Noninvasive Screening for High-Risk Esophageal Varices in Cirrhosis

The primary goal of variceal screening in patients with cirrhosis is to identify high-risk esophageal varices (HREV) and implement preventative measures. Historically, endoscopic screening was recommended for all patients with cirrhosis; however, this approach is increasingly recognized as neither cost-effective nor clinically necessary for all patients. As the prevalence of compensated advanced chronic liver disease (cACLD) continues to rise, there is increasing interest in noninvasive risk stratification methods to effectively tailor patient selection for endoscopic screening. Current clinical guidelines encourage the use of noninvasive predictive scores and algorithms to accurately identify patients at increased risk of having HREV and thereby reduce unnecessary screening endoscopies. In this review, we provide an evaluation of the various available noninvasive methods to predict HREV, including the Baveno criteria, platelet count:spleen diameter ratio, and the EVendo score. We review the performance, strengths, and limitations of these noninvasive methods-especially the machine learning-based EVendo score-and discuss future directions for optimizing risk stratification in patients with cirrhosis.