Fig. 1.

Suggested algorithm for the diagnosis and management of small varices. The green elements summarize the recommended strategy as supported by previous international guidelines that recommend screening endoscopy in all patients diagnosed with cirrhosis (i.e., ACLD). If small varices are detected, treatment with conventional NSBB or carvedilol may be started as primary prophylaxis of variceal bleeding. If no varices are detected, screening endoscopy should be repeated every 1–2 years. The orange elements summarize the Baveno VI recommendations for non-invasive diagnosis of varices in patients with cirrhosis that were designed to avoid screening endoscopies in patients with low liver stiffness (TE < 20 kPa) and normal platelet counts (PLT ≥ 150 G/L). However, since this strategy will miss a considerable number of patients with small varices (that must not be treated—but should be treated in our opinion), we would still recommend to perform screening endoscopies even in patients with TE ≥ 20 kPa or PLT < 150 G/L if cirrhosis (ACLD) is suspected. Finally, the black elements indicate advanced diagnostic/therapeutic options that we recommend for optimal management of patients with small varices: In patients with small varices and even in patients with ACLD without varices (especially in those with TE ≥ 20 kPa or PLT < 150 G/L), HVPG should be measured. If HVPG is measured at ≥ 10 mmHg, the hemodynamic response to NSBB (ideally intravenous testing) or carvedilol should be assessed and hemodynamic responders should be kept on NSBB or carvedilol if a decrease of at least ≥ 10% in HVPG is observed. In hemodynamic non-responders, follow-up endoscopy should be performed every 1–2 years in order to assess the progression to large varices. ACLD, advanced chronic liver disease; cACLD compensated advanced chronic liver disease; HVPG, hepatic venous pressure gradient; LSM, liver stiffness measurement; NSBB, non-selective betablocker; PLT, platelet count; Y, year(s)