How often is upper endoscopy performed in patients with cirrhosis (liver cirrhosis)?

From the Guidelines

Upper endoscopy should be performed in patients with cirrhosis at the time of diagnosis to screen for varices, and then repeated based on findings, with the frequency of surveillance endoscopies depending on the presence and size of varices, as well as the patient's underlying liver disease status. According to the study by Garcia-Tsao et al. 1, the frequency of surveillance endoscopies in patients with no or small varices depends on their natural history.

Key Recommendations:

• For patients with compensated cirrhosis who have no varices on screening endoscopy, endoscopy should be repeated in 2-3 years.
• In those who have small varices, endoscopy should be repeated in 1-2 years.
• In the presence of decompensated cirrhosis, endoscopy should be repeated at yearly intervals. The study also notes that endoscopic screening is still the main means of assessing for the presence of esophageal varices, as noninvasive markers have not yet been proven to be reliable 1.

Rationale:

• The point prevalence of medium/large varices is approximately 15%-25%, and nonselective beta-blockers can prevent bleeding in more than half of patients with medium or large varices 1.
• Endoscopy is crucial in cirrhosis management because it allows for early detection and prophylactic treatment of varices, significantly reducing the risk of life-threatening variceal hemorrhage. Overall, the frequency of upper endoscopy in patients with cirrhosis should be guided by the presence and size of varices, as well as the patient's underlying liver disease status, with the goal of preventing variceal hemorrhage and improving patient outcomes.

From the Research

Frequency of Upper Endoscopy in Patients with Cirrhosis

• Upper endoscopy is a crucial procedure for patients with cirrhosis, as it helps identify esophageal varices and prevents bleeding 2, 3, 4, 5.
• The frequency of upper endoscopy in patients with cirrhosis varies, but it is generally recommended for all patients with cirrhosis to rule out esophageal varices 2, 4.
• A study found that endoscopic screening for varices represents a small proportion of all upper endoscopies performed, but the proportion increased between 2000 and 2003 3.
• Another study suggested that Platelet Count/Spleen Length Ratio can be used as a predictor of esophageal varices, which can help identify patients who require endoscopy for prophylactic management of variceal bleeding 4.

Indications for Upper Endoscopy

• Patients with cirrhosis should undergo upper endoscopy to identify patients with large varices, especially those with low platelet count, splenomegaly, and advanced cirrhosis 2.
• Upper endoscopy is also recommended for patients with cirrhosis who are at high risk of bleeding, such as those with previous variceal bleeding or those with moderately sized or larger varices 5.
• Endoscopic ultrasonography (EUS) can be used to predict early esophageal variceal bleeding in liver cirrhosis and to assess the efficacy of endoscopic variceal ligation (EVL) 6.

Outcomes of Upper Endoscopy

• A study found that varices were found in 52.2% of patients who underwent screening upper endoscopies, and the presence of varices was more common in patients with more severe liver disease 3.
• Another study found that EVL is highly effective in preventing first variceal bleed in liver transplant candidates, with a low risk of band-induced bleeding 5.
• The use of Platelet Count/Spleen Length Ratio as a predictor of esophageal varices can help reduce the burden on endoscopy units and avoid unnecessary screening endoscopies 4.