Baveno VI Recommendation on Avoidance of Screening Endoscopy in Cirrhotic Patients: Are We There Yet?

Abstract

Introduction: Recent studies assessed the predictive value of liver transient elastography, combined or not with platelet count, for the presence of esophageal varices in patients with liver cirrhosis, and multiple cutoffs have been proposed. The Baveno VI consensus states that patients with compensated advanced chronic liver disease, liver stiffness <20 kPa, and a platelet count >150,000 have a very low risk of having varices requiring treatment and can avoid screening endoscopy. We aimed to validate this recommendation in a cohort of cirrhotic patients. Methods: Retrospective analysis of all patients evaluated at the Gastroenterology Department (Centro Hospitalar de Lisboa Central) between September 2009 and October 2015 with a liver stiffness (FibroScan®) compatible with liver cirrhosis as well as upper endoscopy and blood tests within 12 months from elastography. Patients on propranolol ≥80 mg/day or carvedilol ≥12.5 mg/day, as well as those with previous variceal bleeding, variceal endoscopic treatments, or cirrhosis decompensations were excluded. We validated the new Baveno VI recommendation and explored alternative cutoffs. Results: Ninety-seven patients were analyzed, 76.3% (74/97) male, mean age 54.3 ± 11.2 years. Most patients (55.7%) had no varices and 14.4% had varices requiring treatment. Most patients (78.4%) had cirrhosis related to chronic hepatitis C. If the new Baveno VI recommendation had been applied to this cohort, upper endoscopy would have been avoided in 11.3% (11/97) of patients, none of them with esophageal varices requiring treatment: specificity 100%, sensitivity 13.3%, positive predictive value 100%, and negative predictive value 16.3% for absence of varices requiring treatment. If screening endoscopy had been avoided in those patients with liver stiffness <30 kPa and platelet count ≥120,000, endoscopy would have been avoided in 27.8% (27/97) of patients, none of whom with esophageal varices requiring treatment: specificity 100%, sensitivity 32.5%, positive predictive value 100%, and negative predictive value 20% for absence of varices requiring treatment. Conclusions: The new Baveno VI criteria identified compensated cirrhotic patients without varices requiring treatment in whom screening endoscopy could have been avoided safely. Further studies are needed to confirm these findings and potentially explore more ambitious but still safe cutoffs for those criteria.

A combined model based on spleen stiffness measurement and Baveno VI criteria to rule out high-risk varices in advanced chronic liver disease

“…Several studies [9][10][11][12][13][14]39] and one meta-analysis [15] have validated Baveno VI criteria as safe for screening for HRV in cACLD patients, with an overall missed HRV of <5%. The proportion of spared EGDs with Baveno VI criteria is however relatively low (15-25%), as also confirmed by our data (17-22%).…”

“…The above criteria can also be applied for longitudinal follow up, prompting screening endoscopy if LSM increases or PLT decreases [8]. To date, several papers have provided validation of these criteria [7,[9][10][11][12][13][14] confirming that Baveno VI criteria correctly identify 98-100% of patients who could safely avoid endoscopy. These criteria have recently also been adopted by the American Association for the Study of the Liver [3] with a suggestion to use NIT stratification according to Baveno VI criteria in all patients with a new diagnosis of cirrhosis.…”

Prediction of the varices needing treatment with non‐invasive tests in patients with compensated advanced chronic liver disease

“…The Baveno VI consensus workshop recommended that screening endoscopy can be avoided in patients with LS <20 kPa and with a platelet count >150 × 10 9 cells/L among patients with compensated advanced chronic liver disease (cACLD) because the risk of having VNT is very low in these patients . Several studies have validated the efficacy of these criteria and have shown that these criteria can spare screening endoscopy in some patients with cACLD with a very low VNT miss rate . However, because of the low saved endoscopy rate with this criteria, one study has suggested application of the expanded Baveno VI criteria (LS <25 kPa and platelet count >110 × 10 9 cells/L) .…”

Liver stiffness in chronic hepatitis C virus infection

“…Liver stiffness measurement obtained with a FibroScan machine can serve to discriminate esophageal varices; in this study mean liver stiffness varied between 9.94 ± 6 kPa in patients with grade 1 varices and 46.1 ± 15 kPa in those with grade 4 varices (detected and classified by esophagogastroduodenoscopy) [41]. 90 A liver stiffness measurement below 20 kPa together with a platelet count of over 150 × 10 9 /L in patients with compensated advanced chronic liver disease may indicate the absence of oesophageal varices requiring treatment, according to Baveno VI consensus [42]. But a liver stiffness measurement of less than 25 kPa together with a platelet count above 110 × 10 9 cells/L are new criteria (Expanded-Baveno VI) that safely avoid superior digestive endoscopy as varices screening in patients with compensated advanced chronic liver disease.…”