Esophageal Varices

To classify varices, a “moderate” amount of insufflation of the lumen should preferably be used (although this leaves some scope for interpretation, of course). With low-grade varices (grade I), however, the disappearance of the varices on full insufflation should be tested (grade I).

Examples of grade I

Varices extending just above the mucosal level and compression with air insufflation (lower row of images).

Examples of grade II

Varices extending above the mucosal level (with no compression when air is insufflated) up to one-third of the luminal diameter.

Examples of grade III

Varices extending for more than 50% of the luminal diameter, or touching.

Examples of red signs

(also called red wale signs). These are red patches or strips on the varices, as a sign of an increased risk of bleeding, or of bleeding that has already taken place. Small varices lying on larger ones (varices on varices) are often considered to be among the risk signs. This category is sometimes also termed grade IV, although it is not included in the official Paquet classification.

Other classifications in the literature

JRSPH – The Japanese Research Society for Portal Hypertension classification⁽²⁾ is as follows (with an increase in the risk of bleeding in each category, from top to bottom):

NIEC (North Italian Endoscopic Club) index ⁽³⁾ is based on the Japanese classification and uses three main parameters:

Dagradi ⁽⁴⁾

Basic notes on the classifications

• Strictly speaking, the varix classifications only apply to the primary assessment, before (endoscopic) therapy. Classifications after treatment (e.g., with ligation or sclerosis) are more difficult; in this case, the (residual) varices should be described in terms of their number, location, and maximum diameter or red signs.
• In a comparative study ⁽⁵⁾, the Dagradi classification was found to have better sensitivity, but the two others (JRSPH, NIEC) had better specificity and a better positive predictive value. Since its introduction, the Paquet classification has not been validated in this way by other groups.
• Assessment variability: with the exception of one study that compared conventional and transnasal thin gastroscopy ⁽⁶⁾, most studies on this topic have shown only moderate values for interobserver variability — i.e., there were substantial variations in varix grading between different examiners, particularly in relation to the individual criteria ^(7–9). The studies concerned are already quite dated, but a more recent publication including children did not show substantially better results ⁽¹⁰⁾.

References

1. Paquet, KJ. Prophylactic endoscopic sclerosing treatment of the esophageal wall in varices – A Prospective Controlled Randomized Trial. Endoscopy 1982; 14: 4–5
2. Beppu K, Inokuchi K, Koyanagi N, Nakayama S, Sakata H, Kitano S, Kobayashi M. Prediction of variceal hemorrhage by esophageal endoscopy. Gastrointest Endosc. 1981 Nov;27(4):213-8.
3. North Italian Endoscopic Club for the Study and Treatment of Esophageal Varices. Prediction of the first variceal hemorrhage in patients with cirrhosis of the liver and esophageal varices. A prospective multicenter study.N Engl J Med. 1988 Oct 13;319(15):983-9.
4. Dagradi AE, Stempien SJ, Owens LK. Bleeding esophagogastric varices. An endoscopic study of 50 cases. Arch Surg. 1966 Jun;92(6):944-7.
5. Rigo GP, Merighi A, Chahin NJ, Mastronardi M, Codeluppi PL, Ferrari A, Armocida C, Zanasi G, Cristani A, Cioni G, et al. A prospective study of the ability of three endoscopic classifications to predict hemorrhage from esophageal varices. Gastrointest Endosc. 1992 Jul-Aug;38(4):425-9.
6. Pungpapong S, Keaveny A, Raimondo M, Dickson R, Woodward T, Harnois D, Wallace M. Accuracy and interobserver agreement of small-caliber vs. conventional esophagogastroduodenoscopy for evaluating esophageal varices. Endoscopy. 2007 Aug;39(8):673-80. Epub 2007 Jun 22.
7. Bendtsen F, Skovgaard LT, Sørensen TI, Matzen P. Agreement among multiple observers on endoscopic diagnosis of esophageal varices before bleeding. Hepatology. 1990 Mar;11(3):341-7.
8. Calès P, Buscail L, Bretagne JF, Champigneulle B, Bourbon P, Duclos B, Dapoigny M, Dumas R, Pierrugues R, Davion T, et al. Interobserver and intercenter agreement of gastro-esophageal endoscopic signs in cirrhosis. Results of a prospective multicenter study Gastroenterol Clin Biol. 1989 Dec;13(12):967-73.
9. Conn HO, Smith HW, Brodoff M: Observer Variation in the endoscopic diagnosis of esophageal varices. A prospective investigation of the diagnostic validity of esophagoscopy. N Engl J Med. 1965 Apr 22;272:830-4
10. D’Antiga L, Betalli P, De Angelis P, Davenport M, Di Giorgio A, McKiernan PJ, McLin V, Ravelli P, Durmaz O, Talbotec C, Sturm E, Woynarowski M, Burroughs AK. Interobserver Agreement on Endoscopic Classification of Oesophageal Varices in Children: A Multicenter Study. J Pediatr Gastroenterol Nutr. 2015 Apr 15. [Epub ahead of print]