Introduction Oesophageal varices develop and enlarge in cirrhotic patients at a rate of 8% per year and haemorrhage occurs at a rate of 5–15% per annum, causing significant morbidity and mortality. Of the 16,000 deaths/year attributed to cirrhosis, 33% are due to variceal bleeding. Despite improvements in therapy and prophylaxis the mortality from bleeding varices has remained static. Current BSG guidelines recommend screening with OGD at diagnosis and then 1–3 yearly depending on endoscopic findings1.
Methods A retrospective review of clinic letters for all gastroenterologists at STDH from Aug-Oct 2012 was performed. Those eligible for variceal screening i.e. established cirrhosis, decompensated liver disease or evidence of portal hypertension on imaging were identified. Demographic details and liver disease aetiology were recorded. The endoscopy reporting system was reviewed to identify OGDs performed within the last 3 years and the indication for OGD. If an OGD report was absent, the appointment system and case notes were reviewed to establish if the patient refused or failed to attend (FTA) for OGD. Where no evidence of FTA or refusal were found, clinician failure to refer was documented.
Results 84 eligible patients were identified, 64 (76.2%) had an OGD recorded within the last 3 years.
Table 1 shows results according to liver disease aetiology. In the group with a NAFLD/NASH or “other” aetiology, all 16 cases who had not had OGD had not been referred. Of the alcohol aetiology, 7/16 had not been referred for OGD, and 9/16 FTA or were documented to have refused the test.
Conclusion Three quarters of patients eligible for varices screening have had an OGD within the maximum time frame suggested by the BSG guidelines. However, excluding OGDs performed for acute bleeding or other indications only 45/84 (56.6%) have been appropriately screened.
The majority of cases in this audit are secondary to alcoholic liver disease and their high FTA rate reiterates the known difficulties in engaging this group of patients, although numbers are small. This audit suggests a need to improve rates of screening for oesophageal varices; the main reasons suggested by this audit that could be targeted to improve screening rates are appropriate referral by clinicians and reluctance to attend for the test particularly in liver disease secondary to alcohol.
Disclosure of Interest None Declared.
Jalan R, Hayes PC. UK Guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2000; 46(Suppl 3):iii1-iii15
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