What is the standard approach for grading and managing esophageal varices?

Esophageal Varices Grading

Esophageal varices should be graded as small (≤5 mm) or large (>5 mm) during endoscopy, with documentation of red signs (red wale marks or red spots), as this simplified two-tier system directly guides management decisions regarding prophylactic therapy. 1

Standard Grading System

The American Association for the Study of Liver Diseases (AASLD) and American College of Gastroenterology recommend a simplified classification system that has replaced older three-tier grading schemes 1:

• Small varices: ≤5 mm in diameter 1
• Large varices: >5 mm in diameter (this encompasses what was previously classified as "medium" varices in three-grade systems) 1
• Red signs: The presence or absence of red wale marks or red spots must be documented, as these indicate higher bleeding risk 1

This binary classification system is intentionally simplified because the critical management decision—whether to initiate prophylactic therapy—hinges on distinguishing small from large varices rather than making finer gradations 1.

Diagnostic Approach

Initial Screening

• All patients with newly diagnosed cirrhosis should undergo screening esophagogastroduodenoscopy (EGD) to detect varices, as this is the gold standard diagnostic method 1, 2
• EGD provides direct visualization with sensitivity and specificity approaching 100% for variceal detection and classification 2

Surveillance Intervals

The frequency of repeat endoscopy depends on initial findings and disease severity 1, 3, 4:

For compensated cirrhosis:

• No varices: Repeat EGD every 2-3 years 1, 4
• Small varices: Repeat EGD every 1-2 years 1, 4

For decompensated cirrhosis:

• Annual EGD regardless of variceal size, as progression rates are substantially higher (up to 22% progress from small to large varices within one year in Child B/C patients) 1, 3, 4

Management Based on Grading

Small Varices

• Patients with small varices AND high-risk features (Child-Pugh B/C or red wale marks) should receive nonselective beta-blockers 3, 5
• Patients with small varices without high-risk features may be observed with surveillance endoscopy 3

Large Varices

• All patients with large varices require prophylactic therapy with either nonselective beta-blockers (propranolol, nadolol, or preferably carvedilol) or endoscopic band ligation 1, 5
• The European Society of Gastrointestinal Endoscopy (ESGE) recommends carvedilol as the preferred beta-blocker for primary prophylaxis 5
• If beta-blockers are contraindicated or not tolerated, endoscopic band ligation should be performed every 2-4 weeks until variceal eradication 5

Critical Risk Factors for Progression

Document these features as they predict rapid progression from small to large varices 3, 4:

• Alcoholic etiology of cirrhosis 3
• Red wale marks on varices 1, 3
• Ongoing liver injury (continued alcohol use, lack of viral suppression) 3, 4
• Child-Pugh class B or C 3, 4

Patients with these features have progression rates up to 51% at three years and warrant more aggressive surveillance and earlier prophylactic intervention 3.

Common Pitfalls and Caveats

• Avoid three-tier grading systems (small/medium/large) in clinical practice, as the AASLD specifically recommends collapsing medium and large categories together since management is identical 1
• Do not rely on non-invasive methods alone for variceal screening—while transient elastography and platelet counts show promise, their predictive accuracy remains insufficient, potentially misclassifying 2.2% of high-risk patients 2
• Patients already on nonselective beta-blockers for other indications (e.g., hypertension) may not require screening endoscopy, though switching from selective beta-blockers (metoprolol, atenolol) to nonselective agents is necessary 1
• When decompensation occurs in a patient with previously small varices, perform immediate repeat endoscopy rather than waiting for the scheduled surveillance interval, as this indicates worsening portal hypertension 4