Current guidelines do not recommend the use of hepatic pharmacological therapy in patients with steatosis alone. Instead, patients with NASH and significant liver disease (bridging fibrosis) are good candidates for therapy. Dr. Ratzui outlines the current guidelines, best available evidence, and potential pharmacologic management of the patient with NASH.

In this introduction to CLD’s special issue on NAFLD, Drs. Puri and Sanyal define nonalcoholic fatty liver disease (NAFLD) and its progressive form, non-alcoholic steatohepatitis (NASH), addressing histology, risk factors, and work up..

The treatment of NAFLD is a patient-centered process that requires a patient to accept responsibility for lifestyle modifications. Evidence is emerging that allows physicians to guide patients better with diet and exercise counseling. Drs. Paredes, Torres, and Harrison explain.

Transhepatic intrahepatic portosystemic shunt (TIPS) stent placement is a minimally invasive procedure that, given the risk associated with surgical decompression, is preferred for the management of portal decompression. Drs. Bhogal and Sanyal discuss the procedure.

For portal hypertension, drug therapy with nonselective beta-blockers (NSBBs) is considered by many to be first line for primary and secondary prevention of variceal hemorrhage. In this brief and practical review, Dr. Tripathi outlines the benefits and drawbacks of the range of potential drug therapies.

Gastric varices (GV) are present in approximately 20% of patients with portal hypertension. While GVs bleed less frequently than esophageal varices (EV), bleeding is more severe and mortality is higher. Dr. Wong Kee Song reviews the latest recommendations for endoscopic, radiologic, and surgical interventions and comments on potential approaches for prevention.

Gastric antral vascular ectasia (GAVE) and portal hypertensive gastropathy (PHG) are distinct entities with some overlapping properties that have both challenged medical, endoscopic, and surgical therapies owing to the lack of a complete understanding of their respective pathophysiology. Each patient with chronic gastrointestinal bleeding and suspected lesions should be categorized in the appropriate group, because the management is significantly different. Drs. Tekola and Caldwell address the clinical characteristics and management approach for each.

: Portal hypertension is a common complication of cirrhosis and is the result of increased intrahepatic resistance and splanchnic and systemic hemodynamic changes. Elevated portal pressure leads to the formation of portosystemic laterals, which comprise gastroesophageal varices. Once varices have developed, they tend to enlarge and may eventually bleed. Drs. Simonetto and Shah discuss the important and much-debated topic of the management of esophageal varices. .

Ectopic varices represent a clinical challenge because they are difficult to localize, and at present, there are no clear guidelines on the management of ectopic varices due to the diversity of presentation and absence of randomized controlled trials. Drs. Sarin and Kumar review etiology, prevalence, clinical presentation, and management strategies.

The prevention of rebleeding is a cornerstone of the management of portal hypertension in patients with cirrhosis. Listen to Drs. Merkel and Montagnese review the recommendations from the AASLD guidelines and other studies addressing the pharmacological, endoscropic, and interventional treatments available.