How are esophageal varices graded and managed in patients with suspected varices?

Grading of Esophageal Varices

Classification System

Esophageal varices should be graded using a simplified two-tier system: small (<5 mm) or large (>5 mm), with the presence or absence of red color signs documented at endoscopy. 1

Primary Grading Parameters

• Size classification: Varices are categorized as either small (<5 mm diameter) or large (>5 mm diameter) based on quantitative measurement or semiquantitative morphological assessment 1, 2

• When three-tier grading is used (small, medium, large), medium and large varices are managed identically, as they were grouped together in prophylactic trials 1

  • Small varices: minimally elevated veins above esophageal mucosa
  • Medium varices: tortuous veins occupying <1/3 of esophageal lumen
  • Large varices: occupying >1/3 of esophageal lumen 1

• Red color signs must be documented: The presence or absence of red wale marks or red spots dramatically affects bleeding risk, increasing it to 80% when cherry red spots are present 1, 3, 2

Gastric Varices Classification

• Gastroesophageal varices (GOV) extend from esophageal varices:

  • GOV1: extend along lesser curvature, managed like esophageal varices
  • GOV2: extend along fundus, more tortuous 1

• Isolated gastric varices (IGV) occur without esophageal varices:

  • IGV1: located in fundus (requires excluding splenic vein thrombosis)
  • IGV2: located in body, antrum, or pylorus 1

Diagnostic Approach

All patients with newly diagnosed cirrhosis should undergo screening esophagogastroduodenoscopy (EGD) to detect and grade varices. 1, 2

Initial Screening

• EGD is the gold standard for diagnosing and grading esophageal varices, allowing direct visualization and classification 1, 2

• Screening timing: Perform EGD once cirrhosis diagnosis is established 1

• EGD can be avoided in patients already on nonselective beta-blockers for other indications (e.g., hypertension); those on selective beta-blockers should be switched to nonselective agents 1

Surveillance Intervals Based on Initial Findings

• No varices + compensated cirrhosis: Repeat EGD every 2-3 years 1, 2

• Small varices + compensated cirrhosis: Repeat EGD every 1-2 years 1, 2

• Decompensated cirrhosis: Repeat EGD yearly regardless of initial findings 1, 2

• After endoscopic variceal ligation: Follow-up endoscopy at 1-6 months after eradication, then every 6-12 months to monitor for recurrence 4

Management Based on Grading

Large Varices (>5 mm)

All patients with large varices require primary prophylaxis with either nonselective beta-blockers (propranolol, nadolol, or carvedilol) or endoscopic variceal ligation. 3, 4

• Large varices carry a 15% yearly bleeding risk 3, 2

• Both treatment modalities are equally effective for preventing first variceal hemorrhage 3

Small Varices with High-Risk Features

Initiate nonselective beta-blockers immediately for small varices with Child-Pugh B/C classification or red wale marks. 3, 4

• Red color signs (RC2 in Japanese system) indicate high bleeding risk requiring immediate prophylaxis 4

• The combination of small varices with decompensation or red signs warrants treatment despite size 3, 4

Small Varices Without High-Risk Features

• Surveillance without treatment is acceptable if patient is compensated (Child-Pugh A) and no red color signs present 3

• Repeat endoscopy every 1-2 years for compensated patients, annually if decompensated 1, 2

No Varices

• No prophylactic treatment required 3

• Surveillance endoscopy every 2-3 years if compensated, annually if decompensated 1, 2

Critical Prognostic Factors

Three independent risk factors predict variceal hemorrhage: variceal size, red color signs, and degree of hepatic decompensation. 4

• Variceal size: Large varices have 15% yearly bleeding risk 3

• Red color signs: Increase bleeding risk to 80% regardless of variceal size 3, 2

• Hepatic decompensation: Child-Pugh class and presence of ascites/encephalopathy are strongest mortality predictors 3

  • Decompensated cirrhosis with varices has >80% 5-year mortality 3
  • Isolated variceal finding in compensated cirrhosis has ~20% 5-year mortality 3

Common Pitfalls

• Do not rely on noninvasive markers alone: While platelet count, spleen size, and platelet count/spleen diameter ratio correlate with varices, their predictive accuracy remains unsatisfactory for replacing endoscopic screening 1, 5, 6, 7

• Document both size and red signs: Failure to document red color signs misses critical bleeding risk stratification 1, 2

• Distinguish "downhill varices": Upper esophageal varices from superior vena cava obstruction can coexist with portal hypertension-derived varices and require different management 2

• Consider capsule endoscopy limitations: While better tolerated than EGD with 91% agreement on treatment decisions, capsule endoscopy showed only 78% sensitivity for medium/large varices and should not replace EGD for initial screening 8