Baveno VI missed varices in liver cancer; a new rule missed half as many

Design

Retrospective derivation cohort with bootstrap and external validation

Population

598 Italian patients with HCC and compensated advanced chronic liver disease; 149 in Vienna validation

Primary outcome

Varices missed by non-invasive rule-out criteria

Effect

Baveno VI missed 8.5%; SAPHE-R missed 4.0% (4.8% in validation)

Using the Italian Liver Cancer database, investigators studied 598 patients with hepatocellular carcinoma and compensated advanced chronic liver disease who had liver stiffness, endoscopy and blood tests within six months of diagnosis. A third had varices.

Baveno VI criteria, designed for cirrhosis without cancer, would have spared 31% of endoscopies but missed 8.5% of varices and 6% of high-risk varices. A new rule, SAPHE-R — liver stiffness of 16 kPa or less, platelets of 160 × 10⁹/L or more and ALBI grade 1 — missed 4% of varices and 3% of high-risk varices, sparing 18% of endoscopies. It performed similarly in an independent Vienna cohort of 149 patients.

Patients with HCC often need anticoagulation, systemic therapy with bleeding risk such as bevacizumab, or procedures, so knowing whether varices are present matters more than in general cirrhosis. Ruling out any varices, not just high-risk ones, is the relevant target.

The trade-off is fewer endoscopies avoided. The cohorts were mainly viral, European and early-stage, and the rule needs testing in MASLD-related and Indian populations.

• Do not rely on Baveno VI criteria alone to skip endoscopy in patients with hepatocellular carcinoma.
• Consider the SAPHE-R combination — stiffness ≤16 kPa, platelets ≥160 × 10⁹/L, ALBI grade 1 — to identify patients at low risk of varices.
• Arrange endoscopy before starting systemic therapy with bleeding risk when varices have not been ruled out.
• Record liver stiffness, platelets and ALBI grade at HCC diagnosis so the rule can be applied.

Why it matters

Variceal screening decisions in liver cancer carry more weight because treatment often adds bleeding risk.

Don't overread it

A derived and externally validated rule, but not yet tested prospectively or outside European cohorts.

The statistics, in plain English

A miss rate of 4% means about one in 25 patients classed as low risk actually had varices. The validation cohort was small (149 patients), so the true miss rate could be somewhat higher or lower.

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