebo. 15 However, many patients are intolerant to drug side-effects. 10,13 a 1 antagonism has been investigated in three haemodynamic studies. 16±18 Impressive reductions in the HVPG were achieved and these were comparable with SUMMARY Background: Carvedilol is a non-selective vasodilating b-blocker with weak a 1 receptor antagonism. Recent studies have demonstrated its potential as a portal hypotensive agent. Aim: To assess the haemodynamic effects and patient tolerability of the acute and chronic administration of low-dose carvedilol. Methods: Haemodynamic measurements were performed in ten cirrhotic patients before and 1 h after the administration of 12.5 mg oral carvedilol. The study was repeated 4 weeks after daily administration of 12.5 mg carvedilol. Results: After acute administration of carvedilol, there was a 23% reduction in the hepatic venous pressure

TIPSS is effective in the management of variceal bleeding, and has a low complication rate. With surveillance, good patency can be achieved. Careful selection of patients is needed to reduce the encephalopathy rate.