Screening

Check your local protocols for recommendations on screening.

The UK National Institute for Health and Care Excellence (NICE) recommends upper gastrointestinal (GI) endoscopy to detect oesophageal varices in all patients after a diagnosis of cirrhosis.[17]

  • Gastroscopy is considered the most accurate method for identifying varices.[5][6][7]​​[46][47]

For patients with no varices detected on initial endoscopy, NICE recommends repeat surveillance every 3 years.[17]

The British Society of Gastroenterology (BSG) suggests a slightly more frequent interval of every 2-3 years for these patients (depending on whether liver disease is active [e.g., continued alcohol consumption/untreated viral hepatitis or cofactors such as obesity/diabetes] or inactive [aetiological factor removed]).[5][51]

In clinical practice, many UK hospitals use the Baveno VI criteria to circumvent the need for endoscopy in some patients with compensated cirrhosis.[51] ​These criteria identify patients with a low probability of having high-risk gastro-oesophageal varices, in whom screening endoscopy can be safely avoided.​[52]

  • Patients with liver stiffness measurement (LSM) <20 kPa on transient elastography (TE) and platelet count >150,000/mm³ have a very low probability (<5%) of having high-risk varices; therefore, endoscopy can be safely avoided.

  • Patients who do not satisfy these criteria should undergo screening endoscopy at the time of cirrhosis diagnosis.

The BSG notes that the Baveno VI criteria were increasingly adopted during the coronavirus disease-19 (COVID-19) pandemic to prioritise patients at highest risk of varices, thereby reducing the need for routine endoscopy.[51] However, their ongoing use remains a matter of debate, influenced by local resources, clinical context, and patient preference. In centres where annual TE is not available, routine endoscopic screening should continue to be the default approach.[51]

When the Baveno VI criteria are used, the BSG recommends:[51]

  • Annual reassessment of liver stiffness (via TE) and platelet count in patients with active liver disease, including those with ongoing alcohol use, untreated viral hepatitis, or metabolic cofactors like obesity.

  • Screening endoscopy if liver stiffness exceeds 20 kPa or platelet count falls below 150 × 10⁹/L.

Expanded Baveno VI criteria, validated in several patient cohorts with compensated advanced chronic liver disease, suggest that endoscopy may only be indicated if LSM ≥25 kPa and platelet count ≤110 x 10⁹ cells/L.[53] This approach could potentially avoid 40% of endoscopies, while carrying an estimated risk of missing only 0.6% (95% CI 0.3% to 1.4%) of varices requiring treatment.[53]

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