Recommendations

Key Recommendations

If present, varices are usually detected on screening endoscopy as a part of the workup for patients with cirrhosis.

In patients without hemorrhage, varices may be asymptomatic. In these patients an evaluation for signs and symptoms of liver disease and extent of cirrhosis will help stratify risk for bleeding. Several predictive rules for early detection of esophageal varices have been proposed in the last few years, based mainly on liver and spleen stiffness, spleen diameter, platelet count, and hepatic venous pressure gradient (HVPG).[5][29][30][31]​ HVPG is now the gold standard method to assess the presence of clinically significant portal hypertension, defined as HVPG ≥10 mmHg.[5] However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and are well established.[32]

Active bleeding typically presents with hematemesis and/or melena. For patients presenting with acute upper gastrointestinal bleeding (UGIB), other causes should be considered in the history (e.g., peptic ulceration, gastric erosions, and adverse drug effects). Because patients with UGIB can experience rapid clinical deterioration, blood should be sent for typing and cross-matching in the event that blood products become necessary. Prompt diagnosis (and intervention) is essential to improve the clinical outcome.

Medical history

If possible, a full history should be taken to establish the cause of liver disease. Particular enquiries regarding alcohol abuse and possible viral hepatitis should be made. HIV infection may accelerate liver disease in patients with chronic viral hepatitis.

Autoimmune liver disease, hemochromatosis, Wilson disease, and other recognized causes of portal hypertension, such as Budd-Chiari syndrome, myeloproliferative disorders, and sarcoidosis, may contribute to esophageal variceal risk.

Clinical assessment

Physical examination may show signs of chronic liver disease such as ascites, jaundice, and splenomegaly. Other signs include spider angioma, bruising, petechiae, caput medusa, and tremor flapping. There may be evidence of encephalopathy.

Active variceal bleeding typically presents with hematemesis and/or melena.

Laboratory investigations

Blood should be sent for complete blood count, metabolic panel, liver function tests, and coagulation profile. Hepatitis B surface antigen and anti-hepatitis C virus IgG should be performed if the history suggests viral hepatitis as a cause of cirrhosis. Blood should be sent for typing and cross-matching.

Decompensated cirrhosis (Child-Pugh class B/C) predicts development and progression of esophageal varices, and also hemorrhage.[5][9] Child-Pugh score should be calculated based on biochemical and clinical findings, as described below, and the Child-Pugh class determined.​ [ Child Pugh classification for severity of liver disease Opens in new window ]

Child-Pugh scoring uses five clinical measures of liver disease. Each measure is scored as between 1 and 3 points, with 3 indicating the most severe derangement. The clinical measures are:

Encephalopathy

  • None: 1 point

  • Grade 1 to 2: 2 points

  • Grade 3 to 4: 3 points

Ascites

  • None: 1 point

  • Mild/moderate: 2 points

  • Tense: 3 points

Bilirubin (mg/dL)

  • <2: 1 point

  • 2 to 3: 2 points

  • >3: 3 points

Albumin (g/dL)

  • >3.5: 1 point

  • 2.8 to 3.5: 2 points

  • <2.8: 3 points

International normalized ratio

  • <1.7: 1 point

  • 1.7 to 2.3: 2 points

  • >2.3: 3 points.

Chronic liver disease is classified into Child-Pugh class A to C using the scores as above:

  • Class A: 5 to 6 points

  • Class B: 7 to 9 points

  • Class C: 10 to 15 points.

Imaging

Esophago-gastro-duodenoscopy (EGD) is considered the most accurate method to identify varices.[5][6][33][34]

Variceal size is the most important predictor of hemorrhage, with the highest risk of first hemorrhage occurring in patients with large varices (15% per year).[3][4] The endoscopic finding of red wale marks (defined as longitudinal dilated venules resembling whip marks on the variceal surface) is also an important predictor.[3][5]

[Figure caption and citation for the preceding image starts]: (A) Grade I esophageal varices. These collapse to inflation of the esophagus with air. (B) Grade II esophageal varices. These are varices between grades 1 and 3. (C) Grade III esophageal varices. These are large enough to occlude the lumenTripathi D et al. Gut 2015;64:1680-704; used with permission [Citation ends].(A) Grade I esophageal varices. These collapse to inflation of the esophagus with air. (B) Grade II esophageal varices. These are varices between grades 1 and 3. (C) Grade III esophageal varices. These are large enough to occlude the lumen

Identifying patients with a low probability of having high-risk gastroesophageal varices can help to avoid screening EGD (endoscopy). Expanded-Baveno VI criteria have been validated in several patient cohorts (with compensated advanced chronic liver disease) and suggest that endoscopy may only be indicated if liver stiffness measurement (LSM) ≥25 kPa and platelet count ≤110 ×10⁹ cells/L.[35] This prediction rule would potentially avoid 40% of endoscopies, with an associated risk of missing 0.6% (95% CI 0.3% to 1.4%) of varices requiring treatment among patients with compensated advanced chronic liver disease.[35]​ LSM by transient elastography is a noninvasive test carried out by applying a vibrating probe to the thoracic wall at the level of the right liver lobe.[36]

Patients with hematemesis, hemodynamically unstable patients at risk of having blood in the stomach, or patients presenting with an altered mental status (i.e., confusion) should be intubated before endoscopy.[37][38]

Patients with an LSM <20 kPa and platelet count >150,000/mm³ have a very low probability (<5%) of having high‐risk varices; therefore EGD can be safely avoided.[5]

Video capsule endoscopy is a safe and well-tolerated alternative for patients who are not candidates for EGD, or if EGD is not available.[39] However, sensitivity of capsule endoscopy is not sufficient to replace EGD as an initial exploration.[39][40]

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