Upper GI Endoscopy in Oesophageal Varices

Primary Role: Screening and Diagnosis

The American Association for the Study of Liver Diseases recommends that all patients with newly diagnosed cirrhosis should undergo screening EGD to detect the presence and size of varices, as this directly impacts mortality through prevention of first variceal bleeding 1, 2, 3
EGD allows direct visualization and classification of varices into small (<5 mm) or large (>5 mm), with large varices carrying a 15% yearly bleeding risk 1, 4
The presence of red color signs (red wale marks or red spots) must be documented, as these dramatically increase bleeding risk regardless of variceal size, with 80% of patients with cherry red spots experiencing variceal bleeding 4

The American Association for the Study of Liver Diseases recommends repeat EGD every 2-3 years for patients with no varices on initial screening (compensated cirrhosis) 1, 2
Repeat EGD every 1-2 years is recommended for patients with small varices (compensated cirrhosis) 1, 2
For patients with decompensated cirrhosis, repeat EGD is recommended at yearly intervals regardless of initial findings 1, 2

EGD is the primary method for diagnosing variceal hemorrhage, with diagnosis confirmed by: active bleeding from a varix, "white nipple" overlying a varix, clots overlying a varix, or varices with no other bleeding source 1, 7, 3
Contrast-enhanced CT or MRI should be obtained routinely to identify inflow/outflow vessels and determine feasibility of interventional procedures like balloon-occluded retrograde transvenous obliteration 8, 9, 6

Patients with large varices (>5 mm) or medium/small varices with red color signs require prophylactic treatment with either nonselective beta-blockers or endoscopic variceal ligation 1, 4

For patients with Fontan-Associated Liver Disease (FALD), screening for gastro-oesophageal varices is suggested for staging purposes, as their presence relates to worse outcomes 10
A detailed description of variceal location is critical, as "downhill varices" in the upper oesophagus (from elevated superior vena cava pressure) can coexist with true portal hypertension-derived varices 10

Variceal size classification: small (<5 mm) or large (>5 mm) must be documented during any EGD for varices 1, 2, 3
Presence or absence of red color signs (red wale marks or red spots) must be documented during any EGD for varices 1, 3, 4