Screening and Surveillance Endoscopy for Esophageal Varices in Chronic Liver Disease

Initial Endoscopic Screening

Surveillance Endoscopy Intervals

Compensated Cirrhosis – No Varices Detected

Compensated Cirrhosis – Small Varices

Decompensated Cirrhosis – Any Variceal Status

Endoscopic Documentation of Varices

Primary Prophylaxis

Pharmacologic Therapy (First‑Line)

Endoscopic Therapy (Alternative)

Clinical Pitfalls to Avoid

Baveno VII Recommendations for Variceal Screening and Primary Prophylaxis in Compensated Cirrhosis

1. Non‑invasive Screening Strategy

• In compensated cirrhosis, patients with liver stiffness < 20 kPa and platelet count > 150 000/µL can safely forego screening endoscopy because high‑risk varices are effectively excluded. Baveno VII consensus. 8
• When liver stiffness < 12 kPa and platelets > 150 000/µL, clinically significant portal hypertension (CSPH) can be ruled out entirely, eliminating the need for any endoscopic assessment. Baveno VII consensus. 9

2. Indications for Endoscopy

• If liver stiffness ≥ 20 kPa or platelets < 150 000/µL, endoscopy should be performed unless the patient is already receiving a non‑selective beta‑blocker (NSBB). Baveno VII consensus. 8
• With liver stiffness 20–25 kPa or platelets < 150 000/µL, CSPH is probable; endoscopy is indicated for those not yet on NSBB therapy. Baveno VII consensus. 9
• Liver stiffness > 25 kPa denotes a highly likely CSPH; clinicians may start NSBB empirically without awaiting endoscopy, though endoscopy can be performed if variceal status will influence management decisions. Baveno VII consensus. 9

3. Surveillance Intervals When Endoscopy Is Performed

• Compensated cirrhosis – no varices: repeat endoscopy every 2–3 years. Baveno VII consensus. 10
• Compensated cirrhosis – small varices: repeat endoscopy every 1–2 years. Baveno VII consensus. 11
• Decompensated cirrhosis – any variceal finding: repeat endoscopy annually. Baveno VII consensus. 12

4. Primary Prophylaxis Strategy

• All patients with CSPH, irrespective of variceal size, should receive an NSBB to prevent both variceal bleeding and non‑bleeding decompensation events (e.g., ascites). Baveno VII consensus. 9
• For small varices with CSPH, NSBB is the preferred first‑line therapy. Baveno VII consensus. 9

5. Variceal Classification

These definitions are endorsed by the Baveno VII consensus. [10][13]14

6. Special Considerations

• Patients already on NSBB for other indications (e.g., hypertension) may skip screening endoscopy because they are already protected against CSPH‑related complications. Baveno VII consensus. 12
• Gastric varices: GOV1 lesions are managed similarly to esophageal varices; IGV1 lesions require exclusion of splenic vein thrombosis before deciding on therapy. Baveno VII consensus. 13
• High‑risk patients (liver stiffness > 25 kPa): NSBB can be initiated without waiting for endoscopic confirmation of varices. Baveno VII consensus. 9
• Beta‑blocker selection: Selective agents (e.g., metoprolol, atenolol) should be replaced with non‑selective agents (propranolol, nadolol, carvedilol) for portal hypertension management. Baveno VII consensus. 10
• NSBB efficacy requirement: NSBBs are only effective when CSPH is present (hepatic venous pressure gradient > 10 mmHg); they should not be used in patients without CSPH. Baveno VII consensus. 9

Assessment and Management of Esophageal Varices in Cirrhosis

Cirrhosis Staging and Prognosis

• Compensated versus decompensated cirrhosis determines management and surveillance intervals; decompensation is defined by the presence of ascites, variceal hemorrhage, or hepatic encephalopathy and is associated with a median survival of ~1.8 years versus >12 years for compensated disease (AASLD‑Hepatology guidance) 15.
• Child‑Turcotte‑Pugh (CTP) scoring stratifies prognosis: CTP‑A denotes compensated disease, while CTP‑B/C indicates decompensated cirrhosis (AASLD‑Hepatology guidance) 15.
• International normalized ratio (INR) and other synthetic function tests are essential laboratory parameters for assessing disease severity (AASLD‑Hepatology guidance) 15.

Endoscopic Screening and Surveillance

• Screening esophagogastroduodenoscopy (EGD) should be performed at the time of cirrhosis diagnosis in patients who do not meet Baveno VII non‑invasive exclusion criteria (Baveno VII consensus) 16.
• Variceal size is classified endoscopically as small (<5 mm diameter, minimally elevated) or large (≥5 mm or occupying >1/3 of the esophageal lumen) (Baveno VII consensus) 16.
• Presence of red signs (red wale marks or red spots) on varices signals a higher risk of bleeding and must be documented (Baveno VII consensus) 16.

Surveillance Intervals

Endoscopic Findings Indicative of Active or Recent Variceal Hemorrhage

• Active bleeding from a varix observed during endoscopy confirms recent hemorrhage (Baveno VII consensus) 16.
• “White nipple” sign overlying a varix is a characteristic endoscopic marker of recent bleeding (Baveno VII consensus) 16.
• Clots covering a varix indicate recent hemorrhage (Baveno VII consensus) 16.
• Varices identified as the sole potential source of bleeding (no alternative lesion) support the diagnosis of variceal hemorrhage (Baveno VII consensus) 16.

Bleeding Risk Stratification

• Large varices (≥5 mm) are associated with a substantially higher risk of first bleeding episode (Baveno VII consensus) 16.
• Red signs on varices further increase the probability of bleeding (Baveno VII consensus) 16.

Endoscopic Grading of Esophageal and Gastric Varices – Guideline Recommendations

Esophageal Variceal Size Classification

• The American Association for the Study of Liver Diseases (AASLD) recommends a simplified two‑tier system: small varices < 5 mm in diameter (minimally elevated) and large varices ≥ 5 mm or occupying > 1⁄3 of the esophageal lumen; this classification directly determines prophylactic therapy decisions. 17
• This two‑tier system was endorsed at the 2007 consensus meeting because it correlates with treatment thresholds and was the grading used in primary‑prophylaxis trials. 18

Management of Medium‑Sized Varices (Three‑Grade Systems)

• When a three‑grade semiquantitative system is employed, medium‑sized varices should be managed identically to large varices, reflecting their grouping together in clinical trial data. 17

Endoscopic Risk Features Beyond Size

• Red signs (red wale marks or red spots) on varices indicate a substantially higher risk of bleeding and must be documented. 19
• Observation of active bleeding from a varix confirms an episode of acute variceal hemorrhage. 19
• The “white nipple” sign over a varix is characteristic of recent hemorrhage and should be recorded. 19
• Presence of adherent clots covering a varix signifies recent bleeding and warrants documentation. 19

Gastric Variceal Classification

• Gastro‑esophageal varices type 1 (GOV1) – extension along the lesser gastric curvature; managed in the same manner as esophageal varices. 17
• GOV2 – extension along the fundus; typically longer and more tortuous. 18
• Isolated gastric varices type 1 (IGV1) – located in the fundus, tortuous and complex; evaluation must include exclusion of splenic‑vein thrombosis. 17
• IGV2 – located in the gastric body, antrum, or around the pylorus. 18
• Gastric varices are sized as large ≥ 10 mm, medium 5–10 mm, and small < 5 mm. 17

Clinical Management Based on Grading

• Large esophageal varices (≥ 5 mm) carry a markedly higher risk of first bleeding and require primary prophylaxis with non‑selective beta‑blockers or endoscopic band ligation. 18
• Small esophageal varices merit surveillance endoscopy every 1–2 years in patients with compensated cirrhosis; patients without detectable varices should undergo repeat endoscopy every 2–3 years. 19

Documentation and Evidence Alignment

• The two‑grade classification (small vs. large) provides the most clinically actionable information and aligns with evidence‑based treatment thresholds for variceal prophylaxis. 18
• Recording red signs is essential because their presence independently raises bleeding risk regardless of variceal size. 19