How often should a patient with cirrhosis be scoped for varices?

Endoscopic Surveillance for Varices in Cirrhosis

For patients with cirrhosis, endoscopic surveillance for varices should be performed every 2-3 years in compensated cirrhosis without varices, every 1-2 years in those with small varices, and immediately upon decompensation regardless of previous findings.

Initial Screening and Risk Stratification

Initial endoscopic screening is recommended for all patients at the time of cirrhosis diagnosis, with subsequent surveillance frequency determined by:

1. Initial endoscopic findings:

   • No varices detected
   • Small varices (≤5 mm)
   • Large varices (>5 mm)

2. Disease activity status:

   • Compensated cirrhosis with ongoing liver injury (active drinking, untreated viral hepatitis)
   • Compensated cirrhosis with quiescent disease (viral elimination, alcohol abstinence)
   • Decompensated cirrhosis

3. Non-invasive assessment:

   • Patients with liver stiffness <20 kPa AND platelet count >150,000/mm³ have very low probability (<5%) of high-risk varices and may avoid initial endoscopy 1

Surveillance Intervals by Patient Category

Compensated Cirrhosis Without Varices

• With ongoing liver injury: Repeat endoscopy every 2 years 1
• With quiescent disease: Repeat endoscopy every 3 years 1

Compensated Cirrhosis With Small Varices

• With ongoing liver injury: Repeat endoscopy every year 1
• With quiescent disease: Repeat endoscopy every 2 years 1

Decompensated Cirrhosis

• Without previous varices: Immediate endoscopy upon decompensation 1
• With previously known varices: Repeat endoscopy upon decompensation 1
• Without varices on screening: Annual surveillance recommended 1

Post-SVR Cirrhotic Patients

• With cirrhosis who achieved SVR: Repeat endoscopic screening at 2-3 years if no or small varices were identified on initial screening 1

Special Considerations

Endoscopic Technique and Documentation

• Varices should be graded as small (≤5 mm) or large (>5 mm) 1
• The presence or absence of red signs (red wale marks or red spots) should be documented 1

Alternatives to Endoscopy

• While non-invasive methods like platelet count/spleen diameter ratio and transient elastography show promise, endoscopy remains the gold standard for variceal detection 2, 3
• Capsule endoscopy may eventually replace traditional endoscopy but requires further validation 1

Prophylactic Therapy Considerations

• Patients found to have large varices (grade 3) should receive primary prophylaxis regardless of liver disease severity 1
• Patients with grade 2 varices and Child class B or C disease should receive primary prophylaxis 1
• Non-selective beta-blockers are the first-line treatment for primary prophylaxis 4

Common Pitfalls to Avoid

1. Neglecting surveillance after SVR: Patients who achieve SVR after HCV treatment still require variceal surveillance if they have cirrhosis 1

2. Missing decompensation events: Any decompensation event should trigger immediate endoscopic evaluation regardless of previous findings 1

3. Over-reliance on non-invasive methods: While promising, non-invasive methods for predicting varices still have limitations and should not completely replace endoscopy in most clinical settings 3

4. Inadequate documentation: Failure to properly document variceal size and presence of red signs can lead to inappropriate surveillance intervals 1

5. Neglecting cost-effectiveness: Universal screening may not be cost-effective in all settings; risk stratification can help identify patients most likely to benefit 5

By following these evidence-based surveillance intervals, clinicians can optimize early detection of varices and implement timely prophylactic measures to prevent life-threatening variceal hemorrhage, which carries a 6-week mortality rate of approximately 20% 4.