Screening endoscopy in patients with cirrhosis: screening of varices and gastrointestinal neoplasia

We read with great interest the paper by Miaglia et al. reporting the safety and efficacy of endoscopic resection for the treatment of superficial neoplasia in patients with cirrhosis [1].

The standard paradigm of screening gastroesophageal varices in patients with cirrhosis has for the greater part involved esophagogastroduodenoscopy (EGD). More recently, however, the Baveno VI criteria were proposed for identification of patients with cirrhosis who could safely avoid a screening EGD for clinically significant varices. Patients with a liver stiffness < 20 kPa and a platelet count > 150 000/mm³ have a very low risk of having gastroesophageal varices that require therapy, and therefore do not need to undergo endoscopic screening [2].

Although several studies have since validated the Baveno criteria [3], all have failed to acknowledge the possible role of the avoided EGD in screening at the same time for upper gastrointestinal (GI) tract neoplasia in patients with compensated cirrhosis. Cirrhosis is associated with an increased risk of non-hepatic malignancies, namely gastric cancer [4].

ESGE recently published guidelines focused on the role of endoscopy for digestive cancer screening and highlighted the potential benefit of endoscopic resection of precancerous and early lesions in improving the long-term prognosis [5]. Nevertheless, no reference is made regarding the suggested approach in cirrhotic patients.

Miaglia et al. report 65 procedures performed in 49 patients in the upper GI tract. We do not know whether the index endoscopy was performed to screen for varices or not. Most patients had either Child A or B cirrhosis and the mean platelet count was 147 000/mm³. If asymptomatic, at least some of these patients would not have been offered an EGD based on the Baveno VI criteria.

In conclusion, despite growing evidence supporting the role of non-invasive methods to rule out gastroesophageal varices in patients with cirrhosis, EGD should still be considered, particularly in countries with a higher prevalence of upper GI tract cancer.

Publication History

Article published online:
24 June 2020

• References

• 1 Miaglia C, Guillaud O, Rivory J. et al. Safe and effective digestive endoscopic resection in patients with cirrhosis: a single-center experience. Endoscopy 2020; 52: 276-284
• 2 de Franchis R, Baveno Faculty VI. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
• 3 Stafylidou M, Paschos P, Katsoula A. et al. Performance of Baveno VI and Expanded Baveno VI criteria for excluding high-risk varices in patients with chronic liver diseases: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2019; 17: 1744-1755 e1711
• 4 Zullo A, Romiti A, Tomao S. et al. Gastric cancer prevalence in patients with liver cirrhosis. Eur J Cancer Prev 2003; 12: 179-182
• 5 Saftoiu A, Hassan C, Areia M. et al. Role of gastrointestinal endoscopy in the screening of digestive tract cancers in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2020; 52: 293-304