How often should patients with
hepatitis C be screened
for
esophageal varices?
August 2006 | Volume 73 | Number 8 | Pages 758-759
| Christopher Entwisle, MD Division of Gastroenterology and Liver Diseases, George Washington University; Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA |
Zobair M. Younossi, MD, MPH Director, Center for Liver Diseases, Medical Director, Liver Transplant Program, and Medical Director, Inova Research Center, Inova Fairfax Hospital, Falls Church, VA |
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Patients with hepatitis
C should be initially evaluated for cirrhosis: if it is not present,
there is no need to screen for
esophageal varices. A patient with cirrhosis should be screened promptly
with upper endoscopy. If no varices are found, endoscopy should be repeated
every 2 years. The finding
of small varices requires repeat endoscopy annually.1
Hepatitis C Infection and Cirrhosis
Millions of Americans are chronically infected with the hepatitis C
virus, a disease associated with significant morbidity and mortality.
Natural history studies suggest hepatitis C infection progresses to cirrhosis in 20% of cases,2 making
it the most common cause of cirrhosis in the United States.
Cirrhosis almost unavoidably leads to the potentially devastating complications
of portal hypertension, which include ascites, hepatic encephalopathy, and the formation of esophageal varices.
If no varices are present, repeat endoscopy every 2 years
Varices Can Develop Rapidly and be Dangerous
Cirrhosis caused by any chronic liver disease is the main cause of varices
related to portal hypertension. Bleeding from varices is the
most common cause of death from cirrhosis (>30% of deaths). Large
esophageal varices should be identified as early as possible so that
primary prophylactic strategies can be offered.
Patients with cirrhosis have a 50% chance of having varices at the time
of diagnosis. Those with no varices on initial endoscopy
develop them at a rate of 5% to 20% annually. For those found to have
small varices on endoscopy, about 5% to 15% progress to having large
varices each year.3
The risk of hemorrhage increases with the size of varices, as well as
the severity of hepatic dysfunction as determined by the Child-Pugh
classification.
Merkel et al,4 in a randomized, placebo-controlled study
in 161 patients with cirrhosis and small esophageal varices, found that
the nonselective beta-blocker nadolol inhibited the growth of esophageal
varices and reduced the risk of bleeding. These findings should be confirmed
in large trials. Nevertheless, nonselective beta-blockers are the preferred
treatment for patients with medium-sized or large varices that have
not yet bled.
Endoscopy is Still the Best Test
Endoscopy is the standard screening test for identifying varices. A less-invasive method would be preferable: several studies have looked for potential noninvasive markers, including low blood platelet counts, dilated portal veins as seen on ultrasonography, low blood albumin levels, the presence of telangiectasias, and increased spleen size.5,6 Although several independent predictors have been identified, no algorithm has been developed to more narrowly select patients for endoscopic testing.
New technology, such as wireless capsule endoscopy, and other less-invasive methods have shown promise in identifying esophageal varices, but their role remains unproven.
References
1. de Franchis R. Updating consensus in portal hypertension:
report of the Baveno III consensus workshop on definitions,
methodology and therapeutic strategies in portal
hypertension. J Hepatol 2000; 33:846–852.
2. Liang TJ, Rehermann B, Seeff LB, Hoofnagle JH. Pathogenesis, natural history, treatment, and prevention
of hepatitis C. Ann Intern Med 2000; 132:296–305.
3. Garcia N Jr, Sanyal AJ. Portal hypertension. Clin Liver Dis
2001; 5:509–540.
4. Merkel C, Marin R, Angeli P, et al; Gruppo Triveneto per
l’Ipertensione Portale. A placebo-controlled clinical trial
of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology 2004;
127:476–484.
5. Madhotra R, Mulcahy HE, Willner I, Reuben A. Prediction of esophageal varices in patients with cirrhosis. J Clin
Gastroenterol 2002; 34:81–85.
6. Garcia-Tsao G, Escorsell A, Zakko W, et al. Predicting the presence of significant portal hypertension and varices in
compensated cirrhotic patients [abstract]. Hepatology 1997; 26:360A.