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We read with great interest the updated guidelines recently published by Tripathi et al1 on behalf of the Clinical Services and Standards Committee of the British Society of Gastroenterology on the management of variceal haemorrhage (VH) in patients with cirrhosis. One of the topics of discussion was the primary prevention of VH. To our knowledge, these are the first guidelines in the literature to recommend that the initiation of non-selective β-blockers (NSBBs) in patients with small varices should be determined only by coexisting red signs and not the severity of liver disease as recommended by the recent Baveno's VI consensus (Child–Pugh C)2 and US guidelines (Child–Pugh B/C).3 We fully agree with the authors that robust data allowing any formal recommendation in patients with cirrhosis and small varices without red signs, including those with advanced liver disease, never existed. Moreover, concerns have been raised recently that NSBBs may increase the risk for hepatorenal syndrome (HRS) and mortality in patients with end-stage liver disease due to …
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