From the Guidelines
Screening intervals for esophageal varices using esophagogastroduodenoscopy (OGD) should be tailored based on cirrhosis severity and initial findings, with the most recent guidelines suggesting annual screening for patients with decompensated cirrhosis and no varices on initial screening, as recommended by the 2018 EASL clinical practice guidelines 1.
Key Recommendations
- For patients with compensated cirrhosis without varices on initial screening, repeat OGD is recommended every 2-3 years, as suggested by Garcia-Tsao et al. in 2007 1.
- If small varices are found, screening should occur every 1-2 years, according to the same study 1.
- Patients with decompensated cirrhosis should undergo more frequent screening, typically annually, regardless of initial findings, as recommended by the 2018 EASL guidelines 1.
- Those with medium or large varices should be started on primary prophylaxis (typically non-selective beta-blockers like propranolol 20-40mg twice daily or nadolol 20-40mg daily, or endoscopic band ligation) rather than continued surveillance, as suggested by Garcia-Tsao et al. in 2007 1.
Rationale
The recommendations reflect the progressive nature of portal hypertension in cirrhosis, where varices develop and enlarge over time, with larger varices carrying higher bleeding risk, as noted by Garcia-Tsao et al. in 2007 1. Patients with additional risk factors such as alcohol use, coagulopathy, or elevated portal pressures may warrant more frequent screening than the standard intervals. The 2018 EASL guidelines provide more recent and specific recommendations for patients with decompensated cirrhosis, emphasizing the importance of annual screening in this high-risk population 1.
From the Research
OGD Screening Intervals for Varices
- The optimal screening interval for varices is not explicitly stated in the provided studies, but it is recommended that all patients with cirrhosis be screened for gastroesophageal varices 2.
- Screening for varices has been recommended to prevent variceal hemorrhage (primary prophylaxis), and therapy is recommended after the initial episode of variceal bleeding to prevent recurrence (secondary prophylaxis) 3.
- The use of esophageal capsule endoscopy for screening and surveillance of esophageal varices in patients with portal hypertension has been studied, and it may increase adherence to screening programs due to its minimal invasiveness and good tolerance 4.
- Nonselective beta-blockers are the mainstay of medical therapy in the prophylaxis of variceal bleeding and rebleeding in patients with portal hypertension, and their efficacy has been demonstrated by numerous trials 5, 6.
- The risk of having a first cirrhosis-associated variceal bleed is lowered by about 50% by beta-blockers, and the use of beta-blockers is currently recommended for patients with cirrhosis and oesophageal varices that are at risk of bleeding 6.
- It is recommended that patients with large varices should be treated with beta-blockers and variceal band ligation (VBL) should be offered to those cirrhotics who are unable to take beta-blockers 2.