Screening for exclusion of high-risk bleeding features of esophageal varices in cirrhosis through CT and MRI

Esophageal varices (EV) screening guidelines have evolved with improved risk stratification to avoid unnecessary esophagogastroduodenoscopy (EGD) in individuals with low bleeding risks. However, uncertainties persist in the recommendations for certain patient groups, particularly those with hepatocellular carcinoma (HCC) and/or receiving non-selective beta-blockers (NSBB) without prior endoscopy. This study assessed the efficacy of imaging in ruling out EVs and their high-risk features associated with bleeding in patients with cirrhosis and with HCC. We also evaluated the impact of NSBB on the detection of these characteristics. A total of 119 patients undergoing EGD with CT and/or MRI within 90 days of the procedure were included. 87 patients had HCC. A new imaging grading system was developed utilizing the size of EVs and the extent of their protrusion into the esophagus lumen. The negative predictive value (NPV) of EVimaging(−) versus EVimaging (+) (grades 1–3) in ruling out the presence of EV and/or high-risk features by EGD was calculated. The predictive performance of imaging was determined by logistic regression. The NPV of imaging for detecting EV and high-risk features was 81 % and 92 %, respectively. Among HCC patients, the NPV for EV and high-risk features was 80 % and 64 %, respectively. Being on NSBB didn't statistically impact the imaging detection of EV. Imaging was a better predictor of high-risk EGD findings than Child-Turcotte-Pugh scores. Our results suggest that imaging can effectively rule out the presence of EV and high-risk features during EGD, even in patients with HCC and/or receiving NSBB. •CT and/or MRI demonstrate an NPV of 81% for detecting EV at endoscopy and 92% for endoscopic high-risk EV features for bleeding.•CT and/or MR achieved an 80% NPV for EV and 64% for high-risk EV features in HCC patients, indicating efficacy in this group.•Contrary to expectations, being on NSBB did not statistically affect the ability of imaging to detect EV.•Imaging outperformed the Child-Turcotte-Pugh scores in predicting EV high-risk bleeding features during esophagogastroduodenoscopy.