Simple SummaryPatient with hepatocellular carcinoma are at an increased risk of variceal haemorrhage, and often require endoscopic workup to look for the presence of high-risk varices prior to starting systemic therapy. The Baveno VII criteria has been a well-validated non-invasive risk stratification tool in predicting high-risk varices for patients with liver cirrhosis, but data on its use in the hepatocellular carcinoma population is lacking. In this study, we successfully validated the Baveno VII criteria as a safe and accurate modality in predicting high-risk varices and hepatic events in patients with hepatocellular carcinoma.AbstractThe Baveno VII criteria are used in patients with liver cirrhosis to predict high-risk varices in patients with liver cirrhosis. Yet its use in patients with advanced hepatocellular carcinoma (HCC) has not been validated. HCC alone is accompanied with a higher variceal bleeding risk due to its association with liver cirrhosis and portal vein thrombosis. The use of systemic therapy in advanced HCC has been thought to further augment this risk. Upper endoscopy is commonly used to evaluate for the presence of varices before initiation of treatment with systemic therapy. Yet it is associated with procedural risks, waiting time and limited availability in some localities which may delay the commencement of systemic therapy. Our study successfully validated the Baveno VI criteria with a 3.5% varices needing treatment (VNT) missed rate, also with acceptable <5% VNT missed rates when considering alternative liver stiffness (LSM) and platelet cut-offs. The Baveno VII clinically significant portal hypertension rule-out criteria (LSM < 15 kPa and platelet >150 × 109/L) also revealed a low frequency (2%) of hepatic events, whilst the rule-in criteria (LSM > 25 kPa) was predictive of a higher proportion of hepatic events (14%). Therefore, our study has successfully validated the Baveno VII criteria as a non-invasive stratification of the risk of variceal bleeding and hepatic decompensation in the HCC population.