Diagnosis of esophageal varices

Diagnosing and grading esophageal varices are mainstays in the management of patients with chronic liver disease. Esophagogastroduodenoscopy (EGD) is, at present, the gold standard for diagnosis, and must be performed in all patients when the diagnosis of cirrhosis is established and repeated every 2–3 years if no varices are found, or even earlier if decompensation occurs. However, in compensated cirrhotic patients, esophageal varices are present in only about 30 % of cases at baseline endoscopy, and they are large, thus requiring treatment to prevent bleeding in a small minority. Moreover, EGD is an invasive, costly, and unpleasant procedure. The possibility of a noninvasive screening to identify patients with esophageal varices or with large esophageal varices is therefore attractive, particularly in patients with compensated cirrhosis, and has led to the proposal of many noninvasive or minimally invasive tests or techniques. The most promising of these are discussed in this chapter. However, none of them has entered clinical practice, due to lack of accuracy or of adequate validation. Therefore EGD, although non-cost-effective in compensated cirrhotic patients, cannot at present be replaced by other tests in the diagnosis and grading of esophageal varices.