From the Guidelines
Variceal surveillance in the UK should involve regular endoscopic screening for esophageal and gastric varices in patients with cirrhosis, with the frequency of surveillance determined by the presence and size of varices, as well as the patient's underlying liver disease severity, as recommended by the most recent guidelines 1.
Key Recommendations
- Initial endoscopy is recommended at diagnosis to assess for varices, with surveillance endoscopy repeated every 2-3 years for compensated cirrhosis and at 1-2 year intervals for decompensated cirrhosis, or as modified according to the type and severity of underlying liver disease 1.
- For patients with small varices not on treatment, endoscopy should be repeated every 1-2 years, while those with medium or large varices should receive non-selective beta-blockers or undergo endoscopic variceal ligation, with follow-up endoscopy performed every 1-3 years to monitor for recurrence or progression 1.
- Patients who have had variceal bleeding require more intensive surveillance, with endoscopy typically performed 2-4 weeks after the acute bleeding episode, then every 3-6 months until varices are eradicated, followed by surveillance every 6-12 months, as supported by earlier guidelines 1.
Rationale
The rationale for these recommendations is based on the high mortality rate associated with variceal hemorrhage, which can be reduced through regular surveillance and timely intervention, as well as the importance of individualizing the frequency of surveillance based on patient-specific risk factors, such as liver disease severity, platelet count, and liver stiffness measurements 1.
Evidence Base
The evidence base for these recommendations is derived from the most recent and highest quality studies, including the 2020 KASL clinical practice guidelines for liver cirrhosis, which provide a comprehensive framework for the management of varices and related complications 1, as well as earlier studies that have informed the development of these guidelines 1.
From the Research
Variceal Surveillance in the UK
- The British Society of Gastroenterology provides best practice guidance for the outpatient management of cirrhosis, including screening for varices 2.
- The guidance recommends screening for varices as part of a compensated cirrhosis care bundle in the outpatient setting 2.
- Endoscopic screening for varices is a recommended approach for primary prophylaxis of variceal bleeding in patients with cirrhosis 3, 4.
- The cost-effectiveness of screening endoscopy for varices has been evaluated, with some studies suggesting that empiric beta-blocker therapy may be a more cost-effective approach than screening endoscopy 5.
Endoscopic Screening and Treatment
- Endoscopic variceal ligation (EVL) and non-selective beta-blockers (NSBBs) are equally effective treatments for primary prophylaxis of variceal bleeding in patients with medium- or large-sized varices 6.
- EVL is the recommended endoscopic procedure for patients with acute variceal bleeding, and may be combined with vasoactive drugs and antibiotics 6.
- Secondary prophylaxis should start on day six following the initial bleeding episode, and may involve a combination of NSBBs and EVL 6.
Patient Selection and Outcomes
- Patients with cirrhosis should be selected for screening based on their risk factors for variceal bleeding, including the size and presence of stigmata on varices 4.
- The mortality rate for first variceal hemorrhage remains high, despite improvements in diagnosis and treatment 4.
- Screening for varices and prophylactic treatment may help reduce mortality, morbidity, and associated healthcare costs 4.