Gastroenterology

Gastroenterology

Volume 122, Issue 6, May 2002, Pages 1620-1630
Gastroenterology

Endoscopic screening for varices in cirrhosis: Findings, implications, and outcomes☆,☆☆

https://doi.org/10.1053/gast.2002.33419Get rights and content

Abstract

At least two thirds of cirrhotic patients develop esophageal varices during their lifetime. Severe upper gastrointestinal (UGI) bleeding as a complication of portal hypertension develops in about 30%–40% of cirrhotics. Despite significant improvements in the early diagnosis and treatment of esophagogastric variceal hemorrhage, the mortality rate of first variceal hemorrhage remains high (20%–35%). Primary prophylaxis, the focus of this article, is treatment of patients who never had previous variceal bleeding to prevent the first variceal hemorrhage. The potential of preventing first variceal hemorrhage offers the promise of reducing mortality, morbidity, and associated health care costs. This article (1) reviews endoscopic grading of size and stigmata for esophageal and gastric varices, (2) describes data on prevalence and incidence of esophageal and gastric varices from prospective studies, (3) discusses independent risk factors from multivariate analyses of prospective studies for development of first esophageal or gastric variceal hemorrhage and possible stratification of patients based on these risk factors, (4) comments on the potential cost effectiveness of screening all newly diagnosed cirrhotic patients and treating high-risk patients with medical or endoscopic therapies, and (5) recommends further studies of endoscopic screening, stratification, and outcomes in prospective studies of endoscopic therapy. The author's recommendations are to perform endoscopic screening for the following subgroups of cirrhotics: all newly diagnosed cirrhotic patients and all other cirrhotics who are medically stable, willing to be treated prophylactically, and would benefit from medical or endoscopic therapies. Exclude patients who are unlikely to benefit from prophylactic therapies designed to prevent the first variceal hemorrhage, those with short life expectancy, and those with previous UGI hemorrhage (they should have already undergone endoscopy). For low or very low risk cirrhotic patients—those found to have no varices or small varices without stigmata—repeat endoscopy is recommended because screening for progression may be warranted in 2 or more years.

GASTROENTEROLOGY 2002;122:1620-1630

Section snippets

Endoscopic grading of size and stigmata of varices and their risk for hemorrhage

Several endoscopists have described different classifications of esophageal varices by size, form, color, and stigmata.12, 16, 19, 20, 21, 22 These have been used to stratify patients into low- or high-risk subgroups for prediction and study of first esophageal variceal hemorrhage.12, 16, 19, 20, 21, 22, 23 In nonbleeding cirrhotic patients who are normovolemic, most endoscopists can agree on the color of the esophageal varices (blue or other color) and the size of esophageal varices (absent,

Prevalence of esophageal varices

Numerous, randomized, prospective, or controlled studies of β-blockers, sclerotherapy, or rubber band ligation have been reported as prophylactic treatments and describe the safety and efficacy of medical or endoscopic treatments for patients with portal hypertension and esophageal varices.3, 4, 6, 8, 9, 11, 18, 19, 20, 21, 22, 23, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43 Most patients have cirrhosis in reports from the United States or Europe, but other

Risk stratification based on independent determinants of first esophageal variceal hemorrhage from multivariate analyses: Relevance to screening and results

There are several strategies that have been reported for risk stratification and selection of patients for randomized prospective trials. To date, these have been exclusively used to enhance the chance of first esophageal varices in the study by enrolling high-risk patients.3, 12, 27, 51 Another use may be for reassurance and triage of low-risk patients for first variceal hemorrhage to less intense medical follow-up, therapy, or surveillance.

One-time screening endoscopy allowed a significant

Potential cost effectiveness of screening and medical or endoscopic therapies in high-risk patients

No prospective studies have assessed the cost effectiveness of screening endoscopy alone in cirrhotic patients. However, 1 cost-effectiveness analysis used Markov modeling to simulate the natural history of esophageal varices.52 From the literature of endoscopic screening, size of varices and presence of red color signs were incorporated into this model. For the treatments evaluated in this model, prophylactic propranolol resulted in the most cost savings over 5 years and increased

Future recommendations about screening endoscopy and stratification of patients to different treatments

The effectiveness of endoscopic screening has not been compared with no screening for different unselected populations of cirrhotic patients who have not had prior UGI hemorrhage. It is doubtful that endoscopic screening alone (without triaging patients to different treatments and careful follow-up) will lead to a significant change in the overall rate of first esophageal hemorrhage or in mortality. However, motivated patients, such as the high-risk subgroup for developing esophageal variceal

Summary statement about which cirrhotic patients should undergo endoscopic screening for esophageal varices

The author's current recommendations are to perform endoscopic screening for the following subgroups of cirrhotic patients: all newly diagnosed cirrhotic patients and all other cirrhotic patients who are medically stable, willing to be treated prophylactically, and would benefit from medical or endoscopic therapies. The author would exclude patients who are unlikely to benefit from prophylactic therapies designed to prevent the first variceal hemorrhage, those with a short life expectancy, and

Conclusions

1. Stratification of cirrhotic patients into high- and low-risk groups for prediction of first variceal hemorrhage is feasible with clinical and endoscopic parameters.

2. Multivariate analyses of prospective studies indicate that high-risk patients for first variceal hemorrhage have advanced Child–Pugh class, large esophageal varices, and red wale markings. Advanced age, gastric varices, and alcohol-induced cirrhosis increased the risk for variceal hemorrhage and mortality in other studies. It

Acknowledgements

The author is grateful to Julie Pham for word processing this manuscript, Ken Hirabayashi for preparation of the figures, and Rome Jutabha, M.D., and Thomas O. G. Kovacs, M.D., for providing some of the endoscopic photographs.

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    ☆

    Supported in part by National Institutes of Health grants RO1 K24 DK02650, RO1 DK49527, the CURE Human Studies CORE DK41301, and CRC grant MO1-RR00865.

    ☆☆

    Address requests for reprints to: Dennis M. Jensen, M.D., CURE Digestive Disease Research Center, Veterans Administration Greater Los Angeles Healthcare System, Building 115, Room 318, 11301 Wilshire Boulevard, Los Angeles, California 90073-1003. e-mail: [email protected]; fax: (310) 794-2908.

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