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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: 1] [Impact Index Per Article: 1.0] [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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Gounella R, Granado TC, Hideo Ando Junior O, Luporini DL, Gazziro M, Carmo JP. Endoscope Capsules: The Present Situation and Future Outlooks. Bioengineering (Basel) 2023; 10:1347. [PMID: 38135938 PMCID: PMC10741108 DOI: 10.3390/bioengineering10121347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/04/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
This paper presents new perspectives on photonic technologies for capsule endoscopy. It first presents a review of conventional endoscopy (upper endoscopy and colonoscopy), followed by capsule endoscopy (CE), as well as their techniques, advantages, and drawbacks. The technologies for CEs presented in this paper include integration with the existing endoscopic systems that are commercially available. Such technologies include narrow-band imaging (NBI), photodynamic therapy (PDT), confocal laser endomicroscopy (CLE), optical coherence tomography (OCT), and spectroscopy in order to improve the performance of the gastrointestinal (GI) tract examination. In the context of NBI, two optical filters were designed and fabricated for integration into endoscopic capsules, allowing for the visualization of light centered at the 415 nm and 540 nm wavelengths. These optical filters are based on the principle of Fabry-Perot and were made of thin films of titanium dioxide (TiO2) and silicon dioxide (SiO2). Moreover, strategies and solutions for the adaptation of ECs for PDT are also discussed.
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Affiliation(s)
- Rodrigo Gounella
- Group of Metamaterials Microwaves and Optics (GMeta), Department of Electrical Engineering (SEL), University of São Paulo (USP), Avenida Trabalhador São-Carlense, Nr. 400, Parque Industrial Arnold Schimidt, São Carlos 13566-590, Brazil; (T.C.G.); (J.P.C.)
| | - Talita Conte Granado
- Group of Metamaterials Microwaves and Optics (GMeta), Department of Electrical Engineering (SEL), University of São Paulo (USP), Avenida Trabalhador São-Carlense, Nr. 400, Parque Industrial Arnold Schimidt, São Carlos 13566-590, Brazil; (T.C.G.); (J.P.C.)
| | - Oswaldo Hideo Ando Junior
- Academic Unit of Cabo de Santo Agostinho (UACSA), Federal Rural University of Pernambuco (UFRPE), Cabo de Santo Agostinho 54518-430, Brazil;
| | - Daniel Luís Luporini
- Clinica Endoscopia São Carlos, Rua Paulino Botelho de Abreu Sampaio, 958, Centro, São Carlos 13561-060, Brazil;
| | - Mario Gazziro
- Information Engineering Group, Department of Engineering and Social Sciences (CECS), Federal University of ABC (UFABC), Av. dos Estados, 5001, Santo André 09210-580, Brazil;
| | - João Paulo Carmo
- Group of Metamaterials Microwaves and Optics (GMeta), Department of Electrical Engineering (SEL), University of São Paulo (USP), Avenida Trabalhador São-Carlense, Nr. 400, Parque Industrial Arnold Schimidt, São Carlos 13566-590, Brazil; (T.C.G.); (J.P.C.)
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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: 0] [Impact Index Per Article: 0] [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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Yan JS, Yan B, Meng K. Current status and future developments of upper gastrointestinal tract capsule endoscopy. Shijie Huaren Xiaohua Zazhi 2021; 29:960-965. [DOI: 10.11569/wcjd.v29.i16.960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Capsule endoscopy has been widely used for the diagnosis of small bowel diseases due to its safety, noninvasiveness, and acceptability. Despite the potential benefits of capsule endoscopy, there are obvious challenges to capsule endoscopy application in the upper gastrointestinal tract, due to the fast transit speed in the esophagus and large space of the gastric cavity. With the development of innovative technologies, such as magnetic navigation and tethered capsule endoscopy, the indications for capsule endoscopy have recently been expanded. Various capsule endoscopes have been applied to clinical practice, and several state-of-the-art research-oriented designs and devices provide hope for further use in the diagnosis of upper gastrointestinal diseases. In this review, we will summarize the current status and future developments of upper gastrointestinal tract capsule endoscopy.
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Affiliation(s)
- Jing-Shuang Yan
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China,School of Medicine, Nankai University, Tianjin 300071, China
| | - Bin Yan
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ke Meng
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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Alam MW, Vedaei SS, Wahid KA. A Fluorescence-Based Wireless Capsule Endoscopy System for Detecting Colorectal Cancer. Cancers (Basel) 2020; 12:E890. [PMID: 32268557 PMCID: PMC7226276 DOI: 10.3390/cancers12040890] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 12/22/2022] Open
Abstract
Wireless capsule endoscopy (WCE) has been widely used in gastrointestinal (GI) diagnosis that allows the physicians to examine the interior wall of the human GI tract through a pain-free procedure. However, there are still several limitations of the technology, which limits its functionality, ultimately limiting its wide acceptance. Its counterpart, the wired endoscopic system is a painful procedure that demotivates patients from going through the procedure, and adversely affects early diagnosis. Furthermore, the current generation of capsules is unable to automate the detection of abnormality. As a result, physicians are required to spend longer hours to examine each image from the endoscopic capsule for abnormalities, which makes this technology tiresome and error-prone. Early detection of cancer is important to improve the survival rate in patients with colorectal cancer. Hence, a fluorescence-imaging-based endoscopic capsule that automates the detection process of colorectal cancer was designed and developed in our lab. The proof of concept of this endoscopic capsule was tested on porcine intestine and liquid phantom. The proposed WCE system offers great possibilities for future applicability in selective and specific detection of other fluorescently labelled cancers.
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Affiliation(s)
- Mohammad Wajih Alam
- Departement of Electrical and Computer Engineering, University of Saskatchewan, Saskatoon, SK S7N 5A9, Canada; (S.S.V.); (K.A.W.)
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Beg S, Card T, Warburton S, Rahman I, Wilkes E, White J, Ragunath K. Diagnosis of Barrett's esophagus and esophageal varices using a magnetically assisted capsule endoscopy system. Gastrointest Endosc 2020; 91:773-781.e1. [PMID: 31678203 DOI: 10.1016/j.gie.2019.10.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 10/21/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Magnetically assisted capsule endoscopy (MACE) potentially offers a comfortable, patient friendly, and community-based alternative to gastroscopy (EGD). This pilot study aims to explore whether this approach can be used to accurately diagnose Barrett's esophagus (BE) and esophageal varices. METHOD The MiroCam Navi capsule system was used to examine the upper GI tract in patients due to undergo a clinically indicated EGD. A total of 50 participants were enrolled: 34 had known pathology (17 BE, 17 esophageal varices [EV]) and 16 controls. Patients underwent the MACE procedure with the operator blinded to the indication and any previous endoscopic diagnoses. The subsequent EGD was performed by an endoscopist blinded to the MACE findings. Diagnostic yield, comfort, and patient preference between the 2 modalities were compared. RESULTS The mean age of the participants was 61 years, the male/female ratio was 2.1:1, the mean body mass index was 29.5 kg/m2, and the average chest measurement was 105.3 cm. Forty-seven patients underwent both procedures; 3 patients were unable to swallow the capsule. With the use of the magnet, it was possible to hold the capsule within the esophagus for a mean duration of 190 seconds and up to a maximum of 634 seconds. A correct real-time MACE diagnosis was made in 11 of 15 patients with EV (sensitivity 73.3% [95% confidence interval (CI), 44.9%-92.2%] and specificity 100% [95% CI, 89.1%-100%]) and 15 of 16 patients with BE (sensitivity 93.8% [95% CI, 69.8%-99.8%] and specificity of 100% [95% CI, 88.8%-100%]). MACE was considered more comfortable than conventional endoscopy (P < .0001); the mean score was 9.2 for MACE compared with 6.7 for EGD when assessed on a 10-point scale. No MACE- or EGD-related adverse events occurred. CONCLUSION This pilot study demonstrates that MACE is both safe and well tolerated by patients. Accuracy for the diagnosis of BE was high, and therefore MACE may have a role in screening for this condition. (Clinical trial registration number: NCT02852161.).
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Affiliation(s)
- Sabina Beg
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham
| | - Tim Card
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham; Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham
| | - Samantha Warburton
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham
| | - Imdadur Rahman
- University Hospital Southampton NHS trust, Southampton, United Kingdom
| | - Emilie Wilkes
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham
| | - Jonathan White
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham
| | - Krish Ragunath
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham; Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham
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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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Duodenal Varix Rupture - A Rare Cause of Fatal Gastrointestinal Hemorrhage: A Case Report and Review of Literature. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2019; 7:62-66. [PMID: 31650032 PMCID: PMC6812512 DOI: 10.12691/ajmcr-7-4-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Duodenal varices are a rare complication of portal hypertension; with cirrhosis being the most common cause. Reports regarding the disease prognosis and natural history are limited. In addition to the diagnostic difficulty, ectopic duodenal varices pose a significant therapeutic challenge owing to the lack of specific management guidelines. Given the high risk of rupture, they can have devastating clinical outcomes. Rupture typically presents as a gastrointestinal hemorrhage and requires emergent interventions. We present a case of duodenal varix seen on upper endoscopy in a patient with portal hypertension and cirrhosis, together with review of the literature outlining the current understanding of this disease entity. We also highlight the pathogenetic mechanisms as well as the current diagnostic and therapeutic approaches for this potentially fatal disease.
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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: 4.5] [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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Fernandez-Urien I, Panter S, Carretero C, Davison C, Dray X, Fedorov E, Makins R, Mascarenhas M, McAlindon M, McNamara D, Palmer H, Rey JF, Saurin JC, Seitz U, Spada C, Toth E, Wiedbrauck F, Keuchel M. International core curriculum for capsule endoscopy training courses. Endosc Int Open 2017; 5:E526-E538. [PMID: 28596986 PMCID: PMC5462604 DOI: 10.1055/s-0043-106181] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 02/10/2017] [Indexed: 12/19/2022] Open
Abstract
Capsule endoscopy (CE) has become a first-line noninvasive tool for visualisation of the small bowel (SB) and is being increasingly used for investigation of the colon. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines have specified requirements for the clinical applications of CE. However, there are no standardized recommendations yet for CE training courses in Europe. The following suggestions in this curriculum are based on the experience of European CE training courses directors. It is suggested that 12 hours be dedicated for either a small bowel capsule endoscopy (SBCE) or a colon capsule endoscopy (CCE) course with 4 hours for an introductory CCE course delivered in conjunction with SBCE courses. SBCE courses should include state-of-the-art lectures on indications, contraindications, complications, patient management and hardware and software use. Procedural issues require approximately 2 hours. For CCE courses 2.5 hours for theoretical lessons and 3.5 hours for procedural issued are considered appropriate. Hands-on training on reading and interpretation of CE cases using a personal computer (PC) for 1 or 2 delegates is recommended for both SBCE and CCE courses. A total of 6 hours hands-on session- time should be allocated. Cases in a SBCE course should cover SB bleeding, inflammatory bowel diseases (IBD), tumors and variants of normal and cases with various types of polyps covered in CCE courses. Standardization of the description of findings and generation of high-quality reports should be essential parts of the training. Courses should be followed by an assessment of trainees' skills in order to certify readers' competency.
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Affiliation(s)
- Ignacio Fernandez-Urien
- Department of Gastroenterology – CHN, Pamplona, Spain,Corresponding author Ignacio Fernandez-Urien MD, PhD Department of Gastroenterology – CHN, Pamplona (España)c/ Irunlarrea 3 – 31008 Pamplona (Navarra)
| | - Simon Panter
- Department of Gastroenterology – South Tyneside NHS, South Tyneside, United Kingdom
| | | | - Carolyn Davison
- Department of Gastroenterology – South Tyneside NHS, South Tyneside, United Kingdom
| | - Xavier Dray
- Department of Hepatology and Gastroenterology – Saint-Antoine Hospital, Pierre et Marie Curie University & APHP, Paris, France
| | - Evgeny Fedorov
- Department of Abdominal Surgery, Gastroenterology and Endoscopy – Pirogov Russia National Medical University, Moscow University Hospital, Moscow, Russia
| | - Richard Makins
- Department of Gastroenterology – Gloucestershire Hospitals, Gloucester, United Kingdom
| | | | - Mark McAlindon
- Department of Gastroenterology – Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Deirdre McNamara
- Department of Clinical Medicine – Tallaght Hospital, Trinity College, Dublin, Ireland
| | - Hansa Palmer
- Digestive Endoscopy Unit – Royal Free Hampstead NHS Trust, London, United Kingdom
| | | | | | - Uwe Seitz
- Department of Internal Medicine 1 – Bergstrasse Medical Center, University Hospital Heidelberg, Heppenheim, Germany
| | - Cristiano Spada
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Gemelli, Rome, Italy
| | - Ervin Toth
- Department of Gastroenterology – Skåne University Hospital, Lund University, Malmö, Sweden
| | - Felix Wiedbrauck
- Department of Gastroenterology – Allgemeines Krankenhaus Celle, Celle, Germany
| | - Martin Keuchel
- Clinic for Internal Medicine, Bethesda Hospital Bergedorf, Hamburg, Germany
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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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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: 38] [Impact Index Per Article: 5.4] [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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13
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Van Den Abeele J, Rubbens J, Brouwers J, Augustijns P. The dynamic gastric environment and its impact on drug and formulation behaviour. Eur J Pharm Sci 2017; 96:207-231. [DOI: 10.1016/j.ejps.2016.08.060] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 08/30/2016] [Accepted: 08/30/2016] [Indexed: 02/08/2023]
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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: 2.3] [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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15
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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: 1.6] [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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16
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Diagnostic performance of multidetector computed tomography in the evaluation of esophageal varices. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2016. [DOI: 10.1016/j.ejrnm.2015.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Gjeorgjievski M, Cappell MS. Portal hypertensive gastropathy: A systematic review of the pathophysiology, clinical presentation, natural history and therapy. World J Hepatol 2016; 8:231-62. [PMID: 26855694 PMCID: PMC4733466 DOI: 10.4254/wjh.v8.i4.231] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/30/2015] [Accepted: 01/16/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To describe the pathophysiology, clinical presentation, natural history, and therapy of portal hypertensive gastropathy (PHG) based on a systematic literature review. METHODS Computerized search of the literature was performed via PubMed using the following medical subject headings or keywords: "portal" and "gastropathy"; or "portal" and "hypertensive"; or "congestive" and "gastropathy"; or "congestive" and "gastroenteropathy". The following criteria were applied for study inclusion: Publication in peer-reviewed journals, and publication since 1980. Articles were independently evaluated by each author and selected for inclusion by consensus after discussion based on the following criteria: Well-designed, prospective trials; recent studies; large study populations; and study emphasis on PHG. RESULTS PHG is diagnosed by characteristic endoscopic findings of small polygonal areas of variable erythema surrounded by a pale, reticular border in a mosaic pattern in the gastric fundus/body in a patient with cirrhotic or non-cirrhotic portal hypertension. Histologic findings include capillary and venule dilatation, congestion, and tortuosity, without vascular fibrin thrombi or inflammatory cells in gastric submucosa. PHG is differentiated from gastric antral vascular ectasia by a different endoscopic appearance. The etiology of PHG is inadequately understood. Portal hypertension is necessary but insufficient to develop PHG because many patients have portal hypertension without PHG. PHG increases in frequency with more severe portal hypertension, advanced liver disease, longer liver disease duration, presence of esophageal varices, and endoscopic variceal obliteration. PHG pathogenesis is related to a hyperdynamic circulation, induced by portal hypertension, characterized by increased intrahepatic resistance to flow, increased splanchnic flow, increased total gastric flow, and most likely decreased gastric mucosal flow. Gastric mucosa in PHG shows increased susceptibility to gastrotoxic chemicals and poor wound healing. Nitrous oxide, free radicals, tumor necrosis factor-alpha, and glucagon may contribute to PHG development. Acute and chronic gastrointestinal bleeding are the only clinical complications. Bleeding is typically mild-to-moderate. Endoscopic therapy is rarely useful because the bleeding is typically diffuse. Acute bleeding is primarily treated with octreotide, often with concomitant proton pump inhibitor therapy, or secondarily treated with vasopressin or terlipressin. Nonselective β-adrenergic receptor antagonists, particularly propranolol, are used to prevent bleeding after an acute episode or for chronic bleeding. Iron deficiency anemia from chronic bleeding may require iron replacement therapy. Transjugular-intrahepatic-portosystemic-shunt and liver transplantation are highly successful ultimate therapies because they reduce the underlying portal hypertension. CONCLUSION PHG is important to recognize in patients with cirrhotic or non-cirrhotic portal hypertension because it can cause acute or chronic GI bleeding that often requires pharmacologic therapy.
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Affiliation(s)
- Mihajlo Gjeorgjievski
- Mihajlo Gjeorgjievski, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
| | - Mitchell S Cappell
- Mihajlo Gjeorgjievski, Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
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18
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Karatzas A, Triantos C, Kalafateli M, Marzigie M, Labropoulou-Karatza C, Thomopoulos K, Petsas T, Kalogeropoulou C. Multidetector computed tomography versus platelet/spleen diameter ratio as methods for the detection of gastroesophageal varices. Ann Gastroenterol 2016; 29:71-8. [PMID: 26751694 PMCID: PMC4700850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND All patients with liver cirrhosis should undergo screening endoscopy, but there are limitations and this approach places a heavy burden upon endoscopy units. The aim of this study was to compare multidetector computed tomography (MDCT) and the platelet/spleen diameter ratio as non-invasive methods for the detection of gastroesophageal varices. METHODS The study included 38 cirrhotics who underwent upper gastrointestinal (GI) endoscopy and MDCT within one month. Two radiologists reviewed the scans, in order to determine the presence and the size of varices. Blood tests and measurement of the spleen maximum diameter were also carried out and the platelet/spleen diameter ratio was calculated. Endoscopy was considered the gold standard and the results of the two methods were compared to it. RESULTS Varices were detected by upper GI endoscopy in 24 of 38 patients. The mean sensitivity and specificity of MDCT for the two observers was 86.1% and 57.1% respectively. In patients with large varices (>5 mm), the sensitivity was 100% (4/4). Using 909 as a cut-off value of the platelet/spleen diameter ratio this method yielded a sensitivity of 56.5% and a specificity of 35.7%. The difference in sensitivity and specificity between the two methods was statistically significant P<0.05. CONCLUSION MDCT was accurate for the detection of gastroesophageal varices, especially those with clinically significant size (>5 mm), and superior to platelet/spleen diameter ratio. MDCT could replace, in selected patients, upper GI endoscopy as a method for detecting gastroesophageal varices in cirrhotic patients.
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Affiliation(s)
- Andreas Karatzas
- Department of Radiology (Andreas Karatzas, Theodoros Petsas, Christina Kalogeropoulou)
| | - Christos Triantos
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | - Maria Kalafateli
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | - Misiel Marzigie
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | | | - Konstantinos Thomopoulos
- Department of Gastroenterology (Christos Triantos, Maria Kalafateli, Misiel Marzigie, Konstantinos Thomopoulos)
| | - Theodoros Petsas
- Department of Radiology (Andreas Karatzas, Theodoros Petsas, Christina Kalogeropoulou)
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19
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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: 1.7] [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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20
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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: 2.3] [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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21
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Epidemiology, diagnosis and early patient management of esophagogastric hemorrhage. Gastroenterol Clin North Am 2014; 43:765-82. [PMID: 25440924 DOI: 10.1016/j.gtc.2014.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute variceal bleeding (AVB) is a potentially life-threatening complication of cirrhosis and portal hypertension. Combination therapy with vasoactive drugs and endoscopic variceal ligation is the first-line treatment in the management of AVB after adequate hemodynamic resuscitation. Short-term antibiotic prophylaxis, early resuscitation, early use of lactulose for prevention of hepatic encephalopathy, targeting of conservative goals for blood transfusion, and application of early transjugular intrahepatic portosystemic shunts in patients with AVB have further improved the prognosis of AVB. This article discusses the epidemiology, diagnosis, and nonendoscopic management of AVB.
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22
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Haddad JD, Lacey BW. Isolated non-hemorrhagic cecal varices. Gastroenterol Rep (Oxf) 2014; 2:316-9. [PMID: 24855312 PMCID: PMC4219140 DOI: 10.1093/gastro/gou027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 04/22/2014] [Accepted: 04/29/2014] [Indexed: 11/25/2022] Open
Abstract
Ectopic varices (those outside of the gastro-esophageal region) are occasionally found on endoscopy in patients with portal hypertension; however they account for a small minority of all variceal bleeds. Cases of isolated cecal varices are quite rare and, when described, often present with acute hemorrhage or evidence of occult bleeding. We present the case of a 29-year-old male with a history of idiopathic portal vein thrombosis and known esophageal varices, who presented for evaluation of abdominal pain. Cecal varices were found on endoscopy, without evidence of bleeding and without varices in the remainder of the colon or rectum. Endoscopic ultrasound and computed tomography were useful in confirming the diagnosis and natural history of these unusual varices.
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Affiliation(s)
- James D Haddad
- Department of Internal Medicine Naval Medical Center, San Diego, CA, USA and Department of Gastroenterology, Naval Medical Center, San Diego, CA, USA
| | - Brent W Lacey
- Department of Internal Medicine Naval Medical Center, San Diego, CA, USA and Department of Gastroenterology, Naval Medical Center, San Diego, CA, USA
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23
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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: 18] [Impact Index Per Article: 1.8] [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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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: 15] [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: 10] [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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Nusrat S, Khan MS, Fazili J, Madhoun MF. Cirrhosis and its complications: Evidence based treatment. World J Gastroenterol 2014; 20:5442-5460. [PMID: 24833875 PMCID: PMC4017060 DOI: 10.3748/wjg.v20.i18.5442] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 01/17/2014] [Accepted: 02/20/2014] [Indexed: 02/06/2023] Open
Abstract
Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.
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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: 15] [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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Hosoe N, Ogata H, Hibi T. Endoscopic imaging of parasites in the human digestive tract. Parasitol Int 2014; 63:216-20. [PMID: 23993997 DOI: 10.1016/j.parint.2013.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 08/09/2013] [Indexed: 02/08/2023]
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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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Bosch J, Abraldes JG, Albillos A, Aracil C, Bañares R, Berzigotti A, Calleja JL, de la Peña J, Escorsell A, García-Pagán JC, Genescà J, Hernández-Guerra M, Ripoll C, Planas R, Villanueva C. Hipertensión portal: recomendaciones para su evaluación y tratamiento. GASTROENTEROLOGIA Y HEPATOLOGIA 2012; 35:421-50. [DOI: 10.1016/j.gastrohep.2012.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 02/15/2012] [Indexed: 12/16/2022]
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Mangone M, Moretti A, Alivernini F, Papi C, Orefice R, Dezi A, Amadei E, Aratari A, Bianchi M, Tornatore V, Koch M. Platelet count/spleen diameter ratio for non-invasive diagnosis of oesophageal varices: is it useful in compensated cirrhosis? Dig Liver Dis 2012; 44:504-7. [PMID: 22321622 DOI: 10.1016/j.dld.2011.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 12/14/2011] [Accepted: 12/18/2011] [Indexed: 12/11/2022]
Abstract
AIM To assess the diagnostic accuracy of the platelet count/spleen diameter ratio for identification of oesophageal varices and/or hypertensive gastropathy in patients with compensated cirrhosis. METHODS Platelet count/spleen diameter ratio was calculated in 87 consecutive patients with compensated cirrhosis. A new cut-off with the highest sensitivity and specificity for the presence/absence of oesophageal varices and/or hypertensive gastropathy was identified. Performance of the platelet count/spleen diameter ratio considering previously reported cut-off values were then tested in our population. RESULTS A platelet count/spleen diameter ratio <936.4 had the best sensitivity and specificity for the diagnosis of oesophageal varices and for all endoscopic findings of portal hypertension. A value lower than 936.4 allowed identification of 64.5% of patients with oesophageal varices and 66.7% of patients with any sign of portal hypertension; a value higher than 936.4 excluded oesophageal varices in 64.3% of patients and any sign of portal hypertension in 68.6% of patients. CONCLUSIONS In patients with compensated cirrhosis, the platelet count/spleen diameter ratio is not a useful parameter to avoid unnecessary upper endoscopy, independently of the cut-off.
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Affiliation(s)
- Manuela Mangone
- Gastroenterology and Hepatology Unit, San Filippo Neri Hospital, Rome, Italy.
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Stipho S, Tharalson E, Hakim S, Akins R, Shaukat M, Ramirez FC. String capsule endoscopy for screening and surveillance of esophageal varices in patients with cirrhosis. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:54-60. [PMID: 23687586 DOI: 10.4161/jig.22173] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 01/30/2012] [Accepted: 05/15/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND EGD is the gold standard for the screening and surveillance of esophageal varices. A less invasive, safer and sedationless alternative procedure is needed. OBJECTIVE To assess the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) as well as the beyond the chance agreement (kappa index), of string capsule endoscopy (SCE) in the diagnosis of esophageal varices. METHODS Cirrhotic patients underwent string capsule endoscopy (SCE) and EGD for screening and surveillance purposes. Varices were graded at EGD and SCE as small, medium and large. Descriptors at SCE were added as follows: PLUS, for the presence of red wale signs or, MINUS for their absence, irrespective of the estimated variceal size. Clinically significant varices were defined by their size (medium/large at either EGD or SCE) and/or, the PLUS descriptor irrespective of the estimated size at SCE. Sensitivity, specificity, PPV, NPV, accuracy and kappa index were calculated. Procedure time, procedure-related discomfort and patient's preference were documented. RESULTS 100 patients (33 for screening and 67 for surveillance) were enrolled. The sensitivity and specificity of SCE for clinically significant varices when using the PLUS/MINUS descriptors were 82% and 90%, respectively with a PPV of 84% and NPV of 89% and a kappa of 0.73. CONCLUSION String capsule endoscopy had an acceptable sensitivity and specificity for the diagnosis of clinically significant esophageal varices but the lack of air insufflation still hampers its correlation with the grading used with EGD.
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Affiliation(s)
- Sally Stipho
- Gastroenterology Division, Departments of Medicine and Research. Carl T. Hayden Veterans Affairs Medical Center. Phoenix, Arizona
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Chavalitdhamrong D, Jensen DM, Singh B, Kovacs TOG, Han SH, Durazo F, Saab S, Gornbein JA. Capsule endoscopy is not as accurate as esophagogastroduodenoscopy in screening cirrhotic patients for varices. Clin Gastroenterol Hepatol 2012; 10:254-8.e1. [PMID: 22155754 DOI: 10.1016/j.cgh.2011.11.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Revised: 10/20/2011] [Accepted: 11/12/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophagogastroduodenoscopy (EGD) is the standard technique for screening cirrhotic patients for high-risk varices and other significant upper gastrointestinal lesions (HRVLs). We investigated whether esophageal capsule endoscopy (ECE) is as convenient and accurate as EGD for the detection of HRVLs. METHODS We analyzed data from 65 cirrhotic patients without prior upper gastrointestinal bleeding who were examined for varices and HRVLs by ECE and EGD (both procedures were performed on the same day). EGD was performed by 2 physicians (75% of patients were unsedated) who used standard grading for esophageal and gastric varices, portal hypertensive gastropathy, and HRVLs. Coded capsule tracings were read by 2 investigators, blinded to the EGD findings, using standard grading. RESULTS The median procedure time for EGD (with or without biopsy collection) was 3 minutes, compared with 20 minutes for ECE. The overall accuracy for diagnosis of esophageal varices was 63.2% ± 5.9%; for detection of esophageal varices red marks was 68.8% ± 5.4%; and for diagnosis of other HRVLs was 51.5% ± 4.2%. The interobserver agreement in the diagnosis of esophageal varices was 90.8%; in the detection of esophageal varices red marks was 86.2%; and in the diagnosis of other HRVLs was 7.3%. CONCLUSIONS ECE is not as accurate as EGD in the diagnosis of esophageal varices and red markings or in grading esophageal varices. Moreover, ECE had poor accuracy in grading portal hypertensive gastropathy and detecting ulcers, gastric varices, and other significant upper gastrointestinal lesions. It took significantly longer to perform ECE and interpret the results than for EGD. These findings do not support ECE as a preferred tool for screening esophageal varices and HRVLs.
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Affiliation(s)
- Disaya Chavalitdhamrong
- Center for Ulcer Research and Education Digestive Diseases Research Center, Los Angeles, California 90073-1003, USA.
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Influence of operator experience and reporting time on the accuracy of esophageal capsule endoscopy screening for varices. Gastroenterol Nurs 2012; 34:303-11. [PMID: 21814064 DOI: 10.1097/sga.0b013e31822489b1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Conflicting data exist concerning the accuracy of esophageal capsule endoscopy (ECE) for the screening of varices. No study has examined the influence of operator factors on the accuracy of ECE reporting. The primary aims of this study were, therefore, to examine how operator experience with esophagogastroduodenoscopy (EGD) and operator reporting times of capsule videos influenced test accuracy. Twelve cirrhotic patients presenting for EGD had same-day ECE performed. The gold standard for variceal grade was determined using a panel of experienced endoscopists. Six novice capsule endoscopists, blinded to results of EGD, subsequently reported capsule videos for each of the 12 patients.Novice capsule endoscopists accurately identified high-risk varices. The mean area under the receiver operating characteristic curve for identifying high-risk varices for the six operators was 0.88 ±/-0.14. The mean sensitivity, specificity, positive, and negative predictive values for identifying high-risk varices for the six operators were 83%, 93%, 82%, and 97%, respectively. Years of prior EGD experience were not associated with accuracy of capsule reporting (OR = 0.9, 95% CI [0.74, 1.08]; p = .26). Time spent reporting capsule videos was associated with accuracy of capsule reporting for high-risk varices using British Society of Gastroenterology criteria (OR = 1.33, 95% CI [1.05, 1.08]; p = .018). Novice capsule endoscopists are able to accurately identify high-risk esophageal varices. Time taken to report capsule videos, but not amount of prior EGD experience, influenced capsule report accuracy. These findings may have implications for the design of further trials and the cost-effectiveness of ECE screening of varices.
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Abstract
Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This approach places a heavy burden upon endoscopy units and the repeated testing over time may have a detrimental effect on patient compliance. Noninvasive identification of patients at highest risk for oesophageal varices would limit investigation to those most likely to benefit. Upper GI endoscopy is deemed to be the gold standard against which all other tests are compared, but is not without its limitations. Multiple studies have been performed assessing clinical signs and variables relating to liver function, variables relating to liver fibrosis, and also to portal hypertension and hypersplenism. Whilst some tests are clearly preferable to patients, none appear to be as accurate as upper GI endoscopy in the diagnosis of oesophageal varices. The search for noninvasive tests continues.
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Esophageal Capsule Endoscopy for Screening Esophageal Varices among Japanese Patients with Liver Cirrhosis. Gastroenterol Res Pract 2011; 2012:946169. [PMID: 22190914 PMCID: PMC3235577 DOI: 10.1155/2012/946169] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 09/07/2011] [Accepted: 09/12/2011] [Indexed: 12/16/2022] Open
Abstract
Purpose. Although esophageal capsule endoscopy (ECE) is reportedly useful in the diagnosis of esophageal varices (EV), few reports have described the benefits of this technique in Asian countries. The present paper evaluates the usefulness of ECE for diagnosing EV in Japanese patients with cirrhosis.
Methods. We examined 29 patients with cirrhosis (20 males and 9 females; mean age 60 years; Child-Pugh classification A/B/C; 14/14/1) using ECE followed by esophagogastroduodenoscopy (EGD). High-risk EV were defined as F2 and/or RC2 and above. Results. The sensitivity and specificity of ECE for the diagnosis of high-risk EV were 92% and 80%, respectively. Conclusions. The findings showed that ECE is a highly sensitive method of diagnosing high-risk EV that requires endoscopic or pharmacological therapy. Thus, ECE might be a useful method for the screening and followup of EV in patients with cirrhosis.
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Abstract
Care of the liver transplant candidate is one of the most challenging, yet rewarding aspects of hepatology. Anticipation and intervention for the major complications of advanced liver disease increase the likelihood of survival until transplant.
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Affiliation(s)
- Hui-Hui Tan
- Department of Gastroenterology & Hepatology, Singapore General Hospital.
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Thabut D, Moreau R, Lebrec D. Noninvasive assessment of portal hypertension in patients with cirrhosis. Hepatology 2011; 53:683-94. [PMID: 21274889 DOI: 10.1002/hep.24129] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Severe portal hypertension is responsible for complications and death. Although measurement of the hepatic venous pressure gradient is the most accurate method for evaluating the presence and severity of portal hypertension, this technique is considered invasive and is not routinely performed in all centers. Several noninvasive techniques have been proposed to measure portal hypertension. Certain methods evaluate elements related to the pathogenesis of portal hypertension through the measurement of hyperkinetic syndrome, for example, or they investigate the development of hepatic fibrosis through the measurement of increased intrahepatic vascular resistance. Other methods evaluate the clinical consequences of portal hypertension, such as the presence of esophageal varices or the development of portosystemic shunts. Methods evaluating increased hepatic vascular resistance are fairly accurate and mainly involve the detection of hepatic fibrosis by serum markers and transient elastography. The radiological assessment of hyperkinetic syndrome probably has value but is still under investigation. The assessment of severe portal hypertension by the presence of varices may be performed with simple tools such as biological assays, computed tomography, and esophageal capsules. More sophisticated procedures seem promising but are still under development. Screening tools for large populations must be simple, whereas more complicated procedures could help in the follow-up of already diagnosed patients. Although most of these noninvasive methods effectively identify severe portal hypertension, methods for diagnosing moderate portal hypertension need to be developed; this shows that further investigation is needed in this field.
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Affiliation(s)
- Dominique Thabut
- Institut National de la Santé et de la Recherche Médicale Unité 773, Centre de Recherche Biomédicale Bichat-Beaujon, Paris, France
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Defining the threshold: new data on the ability of capsule endoscopy to discriminate the size of esophageal varices. Dig Dis Sci 2011; 56:220-6. [PMID: 20490679 DOI: 10.1007/s10620-010-1272-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 04/27/2010] [Indexed: 01/07/2023]
Abstract
BACKGROUND Endoscopy (esophagogastroduodenoscopy, EGD) to screen for esophageal varices (EV) is recommended in patients with portal hypertension. Reports indicate that capsule endoscopy (CE) is capable of identifying large/medium varices (L/MV) when the varix comprises more than 25% of the circumference of the field of view. AIMS We evaluated the ability of CE to discriminate the size of EV using this grading scale. METHODS Patients underwent CE and EGD on the same day. A blinded investigator interpreted capsule findings. CE labeled EV as L/MV if ≥25% of the lumen circumference was occupied, and small/none for <25%. RESULTS A total of 37 patients were enrolled in this prospective, observational study at a single tertiary-care academic center. Three CE were excluded due to rapid esophageal transit time or technical malfunction. Using a 25% threshold, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EC to discriminate L/MV were 23.5%, 88.2%, 66.7%, and 53.6%, respectively (κ=0.12). Reducing the threshold to 12.5% resulted in sensitivity, specificity, PPV, and NPV of 88.2%, 64.7%, 71.4%, and 84.6%, respectively (κ=0.53). A receiver-operator characteristic (ROC) curve showed a 15% threshold to be optimal in discriminating EV size using CE, resulting in sensitivity, specificity, PPV, and NPV of 76.5%, 82.4%, 81.3%, and 77.8%, respectively (κ=0.59). CONCLUSIONS This study indicates that discriminating EV size by the current capsule scale is unreliable. Lowering the grading threshold improved the ability to discriminate EV size by CE. In the proper context, CE is an alternative to EGD to screen for EV.
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Rondonotti E, Villa F, Dell' Era A, Tontini GE, de Franchis R. Capsule endoscopy in portal hypertension. Clin Liver Dis 2010; 14:209-20. [PMID: 20682230 DOI: 10.1016/j.cld.2010.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Since the introduction of small bowel capsule endoscopy, and more recently of esophageal capsule endoscopy, these diagnostic tools have become available for the evaluation of the consequences of portal hypertension in the esophagus, stomach, and small intestine. The main advantage of the esophageal and the small bowel capsule is the relatively less invasiveness that could potentially increase patients' adherence to endoscopic screening/surveillance programs. When esophageal capsule endoscopy was compared with traditional gastroscopy, it showed good sensitivity and specificity in recognizing the presence and the size of esophageal varices. However, the results are not consistent among studies, and more data are needed.
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Affiliation(s)
- Emanuele Rondonotti
- Università degli Studi di Milano, IRCCS Ca' Granda Ospedale Policlinico Foundation, Italy
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Coelho-Prabhu N, Kamath PS. Current staging and diagnosis of gastroesophageal varices. Clin Liver Dis 2010; 14:195-208. [PMID: 20682229 DOI: 10.1016/j.cld.2010.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Portal hypertension is defined as an increase in hepatic sinusoidal pressure to 6 mm Hg or higher. Cirrhosis is the most common cause of portal hypertension in the western world and results from increased resistance to blood flow at the hepatic sinusoidal level.
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Ganc RL, Malheiros CA, Nakakubo S, Szutan LA, Ganc AJ. Small-bowel lesions caused by portal hypertension of schistosomal origin: a capsule endoscopy pilot study. Gastrointest Endosc 2010; 71:861-6. [PMID: 20363433 DOI: 10.1016/j.gie.2009.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 12/08/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Schistosomiasis is a highly prevalent disease. It can evolve to its hepatosplenic form in up to 10% of the cases. The small-bowel lesions developed during the hepatosplenic stage of the disease have not been described in vivo. OBJECTIVE The aim of this study was to describe, for the first time, in a pilot study, the endoscopic aspects of the lesions in the small bowel of patients with portal hypertension due to schistosomiasis, using the PillCam SB, and to determine the usefulness of the method for the diagnosis of esophageal varices. DESIGN Case series. SETTING Tertiary-care medical center. PATIENTS Nine nonrandomized patients with hepatosplenic schistosomiasis and esophageal varices without previous GI bleeding were selected based on findings from the PillCam SB. Patients using medications that could alter the coagulation, with history of abdominal surgery, who were undergoing treatment of the portal hypertension other than beta-blocker, and with symptoms suggesting bowel obstruction were excluded. The findings were interpreted by a single endoscopist. RESULTS Capsule endoscopy was able to diagnose esophageal varices in all 9 patients. All of the patients presented angioectasias and venectasias in the small bowel. Small-bowel varices were present in 22.2% of the patients; edema and erosions were found in 66.7% and 88.9%, respectively. Lesions of so-called "scarred mucosa" were found in 55.5% of the patients. LIMITATIONS Small number of patients; case series. CONCLUSION The PillCam SB was effective, giving a significant contribution to the description of the esophageal varices and small-bowel lesions of the patients with portal hypertension caused by Schistosoma mansoni.
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Affiliation(s)
- Ricardo L Ganc
- Department of Endoscopy, Santa Casa Faculty of Medicine, São Paulo, Brazil.
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PillCam ESO versus esophagogastroduodenoscopy in esophageal variceal screening: A decision analysis. J Clin Gastroenterol 2009; 43:975-81. [PMID: 19661814 DOI: 10.1097/mcg.0b013e3181a7ed09] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES PillCam ESO has been evaluated as a possible strategy to screen patients with cirrhosis for esophageal varices, but current guidelines recommend patients undergo screening with esophagogastroduodenoscopy (EGD), as it is currently the gold standard. Although recent data have suggested that PillCam ESO may be an acceptable alternative for screening, there is limited data on its cost-effectiveness compared with other screening modalities. This study was performed to compare the cost-effectiveness of PillCam ESO versus EGD for esophageal variceal screening. METHODS Markov models were constructed to compare 2 screening strategies: PillCam ESO versus EGD. In each arm, patients were followed for a time horizon of 15 years in 1-year transition intervals. All variables, transition probabilities, and costs were derived from the medical literature, and sensitivity analyses were performed on the different variables in the model. RESULTS Base-case analysis shows that PillCam ESO is associated with an average expected cost of $22,589 and an average expected effectiveness measure of 12.81 life-years. EGD is associated with an average expected cost of $23,083 and an average expected effectiveness measure of 12.67 life-years. PillCam ESO was found to dominate EGD as a screening strategy for patients with cirrhosis. Sensitivity analyses found several variables within the model to have influential effects on the results. CONCLUSIONS PillCam ESO is the dominant strategy for screening patients with cirrhosis for esophageal varices. However, based on a small difference in costs and effectiveness between each strategy, the results would suggest that PillCam ESO and EGD are essentially equivalent strategies.
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Abstract
The advent of video capsule endoscopy (VCE) in 2000 has dramatically changed the diagnosis and management of many diseases of the small intestine. In this review we discuss the procedure, the various indications and contraindications, adverse effects, and future prospects of VCE. VCE has a significant role in the diagnosis of obscure gastrointestinal hemorrhage and Crohn's disease and has the highest diagnostic yield in comparison to other diagnostic modalities. Furthermore, VCE has gained an important role in the management and surveillance of suspected small bowel tumors and in patients with polyposis syndromes. Capsule enteroscopy may have a role in the work-up of symptomatic celiac disease and in the assessment of drug therapeutic efficacy and adverse small bowel effects. Although VCE is relatively non-invasive, it is contraindicated in patients with swallowing disorders, known or suspected gastrointestinal obstruction, strictures, or fistulas, and in patients with implanted electromedical devices. Other contraindications include pregnancy and children under 10. Capsule retention is the most feared complication of VCE with a frequency of 1%-2%. Risk factors and management of capsule retention are also discussed. It is probable that new indications for VCE will evolve and technological improvements will refine VCE's diagnostic accuracy and simplify video reviewing.
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Affiliation(s)
- Matti Waterman
- Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel
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Vizzutti F, Arena U, Rega L, Pinzani M. Non invasive diagnosis of portal hypertension in cirrhotic patients. ACTA ACUST UNITED AC 2009; 32:80-7. [PMID: 18973850 DOI: 10.1016/s0399-8320(08)73997-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The measure of disease progression in chronic liver disease represents a key challenge in any of the different stages of evolution. Indeed, a correct and reliable measure of the stage of the disease has relevant implications for assessing the effectiveness of the current therapeutic regimens and for predicting the occurrence of complication. Accordingly, a current major effort is directed at evaluating methodologies characterized by no or low invasiveness to be employed as clinical discriminators in patients populations potentially requiring invasive assessment. This appears particularly relevant in patients with compensated cirrhosis, where the only reference standard is the measurement of portal pressure by hepatic venous pressure gradient (HVPG). In this particular context, transient elastography (TE) appears to be promising and needs to be further investigated, possibly in combination with other non-invasive methodologies such as serum markers algorithms and/or imaging techniques. On the other hand, the application of non-invasive methods for monitoring the response to vasoactive treatment for the reduction of portal pressure and the prevention of related complications seems at the moment not realistic.
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Affiliation(s)
- F Vizzutti
- Dipartimento di Medicina Interna, Università degli, Studi di Firenze - Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
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Sacher-Huvelin S, Bourreille A, Le Rhun M, Galmiche JP. [Future prospects in digestive endoscopy: wireless capsule endoscopy]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2009; 33:747-757. [PMID: 19679416 DOI: 10.1016/j.gcb.2009.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Since the beginning of the millennium, the development of wireless capsule endoscopy has represented a major technological advance. The capsule is ingested by the patient and images are transmitted via several sensors positioned on the skin of the patient and downloaded in a computer system. The first applications were focused on the exploration of the small bowel which was previously considered as an obscure area for conventional endoscopy. Wireless capsule endoscopy of the small bowel is now an established technique with many acknowledged indications for the diagnosis of obscure bleeding, anemia of presumed digestive origin, Crohn's disease and small bowel tumors. Recently, thanks to technological progresses, novel capsules have been developed for specific segments of the gut namely the oesophagus and the colon. Recent data suggest that these new capsules could have potential applications for the diagnosis of oesophageal varices, Barrett's oesophagus and for the screening and/or surveillance of polyps of the colon. However, further studies are required before such strategies could be approved for clinical use or even replace conventional endoscopic modalities. In the long-term, progresses in signal processing as well as in the miniaturisation of sensors or markers may lead to a new generation of endoscopic robots. This technological breakthrough may ultimately result in new concepts and change current practice of digestive endoscopy.
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Affiliation(s)
- S Sacher-Huvelin
- Institut des Maladies de l'Appareil Digestif, CIC-Inserm, Hôtel-Dieu, CHU de Nantes, Université de Nantes, 44093 Nantes cedex, France
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Hale W. Esophageal capsule endoscopy: the string is the thing. Gastrointest Endosc 2009; 70:210-1. [PMID: 19631800 DOI: 10.1016/j.gie.2008.12.057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2008] [Accepted: 12/10/2008] [Indexed: 01/14/2023]
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