Can fatty liver cirrhosis develop esophageal varices?

Can Fatty Liver Cirrhosis Develop Esophageal Varices?

Yes, fatty liver cirrhosis (NAFLD/NASH cirrhosis) absolutely can and does develop esophageal varices through the same portal hypertension mechanism as any other cause of cirrhosis, and patients with known NAFLD cirrhosis require routine endoscopic screening for varices. 1

Mechanism and Prevalence

• Portal hypertension develops when the hepatic venous pressure gradient (HVPG) exceeds 10-12 mmHg, triggering the formation of portosystemic collaterals including esophageal varices, regardless of the underlying cause of cirrhosis 1, 2
• Approximately 50% of all cirrhotic patients develop esophageal varices, with prevalence correlating directly with disease severity: 40% in Child-Pugh A patients versus 85% in Child-Pugh C patients 2
• In NAFLD specifically, signs of portal hypertension (including esophageal varices) were present in 28.2% of patients at the time of NAFLD diagnosis, with 88% of these having septal fibrosis or cirrhosis 3
• Among NAFLD patients who underwent endoscopic screening, esophageal varices were found in 44.5% (57 of 128 patients) 3

Pathophysiology in NAFLD Cirrhosis

• The architectural distortion from fibrous tissue and regenerative nodules in NAFLD cirrhosis increases intrahepatic resistance to portal blood flow, identical to other cirrhosis etiologies 4, 2
• Active intrahepatic vasoconstriction from decreased nitric oxide production accounts for 20-30% of the increased resistance 4
• Once portal pressure rises above the critical threshold (HVPG >10-12 mmHg), portosystemic collaterals develop at the gastroesophageal junction, forming esophageal varices 1, 4

Clinical Management Requirements

All patients with confirmed NAFLD cirrhosis must undergo:

• EGD screening for esophageal varices as per AASLD guidelines 1
• Right upper quadrant ultrasound every 6 months for hepatocellular carcinoma surveillance 1
• Referral to transplant center when appropriate 1

Risk Factors for Varices in NAFLD

Independent predictors of esophageal varices in NAFLD patients include:

• Thrombocytopenia (most important predictor) 3
• Type 2 diabetes 3
• Splenomegaly 3
• Advanced fibrosis stage (F3-F4) 1, 3

Important Caveat

• Portal hypertension can occur in a small proportion (6%) of NAFLD patients with mild or no fibrosis (stages 0-2), particularly when associated with severe steatosis 3
• This underscores that while cirrhosis is the primary driver, advanced fibrosis alone can lead to clinically significant portal hypertension and varices 4

Screening Thresholds Using Noninvasive Tests

For NAFLD patients with suspected cirrhosis based on noninvasive tests:

• Liver stiffness by VCTE >15 kPa suggests cirrhosis and warrants variceal screening 1
• Liver stiffness by VCTE ≥25 kPa reliably diagnoses clinically significant portal hypertension 1
• Patients meeting these thresholds should undergo endoscopic evaluation for varices 1