When to repeat endoscopy in patients with cirrhosis (CLD) and varices?

Timing of Repeat Endoscopy in Cirrhosis with Varices

The timing of repeat endoscopy in patients with cirrhosis and varices depends critically on three factors: the size of varices at initial screening, whether the patient has compensated versus decompensated cirrhosis, and whether ongoing liver injury is present. 1

Compensated Cirrhosis Without Varices

Patients with compensated cirrhosis and no varices on initial screening should undergo repeat endoscopy every 2 years if ongoing liver injury or cofactors (active alcohol use, obesity, lack of sustained virologic response in hepatitis C) are present, or every 3 years if liver injury is quiescent (after viral elimination or alcohol abstinence). 1

• The 2017 AASLD guidelines provide the most definitive guidance on this stratification based on disease activity 1
• The older 2000 British Society of Gastroenterology guidelines recommended 3-year intervals for all patients without varices, but this has been refined in more recent guidance 1

Compensated Cirrhosis With Small Varices

Patients with compensated cirrhosis and small varices should have repeat endoscopy every 1 year if ongoing liver injury or cofactors are present, or every 2 years if liver injury is quiescent. 1

• Small varices progress to large varices at a rate of 12% at one year in patients with Child B/C cirrhosis 2
• The progression rate can reach 51% at three years in patients with Child B/C cirrhosis, particularly with alcoholic etiology or red wale marks 2
• Risk factors for rapid progression include alcoholic etiology, presence of red wale marks, ongoing liver injury, and higher Child-Pugh score (B or C) 2

Decompensated Cirrhosis

Any patient with compensated cirrhosis (with or without varices) who develops decompensation should have a repeat endoscopy performed immediately when decompensation occurs, as this indicates worsening portal hypertension and significantly higher risk of variceal progression. 1

For patients with established decompensated cirrhosis and small varices, the EASL and KASL guidelines recommend annual endoscopic surveillance. 2

• Decompensated patients have 72% prevalence of gastroesophageal varices 2
• The risk of progression from small to large varices is substantially higher in decompensated disease compared to compensated cirrhosis 2

Important Caveats and Clinical Considerations

Non-Selective Beta-Blockers May Modify Surveillance Needs

• If patients with small varices and high-risk features (Child B/C or red wale marks) are appropriately treated with non-selective beta-blockers, the need for frequent surveillance endoscopies may be reduced 2
• HVPG-guided therapy showing ≥10% reduction can decrease progression risk, potentially extending surveillance intervals 3
• However, this approach has not been prospectively validated for eliminating surveillance 2

Defining "Ongoing Liver Injury"

The distinction between ongoing versus quiescent liver injury is critical for determining surveillance intervals: 1

• Ongoing injury: Active alcohol consumption, lack of sustained virologic response in hepatitis C, obesity, continued hepatotoxic drug exposure
• Quiescent injury: Viral elimination (SVR in HCV, suppression in HBV), sustained alcohol abstinence

Patients Already on Large Varices or Post-Bleeding

• Patients with large varices requiring primary prophylaxis do not need surveillance endoscopy—they need treatment 1
• Patients who have had variceal bleeding and recovered should be on secondary prophylaxis (beta-blockers plus endoscopic variceal ligation) and undergo repeat endoscopy every 3-6 months until variceal obliteration, then every 3-6 months to monitor for recurrence 1

Non-Invasive Alternatives

• Patients with liver stiffness <20 kPa and platelet count >150,000/mm³ have <5% probability of high-risk varices and may avoid initial screening endoscopy 1
• However, non-invasive markers currently have unsatisfactory predictive accuracy for surveillance purposes and cannot replace endoscopy for monitoring variceal progression 2

Common Pitfall

Do not discontinue surveillance endoscopies even after multiple negative examinations, as varices can develop at any time during the course of cirrhosis, particularly if liver disease progresses or decompensation occurs. 1