Tc-99m labeled sulfur may be used in nuclear imaging to provide some indication of hepatic function in cirrhotic patients. In candidates for liver transplant, CTA is used to asses the drainage of the liver. All patients with cirrhosis must undergo a diagnostic endoscopy for the evaluation of varices. Gastric endoscopy is an option if gastric varices are suspected, and endoscopic ultrasound may also help in the visualization of varices. ERCP is performed if a biliary pathology such as primary sclerosing cholangitis is suspected as the underlying cause of cirrhosis.

• Radionuclide testing may be useful in the diagnosis of cirrhosis:^[1][2]
  • Tc-99m labeled sulfur used for functional imaging techniques provides some indication of hepatic function
  •  99mTc sulfur colloid is normally taken up by cells of the reticuloendothelial system
  • Cirrhosis: heterogeneity in the uptake of 99mTc sulfur colloid by the liver and increased uptake by the spleen and bone marrow provides evidence of portal hypertension^[3]

• The angiographic findings of hepatic perfusion are essential in transplant assessment, given the variability of hepatic drainage from its arterial and venous supplies.

• All patients with cirrhosis should undergo a diagnostic endoscopy to document the presence or absence of varices and to determine the risk for variceal hemorrhage.^[4][5]
• Esophageal varices are dilated collaterals in the lower esophagus that interconnect portal and systemic circulation in patients with portal hypertension.
• Esophageal varices appear as irregular, serpiginous, bluish structures running longitudinally in the submucosa of the esophageal wall on endoscopy.
• It may be difficult to differentiate small varices from esophageal folds and EUS may be helpful.
• Findings on an upper endoscopy diagnostic of esophageal varices include:^[6]
  • Visible submucosal tortuous veins
  • Congested veins without compression during air insufflation
  • Grape-like varicose veins that may occlude the lumen^[7]

• The presence of varices in patients with cirrhosis is considered an independent risk factor for survival.^[10]
• The appearance of esophageal varices is not diagnostic of portal hypertension and does not allow for differentiation between portal hypertension secondary to cirrhosis, pre-sinusoidal hypertension, or portal or splenic vein thrombosis.
• Majority of patients with cirrhosis develop varices and approximately one third bleed at some point.^[11]
• The most popular model used to target patients with high risk of variceal bleed is devised by the North Italian Endoscopic Club for the Study and Treatment of esophageal varices.^[12]
• The severity of the underlying liver disease, presence or absence of red markings on the varices, and variceal size are the most important risk factors for bleeding.
• Gastroscopy (endoscopic examination of the esophagus, stomach and duodenum) is performed in patients with cirrhosis to exclude the possibility of esophageal varices.
• In patients with varices, prophylactic therapy may include:
  • Local therapy:
    • Sclerotherapy
    • Variceal banding
  • Medical therapy:
    • Beta blockers

• Varices may be seen within the submucosa of the esophagus and in the periesophageal or perigastric soft tissue.^[13]
• In the esophagus, EUS does not appear to be superior to endoscopy in the detection of esophageal varices.
• EUS is invaluable in differentiating gastric varices from submucosal tumors and prominent gastric folds.
• The role of EUS in determining whether or not varices are obliterated is under evaluation.
• EUS is a very safe procedure with a complication rate of approximately 0.05%.
• The major complication of EUS is perforation, which is related to the relatively large diameter and stiffness of the endoscope used.

• If a biliary pathology (primary sclerosing cholangitis – PSC) is suspected, ERCP may be performed.
• MRCP (MRI of biliary tract and pancreas) is usually sufficient for diagnosis, but ERCP allows for particular interventions, such as placement of a biliary stent or extraction of gallstones.

• Three dimensional portal venography may be helpful in the diagnosis of gasteroesophageal varices.
• Findings on a portal venography diagnostic of esophageal varices include:^[14][15]
  • Reverse flow in porto-systemic shunts
  • Collateral veins draining into inferior vena cava (IVC)
  • Other collateral veins