Criteria

Background

Detailed classification systems have been developed to identify those varices that are at highest risk of bleeding based on size, endoscopic markings, and liver function.[3][6][42]

The most important predictor of hemorrhage is the size of varices, with the highest risk of first hemorrhage occurring in patients with large varices (15% per year).[3][4] Other important predictors of hemorrhage are decompensated cirrhosis (Child-Pugh B/C) and the endoscopic finding of red wale marks.[3][5]

Child-Pugh classification of the severity of cirrhosis

Child-Pugh scoring uses five clinical measures of liver disease. Each measure is scored as between 1 and 3 points, with 3 indicating the most severe derangement. [ Child Pugh classification for severity of liver disease Opens in new window ] ​​​​ It is also known as the Child-Turcotte-Pugh score. The clinical measures are:

Encephalopathy

  • None: 1 point

  • Grade 1 to 2: 2 points

  • Grade 3 to 4: 3 points

Ascites

  • None: 1 point

  • Mild/moderate: 2 points

  • Tense: 3 points

Bilirubin (mg/dL)

  • <2: 1 point

  • 2 to 3: 2 points

  • >3: 3 points

Albumin (g/dL)

  • >3.5: 1 point

  • 2.8 to 3.5: 2 points

  • <2.8: 3 points

International normalized ratio

  • <1.7: 1 point

  • 1.7 to 2.3: 2 points

  • >2.3: 3 points.

Chronic liver disease is classified into Child-Pugh class A to C using the scores as above:

  • Class A: 5 to 6 points

  • Class B: 7 to 9 points

  • Class C: 10 to 15 points.

North Italian endoscopic club for the study and treatment of esophageal varices[3]

Classification based on size, severity of red wale marks (defined as longitudinal dilated venules resembling whip marks on the variceal surface), and Child-Pugh class.

Size of varices

  • Small

  • Medium

  • Large

In practice, medium and large varices are grouped together as "high-risk varices" as they both require prophylactic therapy to prevent variceal bleeding.[5]

Red wale markings

  • Absent

  • Mild

  • Moderate

  • Severe

Child-Pugh class

  • A

  • B

  • C

A risk stratification for variceal bleeding accompanies this classification, with cumulative scores for individual features added to define a risk class.

Size of varices

  • Small (<25% lumen radius)

  • Medium (25% to 50% lumen radius)

  • Large (>50% of lumen radius)

Red wale markings

  • Absent 3.2

  • Mild 6.4

  • Moderate 9.6

  • Severe 12.8

Child-Pugh class

  • A 6.5

  • B 13.0

  • C 19.5

Risk class according to North Italian endoscopic club score (Risk class: score; 1-year bleeding rate %):

  • Risk Class 1 (<20; 1.6%)

  • Risk Class 2 (20 to 25; 11% )

  • Risk Class 3 (25.1 to 30; 14.8%)

  • Risk Class 4 (30.1 to 35; 23.3%)

  • Risk Class 5 (35.1 to 40; 37.8%)

  • Risk Class 6 (>40; 68.9%).

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