What is the role of upper gastrointestinal (GI) endoscopy in managing oesophageal varices?

Upper GI Endoscopy in Oesophageal Varices

Upper gastrointestinal endoscopy (EGD) is the gold standard for diagnosing oesophageal varices and should be performed at the time cirrhosis is diagnosed to screen for varices and guide prophylactic treatment decisions. 1

Primary Role: Screening and Diagnosis

Initial Screening at Cirrhosis Diagnosis

• All patients with newly diagnosed cirrhosis should undergo screening EGD to detect the presence and size of varices, as this directly impacts mortality through prevention of first variceal bleeding 1
• EGD allows direct visualization and classification of varices into small (<5 mm) or large (>5 mm), with large varices carrying a 15% yearly bleeding risk 1, 2
• The presence of red color signs (red wale marks or red spots) must be documented, as these dramatically increase bleeding risk regardless of variceal size, with 80% of patients with cherry red spots experiencing variceal bleeding 2

When Screening Can Be Avoided

• EGD may be safely avoided in patients already on nonselective beta-blockers for other indications (e.g., arterial hypertension) 1
• Patients with compensated cirrhosis, platelet count >150,000/μL, and liver stiffness <19.5 kPa by vibration-controlled transient elastography have a low probability of high-risk varices and may defer immediate endoscopy 1, 3
• However, noninvasive markers remain unsatisfactory for widespread clinical use, and endoscopic screening remains the recommended standard approach 1

Surveillance Endoscopy Intervals

The frequency of repeat EGD depends on initial findings and disease severity:

• No varices on initial screening (compensated cirrhosis): Repeat EGD every 2-3 years 1
• Small varices (compensated cirrhosis): Repeat EGD every 1-2 years 1
• Decompensated cirrhosis: Repeat EGD at yearly intervals regardless of initial findings 1

Role in Acute Variceal Bleeding

Diagnostic Function

• EGD is the primary method for diagnosing variceal hemorrhage, with diagnosis confirmed by: active bleeding from a varix, "white nipple" overlying a varix, clots overlying a varix, or varices with no other bleeding source 1
• In suspected acute variceal bleeding, endoscopy should be performed within 12 hours after resuscitation and hemodynamic stability 4, 5
• Vasoactive therapy (terlipressin, octreotide, or somatostatin) should be initiated immediately at presentation before endoscopy 5

Therapeutic Function

• Endoscopic band ligation (EBL) is the endoscopic treatment of choice for acute esophageal variceal hemorrhage 5, 6
• For gastric varices (GOV2, IGV1), endoscopic cyanoacrylate injection is recommended 5
• Contrast-enhanced CT or MRI should be obtained routinely to identify inflow/outflow vessels and determine feasibility of interventional procedures like balloon-occluded retrograde transvenous obliteration 1, 3

Role in Primary Prophylaxis

Guiding Treatment Decisions

• Patients with large varices (>5 mm) or medium/small varices with red color signs require prophylactic treatment with either nonselective beta-blockers or endoscopic variceal ligation 1, 2
• EBL for primary prophylaxis should be repeated every 2-4 weeks until variceal eradication, followed by surveillance every 3-6 months in the first year 5
• Small varices without red signs in compensated cirrhosis may be managed with surveillance alone or nonselective beta-blockers if decompensated 2

Role in Secondary Prophylaxis

After successful treatment of acute variceal bleeding:

• Follow-up EBL should be scheduled at 1-4 week intervals to eradicate varices 5, 6
• After variceal eradication, surveillance endoscopy should be performed every 6-12 months 2
• Combination therapy with nonselective beta-blockers plus endoscopic therapy is recommended for secondary prophylaxis 5

Special Populations

Fontan-Associated Liver Disease (FALD)

• Screening for gastro-oesophageal varices is suggested for staging purposes, as their presence relates to worse outcomes 1
• A detailed description of variceal location is critical, as "downhill varices" in the upper oesophagus (from elevated superior vena cava pressure) can coexist with true portal hypertension-derived varices 1
• The risk of bleeding is very low in FALD (6% incidence), and primary prophylaxis cannot be systematically recommended due to the unique hemodynamics and risks of sedation 1

Critical Documentation Requirements

During any EGD for varices, the following must be documented:

• Variceal size classification: small (<5 mm) or large (>5 mm) 1
• Presence or absence of red color signs (red wale marks or red spots) 1, 2
• Location of varices: esophageal vs. gastric, and specific gastric varix type (GOV1, GOV2, IGV1, IGV2) 1
• For gastric varices, detailed description of size, red signs, and location to guide interventional planning 1