This interim guidance relates to the screening of patients with compensated cirrhosis to identify varices. It replaces the previous interim guidance in 2020 when elective NHS services, including routine endoscopy, were halted due to the COVID-19 pandemic and many were not able to reopen until much later that year.
It is acknowledged that there has been a geographically variable impact of the pandemic and therefore there is some variation in service recovery rates across the UK. This guidance is written acknowledging that and balancing it with the interests and needs of patients with cirrhosis.
The COVID-19 pandemic led to many changes to endoscopic practice, including in patients with liver disease. Some of these reflected the need to triage and prioritise those at most need in times of limited capacity, while others recognised an emerging evidence base around non-endoscopic alternatives to facilitate safe management without the need for endoscopy, but not yet scrutinised for UK practice or widely adopted.
We recognise the need for ongoing research into the role of endoscopy and optimal management of portal hypertension in patients with chronic liver disease. This could contribute significantly to the evidence base for future guidance. We support the resumption of clinical and research trials in this area, where local endoscopy capacity allows.
We are also aware of NICE guidance in this field which is due to be updated, the publication of a new consensus statement from Baveno VII, new UK guidelines in cirrhosis management in progress, and other work being done in the UK Gastroenterology and Hepatology community in this field currently, all of which mean that this interim guidance will be reviewed at a minimum interval of 12 months.
Survey of Practice
In a 2022 survey of practice a quarter of responding endoscopy units only modified their varices surveillance practice at the height of the pandemic in 2020, these plus another 40% of units are now recovering, whereas 30% of units feel they are unlikely to recover to pre-pandemic practice for some time. Notably, Baveno VI criteria were used to select patients for surveillance by a third of units. These criteria require access to Fibroscan which may be a limiting factor as only 65% of responding units had easy access all the time. (BASL/BSG Portal Hypertension SIG)
A note on Baveno VII
Baveno VII includes a consensus statement (statement 5.14) that treatment with non-selective beta-blockers (propranolol, nadolol or carvedilol) should be considered for the prevention of decompensation in patients with clinically significant portal hypertension which is defined as Liver Stiffness Measurement (LSM) >25kPa (statement 2.16). This is the most controversial recommendation, and is based on a single prospective trial and retrospective cohort evidence. The use of beta-blockers to prevent any decompensation episode is not in widespread hepatology practice in the UK at the present time and there is uncertainty regarding the PREDESCI data when applying non-invasive tests to guide treatment in patient populations that are no longer seen in UK practice. The field remains under scrutiny for the work in progress mentioned in the introduction. In addition, there are two ongoing large UK studies that will provide evidence as to the benefits of beta-blockers in those with small varices and the best treatment for those with large varices. Therefore no recommendation in this respect is given at present, but will remain under review.
With these factors in mind:
- Units are advised we no longer recommend the routine use of beta-blockers without prior endoscopy for the primary prevention of variceal haemorrhage.
- Units are advised to resume endoscopy for varices surveillance.
- The use of Baveno VI criteria may be helpful in identifying patients for index endoscopy where units have access to Fibroscan. We support this in patients with cirrhosis and LSM ≥20kPa or platelet counts ≤150×109/L. Such patients are included Baveno VI and sections of Baveno VII (section 2.19).
- Where treatment initiatives may have reduced portal pressures e.g. anti-viral therapy, cessation of alcohol drinking; reassessment of liver stiffness measurements and platelet count in line with the above cut offs could be helpful in assessing need for repeat endoscopy in 3 year recall patients.
John Dillon, Vice President Hepatology, BSG
Rebecca Jones, President, BASL
Ian Rowe BASL Research Lead/BSG Research Committee
Ian Penman Vice President Endoscopy, BSG
de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C, on behalf of the Baveno VII Faculty, BAVENO VII – RENEWING CONSENSUS IN PORTAL HYPERTENSION, Journal of Hepatology (2022), doi: https://doi.org/10.1016/j.jhep.2021.12.022
Villanueva C et al. B-blockers to prevent decompensation of cirrhosis in patients with clinically significant portal hypertension (PREDESCI): a randomised, double-blind, placebo controlled, multicentre trial. Lancet 2019;393:1597-1608, doi: http://dx.doi.org/10.1016/ S0140-6736(18)31875-0