Classifying varices in cirrhosis: Who's got the best look?

There is no question endoscopy plays a fundamental role in the diagnosis and management of patients with cirrhosis and oesophageal varices. Although we have now swayed away from performing endoscopy in all patients with cirrhosis as a screening tool to detect varices, it still recommended in those with low platelet counts (<150 000) and high values of elastography (>20 Kpa). 1 The objectives of endoscopy for screening are to assess if they are present and decide if they need therapy with either non-selective beta-blockers (NSBB) or endoscopic band ligation. The decision to start therapy is based on the size and presence of red spots which indicate a high risk of bleeding. Therefore, an adequate examination is key to offer high accuracy and consistency in the classification of varices. There are several classification systems for estimating the size proposed by different authors. The most commonly used and perhaps the easiest for endoscopists is the American Association for Study of Liver Disease (AASLD) two-grade classification system with a cutoff of 5 mm that divides them into small or large.2 There is also a third-grade system that uses a score of small, medium and large, but in reality, medium and large are managed the same way, thus the wider use of the two-grade system. The size of a varix can be measured by means of comparing the size to that of an open biopsy forceps (which measures between 6-7 mm), but this is obviously not done in day-to-day practice. In some instances, there can be hurdles when attempting to classify and describe varices. These issues include the amount of air insufflation, whether they are evaluated on withdrawal or not, and the degree of sedation. Despite this, the bottom line is that we need to know if the patient has varices that need treatment. Since upper endoscopy is widely performed by both gastroenterologists and hepatologists with different degrees of experience, good interobserver agreement (OA) and reproducibility of the currently used grading systems is something we all rely upon when managing patients with varices. Although comparing the agreement of both classifications is important, the real interest in our view is that of assessing the impact of the endoscopists on the level of agreement. In this issue a study by Fateen et al the authors tackle this question with a prospective study.3 They analysed 100 videos of upper endoscopies in patients with cirrhosis performed by a single and experienced endoscopist. Then, nine blinded observers (3 hepatologists, 3 general gastroenterologists and 3 GI trainees) evaluated the videos. The assessments were repeated one year later by the same observers to assess intra-observer agreement. The OA of all observers using the two-grade and the three-grade system was pretty good with a Kappa value >0.7 in almost all scenarios. The absence of varices was almost identical using both grading systems. Agreement with the two-grade and three-grade system was similar and better among hepatologists compared to general gastroenterologists or trainees. Several messages from this paper deserve to be highlighted. Firstly, they compare both classification systems. We believe their effort is laudable and the authors should be commended for prospectively comparing both systems. That said, this comparison of interobserver agreement has been analysed before.4 Secondly, the videos performed by an expert (endoscopist) on portal hypertension is a quality standard to adequately evaluate varices and further reduce bias. Thirdly, the intra-observer agreement was evaluated for an interval (1 year), to assess which practitioners were consistent with their initial score over time. Fourthly, these data support the use of both classification systems; but since the two-grade system has been validated as a predictor of variceal bleeding and is recommended by the AASLD, we prefer this system. Finally, to us, the more important point of this paper is the fact the study highlights the value of experience. There was better agreement among hepatologists. This agreement is likely due to a higher number of endoscopies hepatologists perform in patients with cirrhosis and/ or portal hypertension. So, it is the higher case volume rather than just the fact of being a hepatologist. Indeed, the authors did not have the hepatologists that do not perform endoscopies evaluate the videos. In conclusion, there are two major lessons from this paper; one is that the two-stage classification system is valid and the other is that hepatologists are more consistent with the identification and classification of varices. These findings should make us reflect on how we train our fellows. We perhaps need to think about a specific model while they rotate in the hepatology service by having them review videos and try to set a specific number of endoscopies they should perform in patients with portal hypertension to adequately classify varices. Finally, these results resonate in the forthcoming Baveno VII consensus conference, where how to define variceal size has been a controversial issue for years. A full agreement on a standard classification of varices would facilitate, as recently suggested, incorporating varices as part of a clinical endpoint in future trials for compensated cirrhosis.5