From the Guidelines
Screening for varices and hepatocellular carcinoma (HCC) should begin immediately upon diagnosis of cirrhosis. For varices, all cirrhotic patients should undergo an initial screening endoscopy, with follow-up intervals determined by findings:
- patients with no varices should be rescreened every 2-3 years,
- those with small varices every 1-2 years,
- and those with medium/large varices require treatment rather than surveillance. For HCC screening, all cirrhotic patients should undergo ultrasound examination with or without alpha-fetoprotein (AFP) testing every 6 months indefinitely, as recommended by the most recent guidelines 1. This regular screening schedule is crucial because early detection of varices allows for prophylactic treatment with non-selective beta-blockers or endoscopic band ligation to prevent life-threatening bleeding. Similarly, HCC surveillance improves early tumor detection when curative treatments are still possible, significantly improving survival rates, as supported by studies such as 1 and 1. The 6-month interval for HCC screening is based on tumor doubling time, while variceal screening intervals reflect the typical progression rate of portal hypertension in cirrhosis. It's also important to note that the risk factors for the development of cirrhosis, and therefore also for the development of HCC, are well known and include excess alcohol consumption, infection with viruses such as hepatitis B and C, obesity, and diabetes, as mentioned in 1. Overall, the key to effective management of cirrhosis and prevention of its complications, including HCC, lies in early detection and regular surveillance, as emphasized by various studies and guidelines, including 1, 1, 1, 1, and 1.
From the Research
Screening for Varices and Hepatocellular Carcinoma in Patients with Cirrhosis
- Screening for hepatocellular carcinoma (HCC) in patients with cirrhosis is recommended by international guidelines, including patients with hepatitis B virus (HBV) infections, hepatitis C virus (HCV) infections, and nonalcoholic fatty liver disease (NAFLD) 2.
- The screening modality of choice for HCC is semiannual abdominal ultrasonography, which can be combined with biomarkers such as α-fetoprotein (AFP) to increase accuracy for early HCC detection 2, 3.
- For varices, screening is typically performed using endoscopy, and the timing of screening is not explicitly stated in the provided evidence.
- However, it is recommended that patients with cirrhosis undergo screening for varices and HCC at the time of diagnosis, with regular follow-up screenings every 6-12 months 4, 5.
Frequency of Screening
- Semiannual screening for HCC using abdominal ultrasonography and AFP is recommended for patients with cirrhosis 2, 3.
- The frequency of screening for varices is not explicitly stated in the provided evidence, but it is generally recommended that patients with cirrhosis undergo regular endoscopic screenings to monitor for varices.
- A study found that screening for HCC every 6 months using AFP and ultrasonography can improve early detection and treatment of HCC in patients with cirrhosis 3.
Barriers to Screening
- Despite the recommendations for regular screening, studies have shown that screening for HCC and varices is often underused in clinical practice 5, 6.
- Barriers to screening include lack of regular outpatient care, lack of recognition of liver disease or cirrhosis, and lack of screening orders in patients with known cirrhosis 6.
- Interventions targeted at these steps are needed to increase screening use and improve outcomes for patients with cirrhosis 6.