Trials and guidelines in gastroenterology and hepatology

This collection of trials and guidelines about gastroenterology and hepatology has also ended up with all of general surgery in it, because there was nowhere else to put it. It is separated into "liver stuff", "gut stuff" and "general abdominal surgical stuff"as these are the broad categories into which the material has seemingly organised itself.  The CICM Second Part exam candidate will always be at risk of being expected to know about these common problems, and so it follows that their preparation should prioritise them; whereas there is no way to reliably defend against future questions on esoteric material like venous mesenteric infarction, and so the list of links here does not even attempt to cover the full breadth and depth of the possible range.

Trials and guidelines in liver disease

Clinical trials

Paracetamol overdose

  • Keays et al - 1991 - N-acetylcysteine for paracetamol overdose. n=50, at the Kings's College in London. Survival was much better with N-ac (48% vs 20%), and these were patients with fulminant out-of-control liver failure.

Spontaneous bacterial peritonitis

  • Sort et al - 1999 - albumin for patients with SBP? n=126, in Spain; 1.5g/kg on Day1  and 1g/kg on Day 3.  Albumin improved mortality (10% vs 29%) and reduced renal failure (10% vs 33%), i.e prevented progression to hepatorenal syndrome.

Hepatorenal syndrome

  • Wong et al - 2021 - terlipressin for established Type 1 (acute) hepatorenal syndrome? n-300 in the US. Terlipressin reversed hepatorenal syndrome in 33% vs 17%.

Support of the acute liver failure patient

  • Kribben et al  - 2012 - fractionated plasma separation and adsorption (Prometheus) for acute on chronic liver failure? n=145. No difference in mortality (47% vs 38%)
  • Guevara et al - 2012 - albumin for infections other than SBP? n=110. No difference in survival, but much less hepatorenal syndrome in the albumin group (though the numbers were extremely small,  1 and 4 patients)
  • Bernal et al - 2016 - hypothermia (33–34 °C) for hepatic encephalopathy in acute liver failure; n=46. No ICP advantage (35% vs 27%) or mortality benefit (41% vs 46%).
  • Darweesh et al - 2017 - what if N-ac, but not in paracetamol toxicity? n=155 in Kuiwait. Prospective observational data, not an RCT. Huge survival difference (96.4% vs 23.3%)
  • Louvet et al - 2023 - what if empirical antibiotics for alcoholic hepatitis? n=292 in France and Belgium. No difference in mortality (17.3% vs 21.3%)

Guidelines in liver disease

Guidelines for specific disease processes

Guidelines for the management of acute liver failure

Guidelines for the management of acute on chronic liver failure

Guideines for management of chronic liver disease complications

Guidelines for TIPS

Guidelines for hepatorenal syndrome


Trials and guidelines in critical care gastroenterology

Upper GI bleeding guidelines

Lower GI bleeding guidelines

Biliary sepsis

Inflammatory bowel disease


Mesenteric ischaemia

Guidelines for abdominal surgery in the critically ill


Keays, R., et al. "Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial." British Medical Journal 303.6809 (1991): 1026-1029.

Sort, Pau, et al. "Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis." New England Journal of Medicine 341.6 (1999): 403-409.

Wong, Florence, et al. "Terlipressin plus albumin for the treatment of type 1 hepatorenal syndrome." New England Journal of Medicine 384.9 (2021): 818-828.

Kribben, Andreas, et al. "Effects of fractionated plasma separation and adsorption on survival in patients with acute-on-chronic liver failure." Gastroenterology 142.4 (2012): 782-789.

Darweesh, Samar K., Mona F. Ibrahim, and Mahmoud A. El-Tahawy. "Effect of N-acetylcysteine on mortality and liver transplantation rate in non-acetaminophen-induced acute liver failure: a multicenter study." Clinical drug investigation 37 (2017): 473-482.

Bernal, William, et al. "A multicentre randomized controlled trial of moderate hypothermia to prevent intracranial hypertension in acute liver failure.Journal of hepatology 65.2 (2016): 273-279.

Louvet, Alexandre, et al. "Effect of prophylactic antibiotics on mortality in severe alcohol-related hepatitis: a randomized clinical trial.JAMA 329.18 (2023): 1558-1566.

Guevara, Mónica, et al. "Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study." Journal of Hepatology 57.4 (2012): 759-765.

Newsome, Philip N., et al. "Guidelines on the management of abnormal liver blood tests." Gut 67.1 (2018): 6-19.

Clinical Practice Guideline Panel, et al. "EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis–2021 update." Journal of hepatology 75.3 (2021): 659-689.

Gleeson, Dermot, and Michael A. Heneghan. "British Society of Gastroenterology (BSG) guidelines for management of autoimmune hepatitis." Gut 60.12 (2011): 1611-1629.

Anand, Anil C., et al. "Indian national association for the study of the liver consensus statement on acute liver failure (Part 1): epidemiology, pathogenesis, presentation and prognosis." Journal of Clinical and Experimental Hepatology 10.4 (2020): 339-376.

Anand, Anil C., et al. "Indian national association for the study of liver consensus statement on acute liver failure (Part-2): management of acute liver failure.Journal of Clinical and Experimental Hepatology 10.5 (2020): 477-517.

Wendon, Julia, et al. "EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure.Journal of hepatology 66.5 (2017): 1047-1081.

Andrade, Raúl J., et al. "EASL clinical practice guidelines: drug-induced liver injury." Journal of hepatology 70.6 (2019): 1222-1261.

Moreau, Richard, et al. "EASL Clinical Practice Guidelines on acute-on-chronic liver failure." Journal of Hepatology (2023).

Bajaj, Jasmohan S., et al. "Acute-on-chronic liver failure clinical guidelines.The American journal of gastroenterology 117.2 (2022): 225-252.

Sarin, Shiv Kumar, et al. "Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update." Hepatology international 13 (2019): 353-390.

Angeli, Paolo, et al. "EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis.Journal of hepatology 69.2 (2018): 406-460.

Nanchal, Rahul, et al. "Guidelines for the management of adult acute and acute-on-chronic liver failure in the ICU: cardiovascular, endocrine, hematologic, pulmonary, and renal considerations." Critical care medicine 48.3 (2020): e173-e191.

Aithal, Guruprasad P., et al. "Guidelines on the management of ascites in cirrhosis." Gut 70.1 (2021): 9-29.

Tripathi, Dhiraj, et al. "UK guidelines on the management of variceal haemorrhage in cirrhotic patients." Gut 64.11 (2015): 1680-1704.

Merli, Manuela, et al. "EASL Clinical Practice Guidelines on nutrition in chronic liver disease." Journal of hepatology 70.1 (2019): 172-193.

Montagnese, Sara, et al. "EASL Clinical Practice Guidelines on the management of hepatic encephalopathy." Journal of hepatology 77.3 (2022): 807-824.

Biggins, Scott W., et al. "Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases." Hepatology 74.2 (2021): 1014-1048.

Tripathi, Dhiraj, et al. "Transjugular intrahepatic portosystemic stent-shunt in the management of portal hypertension." Gut 69.7 (2020): 1173-1192.

Flamm, Steven L., et al. "AGA clinical practice update on the evaluation and management of acute kidney injury in patients with cirrhosis: expert review." Clinical Gastroenterology and Hepatology (2022).

Angeli, Paolo, et al. "Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites." Gut 64.4 (2015): 531-537.

Williamson, Catherine, et al. "EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy." Journal of Hepatology (2023).

Okamoto, Kohji, et al. "Management bundles for acute cholangitis and cholecystitis." Japanese Society of Hepato-Biliary-Pancreatic Surgery and Springer (2012).

Hirschfield, Gideon M., et al. "The British Society of Gastroenterology/UK-PBC primary biliary cholangitis treatment and management guidelines." Gut 67.9 (2018): 1568-1594.

Siau, Keith, et al. "British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding." Frontline Gastroenterology 11.4 (2020): 311-323.

Triantafyllou, Konstantinos, et al. "Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline." Endoscopy 53.08 (2021): 850-868.

Lamb, Christopher Andrew, et al. "British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults." Gut 68.Suppl 3 (2019): s1-s106.

Leppäniemi, Ari, et al. "2019 WSES guidelines for the management of severe acute pancreatitis." World journal of emergency surgery 14.1 (2019): 1-20.

Schuster, Kevin M., et al. "American Association for the Surgery of Trauma emergency general surgery guideline summaries 2018: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis, and small bowel obstructionAcute cholecystitis management guidelines summaryAcute colonic diverticulitis management guidelines summaryIntestinal obstruction due to adhesions guideline summaryAcute pancreatitis management guidelines summary." Trauma surgery & acute care open 4.1 (2019): e000281.

Jaber, Samir, et al. "Guidelines for the management of patients with severe acute pancreatitis, 2021." Anaesthesia Critical Care & Pain Medicine 41.3 (2022): 101060.

Crockett, Seth D., et al. "American Gastroenterological Association Institute guideline on initial management of acute pancreatitis." Gastroenterology 154.4 (2018): 1096-1101.

Peden, Carol J., et al. "Guidelines for perioperative care for emergency laparotomy Enhanced Recovery After Surgery (ERAS) Society recommendations: part 1—preoperative: diagnosis, rapid assessment and optimization." World journal of surgery 45.5 (2021): 1272-1290.

Scott, Michael J., et al. "Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS®) Society Recommendations Part 2—Emergency Laparotomy: Intra-and Postoperative Care." World Journal of Surgery (2023): 1-31.

Kirkpatrick, Andrew W., et al. "Intra-abdominal hypertension and the abdominal compartment syndrome: updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome." Intensive care medicine 39 (2013): 1190-1206.

Coccolini, Federico, et al. "The open abdomen in trauma and non-trauma patients: WSES guidelines." World journal of emergency surgery 13.1 (2018): 1-16.

Sartelli, Massimo, et al. "WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections." World journal of emergency surgery 16.1 (2021): 1-48.

Ten Broek, Richard PG, et al. "Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group." World Journal of Emergency Surgery 13.1 (2018): 1-13.

Bugaev, Nikolay, et al. "Promotility agents for the treatment of ileus in adult surgical patients: A practice management guideline from the Eastern Association for the Surgery of Trauma." Journal of Trauma and Acute Care Surgery 87.4 (2019): 922-934.

Tilsed, J. V. T., et al. "ESTES guidelines: acute mesenteric ischaemia." European Journal of Trauma and Emergency Surgery 42 (2016): 253-270.

Becquemin, J. P. "Management of the diseases of mesenteric arteries and veins: Clinical practice guidelines of the European Society for Vascular Surgery (ESVS)." European Journal of Vascular and Endovascular Surgery 53.4 (2017): 455-457.

Low, Donald E., et al. "Guidelines for perioperative care in esophagectomy: enhanced recovery after surgery (ERAS®) society recommendations.World journal of surgery 43 (2019): 299-330.

Melloul, Emmanuel, et al. "Guidelines for perioperative care for pancreatoduodenectomy: enhanced recovery after surgery (ERAS) recommendations 2019." World journal of surgery 44 (2020): 2056-2084.

McGinigle, Katharine L., et al. "Perioperative care in open aortic vascular surgery: A consensus statement by the Enhanced Recovery After Surgery (ERAS) Society and Society for Vascular Surgery.Journal of vascular surgery 75.6 (2022): 1796-1820.

Laine, Loren, et al. "ACG clinical guideline: upper gastrointestinal and ulcer bleeding." Official journal of the American College of Gastroenterology| ACG 116.5 (2021): 899-917.

Sengupta, Neil, et al. "Management of patients with acute lower gastrointestinal bleeding: an updated ACG guideline." The American Journal of Gastroenterology 118.2 (2023): 208-231.

Oakland, Kathryn, et al. "Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology.Gut (2019): gutjnl-2018.