Screening and Surveillance of Oesophageal Varices in Patients With HCV-positive Liver Cirrhosis Successfully Treated by Direct-acting Antiviral Agents

Alessia Ciancio; Davide Giuseppe Ribaldone; Rossella Salamone; Mauro Bruno; Stefania Caronna; Wilma Debernardi Venon; Chiara Giordanino; Alessandra Mondardini; Alessandro Musso; Marco Pennazio; Emanuela Rolle; Marco Sacco; Tatiana Sprujevnik; Claudio De Angelis; Giorgio Maria Saracco

Disclosures

Liver International. 2022;42(5):1121-1131. 

In This Article

Abstract and Introduction

Abstract

Background & Aims: limited evidence is available to guide hepatologists regarding endoscopic surveillance of oesophageal varices (EV) in Hepatitis C Virus (HCV)-positive cirrhotic patients achieving a sustained virologic response. To address these issues, we conducted a long-term prospective study on 427 HCV-positive cirrhotic patients successfully treated by Direct Antiviral Agents (DAAs).

Methods: Patients were divided into two groups according to their baseline Baveno VI status: Group 1 (92, 21.5%, favourable Baveno VI status) and Group 2 (335, 78.5%, unfavourable Baveno VI status). Each patient underwent baseline endoscopy and was endoscopically monitored for a median follow-up of 65.2 months according to Baveno VI recommendations.

Results: About 4.3% of Group 1 patients showed baseline EV compared with 30.1% of Group 2 patients (p < .0001). No patients belonging to Group 1 without baseline EV developed EV at follow-up endoscopy compared with 6.5% in Group 2 patients (p = .02); 69/107 (64.5%) patients with baseline EV showed small varices. During the endoscopic follow-up, EV disappeared/improved in 36 (33.6%), were stable in 39 (36.4%) and worsened in 32 (29.9%) patients, all belonging to Group 2 (p = .001). Improvement in Baveno VI status was observed in 118/335 (35.2%, p < .0001) of Group 2 patients and among those without pre-therapy EV, none developed EV throughout the follow-up.

Conclusions: HCV-positive cirrhotic patients cured by DAAs showing baseline favourable Baveno VI status and no worsening during follow-up can safely avoid endoscopic screening and surveillance. Patients having unfavourable Baveno VI status without baseline EV who improve their status may suspend further endoscopic surveillance.

Introduction

Hepatitis C Virus (HCV)-positive cirrhotic patients achieving a sustained virologic response (SVR) by Direct-Acting Antiviral Agents (DAAs) show a progressive decrease in portal pressure during follow-up reducing the risk of variceal bleeding.[1] However, clinically significant portal hypertension (CSPH) may persist in a significant proportion of them.[2–6] This observation has an important clinical impact by influencing our policy of screening and surveillance of oesophageal varices (EV) in cured patients. Current guidelines[7–9] recommend the use of non-invasive techniques such as transient elastography (TE) and platelet count to reduce endoscopic screening: patients showing a liver stiffness measurement (LSM) <20 kPa and platelet count >150.000/mm[3] can safely avoid endoscopy having a very low risk (<5%) of varices needing treatment (VNT).[10,11] According to the Baveno VI Consensus Workshop, these patients—defined as Baveno VI status favourable—can be safely followed up by yearly repetition of TE and platelet count.[7] However, data supporting this recommendation are still scarce.[12–14]

What it is still matter of debate is the optimal timing for surveillance endoscopy in cured patients showing unfavourable pre-therapy Baveno VI status. According to the international guidelines,[7,9] in compensated patients without comorbidities and no baseline EV or small varices prior to therapy, endoscopy should be repeated at 3- and 2-year intervals respectively. However, the strength of recommendation and level of evidence are very low. A recent clinical practice update-expert review[15] by the American Gastroenterological Association (AGA) suggests follow-up endoscopy after 2–3 years in patients with no EV on prior screening examination and no further surveillance if EV are not found; patients with small EV at baseline should undergo follow-up endoscopy after 2–3 years and no further surveillance if EV unchanged or smaller.

In order to individuate the optimal type, frequency and length of EV surveillance in relation to the clinical status of the patients, we conducted a long-term prospective study on HCV-positive patients with compensated cirrhosis successfully treated by DAAs aiming at monitoring the course of EV according to the Baveno VI criteria[7] as well as the impact on portal hypertension (PH) exerted by changes of Baveno VI status.

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