I have cirrhosis: Why should I have and upper GI endoscopy to screen for varices?

What are esophageal varices?

Esophageal varices are dilated veins in the lower third of the esophagus seen in cirrhosis. Cirrhosis is scarring of the liver. As a consequence of cirrhosis, the blood flow through the liver becomes partially blocked. Blood must, however, somehow return to the heart and it looks for a bypass or shunt. Often the veins in the esophagus are used as shunt, and esophageal varices result. The veins become stretched and thin from the unusual traffic and can burst; this is called variceal bleeding.

A scarred liver (cirrhosis) forces blood around the liver into veins in the esophagus. The esophageal veins enlarge and become varices.

Esophageal variceal bleeding can be deadly but can also be prevented

Variceal bleeding is a devastating complication of cirrhosis with an in-hospital mortality rate of almost 15 %. Approximately 50 % of patients at the time of diagnosis of cirrhosis will have esophageal varices. The strongest predictors of bleeding are high-risk signs such as large varices or red wale marks seen during upper endoscopy. Multiple randomized studies have shown an almost 50 % decrease in the risk of first variceal bleeding in individuals with high-risk esophageal varices who receive primary prophylaxis. Prophylaxis can be with either medication (beta-blockers) or esophageal variceal band ligation during upper endoscopy.

When and how often should I get screened?

A bleeding esophageal varix as seen during upper endoscopy. This can be prevented.

The American Association for the Study of Liver Disease (AASLD) recommends[1] that screening endoscopy for the diagnosis of esophageal varices is done when the diagnosis of cirrhosis is made.[i]

Patients with compensated cirrhosis without varices on screening endoscopy should have endoscopy repeated every 2 years (with ongoing liver injury or associated conditions, such as obesity and alcohol use) or every 3 years (if liver injury is quiescent, e.g., after viral elimination, alcohol abstinence).

Patients with with small varices on screening endoscopy should have endoscopy repeated every year (with ongoing liver injury) or every 2 years (if liver injury is quiescent, e.g., after viral elimination, alcohol abstinence).

If you have cirrhosis or think you may have cirrhosis and nobody has looked for esophageal varices, you need to talk to your doctor or make an appointment with Dr. Klaus Gottlieb.

[1][1] Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. Hepatology. 2017 Jan 1;65(65):310-35.

[i] Unless transient elastography (when available) and platelet count suggest that endoscopy is not necessary.

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