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Developments and controversies in the management of oesophageal and gastric varices
  1. Gautam Mehta1,
  2. Juan G Abraldes2,
  3. Jaime Bosch2
  1. 1Institute of Hepatology, University College London, London, UK
  2. 2Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic-IDIBAPS and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
  1. Correspondence to Professor Jaime Bosch, Hepatic Hemodynamic Laboratory, Hospital Clínic, C. Villarroel 170, 08036 Barcelona, Spain; jbosch{at}clinic.ub.es

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Portal hypertension is a milestone in the progression of cirrhosis and heralds the onset of the fatal complications of liver disease. Over the last two decades significant progress has been made in the diagnosis and treatment of portal hypertension and of variceal haemorrhage (VH) in particular. As Bertrand Russell, the British philosopher, said, ‘the most savage controversies are those about matters as to which there is no good evidence either way’. This article will focus on developments in screening for oesophageal varices (OVs), for the prophylaxis of VH from OVs and gastric varices (GVs), and the remaining controversies that will shape treatment strategies for portal hypertension in the coming decade.

Screening for oesophageal varices

VH is a catastrophic event for the patient with cirrhosis, with 1-year mortality of up to 40% following an episode of VH.1 2 Since one-third of patients with OVs will develop VH, screening for OVs in the cirrhotic population is mandatory on the basis of the availability of effective diagnostic and prophylactic measures.

Oesophagogastroduodenoscopy (OGD) is considered the primary modality for the detection and surveillance of OVs, and is recommended at the time of diagnosis of cirrhosis.3 4 With this approach, OVs are found to be present in ∼40% of patients with compensated cirrhosis.5 The interval for endoscopic surveillance for OVs following an initial negative examination depends on the rate of progression of OVs. The overall incidence of OVs is 5–10% per year,5 although this is modified by the severity of portal hypertension. Current guidance is for OGD to be repeated at 1–3 yearly intervals depending on the severity of liver disease (box 1).3 4

Box 1 Recommendations for the diagnosis and management of OV

Recommendations for endoscopic screening for OVs (modified from Garcia-Tsao et al4):

  1. Compensated cirrhosis without varices: 2–3 years.

  2. Compensated cirrhosis with clinically significant portal hypertension (HVPG >10 mm Hg) without varices: 1–2 years.

  3. Compensated cirrhosis and small varices: 1–2 years.*

  4. Decompensated cirrhosis: 1 year. …

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