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Borhani A, Luu H, Mohseni A, Xu Z, Shaghaghi M, Tolosa C, Attari MMA, Madani SP, Shahbazian H, Khoshpouri P, Afyouni S, Zandieh G, Kamel IR, Kim AK. Screening for exclusion of high-risk bleeding features of esophageal varices in cirrhosis through CT and MRI. Clin Imaging 2024; 110:110168. [PMID: 38703476 DOI: 10.1016/j.clinimag.2024.110168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND & AIM Esophageal varices (EV) screening guidelines have evolved with improved risk stratification to avoid unnecessary esophagogastroduodenoscopy (EGD) in individuals with low bleeding risks. However, uncertainties persist in the recommendations for certain patient groups, particularly those with hepatocellular carcinoma (HCC) and/or receiving non-selective beta-blockers (NSBB) without prior endoscopy. This study assessed the efficacy of imaging in ruling out EVs and their high-risk features associated with bleeding in patients with cirrhosis and with HCC. We also evaluated the impact of NSBB on the detection of these characteristics. METHODS A total of 119 patients undergoing EGD with CT and/or MRI within 90 days of the procedure were included. 87 patients had HCC. A new imaging grading system was developed utilizing the size of EVs and the extent of their protrusion into the esophagus lumen. The negative predictive value (NPV) of EVimaging(-) versus EVimaging (+) (grades 1-3) in ruling out the presence of EV and/or high-risk features by EGD was calculated. The predictive performance of imaging was determined by logistic regression. RESULTS The NPV of imaging for detecting EV and high-risk features was 81 % and 92 %, respectively. Among HCC patients, the NPV for EV and high-risk features was 80 % and 64 %, respectively. Being on NSBB didn't statistically impact the imaging detection of EV. Imaging was a better predictor of high-risk EGD findings than Child-Turcotte-Pugh scores. CONCLUSIONS Our results suggest that imaging can effectively rule out the presence of EV and high-risk features during EGD, even in patients with HCC and/or receiving NSBB.
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Affiliation(s)
- Ali Borhani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Harry Luu
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alireza Mohseni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ziyi Xu
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mohammadreza Shaghaghi
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Celestina Tolosa
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Seyedeh Panid Madani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Haneyeh Shahbazian
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Pegah Khoshpouri
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Shadi Afyouni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ghazal Zandieh
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ihab R Kamel
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Amy K Kim
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Khalifa A, Rockey DC. Role of Endoscopy in the Diagnosis, Grading, and Treatment of Portal Hypertensive Gastropathy and Gastric Antral Vascular Ectasia. Gastrointest Endosc Clin N Am 2024; 34:263-274. [PMID: 38395483 DOI: 10.1016/j.giec.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Portal hypertensive gastropathy (PHG) and gastric antral vascular ectasia (GAVE) are 2 distinct gastric vascular abnormalities that may present with acute or chronic blood loss. PHG requires the presence of portal hypertension and is typically associated with chronic liver disease, whereas there is controversy about the association of GAVE with chronic liver disease and/or portal hypertension. Distinguishing between GAVE and PHG is crucial because their treatment strategies differ. This review highlights characteristic endoscopic appearances and the clinical features of PHG and GAVE, which, in turn, aid in their appropriate management.
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Affiliation(s)
- Ali Khalifa
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA.
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Jiang X, Pan J, Xu Q, Song YH, Sun HH, Peng C, Qi XL, Qian YY, Zou WB, Yang Y, Jin SQ, Duan BS, Wu S, Chu Y, Xiao DH, Hu LJ, Cao JZ, Dai JF, Liu X, Xia T, Zhou W, Chen T, Zhou CH, Wu W, Liu SJ, Yang ZY, Wang F, Zhang L, Li CZ, Xu H, Wang JX, Wei B, Lin Y, Deng X, Qu LH, Shen YQ, Wang H, Huang YF, Bao HB, Zhang S, Li L, Shi YH, Wang XY, Zou DW, Wan XJ, Xu MD, Mao H, He CH, Li Z, Zuo XL, He SX, Xie XP, Liu J, Yang CQ, Spada C, Li ZS, Liao Z. Diagnostic accuracy of magnetically guided capsule endoscopy with a detachable string for detecting oesophagogastric varices in adults with cirrhosis: prospective multicentre study. BMJ 2024; 384:e078581. [PMID: 38443074 PMCID: PMC10912951 DOI: 10.1136/bmj-2023-078581] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE To evaluate the diagnostic accuracy and safety of using magnetically guided capsule endoscopy with a detachable string (ds-MCE) for detecting and grading oesophagogastric varices in adults with cirrhosis. DESIGN Prospective multicentre diagnostic accuracy study. SETTING 14 medical centres in China. PARTICIPANTS 607 adults (>18 years) with cirrhosis recruited between 7 January 2021 and 25 August 2022. Participants underwent ds-MCE (index test), followed by oesophagogastroduodenoscopy (OGD, reference test) within 48 hours. The participants were divided into development and validation cohorts in a ratio of 2:1. MAIN OUTCOME MEASURES The primary outcomes were the sensitivity and specificity of ds-MCE in detecting oesophagogastric varices compared with OGD. Secondary outcomes included the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices and the diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices. RESULTS ds-MCE and OGD examinations were completed in 582 (95.9%) of the 607 participants. Using OGD as the reference standard, ds-MCE had a sensitivity of 97.5% (95% confidence interval 95.5% to 98.7%) and specificity of 97.8% (94.4% to 99.1%) for detecting oesophagogastric varices (both P<0.001 compared with a prespecified 85% threshold). When using the optimal 18% threshold for luminal circumference of the oesophagus derived from the development cohort (n=393), the sensitivity and specificity of ds-MCE for detecting high risk oesophageal varices in the validation cohort (n=189) were 95.8% (89.7% to 98.4%) and 94.7% (88.2% to 97.7%), respectively. The diagnostic accuracy of ds-MCE for detecting high risk oesophagogastric varices, oesophageal varices, and gastric varices was 96.3% (92.6% to 98.2%), 96.9% (95.2% to 98.0%), and 96.7% (95.0% to 97.9%), respectively. Two serious adverse events occurred with OGD but none with ds-MCE. CONCLUSION The findings of this study suggest that ds-MCE is a highly accurate and safe diagnostic tool for detecting and grading oesophagogastric varices and is a promising alternative to OGD for screening and surveillance of oesophagogastric varices in patients with cirrhosis. TRIAL REGISTRATION ClinicalTrials.gov NCT03748563.
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Affiliation(s)
- Xi Jiang
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Jun Pan
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Qing Xu
- Department of Gastroenterology and Hepatology, Tongji Hospital of Tongji University School of Medicine, Shanghai, China
| | - Yu-Hu Song
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Huan-Huan Sun
- Department of Gastroenterology, Shanxi Clinical Research Centre of Digestive Disease (cancer division), the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Cheng Peng
- Department of Gastroenterology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiao-Long Qi
- CHESS Centre, Department of Radiology, Basic Medicine Research and Innovation Centre of Ministry of Education, Zhongda Hospital, Medical School, Southeast University, Nurturing Centre of Jiangsu Province for State Laboratory of AI Imaging and Interventional Radiology, Nanjing, China
| | - Yang-Yang Qian
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Wen-Bin Zou
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Yang Yang
- Department of Gastroenterology and Endoscopy, The Fifth affiliated Zhuhai Hospital of Zunyi Medical University, Zhuhai, China
| | - Shao-Qin Jin
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Ben-Song Duan
- Department of Gastroenterology, Endoscopy Centre, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shan Wu
- Department of Endoscopy, The Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ye Chu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ding-Hua Xiao
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Li-Juan Hu
- Department of Gastroenterology, Shanghai Pudong New Area Gongli Hospital, Shanghai, China
| | - Jun-Zhi Cao
- Department of Gastroenterology, Yangpu Hospital, Tongji University, Shanghai, China
| | - Jin-Feng Dai
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiao Liu
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Tian Xia
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Wei Zhou
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Tao Chen
- Department of Gastroenterology, Endoscopy Centre, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chun-Hua Zhou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Wu
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shao-Jun Liu
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhen-Yu Yang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Fen Wang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Lu Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Cheng-Zhong Li
- Department of Infectious Diseases, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hao Xu
- Department of Infectious Diseases, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jun-Xue Wang
- Department of Infection, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Bo Wei
- Department of Infection, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yong Lin
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Xing Deng
- Department of Gastroenterology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Li-Hong Qu
- Department of Infectious Diseases, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ying-Qiu Shen
- Department of Infectious Diseases, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hui Wang
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi-Fei Huang
- Department of Gastroenterology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hai-Biao Bao
- Department of Gastroenterology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Shuo Zhang
- Department of Gastroenterology, The Second Affiliated Hospital of Zhejiang Chinese University, Hangzhou, China
| | - Li Li
- Department of Gastroenterology, Yangpu Hospital, Tongji University, Shanghai, China
| | - Yi-Hai Shi
- Department of Gastroenterology, Shanghai Pudong New Area Gongli Hospital, Shanghai, China
| | - Xiao-Yan Wang
- Department of Gastroenterology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Duo-Wu Zou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xin-Jian Wan
- Department of Endoscopy, The Sixth People's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mei-Dong Xu
- Department of Gastroenterology, Endoscopy Centre, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hua Mao
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Chao-Hui He
- Department of Gastroenterology and Endoscopy, The Fifth affiliated Zhuhai Hospital of Zunyi Medical University, Zhuhai, China
| | - Zhen Li
- Department of Gastroenterology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiu-Li Zuo
- Department of Gastroenterology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shui-Xiang He
- Department of Gastroenterology, Shanxi Clinical Research Centre of Digestive Disease (cancer division), the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiao-Ping Xie
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Liu
- Department of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chang-Qing Yang
- Department of Gastroenterology and Hepatology, Tongji Hospital of Tongji University School of Medicine, Shanghai, China
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
| | - Zhuan Liao
- Department of Gastroenterology, Changhai Clinical Research Unit, National Clinical Research Centre for Digestive Diseases, National Key Laboratory of Immunity and Inflammation, Changhai Hospital, Naval Medical University, Shanghai 200433, China
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Njei B, Al-Ajlouni YA, McCarty TR. Novel capsule endoscopy for detecting varices. BMJ 2024; 384:q506. [PMID: 38443073 DOI: 10.1136/bmj.q506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Affiliation(s)
- Basile Njei
- Section of Digestive Diseases, Yale University, New Haven, CT, USA
| | | | - Thomas R McCarty
- Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, TX, USA
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Papaefthymiou A, Koffas A, Laskaratos FM, Epstein O. Upper gastrointestinal video capsule endoscopy: The state of the art. Clin Res Hepatol Gastroenterol 2022; 46:101798. [PMID: 34500118 DOI: 10.1016/j.clinre.2021.101798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/28/2021] [Accepted: 08/16/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Video capsule can illuminate the entire gastrointestinal mucosa. Upper gastrointestinal capsule endoscopy (UGICE) has the potential to survey for oesophageal, gastric and duodenal pathology and determine whether biopsy or intervention is indicated. AIMS This review traces the evolution of foregut video capsule endoscopy. METHODS A broad literature research was performed independently by two investigators. Extracted articles were organized and evaluated to interpret all current data. RESULTS In contrast to small bowel capsule, UGICE required sequential innovations to deal with rapid oesophageal transit, the irregular shape of the stomach and unpredictable gastric peristalsis. Oesophageal capsule endoscopy required the development of a two-camera device operating at a high frame rate, and postural change was developed to improve image capture, especially at the level of the Z-line, thus providing good imaging of Barrett's oesophagus, erosive oesophagitis and oesophageal varices, with optimal patients' tolerance. UGICE in patients presenting to the emergency room with acute bleeding has demonstrated accuracy when deciding on the need for emergency intervention. The latest development of a high frame rate UGICE, designed to image the oesophagus, stomach and duodenum has overtaken dedicated oesophageal capsule development. Capsule control is possible by exposing a magnetised capsule to an external magnetic field, and early reports indicate high accuracy in the oesophagus and stomach with high levels of patient acceptability. There is little information on cost-benefit. CONCLUSIONS Capsule endoscopy offers gastroenterologists a new device to investigate the upper gastrointestinal tract with promising future potential.
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Affiliation(s)
- Apostolis Papaefthymiou
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, Larisa 41110, Greece; First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Macedonia, Greece
| | - Apostolos Koffas
- Department of Gastroenterology, General University Hospital of Larisa, Mezourlo, Larisa 41110, Greece
| | - Faidon-Marios Laskaratos
- Endoscopy Unit, Digestive Diseases Centre, Barking Havering and Redbridge University Hospitals NHS Trust, London, United Kingdom
| | - Owen Epstein
- Centre for Gastroenterology, Royal Free Hospital, Pond St, London NW3 2QG, United Kingdom..
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Zhu JH, Pan J, Xu XN, Liu YW, Qian YY, Jiang X, Jiang B, Zhou W, Linghu EQ, Li ZS, Liao Z. Noncontact magnetically controlled capsule endoscopy for infection-free gastric examination during the COVID-19 pandemic: a pilot, open-label, randomized trial. Endosc Int Open 2022; 10:E163-E170. [PMID: 35178334 PMCID: PMC8847063 DOI: 10.1055/a-1648-2238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 08/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Endoscopists have been at increased risk because of their direct contact with patients during the COVID-19 pandemic. For patients, being diagnosed with and monitored for gastrointestinal cancer and digestive diseases in timely fashion has been challenging, given pandemic-related adjustments in endoscopy departments. We developed a novel noncontact magnetically controlled capsule endoscopy (ncMCE) system in our medical center. In the current study, we aimed to evaluate the feasibility and safety of ncMCE for gastric examination. Patients and methods Patients were randomly assigned to groups that received ncMCE or MCE in a 1:1 ratio from March 26, 2020 to April 26, 2020. Primary endpoints were feasibility assessed by completion rate (CR) and safety based on the occurrence of adverse events (AEs) including infection. Secondary endpoints included maneuverability of endoscopists, pre-procedure perception and post-procedure satisfaction of patients, gastric examination time (GET), and diagnostic yield (DY). Results Forty patients were enrolled with 100 % CR in both groups without any AEs. Neither the endoscopist nor the patients were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within 14 days after gastric examination. There were no significant differences in maneuverability (19.3 vs. 20.0, P = 0.179), pre-procedure perception (9 vs. 9, P = 0.626) and post-procedure satisfaction (45 vs. 44, P = 0.999), ord DY (20 % vs. 30 %, P = 0.465). Conclusions ncMCE is a feasible and safe method of gastric examination, which has the potential to protect both medical staff and patients from COVID-19 infection while providing serving as an essential endoscopy service.
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Affiliation(s)
- Jia-Hui Zhu
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Jun Pan
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Xiao-Nan Xu
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Ya-Wei Liu
- Department of Gastroenterology, The First Medical Center of PLA General Hospital/Chinese PLA Postgraduate Military Medical School, Beijing, China
| | - Yang-Yang Qian
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Xi Jiang
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Bin Jiang
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Wei Zhou
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - En-Qiang Linghu
- Department of Gastroenterology, The First Medical Center of PLA General Hospital/Chinese PLA Postgraduate Military Medical School, Beijing, China
| | - Zhao-Shen Li
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Zhuan Liao
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
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Hanscom M, Stead C, Feldman H, Marya NB, Cave D. Video Capsule Endoscopy and Device-Assisted Enteroscopy. Dig Dis Sci 2022; 67:1539-1552. [PMID: 34383197 PMCID: PMC8358900 DOI: 10.1007/s10620-021-07085-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2021] [Indexed: 12/09/2022]
Abstract
Mark Hanscom Courtney Stead Harris Feldman Neil B. Marya David Cave.
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Affiliation(s)
- Mark Hanscom
- grid.168645.80000 0001 0742 0364Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA 01655 USA
| | - Courtney Stead
- grid.168645.80000 0001 0742 0364Department of Medicine, University of Massachusetts Medical School, Worcester, MA USA
| | - Harris Feldman
- grid.168645.80000 0001 0742 0364Department of Medicine, University of Massachusetts Medical School, Worcester, MA USA
| | - Neil B. Marya
- grid.168645.80000 0001 0742 0364Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA 01655 USA
| | - David Cave
- grid.168645.80000 0001 0742 0364Division of Gastroenterology, University of Massachusetts Medical School, Worcester, MA 01655 USA
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Wang S, Huang Y, Hu W, Mao H, McAlindon ME, Liu Y, Yang L, Zhang C, Xu M, He C, Dang T, Wu B, Ji D, Zhang L, Mao X, Zhang L, Liu C, Xu D, Li Y, Li G, Han J, Lv F, Liang X, Jin S, Zhang S, Tai FWD, Xu Q, Yang C, Wang G, Wang L, Li B, Yang H, Xie P, Deng L, Ren L, Chang Z, Wang X, Wang S, Gao X, Li J, Zhu L, Wang F, Zhang L, Zhang G, Jiang X, Pan J, Meng W, Li X, Hou J, Dray X, Liao Z, Qi X. Detachable string magnetically controlled capsule endoscopy for detecting high-risk varices in compensated advanced chronic liver disease (CHESS1801): A prospective multicenter study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2021; 6:100072. [PMID: 34327406 PMCID: PMC8315440 DOI: 10.1016/j.lanwpc.2020.100072] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/15/2020] [Accepted: 11/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastroesophageal varices is a serious complication of compensated advanced chronic liver disease (cACLD). Primary prophylaxis to reduce the risk of variceal hemorrhage is recommended if high-risk varices (HRV) are detected. We performed this study to compare the accuracy, patients' satisfaction and safety of detection of HRV by detachable string magnetically controlled capsule endoscopy (DS-MCCE) with esophagogastroduodenoscopy (EGD) as the reference. METHODS We prospectively recruited participants with cACLD from 12 university hospitals (11 in China and one in the United Kingdom) between November 2018 and December 2019 (ClinicalTrials.gov, NCT03749954). All participants underwent DS-MCCE, followed by EGD within a week in a blinded fashion. Following endoscopy, and on the same day, participants were asked to fill in a satisfaction questionnaire regarding their experience. FINDINGS A total of 105 eligible participants were enrolled. With EGD as the reference standard, the concordance index, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of DS-MCCE in diagnosis of HRV were 0•90 (95% confidence interval [CI]: 0•83-0•95), 92% (95% CI: 78-98%), 88% (95% CI: 78-95%), 80% (95% CI: 70-92%), 95% (95% CI: 90-100%), 7•91 (95% CI: 4•10-15•30), and 0•09 (95% CI: 0•03-0•30), respectively. The kappa score of 0•78 (95% CI: 0•65-0•90) suggested substantial agreement between DS-MCCE and EGD. Moreover, in participants undergoing EGD without sedation, the satisfaction of DS-MCCE was significantly better than that of EGD (p < 0•0001, d = 1•15 [95%CI: 0•88-1•42]). All participants confirmed the excretion of the capsule, and no adverse events occurred. INTERPRETATION DS-MCCE is an accurate alternative to EGD for detecting HRV in cACLD, which is safe and associated with better satisfaction. FUNDING A full list of funding can be found in the Funding Support section.
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Affiliation(s)
- Shuai Wang
- CHESS Center, Department of Liver Diseases, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yifei Huang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Weiling Hu
- Department of Gastroenterology, Sir Run Run Shaw Hospital, Medical School; Institute of Gastroenterology, Zhejiang University, Hangzhou, China
| | - Hua Mao
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Mark Edward McAlindon
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Yanna Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Li Yang
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chunqing Zhang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Ming Xu
- Department of Gastroenterology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Chaohui He
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Tong Dang
- Department of Gastroenterology, The Second Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Bin Wu
- Department of Gastroenterology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province Engineering and Technology Research Center of Digestive Endoscopy, Guangzhou, China
| | - Dong Ji
- CHESS Center, Department of Liver Diseases, The Fifth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Liting Zhang
- Department of Hepatology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaorong Mao
- Department of Infectious Diseases, The First Hospital of Lanzhou University, Lanzhou, China
| | - Lei Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Chuan Liu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Dan Xu
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Yasong Li
- Department of Liver Diseases, the Seventh Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Guoan Li
- Department of Liver Diseases, the Seventh Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Juqiang Han
- Department of Liver Diseases, the Seventh Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Fangfang Lv
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xiao Liang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shaoqin Jin
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shaoheng Zhang
- Department of Gastroenterology, Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Foong Way David Tai
- Academic Department of Gastroenterology and Hepatology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Qing Xu
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Changqing Yang
- Division of Gastroenterology and Hepatology, Digestive Disease Institute, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guangchuan Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Lifen Wang
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bo Li
- Department of Gastroenterology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Haiyun Yang
- Department of Gastroenterology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Ping Xie
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Lulin Deng
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zunyi Medical University, Zhuhai, China
| | - Limei Ren
- Department of Gastroenterology, The Second Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Zhiheng Chang
- Department of Gastroenterology, The Second Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Xing Wang
- Department of Gastroenterology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province Engineering and Technology Research Center of Digestive Endoscopy, Guangzhou, China
| | - Shan Wang
- Department of Hepatology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Xiaoqin Gao
- Department of Hepatology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Junfeng Li
- Department of Infectious Diseases, The First Hospital of Lanzhou University, Lanzhou, China
| | - Longdong Zhu
- Department of Infectious Diseases, The First Hospital of Lanzhou University, Lanzhou, China
| | - Fangzhao Wang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Lingen Zhang
- Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Guo Zhang
- Department of Gastroenterology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Xi Jiang
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Jun Pan
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Wenbo Meng
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Xun Li
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Jinlin Hou
- Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xavier Dray
- Sorbonne University, Centre for Digestive Endoscopy, Saint Antoine Hospital, APHP, Paris, France
| | - Zhuan Liao
- National Clinical Research Center for Digestive Diseases, Department of Gastroenterology, Changhai Hospital, Shanghai, China
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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9
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Abstract
OBJECTIVES Variceal hemorrhage (VH) is a serious complication of portal hypertension (PH). We evaluated the feasibility, safety, and clinical impact of esophageal capsule endoscopy (ECE) in pediatric and young adult patients with known or suspected PH. METHODS Children and young adults with PH at Boston Children's Hospital (2005-2017) were offered ECE for variceal screening or surveillance. Patient histories, ECE findings, and clinical outcomes were reviewed retrospectively. RESULTS One hundred and forty-nine ECE studies were performed in 98 patients (57.1% male patients) using 3 ECE devices for variceal screening (66.5%) or surveillance (33.5%). Three readers interpreted the studies (88.3%, 10.3%, and 1.4%, respectively). Median age was 16 years (IQR 13.7-18.5). One hundred and three ECE studies involved patients <18 years (69.1%). Fifteen patients (29 ECE studies) had a gastrointestinal (GI) bleeding (GIB) history, 5 in the preceding 12 months.Sixty-two ECE studies (44.9%) detected varices: 59 esophageal (40 small, 19 medium/large), 17 gastric, 6 duodenal. Other findings included: portal gastropathy (25, 18.1%), esophagitis (20, 14.5%), ulcers (5, 3.6%), erosions (31, 22.5%), heterotopic tissue (13, 9.4%), blood flecks (23, 16.7%), and mucosal scars (17, 12.3%). There were 2 transient capsule retentions and no major adverse events.ECE led to follow-up EGD in 11 (7 variceal banding) and medication initiation in 12 (4 proton-pump inhibitor, 7 nonselective beta blocker, 2 other) cases. Four patients had GIB within 12 months of ECE. CONCLUSION ECE is a feasible alternative to EGD for screening and surveillance of esophageal varices in children and young adults.
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10
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Abstract
Complications of portal hypertension include portal hypertensive gastropathy and colopathy. These disorders may cause chronic or acute gastrointestinal bleeding. The diagnosis is made endoscopically; therefore, there is great variability in their assessment. Portal hypertensive gastropathy can range from a mosaic-like pattern resembling snakeskin mucosa to frankly bleeding petechial lesions. Portal hypertensive colopathy has been less well-described and is variably characterized (erythema, vascular lesions, petechiae). Treatment is challenging and results are inconsistent. Currently, available evidence does not support the use of beta-blockers for primary prevention. Further investigation of the pathogenesis, natural history, and treatment of these disorders is needed.
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11
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12
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Park J, Cho YK, Kim JH. Current and Future Use of Esophageal Capsule Endoscopy. Clin Endosc 2018; 51:317-322. [PMID: 30078304 PMCID: PMC6078930 DOI: 10.5946/ce.2018.101] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2010] [Accepted: 07/17/2018] [Indexed: 12/28/2022] Open
Abstract
Capsule endoscopy can be a diagnostic option for patients with esophageal diseases who cannot tolerate esophagogastroduodenoscopy.Functional modifications of the capsule allow for thorough examination of the esophagus. Esophageal capsule endoscopy has so farfailed to show sufficient performance to justify the replacement of traditional endoscopy for the diagnosis of esophageal diseasesbecause the esophagus has a short transit time and common pathologies appear near the esophagogastric junction. However,technological improvements are being introduced to overcome the limitations of capsule endoscopy, which is expected to become agood alternative to conventional endoscopy.
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Affiliation(s)
- Junseok Park
- Department of Internal Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea
| | - Young Kwan Cho
- Department of Internal Medicine, Eulji University School of Medicine, Seoul, Korea
| | - Ji Hyun Kim
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan, Korea
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13
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Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update. Gastroenterol Res Pract 2018; 2018:4202091. [PMID: 29977287 PMCID: PMC6011072 DOI: 10.1155/2018/4202091] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/30/2018] [Indexed: 12/14/2022] Open
Abstract
The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.
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14
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Abstract
Acute esophageal variceal hemorrhage is a dreaded complication of portal hypertension. Its management has evolved rapidly in recent years. Endoscopic therapy is often employed to arrest bleeding varices as well as to prevent early rebleeding. The combination of vasoconstrictor and endoscopic therapy is superior to vasoconstrictor or endoscopic therapy alone for control of acute esophageal variceal hemorrhage. After control of acute variceal bleeding, combination of banding ligation and beta-blockers is generally recommended to prevent variceal rebleeding. To prevent the catastrophic event of acute variceal bleeding, endoscopic banding ligation is an important tool in the prophylaxis of first bleeding. Endoscopic obturation with cyanoacrylate is usually utilized to arrest acute gastric variceal hemorrhage as well as to prevent rebleeding. It can be concluded that endoscopic therapies play a pivotal role in management of portal hypertensive bleeding.
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Affiliation(s)
- Gin-Ho Lo
- Department of Medical Research, E-Da Hospital, Kaohsiung, School of Medicine for International Students, I-Shou University, 1, Yi-Da Road, Kaohsiung, 824, Taiwan.
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15
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Li T, Qu Y, Yang B, Xue Y, Wang L. Evaluation of large esophageal varices in cirrhotic patients by transient elastography: a meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:464-72. [PMID: 27444047 DOI: 10.17235/reed.2016.3980/2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND PURPOSE Transient elastography (TE) has been shown to be a valuable tool for the prediction of large esophageal varices. However, the conclusions have not been always consistent throughout the different studies. Therefore, we performed a further meta-analysis in order to evaluate the diagnostic accuracy of transient elastography for the prediction of large esophageal varices. METHODS We performed a systematic literature search in PubMed, EMBASE, Web of Science, and CENTRAL in The Cochrane Library without time restriction. The strategy we used was "(fibroscan OR transient elastography OR stiffness) AND esophageal varices". Accuracy measures such as pooled sensitivity, specificity, among others, were calculated using Meta-DiSc statistical software. RESULTS Twenty studies (2,994 patients) were included in our meta-analysis. The values of pooled sensitivity, specificity, positive and negative likelihood ratios and diagnostic odds ratio were as follows: 0.81 (95% CI, 0.79-0.84), 0.71 (95% CI, 0.69-0.73), 2.63 (95% CI, 2.15-3.23), 0.27 (95% CI, 0.22-0.34) and 10.30 (95% CI, 7.33-14.47). The area under the receiver operating characteristics curve was 0.83. The Spearman correlation coefficient was 0.246 with a p-value of 0.296, indicating the absence of any significant threshold effects. In our subgroup analysis, the heterogeneity could be partially explained by the geographical origin of the study or etiology; or it could be partially explained blindingly, through the appropriate interval and cut-off value of the liver stiffness (LS). CONCLUSIONS Transient elastography could be used as a valuable non-invasive screening tool for the prediction of large esophageal varices. However, since LS cut-off values vary throughout the different studies and significant heterogeneity also exists among them, we need more reasonable approaches or flow diagram in order to improve the operability of this technology.
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Affiliation(s)
- Tao Li
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Yundong Qu
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Baohua Yang
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Yan Xue
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
| | - Lei Wang
- Department of Infectious Diseases and Hepatology, the Second Hospital of Shandong University, China
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16
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Iwata Y, Nishikawa H, Enomoto H, Yoh K, Ishii A, Yuri Y, Ishii N, Miyamoto Y, Hasegawa K, Nakano C, Takata R, Nishimura T, Aizawa N, Sakai Y, Ikeda N, Takashima T, Iijima H, Nishiguchi S. Efficacy of capsule endoscopy in patients with cirrhosis for the diagnosis of upper gastrointestinal lesions and small bowel abnormalities: a study protocol for prospective interventional study. BMJ Open Gastroenterol 2017; 4:e000168. [PMID: 29177064 PMCID: PMC5689481 DOI: 10.1136/bmjgast-2017-000168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION AND AIMS The role of capsule endoscopy (CE) in patients with liver cirrhosis (LC) has yet to be established; however, it is likely that it will remain a valuable diagnostic modality in several groups of patients with LC. The primary aims of the current prospective interventional study are to examine the prevalence for small bowel lesions and transit time of CE in the gastrointestinal tract in patients with LC with oesophageal varices (EVs) requiring endoscopic therapies. METHODS AND ANALYSIS The current study will be a single-centre prospective interventional study. Our study participants are LC subjects with portal hypertension who were determined to be necessary for prophylactic endoscopic therapies for EVs. From the view point of safety, patients with gastrointestinal obstruction or fistula or those being suspected of having gastrointestinal obstruction or fistula will be excluded from our study. Patients with implanted medical devices will be also excluded. CE will be performed prior to prophylactic endoscopic therapies in the same hospitalisation and relevant images will be analysed after 8 hours by expert endoscopists. This study will continue to recruit until 50 participants. ETHICS AND DISSEMINATION This study has received approval from the Institutional Review Board at Hyogo College of Medicine (approval no. 2680). The study protocol, informed assent form and other submitted files were reviewed and acknowledged. Final data will be publicly scattered regardless of the study results. A report releasing study results will be submitted for publication in a suitable journal after being finished in data collection. TRIAL REGISTRATION NUMBER UMIN000028433 (https://upload.umin.ac.jp/).
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Affiliation(s)
- Yoshinori Iwata
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Nishikawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirayuki Enomoto
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazunori Yoh
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Akio Ishii
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yukihisa Yuri
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Noriko Ishii
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yuho Miyamoto
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kunihiro Hasegawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Chikage Nakano
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ryo Takata
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takashi Nishimura
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nobuhiro Aizawa
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Yoshiyuki Sakai
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naoto Ikeda
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Tomoyuki Takashima
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroko Iijima
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Shuhei Nishiguchi
- Division of Hepatobiliary and Pancreatic disease, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
- Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Japan
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17
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Abstract
Portal hypertension is the central driver of complications in patients with chronic liver diseases and cirrhosis. The diagnosis of portal hypertension has important prognostic and clinical implications. In particular, screening for varices in patients with portal hypertension can effectively reduce the morbidity and mortality of variceal bleeding. In this article, we review the invasive and non-invasive methods to assess portal hypertension. Hepatic venous pressure gradient remains the gold standard to measure portal pressure but is invasive and seldom performed outside expert centers and research settings. In recent years, a number of non-invasive tests of fibrosis have shown good correlation with liver histology. They also show promise in identifying patients with portal hypertension and large varices. As a result, the latest Baveno VI consensus guidelines endorse the use of liver stiffness measurement by transient elastography and platelet count as initial assessment to select patients for varices screening. On the other hand, the performance of non-invasive tests in assessing the response to non-selective beta-blockers or transjugular intrahepatic portosystemic shunting is either suboptimal or unclear.
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18
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McCarty TR, Afinogenova Y, Njei B. Use of Wireless Capsule Endoscopy for the Diagnosis and Grading of Esophageal Varices in Patients With Portal Hypertension: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2017; 51:174-182. [PMID: 27548729 PMCID: PMC5218864 DOI: 10.1097/mcg.0000000000000589] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Esophageal variceal bleeding is a severe complication of portal hypertension with significant morbidity and mortality. Although traditional screening and grading of esophageal varices has been performed by endogastroduodenoscopy (EGD), wireless video capsule endoscopy provides a minimally invasive alternative that may improve screening and surveillance compliance. AIM OF THE STUDY The aim of the study was to perform a systematic review and structured meta-analysis of all eligible studies to evaluate the efficacy of wireless capsule endoscopy for screening and diagnosis of esophageal varices among patients with portal hypertension. METHODS Searches of PubMed, EMBASE, Web of Science, and the Cochrane Library databases were performed through December 2015. Bivariate and hierarchical models were used to compute the pooled sensitivity and specificity, and to plot the summary receiver operating characteristics curve with summary point and corresponding 95% confidence region. Bias of included studies was assessed using the quality assessment of diagnostic accuracy studies-2. RESULTS Seventeen studies from 2005 to 2015 were included in this meta-analysis (n=1328). The diagnostic accuracy of wireless capsule endoscopy in the diagnosis of esophageal varices was 90% [95% confidence interval (CI), 0.88-0.93]. The diagnostic pooled sensitivity and specificity were 83% (95% CI, 0.76-0.89) and 85% (95% CI, 0.75-0.91), respectively. The diagnostic accuracy of wireless capsule endoscopy for the grading of medium to large varices was 92% (95% CI, 0.90-0.94). The pooled sensitivity and specificity were 72% (95% CI, 0.54-0.85) and 91% (95% CI, 0.86-0.94), respectively, for the grading of medium to large varices. The use of capsule demonstrated only mild adverse events. A sensitivity analysis limited to only high quality studies revealed similar results. DISCUSSION Wireless esophageal capsule endoscopy is well tolerated and safe in patients with liver cirrhosis and suspicion of portal hypertension. The sensitivity of capsule endoscopy is not currently sufficient to replace EGD as a first exploration in these patients, but given its high accuracy, it may have a role in cases of refusal or contraindication to EGD.
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Affiliation(s)
- Thomas R. McCarty
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Yuliya Afinogenova
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Basile Njei
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
- Investigative Medicine Program, Yale Center of Clinical Investigation, New Haven, CT, USA
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19
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Fernández-Urién I, Carretero C, González B, Pons V, Caunedo Á, Valle J, Redondo-Cerezo E, López-Higueras A, Valdés M, Menchen P, Fernández P, Muñoz-Navas M, Jiménez J, Herrerías JM. Incidence, clinical outcomes, and therapeutic approaches of capsule endoscopy-related adverse events in a large study population. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 107:745-52. [PMID: 26671587 DOI: 10.17235/reed.2015.3820/2015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Capsule endoscopy (CE) has become a first-line tool for small bowel (SB) examination. However, adverse events (AEs), such as CE retention or aspiration, may occur. The aims of this study were to evaluate incidence, clinical outcomes and therapeutic approaches of CE-related AEs in the largest series published to date. METHODS Data from 5428 procedures performed at 12 institutions between August 2001 and January 2012 were retrospectively analyzed. Baseline patient characteristics; procedure; type, localization and symptoms before/after AEs; previous patency tests performed; therapeutic management and patient's outcome were recorded. RESULTS The overall incidence of CE-related AEs was 1.9%: 2.0% for SB, 0.9% for esophageal and 0.5% for colon CE. The incidence of capsule retention was significantly higher than capsule aspiration (1.87% vs. 0.003%; p < 0.05), in patients suffering from inflammatory bowel disease (IBD) than in obscure GI bleeding (OGIB) (3.3% vs. 1.5%; p < 0.05) and in patients with the combination of nausea/vomiting, abdominal pain and distension. The SB was the most frequent localization of retention (88.2%). The use of patency tests -except for Patency© capsule- before CE was not a good predictor for AEs. Most of the patients with AEs developed no or mild symptoms (97%) and were managed by non-surgical methods (64.4%). CONCLUSIONS CE-related AEs are uncommon and difficult to predict by imagiological examinations. SB retention, that is usually asymptomatic, is the most frequent AE. In absence of symptoms, non-surgical management of CE-related AEs is recommended.
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Affiliation(s)
| | | | | | - Vicente Pons
- Hospital Universitario y Politécnico La Fe. Valencia
| | | | | | | | | | | | - Pedro Menchen
- Hospital General Universitario Gregorio Marañon Hospital. Madrid
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20
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Williams MJ, Hayes P. Improving the management of gastrointestinal bleeding in patients with cirrhosis. Expert Rev Gastroenterol Hepatol 2016; 10:505-15. [PMID: 26581713 DOI: 10.1586/17474124.2016.1122523] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gastrointestinal bleeding remains a major cause of mortality in patients with cirrhosis. The most common source of bleeding is from gastroesophageal varices but non-variceal bleeding from peptic ulcer disease also carries a significant risk in patients with liver disease. The prognosis is related to the severity of the underlying liver disease, and deaths often occur due to liver failure, infection or renal failure. Optimal management should therefore not only achieve haemostasis but address these complications as well. The management of gastrointestinal bleeding in patients with cirrhosis includes a range of medical, endoscopic and radiological interventions. This article updates the recent developments in this area and highlights topics where further research is still required.
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Affiliation(s)
- Michael J Williams
- a Centre for Liver and Digestive Diseases , Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Peter Hayes
- a Centre for Liver and Digestive Diseases , Royal Infirmary of Edinburgh , Edinburgh , UK
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21
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Third-Generation Capsule Endoscopy Outperforms Second-Generation Based on the Detectability of Esophageal Varices. Gastroenterol Res Pract 2016; 2016:9671327. [PMID: 27980536 PMCID: PMC5131243 DOI: 10.1155/2016/9671327] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/13/2016] [Accepted: 10/20/2016] [Indexed: 12/28/2022] Open
Abstract
Background and Aim. The third-generation capsule endoscopy (SB3) was shown to have better image resolution than that of SB2. The aim of this study was to compare SB2 and SB3 regarding detectability of esophageal varices (EVs). Methods. Seventy-six consecutive liver cirrhosis patients (42 men; mean age: 67 years) received SB3, and 99 (58 men; mean age, 67 years old) received SB2. All patients underwent esophagogastroduodenoscopy within 1 month prior to capsule endoscopy as gold standard for diagnosis. The diagnosis using SB3 and SB2 for EVs was evaluated regarding form (F0–F3), location (Ls, Lm, and Li), and the red color (RC) sign of EVs. Results. SB2 and SB3 did not significantly differ on overall diagnostic rates for EV. Sensitivity, specificity, positive predictive value, and negative predictive value of SB2/SB3 for EV diagnosis were, respectively, 65%/81%, 100%/100%, 100%/100%, and 70%/62%. However, the diagnostic rates for EV form F1 were 81% using SB3 and 52% using SB2 (P = 0.009). Further, the diagnostic rates for Ls/Lm varices were 79% using SB3 and 81% using SB2, and, for Li, varices were 84% using SB3 and 52% using SB2 (P = 0.02). Conclusion. SB3 significantly improved the detectability of EVs compared with SB2.
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Shao XD, Qi XS, Guo XZ. Esophageal Stent for Refractory Variceal Bleeding: A Systemic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4054513. [PMID: 27517043 PMCID: PMC4969514 DOI: 10.1155/2016/4054513] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 06/15/2016] [Accepted: 06/20/2016] [Indexed: 12/14/2022]
Abstract
Background. Preliminary studies suggest that covered self-expandable metal stents may be helpful in controlling esophageal variceal bleeding. Aims. To evaluate the effectiveness and safety of esophageal stent in refractory variceal bleeding in a systematic review and meta-analysis. Methods. A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 1970 to December 2015. Data were selected and abstracted from eligible studies and were pooled using a random-effects model. Heterogeneity was assessed using I (2) test. Results. Five studies involving 80 patients were included in the analysis. The age of patients ranged from 18 to 91 years. The mean duration of follow-up was 46.8 d (range, 30-60 d). The success rate of stent deployment was 96.7% (95% CI: 91.6%-99.5%) and complete response to esophageal stenting was in 93.9% (95% CI: 82.2%-99.6%). The incidence of rebleeding was 13.2% (95% CI: 1.8%-32.8%) and the overall mortality was 34.5% (95% CI: 24.8%-44.8%). Most of patients (87.4%) died from hepatic or multiple organ failure, and only 12.6% of patients died from uncontrolled bleeding. There was no stent-related complication reported and the incidence of stent migration was 21.6% (95% CI: 4.7%-46.1%). Conclusion. Esophageal stent may be considered in patients with variceal bleeding refractory to conventional therapy.
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Affiliation(s)
- Xiao-Dong Shao
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang 110016, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang 110016, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Shenyang Military Area Command, Shenyang 110016, China
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Kim TY, Kim TY, Kim Y, Lim S, Jeong WK, Sohn JH. Diagnostic Performance of Shear Wave Elastography for Predicting Esophageal Varices in Patients With Compensated Liver Cirrhosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:1373-1381. [PMID: 27208198 DOI: 10.7863/ultra.15.07024] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 10/07/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the diagnostic performance of shear wave elastography (SWE) for predicting the presence of esophageal varices and high-risk esophageal varices in patients with compensated cirrhosis and to compare it with other nonspecific predictors and according to the presence of splenomegaly. METHODS Clinical data from 103 patients with compensated cirrhosis who underwent sonography, SWE, and endoscopy were collected consecutively. Liver stiffness was measured by SWE. Comparisons of the accuracy of prediction between groups were made by areas under the receiver operating characteristic curves (AUROCs), and regression analyses were performed for the multiple variables related to the presence of esophageal varices and high-risk varices. RESULTS The optimal cutoff values for predicting the presence of esophageal varices and high-risk varices were 13.9 and 16.1 kPa, respectively. The AUROC of liver stiffness for prediction of esophageal varices was significantly higher than the AUROCs of platelet count, spleen diameter, and platelet count/spleen diameter ratio (P = .025; P = .001; P = .027). For predicting esophageal varices in patients without splenomegaly, the AUROC of liver stiffness was higher than that of the platelet count/spleen diameter ratio. In multivariate logistic regression analysis, liver stiffness and the platelet count/spleen diameter ratio were independent predictors of esophageal varices (P < .001; P = .038). For the presence of high-risk varices, only liver stiffness was a statistically significant independent predictor (P = .012). CONCLUSIONS In patients with compensated cirrhosis, liver stiffness measured by SWE is a new effective noninvasive diagnostic tool for predicting the presence of esophageal varices. It is more accurate than the platelet count/spleen diameter ratio, especially in patients without splenomegaly. In addition, the SWE value was the only effective independent factor for predicting high-risk esophageal varices.
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Affiliation(s)
- Tae Yoon Kim
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Korea
| | - Tae Yeob Kim
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Korea
| | - Yongsoo Kim
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Korea
| | - Sanghyeok Lim
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Korea
| | - Woo Kyoung Jeong
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Joo Hyun Sohn
- Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri-si, Korea
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Krok KL, Wagennar RR, Kantsevoy SV, Thuluvath PJ. Esophageal capsule endoscopy is not the optimal technique to determine the need for primary prophylaxis in patients with cirrhosis. Arch Med Sci 2016; 12:365-71. [PMID: 27186182 PMCID: PMC4848367 DOI: 10.5114/aoms.2016.59263] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 11/27/2014] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Capsule endoscopy has been suggested as a potential alternative to endoscopy for detection of esophagogastric varices and severe portal hypertensive gastropathy (PHG). The aim of the study was to determine whether PillCam esophageal capsule endoscopy could replace endoscopy for screening purposes. MATERIAL AND METHODS Sixty-two patients with cirrhosis with no previous variceal bleeding had PillCam capsule endoscopy and video endoscopy performed on the same day. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of capsule endoscopy were compared to endoscopy for the presence and severity of esophageal and gastric varices, PHG and the need for primary prophylaxis. Patients' preference was assessed by a questionnaire. RESULTS Four (6%) patients were unable to swallow the capsule. Sensitivity, specificity, PPV and NPV of capsule endoscopy for detecting any esophageal varices (92%, 50%, 92%, 50%), large varices (55%, 91%, 75%, 80%), variceal red signs (58%, 87%, 69%, 80%), PHG (95%, 50%, 95%, 50%), and the need for primary prophylaxis (91%, 57%, 78%, 80%) were not optimal, with only moderate agreement (κ) between capsule and upper GI endoscopy. Had only a capsule endoscopy been performed, 12 (21.4%) patients would have received inappropriate treatment. Capsule endoscopy also failed to detect (0/13) gastric varices. The majority of patients ranked capsule endoscopy as more convenient (69%) and their preferred (61%) method. CONCLUSIONS Despite the preference expressed by patients for capsule endoscopy, we believe that upper GI endoscopy should remain the preferred screening method for primary prophylaxis.
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Affiliation(s)
- Karen L. Krok
- Division of Gastroenterology, Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Rebecca Rankin Wagennar
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sergey V. Kantsevoy
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, Maryland, USA
| | - Paul J. Thuluvath
- Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, Maryland, USA
- University of Maryland School of Medicine, Baltimore, USA
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Qu Y, Li T, Ye Q, Zhang L, Wang L. A Beginning or the End? A Meta-analysis to Assess the Diagnostic Accuracy of Transient Elastography for the Prediction of Esophageal Varices. Saudi J Gastroenterol 2016; 22:345-352. [PMID: 27748319 PMCID: PMC5051217 DOI: 10.4103/1319-3767.191138] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS To assess the accuracy of transient elastography (TE) in the prediction of esophageal varices (EV). MATERIALS AND METHODS The literature search was conducted by using PubMed, EMBASE, Web of Science, and CENTRAL on The Cochrane Library without time or language restrictions. Terms used were "FibroScan," "transient elastography," "stiffness," and "esophageal varices." The pooled sensitivity, specificity, and other parameters were obtained using a bivariate mixed-effects regression model. RESULT Twenty studies (2530 patients) were identified for inclusion. The pooled sensitivity, specificity, positive and negative likelihood ratios, and diagnostic odds ratio were 0.84 (95% confidence interval [CI], 0.79-0.87), 0.68 (95% CI, 0.61-0.73), 2.58 (95% CI, 2.15-3.10), 0.24 (95% CI, 0.19-0.32), and 10.60 (95%CI, 7.20-15.62), respectively. The summary area under receiver operating characteristics (AUROC) curves was 0.82 (95% CI, 0.79-0.86). Especially, for hepatitis C patients, the diagnostic performance of TE for detecting the presence of EV was similar to all other patients with a sensitivity of 0.83 and a specificity of 0.63, but without heterogeneity (I2 = 0.00). For the prediction of large esophageal varices in patients with viral liver cirrhosis, the pooled sensitivity and specificity of TE were 0.82 (95% CI 0.74-0.89) and 0.77 (95% CI 0.65-0.85), respectively, without significant heterogeneity (I2 = 0.00). CONCLUSION Transient elastography has good sensitivity and moderate specificity. TE can be used as an effective noninvasive screening tool for the prediction of esophageal varices, especially in hepatitis C patients, and for the prediction of large esophageal varices in patients with viral liver cirrhosis.
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Affiliation(s)
- Yundong Qu
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan 250033, China
| | - Tao Li
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan 250033, China
| | - Qian Ye
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan 250033, China
| | - Lixin Zhang
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan 250033, China
| | - Lei Wang
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan 250033, China,Address for correspondence: Dr. Lei Wang, Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, 247 Beiyuan Road, Jinan 250033, China. E-mail:
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26
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Tripathi D, Stanley AJ, Hayes PC, Patch D, Millson C, Mehrzad H, Austin A, Ferguson JW, Olliff SP, Hudson M, Christie JM. U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64:1680-704. [PMID: 25887380 PMCID: PMC4680175 DOI: 10.1136/gutjnl-2015-309262] [Citation(s) in RCA: 396] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 03/17/2015] [Indexed: 12/12/2022]
Abstract
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
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Affiliation(s)
- Dhiraj Tripathi
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Peter C Hayes
- Liver Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David Patch
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital and University College London, London, UK
| | - Charles Millson
- Gastrointestinal and Liver Services, York Teaching Hospitals NHS Foundation Trust, York, UK
| | - Homoyon Mehrzad
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Andrew Austin
- Department of Gastroenterology, Derby Hospitals NHS Foundation Trust, Derby, UK
| | - James W Ferguson
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Simon P Olliff
- Department of Interventional Radiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mark Hudson
- Liver Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - John M Christie
- Department of Gastroenterology, Royal Devon and Exeter Hospital, Devon, UK
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Bosch J. EASL Recognition Award Recipient 2015: Prof. Roberto de Franchis. J Hepatol 2015; 63:787-8. [PMID: 26272824 DOI: 10.1016/j.jhep.2015.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 12/04/2022]
Affiliation(s)
- Jaume Bosch
- Liver Unit, Hospital Clínic-IDIBAPS, University of Barcelona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREhd), Spain.
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Bozic MA, Puri K, Molleston JP. Screening and Prophylaxis for Varices in Children with Liver Disease. Curr Gastroenterol Rep 2015; 17:27. [PMID: 26122248 DOI: 10.1007/s11894-015-0450-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Esophageal varices in children with portal hypertension are quite common. Bleeding from these varices frequently occurs. Prophylactic measures to prevent such bleeding can be undertaken either before ("primary," prompted by a screening endoscopy) or after ("secondary") an initial variceal bleed. There are no clear pediatric guidelines for primary or secondary prophylaxis of esophageal varices. Adult studies clearly support the use of pharmacologic (beta blockers) and endoscopic (endoscopic band ligation, EBL) management for both primary and secondary prophylaxis of esophageal varices in patients with portal hypertension. Pediatric studies are limited. There are inadequate data to recommend use of beta blockers to prevent variceal bleeding or rebleeding in children with portal hypertension. There is very limited support for EBL for primary prophylaxis in children and more compelling support for EBL for secondary prophylaxis. Further randomized controlled studies are needed but are difficult to implement in this vulnerable population.
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Affiliation(s)
- Molly A Bozic
- Department of Pediatrics, Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN, 46202, USA
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Lesiones vasculares gástricas en la cirrosis: gastropatía y ectasia vascular antral. GASTROENTEROLOGIA Y HEPATOLOGIA 2015; 38:97-107. [DOI: 10.1016/j.gastrohep.2014.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/12/2014] [Accepted: 10/27/2014] [Indexed: 02/08/2023]
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Parker CE, Spada C, McAlindon M, Davison C, Panter S. Capsule endoscopy--not just for the small bowel: a review. Expert Rev Gastroenterol Hepatol 2015; 9:79-89. [PMID: 25484107 DOI: 10.1586/17474124.2014.934357] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Video capsule endoscopy is being increasingly used to investigate the esophagus and colon as well as the small bowel. With the advancement of technology used in capsule endoscopy there have been marked improvements in diagnostic rates for colon capsule endoscopy in the detection of colonic polyps and colorectal cancer. It is also being increasingly used in the field if inflammatory bowel disease to investigate for mucosal inflammation and could potentially be used to assess mucosal healing. It also has role in completing the evaluation of colonic pathology in those in whom colonoscopy is incomplete. Esophageal capsule is preferred by patients over esophagogastroduodenoscopy (EGD) but as yet does not rival EGD in terms of diagnostic accuracy however the advent of magnetically steerable capsules may improve this. This review covers advances in the field of colon and esophageal capsule endoscopy; it covers diagnostic capabilities of these 2 tools as well as technical aspects of both procedures and preparation.
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Affiliation(s)
- Clare Elizabeth Parker
- Department of Gastroenterology, South Tyneside NHS Foundation Trust, South Tyneside District Hospital Harton Lane, South Shields NE34 0PL, UK
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31
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Hosoe N, Naganuma M, Ogata H. Current status of capsule endoscopy through a whole digestive tract. Dig Endosc 2015; 27:205-15. [PMID: 25208463 DOI: 10.1111/den.12380] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 09/05/2014] [Indexed: 02/06/2023]
Abstract
More than a decade has passed since small-bowel capsule endoscopy (CE) was first reported. Small-bowel CE is a non-invasive tool that allows visualization of the entire small-intestinal mucosa and facilitates detection of small-intestinal abnormalities. Several studies have shown benefit of small-bowel CE for certain disorders. Because it is non-invasive, CE has been applied to other organs including the esophagus, stomach, and colon. The main indications for esophageal CE (ECE) are screening for gastroesophageal reflux disease/Barrett's esophagus, and esophageal varices. However, the clinical benefit of ECE is unconfirmed. Magnetically guided CE (MGCE) was developed to visualize the gastric mucosa. MGCE is a new concept with room for improvement of capsule navigation and the preparation protocol. Recently, two new small-bowel CE tools were released. First-generation colon CE (CCE-1) has moderate sensitivity and specificity compared with colonoscopy for colorectal neoplasia surveillance. To obtain higher accuracy, a second-generation CCE (CCE-2) was developed with a high sensitivity for detecting clinically relevant polypoid lesions. A possible application of CCE is for inflammatory bowel disease. In the near future, CE may include diagnostic and therapeutic functions such as magnifying endoscopy systems, targeted biopsy forceps, and drug delivery systems.
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Affiliation(s)
- Naoki Hosoe
- Center for Diagnostic and Therapeutic Endoscopy, School of Medicine, Keio University, Tokyo, Japan
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32
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Evaluation of the Small Bowel and Colon. Gastrointest Endosc 2015. [DOI: 10.1007/978-1-4939-2032-7_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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Abstract
Gastroesophageal varices are present in almost half of patients with cirrhosis at the time of initial diagnosis. Variceal bleeding occurs in 25% to 35% of patients with cirrhosis. Effective and timely care can prevent variceal bleeding (primary prophylaxis). For example, clinical studies demonstrate that both beta-blockers and endoscopic variceal ligation are effective in preventing a first episode of variceal bleeding. The major challenge is to screen patients in a timely manner and institute a form of therapy that has the highest chance of success in terms of patient compliance and effectiveness.
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Oliva S, Cohen SA, Nardo GD, Gualdi G, Cucchiara S, Casciani E. Capsule endoscopy in pediatrics: A 10-years journey. World J Gastroenterol 2014; 20:16603-16608. [PMID: 25469028 PMCID: PMC4248203 DOI: 10.3748/wjg.v20.i44.16603] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 07/08/2014] [Accepted: 08/28/2014] [Indexed: 02/06/2023] Open
Abstract
Video capsule endoscopy (CE) for evaluation the esophagus (ECE), small bowel (SBCE) and the colon (CCE) is particularly useful in pediatrics, because this imaging modality does not require ionizing radiation, deep sedation or general anesthesia. The risk of capsule retention appears to be dependent on indication rather than age and parallels the adult experience by indication, making SBCE a relatively safe procedure with a significant diagnostic yield. The newest indication, assessment of mucosal change, greatly enhances and expands its potential benefit. The diagnostic role of CE extends beyond the SB. The use of ECE also may enhance our knowledge of esophageal disease and assist patient care. Colon CCE is a novel minimally invasive and painless endoscopic technique allowing exploration of the colon without need for sedation, rectal intubation and gas insufflation. The limited data on ECE and CCE in pediatrics does not yet allow the same conclusions regarding efficacy; however, both appear to provide safe methods to assess and monitor mucosal change in their respective areas with little discomfort. Moreover, although experience has been limited, the patency capsule may help lessen the potential of capsule retention; and newly researched protocols for bowel cleaning may further enhance CE’s diagnostic yield. However, further research is needed to optimize the use of the various CE procedures in pediatric populations.
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Redondo-Cerezo E, Sánchez-Capilla AD, De La Torre-Rubio P, De Teresa J. Wireless capsule endoscopy: Perspectives beyond gastrointestinal bleeding. World J Gastroenterol 2014; 20:15664-15673. [PMID: 25400450 PMCID: PMC4229531 DOI: 10.3748/wjg.v20.i42.15664] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Revised: 04/09/2014] [Accepted: 06/26/2014] [Indexed: 02/06/2023] Open
Abstract
Wireless capsule endoscopy (CE) is a technology developed for the endoscopic exploration of the small bowel. The first capsule model was approved by the Food and Drug Administration in 2001, and its first and essential indication was occult gastrointestinal (GI) bleeding. Over subsequent years, this technology has been refined to provide superior resolution, increased battery life, and capabilities to view different parts of the GI tract. Indeed, cases for which CE proved useful have increased significantly over the last few years, with new indications for the small bowel and technical improvements that have expanded its use to other parts of the GI tract, including the esophagus and colon. The main challenges in the development of CE are new devices with the ability to provide therapy, air inflation for a better vision of the small bowel, biopsy sampling systems attached to the capsule and the possibility to guide and move the capsule with an external motion control. In this article we review the current and new indications of CE, and the evolving technological changes shaping this technology, which has a promising potential in the coming future of gastroenterology.
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Annicchiarico BE, Riccioni ME, Siciliano M, Urgesi R, Spada C, Caracciolo G, Gasbarrini A, Costamagna G. A pilot study of capsule endoscopy after a standard meal for the detection and grading of oesophageal varices in cirrhotic patients. Dig Liver Dis 2014; 46:997-1000. [PMID: 25192604 DOI: 10.1016/j.dld.2014.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/28/2014] [Accepted: 08/03/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Capsule endoscopy has been proposed as an alternative to fibreoptic endoscopy for oesophageal varices evaluation in cirrhotics. However, it shows only moderate sensitivity compared to fibreoptic endoscopy. AIM To compare post-meal capsule endoscopy to fibreoptic endoscopy, based on the hypothesis that meal-induced increase of portal pressure can enhance its sensitivity. METHODS Twenty-five patients were submitted to fibreoptic endoscopy and, after a standard meal, capsule endoscopy. RESULTS Post-meal capsule endoscopy detected varices in the 18 patients in whom fibreoptic endoscopy detected varices plus 3 more subjects (sensitivity 100%, specificity 70%); large varices in the 4 patients in whom fibreoptic endoscopy graded varices as large, plus 5 more subjects; red markers in the 5 patients in whom fibreoptic endoscopy detected red markers, plus 3 more subjects. High-risk varices were identified in 11 patients by post-meal capsule endoscopy and in 10 by fibreoptic endoscopy (sensitivity 100%, specificity 93.8%). CONCLUSIONS Post-meal capsule endoscopy identified more varices, large varices and red markers than fibreoptic endoscopy. The two methods detected similar proportions of high-risk varices. These data suggest that a standard meal can enhance the sensitivity of capsule endoscopy in the detection and grading of oesophageal varices in cirrhotics.
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Affiliation(s)
| | | | - Massimo Siciliano
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Riccardo Urgesi
- Gastroenterology and Digestive Endoscopy Unit, Ospedale Belcolle, Viterbo, Italy.
| | - Cristiano Spada
- Digestive Endoscopy Unit, Catholic University of Sacred Heart, Rome, Italy
| | - Gianluigi Caracciolo
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Catholic University of Sacred Heart, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Catholic University of Sacred Heart, Rome, Italy
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Colli A, Gana JC, Turner D, Yap J, Adams‐Webber T, Ling SC, Casazza G. Capsule endoscopy for the diagnosis of oesophageal varices in people with chronic liver disease or portal vein thrombosis. Cochrane Database Syst Rev 2014; 2014:CD008760. [PMID: 25271409 PMCID: PMC7173747 DOI: 10.1002/14651858.cd008760.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Current guidelines recommend performance of oesophago-gastro-duodenoscopy at the time of diagnosis of hepatic cirrhosis to screen for oesophageal varices. These guidelines require people to undergo an unpleasant invasive procedure repeatedly with its attendant risks, despite the fact that half of the people do not have identifiable oesophageal varices 10 years after the initial diagnosis of cirrhosis. Video capsule endoscopy is a non-invasive test proposed as an alternative method for the diagnosis of oesophageal varices. OBJECTIVES To determine the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices in children or adults with chronic liver disease or portal vein thrombosis, irrespective of the aetiology. To investigate the accuracy of capsule endoscopy as triage or replacement of oesophago-gastro-duodenoscopy. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Diagnostic Test Accuracy Studies Register (October 2013), MEDLINE (Ovid SP) (1950 to October 2013), EMBASE (Ovid SP) (1980 to October 2013), ACP Journal Club (Ovid SP) (1991 to October 2013), Database of Abstracts of Reviews of Effects (DARE) (Ovid SP) (third quarter), Health Technology Assessment (HTA) (Ovid SP) (third quarter), NHS Economic Evaluation Database (NHSEED) (Ovid SP) (third quarter), and Science Citation Index Expanded (SCI-EXPANDED) (ISI Web of Knowledge) (1955 to October 2013). We applied no language or document type restrictions. SELECTION CRITERIA Studies that evaluated the diagnostic accuracy of capsule endoscopy for the diagnosis of oesophageal varices using oesophago-gastro-duodenoscopy as the reference standard in children or adults of any age, with chronic liver disease or portal vein thrombosis. DATA COLLECTION AND ANALYSIS We followed the available guidelines provided in the Cochrane Handbook for Diagnostic Test of Accuracy Reviews. We calculated the pooled estimates of sensitivity and specificity using the bivariate model due to the absence of a negative correlation in the receiver operating characteristic (ROC) space and of a threshold effect. MAIN RESULTS The search identified 16 eligible studies, in which only adults with cirrhosis were included. In one study, people with portal thrombosis were also included. We classified most of the studies at high risk of bias for the 'Participants selection' and the 'Flow and timing' domains. One study assessed the accuracy of capsule endoscopy for the diagnosis of large (high-risk) oesophageal varices. In the remaining15 studies that assessed the accuracy of capsule endoscopy for the diagnosis of oesophageal varices of any size in people with cirrhosis, 936 participants were included; the pooled estimate of sensitivity was 84.8% (95% confidence interval (CI) 77.3% to 90.2%) and of specificity 84.3% (95% CI 73.1% to 91.4%). Eight of these studies included people with suspected varices or people with already diagnosed or even treated varices, or both, introducing a selection bias. Seven studies including only people with suspected but unknown varices were at low risk of bias; the pooled estimate of sensitivity was 79.7% (95% CI 73.1% to 85.0%) and of specificity 86.1% (95% CI 64.5% to 95.5%). Six studies assessed the diagnostic accuracy of capsule endoscopy for the diagnosis of large oesophageal varices, associated with a higher risk of bleeding; the pooled sensitivity was 73.7% (95% CI 52.4% to 87.7%) and of specificity 90.5% (95% CI 84.1% to 94.4%). Two studies also evaluated the presence of red marks, which are another marker of high risk of bleeding; the estimates of sensitivity and specificity varied widely. Two studies obtained similar results with the use of a modified device as index test (string capsule). Due to the absence of data, we could not perform all planned subgroup analyses. Interobserver agreement in the interpretation of capsule endoscopy results and any adverse event attributable to capsule endoscopy were poorly assessed and reported. Only four studies evaluated the interobserver agreement in the interpretation of capsule endoscopy results: the concordance was moderate. The participants' preferences for capsule endoscopy or oesophago-gastro-duodenoscopy were reported differently but seemed in favour of capsule endoscopy in nine of 10 studies. In 10 studies, participants reported some minor discomfort on swallowing the capsule. Only one study identified other significant adverse events, including impaction of the capsule due to previously unidentified oesophageal strictures in two participants. No adverse events were reported as a consequence of the reference standard. AUTHORS' CONCLUSIONS We cannot support the use of capsule endoscopy as a triage test in adults with cirrhosis, administered before oesophago-gastro-duodenoscopy, despite the low incidence of adverse events and participant reports of being better tolerated. Thus, we cannot conclude that oesophago-gastro-duodenoscopy can be replaced by capsule endoscopy for the detection of oesophageal varices in adults with cirrhosis. We found no data assessing capsule endoscopy in children and in people with portal thrombosis.
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Affiliation(s)
- Agostino Colli
- Ospedale "A Manzoni" LeccoDepartment of Internal MedicineVia dell'Eremo, 9/11LeccoItaly23900
| | - Juan Cristóbal Gana
- Division of Paediatrics, Escuela de Medicina, Pontificia Universidad Católica de ChileGastroenterology, Hepatology, and Nutrition Unit85 LiraSantiagoRegion MetropolitanaChile8330074
| | - Dan Turner
- Shaare Zedek Medical CenterPediatric Gastroenterology UnitP.O.B 3235JerusalemIsrael91031
| | - Jason Yap
- University of AlbertaDivision of Pediatric Gastroenterology, Hepatology and Nutrition, Dept. of Pediatrics, Stollery Children's Hospital, Faculty of MedicineAberhart Centre 111402 University AveEdmontonABCanadaT6G 2J3
| | | | - Simon C Ling
- The Hospital for Sick ChildrenDivision of Gastroenterology, Hepatology & Nutrition555 University AvenueTorontoONCanadaM5G 1X8
| | - Giovanni Casazza
- Università degli Studi di MilanoDipartimento di Scienze Biomediche e Cliniche "L. Sacco"via GB Grassi 74MilanItaly20157
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Triantos C, Kalafateli M. Endoscopic treatment of esophageal varices in patients with liver cirrhosis. World J Gastroenterol 2014; 20:13015-13026. [PMID: 25278695 PMCID: PMC4177480 DOI: 10.3748/wjg.v20.i36.13015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/15/2014] [Accepted: 05/26/2014] [Indexed: 02/06/2023] Open
Abstract
Variceal bleeding is a life-threatening complication of portal hypertension with a six-week mortality rate of approximately 20%. Patients with medium- or large-sized varices can be treated for primary prophylaxis of variceal bleeding using two strategies: non-selective beta-blockers (NSBBs) or endoscopic variceal ligation (EVL). Both treatments are equally effective. Patients with acute variceal bleeding are critically ill patients. The available data suggest that vasoactive drugs, combined with endoscopic therapy and antibiotics, are the best treatment strategy with EVL being the endoscopic procedure of choice. In cases of uncontrolled bleeding, transjugular intrahepatic portosystemic shunt (TIPS) with polytetrafluoroethylene (PTFE)-covered stents are recommended. Approximately 60% of the patients experience rebleeding, with a mortality rate of 30%. Secondary prophylaxis should start on day six following the initial bleeding episode. The combination of NSBBs and EVL is the recommended management, whereas TIPS with PTFE-covered stents are the preferred option in patients who fail endoscopic and pharmacologic treatment. Apart from injection sclerotherapy and EVL, other endoscopic procedures, including tissue adhesives, endoloops, endoscopic clipping and argon plasma coagulation, have been used in the management of esophageal varices. However, their efficacy and safety, compared to standard endoscopic treatment, remain to be further elucidated. There are safety issues accompanying endoscopic techniques with aspiration pneumonia occurring at a rate of approximately 2.5%. In conclusion, future research is needed to improve treatment strategies, including novel endoscopic techniques with better efficacy, lower cost, and fewer adverse events.
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Somsouk M, To'o K, Ali M, Vittinghoff E, Yeh BM, Yee J, Monto A, Inadomi JM, Aslam R. Esophageal varices on computed tomography and subsequent variceal hemorrhage. ACTA ACUST UNITED AC 2014; 39:251-6. [PMID: 24366107 DOI: 10.1007/s00261-013-0057-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Endoscopy is recommended to screen for esophageal varices in patients with cirrhosis. The objective of this study was to identify features on abdominal CT imaging associated variceal hemorrhage (VH). METHODS A case-control study was performed among patients with cirrhosis who had a CT scan. Consecutive patients who experienced VH were included as cases, and patients without VH served as controls. Two radiologists recorded the maximal esophageal varix diameter in addition to other measures of portal hypertension at CT. RESULTS The most powerful CT parameter associated with VH was the esophageal varix diameter (5.8 vs. 2.7 mm, p < 0.001; adjusted OR 1.84 per mm, p = 0.009). 63% of individuals with VH had a maximal varix diameter ≥5 mm compared to 7.5% of cirrhotic patients without VH (p < 0.001). In contrast, the proportion of individuals whose largest varix was <3 mm was 7.4% among VH cases compared to 54.7% among controls (p = 0.001). The varix diameter powerfully discriminated those with and without VH (C-statistic 0.84). CONCLUSIONS A large esophageal varix diameter is strongly associated with subsequent VH. A threshold of <3 and ≥5 mm appears to identify patients with cirrhosis at low and high risk for hemorrhage.
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Affiliation(s)
- Ma Somsouk
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA, 94110, USA,
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Kahloon A, Chalasani N, DeWitt J, Liangpunsakul S, Vinayek R, Vuppalanchi R, Ghabril M, Chiorean M. Endoscopic therapy with 2-octyl-cyanoacrylate for the treatment of gastric varices. Dig Dis Sci 2014; 59:2178-83. [PMID: 24788319 DOI: 10.1007/s10620-014-3148-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 03/30/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastric variceal bleeding is associated with significant morbidity and mortality and limited endoscopic therapeutic options. AIM The aim of this study was to evaluate the short- and long-term efficacy and safety of endoscopic therapy with 2-octyl-cyanoacrylate in patients with gastric variceal bleeding. METHODS A single-center retrospective review of patients receiving endoscopic therapy for gastric variceal hemorrhage. Patient demographics, laboratory, and procedural data were collected. Patients were followed to death, liver transplantation, or last follow-up. Success rates were defined as immediate control of bleeding; early re-bleeding (1-7 days), short-term re-bleeding (1-12 weeks), overall survival, and serious procedure complications. RESULTS A total of 41 patients (39 with cirrhosis) underwent 54 cyanoacrylate injections during study period. Mean age was 57 and 73 % were males. Twenty-four (58.5 %) patients had failed or were deemed ineligible for transjugular intra-hepatic portosystemic shunt, and 5 % were done for primary prophylaxis. Immediate hemostasis was achieved in five active bleeders. During a median survival time of 117 days, early re-bleeding was seen in 1 (2.4 %), short-term re-bleeding in five patients (12 %), and varices were eradicated in 15 (46.8 %) patients on follow-up. Mean MELD score at the time of the first injection was 17.1 ± 7.8. Mean volume injected was 3.4 cc and median number of varices injected per session was one. Eight patients died during the long-term follow-up: metastatic cancer (2), infections (3), liver failure (1), and re-bleeding (2). There were no serious procedure-related complications. CONCLUSIONS Endoscopic cyanoacrylate therapy appears effective and safe for treatment of patients with bleeding from gastric varices or high-risk stigmata.
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Affiliation(s)
- Arslan Kahloon
- Department of Internal Medicine, University of Tennessee College of Medicine, Chattanooga, 979 East Third Street, Suite C-825, Chattanooga, TN, 37403, USA,
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Meltzer AC, Ward MJ, Gralnek IM, Pines JM. The cost-effectiveness analysis of video capsule endoscopy compared to other strategies to manage acute upper gastrointestinal hemorrhage in the ED. Am J Emerg Med 2014; 32:823-32. [PMID: 24961149 PMCID: PMC4108573 DOI: 10.1016/j.ajem.2013.11.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 11/05/2013] [Accepted: 11/07/2013] [Indexed: 12/29/2022] Open
Abstract
STUDY OBJECTIVE Acute upper gastrointestinal (GI) hemorrhage is a common presentation in hospital-based emergency departments (EDs). A novel diagnostic approach is to use video capsule endoscopy to directly visualize the upper GI tract and identify bleeding. Our objective was to evaluate and compare the relative costs and benefits of video capsule endoscopy compared to other strategies in low- to moderate-risk ED patients with acute upper GI hemorrhage. METHODS We constructed a model using standard decision analysis software to examine the cost-effectiveness of 4 available strategies for a base-case patient who presents to the ED with either mild- or moderate-risk scenarios (by Glasgow-Blatchford Score) for requiring invasive hemostatic intervention (ie, endoscopic, surgical, etc) The 4 available diagnostic strategies were (1) direct imaging with video capsule endoscopy performed in the ED; (2) risk stratification using the Glasgow-Blatchford score; (3) nasogastric tube placement; and, finally, (4) an admit-all strategy. RESULTS In the low-risk scenario, video capsule endoscopy was the preferred strategy (cost $5691, 14.69 quality-adjusted life years [QALYs]) and was more cost-effective than the remaining strategies including nasogastric tube strategy (cost $8159, 14.69 QALYs), risk stratification strategy (cost $10,695, 14.69 QALYs), and admit-all strategy (cost $22,766, 14.68 QALYs). In the moderate-risk scenario, video capsule endoscopy continued to be the preferred strategy (cost $9190, 14.56 QALYs) compared to nasogastric tube (cost $9487, 14.58 QALYs, incremental cost-effectiveness ratio $15,891) and more cost effective than admit-all strategy (cost, $22,584, 14.54 QALYs.) CONCLUSION Video capsule endoscopy may be cost-effective for low- and moderate-risk patients presenting to the ED with acute upper GI hemorrhage.
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Affiliation(s)
- Andrew C Meltzer
- Department of Emergency Medicine, George Washington University, Washington, DC, USA.
| | - Michael J Ward
- Department of Emergency Medicine, Vanderbilt University, Nashville, TN, USA
| | - Ian M Gralnek
- Bruce and Ruth Rappaport Faculty Of Medicine, Technion-Israel Institute Of Technology, GI Outcomes Unit, Department Of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
| | - Jesse M Pines
- Department of Emergency Medicine, George Washington University, Washington, DC, USA
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Romero-Vázquez J, Argüelles-Arias F, García-Montes JM, Caunedo-Álvarez &A, Pellicer-Bautista FJ, Herrerías-Gutiérrez JM. Capsule endoscopy in patients refusing conventional endoscopy. World J Gastroenterol 2014; 20:7424-7433. [PMID: 24966612 PMCID: PMC4064087 DOI: 10.3748/wjg.v20.i23.7424] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/20/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy is nowadays the diagnostic technique of choice in the study of small bowel pathologies, allowing the non-invasive study of the entire mucosa. This has led, together with new technical advances, to the creation of two new models (PillCam ESO and PillCam Colon) for the study of esophageal and colonic diseases. These two new capsules offer an interesting alternative to conventional endoscopy in the study of the upper and lower digestive tracts, because traditional endoscopy is often unpleasant and uncomfortable for the patient, can be painful, often requires moderate or deep sedation and is not without complications (hemorrhage, perforation, etc.). PillCam Colon is particularly important for its usefulness in the diagnosis of colonic polyps, and is a potentially useful tool in cases of incomplete colonoscopy or in colorectal cancer screening, even more when most patients are reluctant to undergo screening programs due to the said disadvantages of conventional colonoscopy. This article discusses the advantages of capsule endoscopy over conventional endoscopy, its current application possibilities and indications in routine clinical practice. In the various sections of the work, we assess the application of endoscopic capsule in different sections of the digestive tract (esophagus, stomach, and colon) and finally the potential role of panendoscopy with PillCam Colon.
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Laurain A, de Leusse A, Gincul R, Vanbiervliet G, Bramli S, Heyries L, Martane G, Amrani N, Serraj I, Saurin JC, Borentain P, Filoche B, Duburque C, Gaudric M, Sogni P, Dumortier J. Oesophageal capsule endoscopy versus oesophago-gastroduodenoscopy for the diagnosis of recurrent varices: a prospective multicentre study. Dig Liver Dis 2014; 46:535-40. [PMID: 24631032 DOI: 10.1016/j.dld.2014.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 01/22/2014] [Accepted: 02/04/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Oesophago-gastroduodenoscopy is the standard method for the diagnosis of recurrent oesophago-gastric varices after endoscopic treatment and eradication. The aim of this study was to evaluate the PillCam Eso capsule endoscopy in this setting. METHODS Prospective, multicentre study in which patients with history of oesophageal varices treated by band ligation underwent PillCam Eso capsule and oesophago-gastroduodenoscopy. Capsule recordings were blindly read by two endoscopists. Indication for a new prophylactic treatment and patient satisfaction were determined for both procedures. RESULTS 80 patients (80% males, mean age: 57±12 years) were included, after a median delay of 16 months from last endoscopic treatment. Recurrent oesophageal varices requiring a new prophylactic treatment were detected in 26 patients (32.5%). The mean oesophageal transit time of the capsule was 153 s (range 2-930 s). Capsule sensitivity, specificity, negative and positive predictive values for indication of new prophylactic treatments were 65%, 83%, 83%, and 65%, respectively. Capsule adequately classified 77.5% of the patients for prophylaxis indication. Inter-observer concordance for capsule readings was 88% for the prophylaxis indication. CONCLUSION This study demonstrates that accuracy of PillCam Eso capsule for the diagnosis of recurrent oesophageal varices after endoscopic eradication is suboptimal. PillCam Eso capsule might therefore be proposed in patients unable or unwilling to undergo oesophago-gastroduodenoscopy.
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Affiliation(s)
- Anne Laurain
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France
| | - Antoine de Leusse
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Jean Mermoz Hospital, Lyon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Rodica Gincul
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Geoffroy Vanbiervliet
- Archet II Hospital, Department of Digestive Diseases, Nice, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Slim Bramli
- Avignon Hospital, Department of Digestive Diseases, Avignon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Laurent Heyries
- Conception Hospital - AP-HM, Department of Digestive Diseases, Marseille, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Gabriel Martane
- Avignon Hospital, Department of Digestive Diseases, Avignon, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Naima Amrani
- Ibn Sina Hospital, Department of Digestive Diseases, Rabat, Morocco; Société Française d'Endoscopie Digestive, Paris, France
| | - Ilham Serraj
- Ibn Sina Hospital, Department of Digestive Diseases, Rabat, Morocco
| | - Jean-Christophe Saurin
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France; Lyon Sud Hospital, Department of Digestive Diseases, Pierre Benite, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Patrick Borentain
- Conception Hospital - AP-HM, Department of Digestive Diseases, Marseille, France
| | - Bernard Filoche
- Saint Philibert Hospital, Department of Digestive Diseases, Lomme, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Clotilde Duburque
- Saint Philibert Hospital, Department of Digestive Diseases, Lomme, France
| | - Marianne Gaudric
- Cochin Hospital - AP-HP, Department of Digestive Endoscopy, Paris, France; Société Française d'Endoscopie Digestive, Paris, France
| | - Philippe Sogni
- Cochin Hospital - AP-HP, Department of Digestive Endoscopy, Paris, France
| | - Jérôme Dumortier
- Edouard Herriot Hospital - HCL, Department of Digestive Diseases, Claude Bernard Lyon 1 University, Lyon, France.
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Pár G, Trosits A, Pakodi F, Szabó I, Czimmer J, Illés A, Gódi S, Bajor J, Sarlós P, Kenyeres P, Miseta A, Vincze A, Pár A. [Transient elastography as a predictor of oesophageal varices in patients with liver cirrhosis]. Orv Hetil 2014; 155:270-6. [PMID: 24509356 DOI: 10.1556/oh.2014.29824] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION One of the most serious complications of liver cirrhosis is variceal bleeding. Early recognition of the oesophageal varices is of primary importance in the prevention of variceal bleeding. Endoscopy is the only means to directly visualize varices and measure their size, as one of the most important predictor of the risk of bleeding. During the course of cirrhosis repeated oesophago-gastro-bulboscopic examinations are recommended. As these interventions are expensive and often poorly accepted by patients who may refuse further follow-up, there is a need for non-invasive methods to predict the progression of portal hypertension as well as the presence and the size of oesophageal varices. After several combinations of biological and ultrasonographical parameters proposed for the detection of advanced fibrosis, it was suggested that liver stiffness measured by transient elastography, a novel non-invasive technology may reflect not only fibrosis and portal pressure but it may even predict the presence or absence of large oesophageal varices in patients with cirrhosis. AIM The aim of the authors was to study the diagnostic accuracy of transient elastography using FibroScan for selecting patients who are at risk of bearing large (Paquet-grade ≥ II) oesophageal varices and high risk of bleeding. METHOD The authors performed upper tract endoscopy and transient elastography in 74 patients with chronic liver disease (27 patients with chronic hepatitis and 47 patients with liver cirrhosis). The relationships between the presence of oesophageal varices (Paquet-grade 0-IV) and liver stiffness (kPa), as well as the hematological and biochemical laboratory parameters (prothrombine international normalized ratio, platelet count, aspartate aminotransferase, alanine aminotransferase, albumin, and aspartate aminotransferase/platelet ratio index) were investigated. The predictive role of liver stiffness for screening patients with varices and those who are at high risk of variceal bleeding was also analysed. RESULTS Liver stiffness values significantly correlated with the grade of oesophageal varices (Paquet-grade) (r = 0.67, p<0.0001). The liver stiffness value of 19.2 kPa was highly predictive for the presence of oesophageal varices (AUROC: 0.885, 95% CI: 0.81-0.96) and for the presence of high grade varices (P≥II) (AUROC: 0.850, 95% CI: 0.754-0.94). Using the cut-off value of 19.2 kPa, the sensitivity of transient elastography was 85%, specificity was 87%, positive predictive value was 85%, negative predictive value was 87% and validity was 86% for the detection of varices. Liver stiffness values less than 19.2 kPa were highly predicitive for the absence of large (P≥II) varices (sensitivity, 95%; specificity, 70%; positive predictive value, 54%; negative predictive value, 97%). CONCLUSIONS Transient elastography may help to screen patients who are at high risk of bearing large (P≥II) oesophageal varices which predict variceal bleeding and, therefore, need endoscopic screening. Lives stiffness values higher than 19.2 kPa indicate the need for oesophageal-gastro-bulboscopy, while liver stiffness values lower than 19.2 kPa make the presence of large oesophageal varices unlikely.
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Affiliation(s)
- Gabriella Pár
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Andrea Trosits
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Ferenc Pakodi
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Imre Szabó
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - József Czimmer
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Anita Illés
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Szilárd Gódi
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Judit Bajor
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Patrícia Sarlós
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Péter Kenyeres
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Attila Miseta
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ Laboratóriumi Medicina Intézet Pécs
| | - Aron Vincze
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
| | - Alajos Pár
- Pécsi Tudományegyetem, Általános Orvostudományi Kar, Klinikai Központ I. Belgyógyászati Klinika Pécs Rákóczi u. 2. 7623
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Abstract
Portal hypertensive gastropathy (PHG) and colopathy (PHC) are considered complications of portal hypertension. Both entities are clinically relevant because they may cause insidious blood loss or even acute massive gastrointestinal hemorrhage. Endoscopic evaluation is necessary for the diagnosis of PHG and PHC. The existence of different endoscopic criteria for PHG and PHC makes consensus difficult and results in a broad range of reported prevalence. Therapy targeted at reduction of portal pressure and mucosal blood flow has been used to treat acute bleeding; nonselective β-blockers are the most frequently used agents. Further studies are needed to clarify the natural history, pathogenesis, and treatment of PHG and PHC.
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Affiliation(s)
- Nathalie H. Urrunaga
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, 22 S. Greene Street, N3W156, Baltimore, MD 21201, USA
| | - Don C. Rockey
- Department of Internal Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 803, Charleston, SC 29425, USA,Corresponding author.
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Abstract
Assessing the presence of clinically significant portal hypertension and esophageal varices is clinically important in cirrhosis. The reference standard techniques to assess the presence of portal hypertension and varices are the measurement of the hepatic vein pressure gradient and esophagogastroduodenoscopy, respectively. Some newer methods have shown a good performance, but none has been proven precise enough to replace hepatic vein pressure gradient measurement or esophagogastroduodenoscopy for the diagnosis of portal hypertension or the presence and grade of esophageal varices.
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Aoyama T, Oka S, Aikata H, Nakano M, Watari I, Naeshiro N, Yoshida S, Tanaka S, Chayama K. Is small-bowel capsule endoscopy effective for diagnosis of esophagogastric lesions related to portal hypertension? J Gastroenterol Hepatol 2014; 29:511-6. [PMID: 23981241 DOI: 10.1111/jgh.12372] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Effectiveness of capsule endoscopy (CE) for screening the small bowel in patients with portal hypertension (PHT) has been reported. However, few reports discuss CE detection of specific esophagogastric lesions related to PHT. Thus, we assessed whether CE is useful for detecting such lesions. METHODS One hundred nineteen consecutive patients with PHT comprised the study group. All had undergone esophagogastroduodenoscopy (EGD) prior to CE. The diagnostic yield of CE for esophageal varices (EVs), gastric varices (GVs), and portal hypertensive gastropathy (PHG) was evaluated. In addition, diagnostic yield in relation to form, location of the varices, grade, and extent of PHG was evaluated. RESULTS EVs were found by EGD in 71 patients. The overall diagnostic yield of CE for EVs was 72% (51/71). The diagnostic yield was significantly greater for F2/F3 EVs than for F1 EVs (87% vs 61%, P = 0.03). The diagnostic yield was significantly greater for Lm/Ls EVs than for Li EVs (85% vs 55%, P = 0.01). The diagnostic yield was significantly greater for locus superior/locus medialis EVs than for locus inferior EVs (85% vs 55%, P = 0.01). GVs were found by EGD in 29 patients. Only one case was detected by CE. PHG was found by EGD in 35 patients. The diagnostic yield of CE for PHG was 69% (24/35). There was no difference in diagnostic yield between cases of severe and mild PHG (82% vs 63%, P = 0.44). Diagnostic yield of CE for PHG in the gastric body was significantly greater than that in the fundus (100% vs 48%, P = 0.0009). CONCLUSION CE is reliable for diagnosis of F2/F3 and/or Lm/Ls EVs and of PHG in the gastric body.
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Affiliation(s)
- Taiki Aoyama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Wang A, Banerjee S, Barth BA, Bhat YM, Chauhan S, Gottlieb KT, Konda V, Maple JT, Murad F, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Rodriguez SA. Wireless capsule endoscopy. Gastrointest Endosc 2013; 78:805-815. [PMID: 24119509 DOI: 10.1016/j.gie.2013.06.026] [Citation(s) in RCA: 189] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 06/25/2013] [Indexed: 02/07/2023]
Abstract
Over the last decade, WCE has established itself as a valuable test for imaging the small intestine. It is a safe and relatively easy procedure to perform that can provide valuable information in the diagnosis of small-bowel conditions. Its applications still remain limited within the esophagus and colon. Future developments may include improving visualization within the esophagus and developing technologies that may allow manipulation of the capsule within the GI tract and biopsy capabilities.
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Saad Y, Said M, Idris MO, Rabee A, Zakaria S. Liver stiffness measurement by fibroscan predicts the presence and size of esophageal varices in egyptian patients with HCV related liver cirrhosis. J Clin Diagn Res 2013; 7:2253-7. [PMID: 24298490 DOI: 10.7860/jcdr/2013/6026.3484] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Accepted: 06/11/2013] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIM Liver stiffness measured by transient elastgraphy correlates with Hepatic vein pressure gradient, liver Stiffness value of 21 kpa predicts significant portal hypertension. Aim is to predict esophageal varices presence by fibroscan and possible grading by degree of liver stiffness in HCV related cirrhotic patients. MATERIAL AND METHODS Thirty two HCV related cirrhotic patients were recruited, age > 18 years, BMI< 35, no history of: upper GI bleeding, hepatocellular carcinoma, abdominal collaterals, ascites. Patients underwent clinical examination, laboratory investigations, abdominal ultrasonography, upper endoscopy and fibroscan. They divided into (Group I= no varices, Group II =small varices (Grade 1 & 2), Group III = large varices (Grade 3 & 4). RESULTS Age is higher in Group III than I & II (55+6.6 vs 49.5+4.7 & 48.9+4.7, p-value 0.04) respectively, Groups were gender & BMI matched, fibroscan values in Group I vs II & III were 27 Vs 49.4, p value 0.01, cutoff 29.7 Kpa (sensitivity 95% & specificity 67%) while its value in Group II vs III were 38.4 vs 60.4, p value 0.002, cutoff 38.2 Kpa (sensitivity 100% & specificity77.3%). Platelet count, splenic size, platelet count/splenic size in Group I vs II & III were 107.166 vs 72.900, 13.8 vs 15.4, 803.6 vs 478, p value 0.01, 0.008, 0.005, cutoff 80.000, 14.5, 545, sensitivity & specificity (85%&75%, 75%&75%, 85%&84%) respectively. On multivariate analysis fibroscan (OR 1.113; p=0.005) & platelet count/splenic size (OR 0.995; p=0.012) were positive predictors of esophageal varices presence. CONCLUSION Fibroscan is a good non-invasive method to predict esophageal varices presence & possible grading with high sensitivity.
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Affiliation(s)
- Yasmin Saad
- Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University , Cairo, Egypt
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Abstract
Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of ∼20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child-Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in ∼60% of patients 1-2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.
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