ACG Releases Guideline for the Management of Vascular Liver Disorders

The American College of Gastroenterology (ACG) has released a new clinical guideline for the management of vascular disorders of the liver. The guideline includes recommendations relating to thrombotic and bleeding risk in cirrhosis, portal and mesenteric venous thrombosis in patients with and without cirrhosis, hereditary hemorrhagic telangiectasia (HHT) involving the liver, Budd-Chiari syndrome (BCS), and mesenteric arterial aneurysms.

“Disorders of the mesenteric, portal, and hepatic veins and mesenteric and hepatic arteries have important clinical consequences and may lead to acute liver failure, chronic liver disease, noncirrhotic portal hypertension, cirrhosis, and hepatocellular carcinoma,” the guideline authors wrote. “Although literature in the field of vascular liver disorders is scant, these disorders are common in clinical practice, and general practitioners, gastroenterologists, and hepatologists may benefit from expert guidance and recommendations for management of these conditions.”


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To develop the guideline, the authors analyzed literature that was published from 2000 through 2018. In total, the authors highlighted 28 key concepts and made 23 recommendations.

One of the strong recommendations that the authors developed was for the management of portal and mesenteric vein thrombosis in patients with or without cirrhosis. For this, the authors recommended that Doppler ultrasonography be used as the initial noninvasive modality for the diagnosis of portal vein thrombosis (PVT). 

The authors made several other strong recommendations for the management of portal and mesenteric vein thrombosis, including:

  • Perform a contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) scan to assess the extension of thrombus into the mesenteric veins and to exclude tumor thrombus among patients with cirrhosis who develop new portal and/or mesenteric vein thrombus.
  • Prescribe anticoagulation for all noncirrhotic patients with acute symptomatic portal or mesenteric vein thrombosis in the absence of any contraindication.
  • Use nonselective β-blockers to prevent variceal bleeding in patients with high-risk varices and portal and/or mesenteric vein thrombosis requiring anticoagulation.


Doppler ultrasonography should also be used as the initial diagnostic test for evaluation of BCS, according to a conditional recommendation made by the authors. And when selecting a treatment for patients with BCS, the authors made a strong recommendation that a stepwise management approach be used—from least- to most-invasive therapies—with systemic anticoagulation being the initial treatment of choice.

Among the other strong recommendations included in the guideline are:

  • In the management of patients with mesenteric artery aneurysm, clinicians should intervene for all aneurysms greater than 2 cm in diameter, even when asymptomatic.
  • In the management of patients with HHT, there should not be routine screening for liver vascular malformations (LVMs).
  • In the diagnosis of LVMs in patients with HHT who develop symptoms/signs of heart failure, biliary ischemia, hepatic encephalopathy, mesenteric ischemia, or portal hypertension, clinicians should perform a contrast CT scan or an MRI/magnetic resonance cholangiopancreatography scan.


“These recommendations and guidelines should be tailored to individual patients and circumstances in routine clinical practice,” the authors wrote.

—Colleen Murphy


Simonetto DA, Singal AK, Garcia-Tsao G, Caldwell SH, Ahn J, Kamath PS. ACG clinical guideline: disorders of the hepatic and mesenteric circulation. Am J Gastroenterol. 2020;115(1):18-40. doi: 10.14309/ajg.0000000000000486.