Reply to Liberal et al.

We read with great interest the letter of Liberal R et al. Although our paper was not designed to evaluate the incidence of early neoplasia, we emphasized that endoscopy for screening of varices may also detect neoplastic lesions in the upper gastrointestinal (GI) tract.

In total, 21 lesions were diagnosed during pre-transplantation evaluation independently from screening for varices, 21 patients had decompensated cirrhosis (excluded for the use of Baveno VI criteria), and 99 lesions were colorectal. Unfortunately, the indication of the initial endoscopy procedure that detected early upper GI neoplasia was not recorded in our work.

Alcohol and smoking are the two main risk factors for both esophageal squamous cell carcinoma (SCC) and liver cirrhosis, with alcohol still the primary cause of liver cirrhosis and also the top indication for liver transplantation in France [1]. The risk of esophageal cancers in cirrhotic patients is between 2.6 and 7.25 times higher than in non-cirrhotic patients [2], mainly due to SCC and not to Barrett’s neoplasia [3]. In contrast, the relative risk of gastric cancer in cirrhotic patients is between 1.0 and 5.5 [2], with the excess risk due to tobacco and alcohol consumption and not due to the liver disease itself [4].

These elements do not sustain the performance of a systematic screening endoscopy to detect varices in cirrhotic patients when Baveno VI criteria are met, because they have high levels of sensitivity (but not 100 %) [5]. However, endoscopic screening should be discussed for patients with both alcohol and tobacco abuse, although not strictly recommended by the recent ESGE position statement when a history of previous SCC is missing. Systematic endoscopy should also be recommended when the liver cirrhosis is decompensated, if there are symptoms, or when a colonoscopy is already indicated because adding a gastroscopy is an easy way to diagnose both varices and neoplasia in only one session.

Publication History

Article published online:
24 June 2020

• References

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• 5 Stafylidou M, Paschos P, Katsoula A. et al. Performance of Baveno VI and expanded Baveno VI criteria for excluding high-risk varices in patients with chronic liver diseases: a systematic review and meta-analysis. Clin Gastroenterol Hepatol 2019; 17: 1744-1755.e11