Portal Hypertension V E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 410

Veröffentlichungsjahr: 2011

Beschreibung

Every five years, hepatologists with an interest in portal hypertension (high blood pressure in the portal vein), gather in Baveno, Italy, for the Baveno International Consensus Workshop on Portal Hypertension, attending workshops and examining the latest in clinical data and research on this condition. This book documents the contents of the meeting so that practitioners who could not be present at the conference still have access to the proceedings.

Leseprobe

Contents

Cover

Title Page

Copyright

Contributors

Preface

Introduction

Baveno I to IV

Beyond Baveno V

Acknowledgements

Symposium 1: Diagnostic Tools

Lecture 1: Hepatic Venous Pressure Gradient, Biopsy or Both?

Introduction

Hepatic Venous Pressure Gradient

Liver Biopsy

Natural History of Chronic Liver Disease

HVPG, Biopsy or Both?

Summary

Lecture 2: Elastography in the Non-Invasive Evaluation of the Extent of Fibrosis and in the Diagnosis of Portal Hypertension

Introduction

Transient Elastography: Principle and Interpretation

Diagnostic Performance of Transient Elastography for the Extent of Fibrosis

Diagnostic Performance of Transient Elastography for Portal Hypertension

Limitations of Transient Elastography

Conclusions and Perspectives

Lecture 3: Ultrasound in the Non-Invasive Evaluation of Fibrosis and Portal Hypertension

Introduction

Diagnosis and Staging of Fibrosis

Diagnosis of Cirrhosis

Classification, Diagnosis and Quantification of Portal Hypertension

Prediction of Prognosis in Cirrhosis

New US Technologies and Future Applications

Lecture 4: Non-Invasive and Minimally Invasive Diagnosis of Varices

Introduction

Possible Alternatives to Esophagogastroduodenoscopy (EGD)

Conclusions

Lecture 5: Clinical Epidemiological and Statistical Challenges in Defining, Recording and Analysing Endpoints

Introduction

Clinical Course in Patients with Portal Hypertension

Clinical Epidemiology Deals with These Problems

Statistical Tools

Definition and Recording of Endpoints

Definition of Observation Time

Surrogate Endpoints

Combined Endpoints

Competing Endpoints

Changes Over Time in Risk

Correlated Endpoints

Repeated Endpoints and Multistate Models

Session 1: Pre-Primary and Primary Prophylaxis

Lecture 6: Pre-primary and Primary Prophylaxis: What Has Been Done?

Introduction

Pre-Primary Prophylaxis in Portal Hypertension

Primary Prophylaxis of Variceal Bleeding

Conclusions

Lecture 7: Pre-Primary and Primary Prophylaxis: What Should We Do Next?

Introduction

Pre-Primary Prophylaxis

Primary Prophylaxis

Bavevo V Consensus Statements: Pre-primary and Primary Prophylaxis

Pre-Primary Prophylaxis (prevention of the formation of varices)

Prevention of the First Bleeding Episode

Session 2: Definition of Key Events

Lecture 8: Failure to Control Bleeding and Failure to Control Rebleeding

Introduction

The Retrospective Validation of Baveno IV Criteria

Conclusion

Questionnaire to the Expert Panel

Failure to Control Bleeding

Failure to Prevent Rebleeding

Baveno V Consensus Statements: Definition of Key Events Regarding the Bleeding Episode

Baveno IV definitions and criteria for failure to control bleeding

Baveno IV Definitions and Criteria for Failure of Secondary Prophylaxis

Baveno V Definitions and Criteria for Failure to Control Bleeding

Baveno V Definitions and Criteria for Failure of Secondary Prophylaxis

Areas Requiring Further Study (5;D)

Lecture 9: Should Prognostic Variables be used to Direct Patient Management in the Acute Setting?

Introduction

Prognostic Factors in Acute Variceal Bleeding

Possible Strategies for Patients with High-Risk Treatment Failure

Conclusions

Session 3: Treatment of Acute Bleeding

Lecture 10: Treatment of Acute Bleeding

Introduction

General Management

Primary Therapy for Acute Variceal Bleeding

Rescue Therapy for Acute Treatment Failure

Baveno V Consensus Statements: Treatment of the Acute Bleeding Episode

Blood Volume Restitution

Antibiotic Prophylaxis

Prevention of Hepatic Encephalopathy

Assessment of Prognosis

Timing of Endoscopy

Pharmacological Treatment

Endoscopic Treatment

Early TIPS Placement

Use of Balloon Tamponade

Use of Self-Expandable Metal Stents

Management of Treatment Failures

Areas Requiring Further Study

Session 4: Prevention of Rebleeding

Lecture 11: Preventing Rebleeding in 2010

Beta-Blockers Alone or Combined with Other Drugs

Endoscopic Therapy: Endoscopic Variceal Ligation or Combined with Other Endoscopic procedures

Drugs Alone or with Endoscopic Variceal Ligation? Endoscopic Variceal Ligation Alone or with Drugs?

Transjugular Intrahepatic Portosystemic Shunt Versus Endoscopic Treatment

Rescue Therapy: Always TIPS? Treatment of Poor Candidates for TIPS

Secondary Prophylaxis of Variceal Bleeding: Role of Surgery

The Role of HVPG Monitoring in Secondary Prophylaxis

Baveno V Consensus Statements: Prevention of Rebleeding

Time to start secondary prophylaxis

Lecture 12: Stages Classification of Cirrhosis: Where Do We Stand?

Introduction

The Concept of Clinical Stages in Cirrhosis

Key Events in the Clinical Course of Compensated Cirrhosis

Key Events in the Clinical Course of Decompensated Cirrhosis

Disease Stages

What Next

Concluding Remarks

Session 5: Vascular Disease of the Liver

Lecture 13: Budd-Chiari Syndrome – Hepatic Venous Outflow Tract Obstruction

Introduction

Epidemiology

Causal Factors for Primary Budd-Chiari Syndrome

Manifestations

Diagnosis

Therapy

Prognosis

Lecture 14: Extrahepatic Portal Vein Obstruction (EHPVO)

Introduction

Definition

Aetiology

Clinical Presentation

Diagnosis

Natural History

Classification

Treatment with Anticoagulants

Treatment of Bleeding

Treatment of Chronic EHPVO in Children

Portal Biliopathy

Baveno V Consensus Statements: Non-Cirrhotic Portal Hypertension

Budd-Chiari Syndrome (BCS – hepatic venous outflow tract obstruction (HVOTO))

Extrahepatic Portal Vein Obstruction (EHPVO)

Lecture 15: The Coagulopathy of Chronic Liver Disease. Is the Long and Widely Held Belief Being Dispelled?

Introduction

How the Dogma was Born and how it is Challenged

Hyper- Rather than Hypocoagulability Seems to be the Distinctive Feature of Chronic Liver Disease

Concluding Remarks

Lecture 16: Anticoagulation Therapy in Cirrhosis with Portal Vein Thrombosis

Introduction

Pathophysiology

Rationale for Treatment

Anticoagulation to Treat Portal Vein Thrombosis in Cirrhosis

Choice of Anticoagulant Therapy and Safety of Anticoagulation

Conclusions

Lecture 17: Variceal Bleeding, Infections and the Hepatorenal Syndrome

Introduction

Causes of AKI

Diagnosis of HRS

Treatment of type 1 HRS

Prevention of type 1 HRS

Conclusions

Lecture 18: Portal Hypertension in Children: Current Practice and the Need for Evidence

Introduction

Survey of Current Expert Practice

Evidence Supporting Current Paediatric Practice

Challenges Undertaking Controlled Studies of Children with Portal Hypertension

Conclusions

Symposium 2: A Look into the Future: New Treatments on the Horizon

Lecture 19: Statins in Portal Hypertension

The Need for New Drugs in Portal Hypertension

Rationale for the use of Statins in Cirrhosis

Statins in Patients with Cirrhosis

Other Potential Benefits of Statins in Cirrhosis

Future Perspectives

Lecture 20: A Look into the Future: New Treatments on the Horizon – Antiviral Therapy

Introduction

Effects of AVT on Portal Pressure

Impact of Long-Term Interferon-Based Therapy on the Clinical Manifestations of Portal Hypertension

Lecture 21: Antifibrotic Drugs

Introduction

General Features of Antifibrogenic Agents

The Potential Antifibrogenic Action of Antiviral Drugs

Angiotensin II Receptor Blockers

Antioxidants and “Herbal” Drugs

Probiotics and Other Strategies to Modulate the Gut Flora: is it Worth a Try?

Antiangiogenic is Also Antifibrogenic

Compensated Cirrhosis: the Ideal Ground for Experimenting Antifibrotic Drugs

Lecture 22: New Drugs in the Treatment of Portal Hypertension

Rational Basis for Drug Therapy

New Beta-Blockers

Treatments Aimed at Diminishing Intrahepatic Resistance

Angiogenesis in Portal Hypertension

Acknowledgments

Index

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Library of Congress Cataloging-in-Publication Data

Baveno International Consensus Workshop (5th) Portal hypertension V : proceedings of the Fifth Baveno International Consensus Workshop / edited by Roberto de Franchis. – 5th ed. p. ; cm. Portal hypertension 5 Portal hypertension five Includes bibliographical references and index. ISBN 978-1-4443-3449-4 (alk. paper) 1. Portal hypertension–Congresses. I. De Franchis, Roberto. II. Title. III. Title: Portal hypertension 5. IV. Title: Portal hypertension five. [DNLM: 1. Hypertension, Portal–Congresses. 2. Gastrointestinal Hemorrhage–complications– Congresses. 3. Liver Diseases–complications–Congresses. WI 720] RC848.P6B38 2011 616.3′62–dc22 2010038433

ISBN: 978-1-4443-3449-4

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781444393965; Wiley Online Library 9781444393989; ePub 9781444393972

Contributors

Shahab Abid, MD, MBBS, FCPS, FRCP (Edin.), FACGAssociate Professor, Department of Gastroenterology, Aga Khan University Hospital, Karachi, Pakistan

Juan G Abraldes, MDHepatic Haemodynamic Laboratory, Liver Unit, Hospital Clinic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

Agustin Albillos, MDDepartment of Gastroenterology, Hospital Ramon y Cajal, University of Alcalà, Madrid, Spain

Per Kragh Andersen, PhD, MSCProfessor of Biostatistics, Department of Biostatistics, Institute of Public Health, University of Copenhagen, Denmark

Rafael Bañares, MDLiver Unit, Hospital General, Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain

Giovanni Barosi, MDDirector, Laboratory of Clinical Epidemiology, IRCCS Policlinico San Matteo, Pavia, Italy

Flemming Bendtsen, MDDepartment of Medical Gastroenterology, Hvidovre Hospital, and Faculty of Health Sciences, University of Copenhagen, Denmark

Annalisa Berzigotti, MD Researcher, Hepatic Haemodynamic Laboratory, Liver Unit, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd); Specialist, Ultrasound Section, Centre Diagnostic per la Imatge, Hospital Clinic, Barcelona, Spain

Jaime Bosch, MDHepatic Haemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain

Concepción Bru Saumell, MD Professor of Radiology, University of Barcelona, and Senior Consultant at Ultrasound Section, Centre Diagnostic per la Imatge, Hospital Clinic, Barcelona, Spain

Christophe Bureau, MDDepartment of Hepato-Gastroenterology, Fédération Digestive Purpan, CHU Toulouse, Inserm U858, and Université Paul Sabatier, Toulouse, France

Andrew K Burroughs, MDRoyal Free Sheila Sherlock Liver Centre, Royal Free Hospital, and UCL, London, UK

Paul Calès, MDDepartment of Hepato-Gastroenterology, University Hospital, Angers, France

Laurent Castéra, MD, PhDDepartment of Hepato-Gastroenterology, Hospital Saint-André & Haut Lévêque, University Hospital of Bordeaux, France

María-Vega Catalina, MDLiver Unit, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain

Yogesh Kumar Chawla, MD, DMProfessor & Head, Department of Hepatology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India

Gennaro D’Amico, MDGastroenterology Unit, Ospedale V Cervello, Palermo, Italy

Mario D’Amico, MDResearch Fellow at Hepatic Haemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Spain

Roberto de Franchis, MD, AGAFProfessor of Gastroenterology, Department of Medical Sciences, University of Milan, and Head, Gastroenterology 3 Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy

María Gabriela Delgado Navas, MDHepatic Haemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain

Alessandra Dell’Era, MD, PhD Assistant Professor of Gastroenterology, Department of Medical Sciences, Università degli Studi di Milano, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy

Angels Escorsell, MDConsultant, ICU, Liver Unit, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Spain

Juan Carlos García-Pagán, MD, PhDConsultant, ICU, Liver Unit, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), University of Barcelona, Spain

Guadalupe Garcia-Tsao, MDSection of Digestive Diseases, Yale University School of Medicine, New Haven, CT, and VA Connecticut Healthcare System, West Haven, CT, USA

Rosa Gilabert Sole, MDChief of Ultrasound Section, Centre Diagnostic per la Imatge, Hospital Clinic, Barcelona, Spain

Norman D Grace, MD, FACP, FACGProfessor of Medicine, Tufts University School of Medicine, Lecturer on Medicine, Harvard Medical School, and Director of Clinical Hepatology, Brigham and Women’s Hospital, Boston, MA, USA

Roberto J Groszmann, MD, FRCPEmeritus Professor of Medicine and Senior Research Scientist, Yale University School of Medicine, New Haven, CT, and VA Connecticut Healthcare System Digestive Diseases Section, West Haven, CT, USA

Peter Hayes, MD, PhDProfessor of Hepatology, University of Edinburgh, UK

Harry LA Janssen, MD, PhDErasmus University Medical Centre, Department of Gastroenterology & Hepatology, Rotterdam, The Netherlands

Patrick S Kamath, MDProfessor of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA

Ashish Kumar, MD, DMAssociate Professor of Hepatology & Assistant Dean, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India

Loren Laine, MDProfessor of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

Vincenzo La Mura, MD Hepatic Haemodynamic Laboratory, Liver Unit, Hospital Clinic, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd) and Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

Didier Lebrec, MDInserm U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Denis Diderot Paris 7, and Department of Hepatology, Hôpital Beaujon, Clichy, France

Simon C Ling, MBChBAssociate Professor of Paediatrics, Division of Gastroenterology, Hepatology & Nutrition, The Hospital for Sick Children and University of Toronto, Ontario, Canada

Gin-Ho Lo, MDProfessor of Medical Nutrition, I-Shou University, and Director, Medical Education, Digestive Centre, E-DA Hospital, Kaohsiung, Taiwan

Carlo Merkel, MDAssociate Professor of Internal Medicine, Hepatic Haemodynamic Laboratory and Clinica Medica 5, Department of Clinical and Experimental Medicine, University of Padua, Padova, Italy

Manuela Merli, MDAssociate Professor of Gastroenterology, Division of Gastroenterology, Department of Clinical Medicine, University of Rome “La Sapienza”, Rome, Italy

Richard Moreau, MDInserm U773, Centre de Recherche Biomédicale Bichat-Beaujon CRB3, Université Denis Diderot Paris 7, and Department of Hepatology, Hôpital Beaujon, Clichy, France

Frederik Nevens, MDDepartment of Liver and Pancreatic Disease, UZ Gasthuisberg KU Leuven, Leuven, Belgium

Massimo Pinzani, MD, PhDDepartment of Internal Medicine, Centre for Research, High Education and Transfer “DENOThe”, University of Florence, Italy

Massimo Primignani, MDGastroenterology 3 Unit, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, Milan, Italy

Diego Rincón, MDLiver Unit, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain

Cristina Ripoll, MDResearch physician, Hepatology and Liver Transplant Unit, Digestive Diseases Department, Hospital General Universitario Gregorio Marañón, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain

Shiv Kumar Sarin, MD, DMDirector, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India

Tilman Sauerbruch, MDProfessor of Medicine, Chairman of the Department of Internal Medicine I, University of Bonn, Germany

Susana Seijo, MDHepatic Haemodynamic Laboratory, Liver Unit, Hospital Clinic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Spain

Marco Senzolo MD, PhDGastroenterology, Department of Surgical and Gastroenterological Sciences, University Hospital of Padua, Padova, Italy

Benjamin L Shneider, MD Professor of Pediatrics, Director of Pediatric Hepatology, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

Thorkild IA Sørensen, MDProfessor of Clinical Epidemiology, Institute of Preventive Medicine, Copenhagen University Hospital, Copenhagen, Denmark

Dominique Thabut, MDDepartment of Hepato-Gastroenterology, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, Pierre et Marie Curie University, Paris, France

Armando Tripodi, PhDAngelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Internal Medicine, IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation, and University of Milan, Italy

Dominique-Charles Valla, MDProfesseur des Universités-Practicien Hospitalier, Chef de Service, Department of Hepatology, Hôpital Beaujon, AP-HP, Université Denis Diderot-Paris 7, and Inserm U773, Clichy, France

Candid Villanueva, MDGastrointestinal Bleeding Unit, Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

Jean-Pierre Vinel, MD Professor of Hepato-Gastroenterology, Head of the Department of Hepato-Gastroenterology, University Hospital Toulouse-Purpan, and Inserm U858, Toulouse, France

Julio Vorobioff, MDAssociate Professor of Medicine, University of Rosario Medical School, Rosario, Argentina

Marco Zoli, MDProfessor of Medicine, Department of Internal Medicine, Ageing and Nephrology, University of Bologna, Italy

Preface

Portal hypertension is associated with the most severe complications of cirrhosis, including ascites, hepatic encephalopathy and bleeding from gastro-oesophageal varices. Despite the progress achieved over the last decades, the six-week mortality associated with variceal bleeding is still in the order of 10–20%. Awareness of the difficulty inherent to the evaluation of diagnostic tools and the design and conduct of good clinical trials for the treatment of portal hypertension has led to the organization of a series of consensus meetings. The first one was organized in 1986 in Groningen, The Netherlands by Andrew Burroughs. After Groningen, other meetings followed, in Baveno in 1990 (Baveno I) and 1995 (Baveno II), in Milan in 1992, in Reston, USA, in 1996, in Stresa in 2000 (Baveno III), again in Baveno in 2005 (Baveno IV), and in Atlanta, USA in 2007.

The aims of these meetings were to develop definitions of key events in portal hypertension and variceal bleeding, to review the existing evidence on the natural history, the diagnosis and the therapeutic modalities of portal hypertension and to issue evidence-based recommendations for the conduct of clinical trials and the management of patients. All these meetings were successful and produced consensus statements on some important points, although some issues remained unsettled.

To continue the work of the previous meetings, with the help and encouragement of a group of friends from 14 countries, many of whom had taken part in the previous four Baveno meetings, we organized a Baveno V workshop which took place in Stresa on May 21–22, 2010.

The aims of the Baveno V workshop were the same as in Baveno I–IV, namely, to refine and extend the definitions of key events concerning the bleeding episode, in the light of the feedback we had received from studies carried out after Baveno IV, and to reassess the diagnostic tools and the therapeutic options in patients with portal hypertension. In addition, we continued the effort that was begun in Groningen and continued in the following workshops, of producing updated guidelines aimed at improving the quality of our future studies and of patients’ care in general. We were very fortunate in being able to bring to these workshops many of the experts responsible for most of the major achievements of the last years in this field.

The structure of the Baveno V workshop included two symposia, five consensus sessions, eight lectures and a report from paediatrics. The symposia were devoted to the evaluation of the new diagnostic tools that have been developed or refined in the last few years and of the new treatment options that have appeared on the horizon. Of the five sessions, one concerned the definition of key events of the bleeding episode, three covered the therapeutic options in patients with portal hypertension, and the fifth was dedicated to non-cirrhotic portal hypertension. The eight lectures were different in scope: the first one was introductory and summarized the past history of the Baveno workshops and the impact that the publications derived from these workshops have had on the medical literature. In addition, it outlined what needs to be done in the future if the Baveno tradition is to continue. The second lecture was of a methodological nature and described the types and uses of endpoints in clinical trials. The third, fourth, fifth, sixth and seventh lectures addressed important clinical issues, such as the opportunity to use prognostic variables to direct therapy of the acute bleeding episode, the state of advancement in the validation of the stages classification of cirrhosis, the coagulopathy of cirrhosis, the use of anticoagulant therapy in cirrhosis with portal vein thrombosis, and the relationship between variceal bleeding, infection and the hepatorenal stndrome. The eighth lecture outlines the differences and similarities between adult and paediatric portal hypertension, and reported a survey of paediatric experts in portal hypertension on the management of varices in children. These proceedings follow closely the structure of the workshop. The consensus statements that were agreed upon in each session are reported at the end of the pertinent chapters. The levels of available evidence and the strength of recommendations are graded according to the Oxford System: (http://www.cebm.net/index.aspx?o=1025).

Our deepest thanks go to all the friends who accepted to give lectures and to serve as chairpersons and panellists of the sessions, and who helped us by working hard in the preparation of the workshop and of the chapters.

We also wish to thank Beatrice Rusconi, Gaetano Sabattini, Denise Santi, Anna Maria Sorresso and the entire staff of ADB Eventi e Congressi who managed brilliantly the organization of the workshop, and Sandra Covre, who acted as a consultant in the organization process.

In addition, we are grateful to the European Association for the Study of the Liver (EASL), who supported and endorsed the workshop, and to the following scientific societies who endorsed Baveno V: Associazione Italiana Gastroenterologi ed Endoscopisti Ospedalieri (AIGO), Associazione Italiana per lo Studio del Fegato (AISF), American Society for Gastrointestinal Endoscopy (ASGE), Società Italiana di Endoscopia Digestiva (SIED), Società Italiana di Gastroenterologia (SIGE).

Finally, we wish to thank all the companies who sponsored the workshop, and especially Ferring Pharmaceuticals, who made the publication of this book possible through a generous grant, Phil Boothroyd of Ferring, and Oliver Walter of Blackwell for their encouragement and cooperation in this project, and Blackwell Publishing for the timely and excellent production of this volume.

Roberto de Franchis On behalf of the Baveno V Scientific Committee

Symposium 1

Diagnostic Tools

Chairperson: Guadalupe Garcia-Tsao

Speakers: Annalisa Berzigotti, Laurent Castéra, Roberto de Franchis, Guadalupe Garcia-Tsao