What is the role of endoscopic surveillance in patients with liver cirrhosis?

From the Guidelines

Endoscopic surveillance is recommended for all patients with liver cirrhosis to screen for esophageal and gastric varices, with the frequency of surveillance depending on the presence and size of varices, as well as the patient's underlying liver disease severity. The most recent and highest quality study, 1, recommends that endoscopic surveillance be performed at 2–3-year intervals in patients with compensated liver cirrhosis and at 1–2-year intervals in those with decompensated liver cirrhosis.

Key Considerations

• Initial upper endoscopy should be performed at the time of cirrhosis diagnosis to assess for the presence of varices and evaluate the risk of bleeding.
• Patients without varices on initial screening should have follow-up endoscopy performed every 2-3 years if they have compensated cirrhosis, and annually if they have decompensated cirrhosis, as suggested by 2 and 3.
• Patients with small varices should undergo endoscopy every 1-2 years, while those with medium to large varices who are on appropriate therapy should have repeat endoscopy every 1-2 years to assess for variceal progression or recurrence.
• Surveillance intervals may need adjustment based on individual risk factors such as ongoing alcohol use, worsening liver function, or portal hypertension severity, as noted in 2 and 3.

Surveillance Schedule

• Compensated cirrhosis without varices: every 2-3 years
• Decompensated cirrhosis without varices: every 1-2 years
• Small varices: every 1-2 years
• Medium to large varices on therapy: every 1-2 years This surveillance schedule is crucial because approximately 30-40% of cirrhotic patients have varices at diagnosis, and the annual risk of first variceal bleeding ranges from 5-15%, as mentioned in the example answer. Early detection allows for prophylactic treatment with beta-blockers or band ligation, which can reduce bleeding risk by up to 50%.

From the Research

Endoscopic Surveillance in Patients with Liver Cirrhosis

• The management of patients with compensated cirrhosis recommends universal screening endoscopy followed by prophylactic beta-blocker therapy to prevent initial hemorrhage in those found to have esophageal varices 4.
• However, the cost-effectiveness of this recommendation has not been established, with studies suggesting that empiric beta-blocker therapy for the primary prophylaxis of variceal hemorrhage is a cost-effective measure 4.
• Endoscopic band ligation is an effective treatment for primary prophylaxis, acute bleeding, and secondary prophylaxis of esophageal varices, as well as for acute bleeding and secondary prophylaxis of select gastric varices 5.
• The appropriate endoscopic therapy depends on the location of the bleed, history or presence of acute bleeding, and risk factors for intervention-related adverse events 5.

Screening and Surveillance

• Patients with cirrhosis should be screened for esophageal varices, with recommended endoscopic therapy for acute variceal bleeding being endoscopic variceal banding 6.
• Treatment with Sengstaken-Blakemore tube or self-expanding covered metallic esophageal stent can be used for acute variceal bleeding refractory to standard pharmacologic and endoscopic therapy 6.
• Several quality metrics have been developed by the American Association for the Study of Liver Diseases for the evaluation and management of esophageal and gastric varices in patients with cirrhosis, including variceal screening and surveillance, primary and secondary prophylaxis of variceal bleeding, and therapy for patients with acute variceal bleeding 7.

Treatment Options

• Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL), with both treatments being equally effective 8.
• The combination of NSBBs and EVL is the recommended management for secondary prophylaxis, whereas transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment 8.
• Other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping, and argon plasma coagulation, have been used in the management of esophageal varices, but their efficacy and safety remain to be further elucidated 8.