Japanese Grading System for Esophageal Varices
Understanding the Japanese Classification System
The Japanese grading system classifies esophageal varices using two primary parameters: Form (F) and Red Color signs (RC), which differ from the Western simplified small/large classification 1.
Form (F) Grading
- F0: No varices detected 2
- F1: Small, straight varices that are minimally elevated above the esophageal mucosal surface 2
- F2: Moderately enlarged, tortuous varices occupying less than one-third of the esophageal lumen 2
- F3: Large, coil-shaped varices occupying more than one-third of the esophageal lumen 2
Red Color (RC) Signs
- RC0: No red color signs present 3
- RC1: Mild red color signs 3
- RC2: Prominent red color signs (red wale marks or red spots) 4, 3
High-risk varices in the Japanese system are defined as F2 or greater and/or RC2 or above 3.
Management Algorithm Based on Japanese Grading
F0 (No Varices)
- Repeat EGD every 2-3 years in compensated cirrhosis 1
- Repeat EGD annually in decompensated cirrhosis 1
F1 (Small Varices)
Without red color signs (RC0-1):
- Repeat EGD every 1-2 years in compensated cirrhosis 1
- Consider nonselective beta-blockers if decompensated cirrhosis is present 4
With prominent red color signs (RC2):
- Initiate prophylactic treatment immediately with either nonselective beta-blockers (propranolol or nadolol) targeting heart rate 55-60 bpm, or endoscopic variceal ligation 4
- Red color signs mandate treatment regardless of variceal size, as 80% of patients with cherry red spots experience variceal bleeding 4, 5
F2-F3 (Medium to Large Varices)
All patients require prophylactic treatment 1:
Treatment options include:
- Nonselective beta-blockers (propranolol or nadolol) with target heart rate 55-60 bpm 4
- Carvedilol as an alternative beta-blocker 4
- Endoscopic variceal ligation (EVL) 1
- Combination of nonselective beta-blockers plus EVL for enhanced protection 4
The presence of RC2 signs in F2-F3 varices indicates extremely high bleeding risk and warrants aggressive prophylaxis 4, 5.
Critical Clinical Pearls
Prognostic Factors
The Japanese system's strength lies in identifying three independent risk factors for hemorrhage 4:
- Variceal size (F grade)
- Red color signs (RC grade)
- Degree of hepatic decompensation (Child-Pugh class)
Surveillance After Treatment
- Following EVL, perform follow-up endoscopy at 1-6 months after variceal eradication, then every 6-12 months 4
- Monitor heart rate targets and medication tolerance in patients on beta-blockers 4
Common Pitfalls
- Do not dismiss F1 varices with RC2 signs as "low risk"—they require the same aggressive prophylaxis as large varices 4
- The Japanese F1/F2/F3 system provides more granular risk stratification than the Western small/large dichotomy, but Western guidelines group F2 and F3 together for treatment purposes 1
- Interobserver variability exists in grading varices endoscopically, with kappa values ranging from -0.025 to 0.975 6
Diagnostic Accuracy
Capsule endoscopy shows 92% sensitivity and 80% specificity for detecting high-risk varices (F2 and/or RC2) in Japanese patients, offering a potential alternative screening method 3.