What is the best test to rule out gastric varices?

Best Diagnostic Test for Ruling Out Gastric Varices

Upper endoscopy (esophagogastroduodenoscopy or EGD) is the gold standard test for diagnosing and ruling out gastric varices. 1

Diagnostic Approach to Gastric Varices

First-Line Diagnostic Test

• Upper endoscopy is the most accurate method for diagnosing gastric varices, allowing direct visualization and classification of varices 1
• Endoscopy provides high accuracy in diagnosing the etiology of upper GI hemorrhage and can simultaneously offer therapeutic options 1
• Gastric varices are classified during endoscopy according to their size (grade 1,2, or 3) and location, which guides management decisions 1

Second-Line Diagnostic Tests

• Contrast-enhanced CT or MRI should be obtained routinely in patients with suspected gastric varices to:
  • Identify inflow and outflow vessels 1
  • Determine feasibility of interventional procedures like BRTO 1
  • Detect portal or splenic vein occlusion that may affect treatment options 1, 2
  • CT has been shown to detect gastric varices with high sensitivity and specificity 1

Advanced Imaging Options

• Endoscopic ultrasound (EUS) with color Doppler evaluation can be used as a complementary test when the diagnosis remains uncertain 3
• CT angiography is highly effective for detecting gastric varices and identifying portal vein occlusion and collateral pathways 2
• Spleen stiffness measurement using elastography has shown promise as a non-invasive predictor of varices, with better results than liver elastography 4

Clinical Considerations

Risk Stratification

• For patients with compensated cirrhosis, a combination of non-invasive tests may help determine the need for endoscopy:
  • Vibration controlled transient elastography (VCTE) with a cutoff of 19.5 kPa can help rule out high-risk esophageal varices 1
  • Platelet count >150,000/mL combined with VCTE <19.5 kPa may identify patients at low risk for high-risk varices 1
  • However, these criteria should not replace endoscopy in high-risk patients 1

Special Situations

• In patients with isolated gastric varices due to splenic vein thrombosis (segmental portal hypertension), CT angiography is particularly important to identify the underlying vascular abnormality 2, 5
• For patients with acute variceal bleeding, endoscopy should be performed within 12 hours of presentation 6
• In patients with decompensated cirrhosis or known portal hypertension, endoscopic evaluation should be pursued regardless of elastography results 1

Pitfalls to Avoid

• Gastric varices can be misinterpreted as other pathologies (like tumors) on radiologic studies, making endoscopic confirmation essential 7
• Relying solely on non-invasive tests may miss up to 2.2% of high-risk varices in high-risk populations 1
• Small gastric varices may be missed on venography while endoscopy sometimes misinterprets non-tortuous veins as varices 8
• Gastric varices are often located along the lesser curvature of the stomach rather than just in the fundus, requiring thorough endoscopic examination 9

Conclusion

While non-invasive tests like CT, MRI, and elastography provide valuable complementary information, upper endoscopy remains the definitive test for ruling out gastric varices due to its superior diagnostic accuracy and ability to simultaneously provide therapeutic intervention when needed.