Is portal hypertensive enteropathy an important additional cause of blood loss in portal hypertensive patients?

Diagnostic accuracy of magnetically guided capsule endoscopy with a detachable string for detecting oesophagogastric varices in adults with cirrhosis: prospective multicentre study

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.

The Role of Video Capsule Endoscopy in Liver Disease

In the setting of chronic liver disease, capsule endoscopy is safe and well tolerated, making it an appealing diagnostic procedure. It is used mainly for the surveillance of esophageal varices, investigation of anemia, and exploration of the small bowel for complications of portal hypertension. Capsule endoscopy is recognized as a viable alternative in patients unable or unwilling to undergo upper gastrointestinal endoscopy for investigations of esophageal varices. In evaluating the small bowel of patients with liver disease and unexplained anemia, capsule endoscopy increases recognition of mucosal abnormalities, although their clinical significance is often unclear.

Small-bowel mucosal changes in Egyptian cirrhotic patients with portal hypertension using capsule endoscopy versus single-balloon enteroscopy

Background

Small-bowel mucosal abnormalities that may occur secondary to portal hypertension in patients with liver cirrhosis have an impact on health and quality of life. In spite of the importance of these changes, little is known about the frequency and features of small-bowel changes in cirrhotic patients with portal hypertension. Eighty cirrhotic patients with or without esophageal or gastric varices were recruited in this study as well as 60 age- and sex-matched controls. All study participants underwent capsule endoscopy. In addition, half of the patients and controls were randomized to receive single-balloon enteroscopy.

Results

The prevalence of small-bowel mucosal changes was statistically significantly higher in cirrhotic patients than in controls; 57% versus 6.7%, respectively (p < 0.05). Cirrhotic patients with portal hypertensive gastropathy showed a significant increase in the small-bowel changes (p < 0.001). Small-bowel changes were significantly higher in patients with higher MELD and Child-Pugh scores (p < 0.001). Moreover, capsule endoscopy was more effective in the detection of small-bowel changes than single-balloon enteroscopy.

Conclusions

Mucosal changes associated with portal hypertensive enteropathy are more prevalent in cirrhotic patients, regardless of the presence or absence of gastric varices. Small-bowel mucosal changes in patients with portal hypertensive enteropathy were more common in patients who suffered from portal hypertensive gastropathy and were positively correlated with advanced chronic liver disease.

Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study

BACKGROUND/AIMS

The clinical course and exacerbation of portal hypertensive enteropathy (PHE) are yet to be fully clarified. This study aimed to identify factors related to PHE exacerbation in patients with liver cirrhosis (LC).

METHODS

Fifty patients with LC (33 male; mean age, 67 years), who underwent capsule endoscopy (CE) at the Hiroshima University Hospital between February 2009 and September 2015, were followed up for >6 months. Exacerbation is defined as the appearance of new lesions or worsening of existing lesions. The association between PHE exacerbation and the clinical factors was evaluated.

RESULTS

PHE exacerbation was identified in 24 out of 50 (48%) of cases: erythema (14 cases); angioectasia (11 cases); erosions (9 cases); villous edema (8 cases); and esophageal varices (EVs; 6 cases). The following factors were significantly associated with PHE exacerbation: portosystemic shunts, EVs and portal hypertensive gastropathy (PHG) exacerbation. After therapy, CE findings among the 24 cases were as follows: villous edema (19 cases); erythema (17 cases); angioectasia (16 cases); erosions (12 cases); and EVs (9 cases), and no observable abnormalities in 2 cases. On multivariate analysis, exacerbation of EVs and PHG were independent predictors of PHE exacerbation.

CONCLUSION

EVs and PHG exacerbation may predict PHE exacerbation in patients with LC.

Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System

BACKGROUND/AIMS

To evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system.

METHODS

Consecutive patients with PH presenting with unexplained anemia and/or occult gastrointestinal bleeding were evaluated using the PillCam SB3 CE system. Abnormal findings were categorized as vascular or non-vascular. The patients with ongoing bleeding caused by PHE were treated. The correlation of the CE scores of PHE with the clinical, laboratory, and endoscopic features was determined.

RESULTS

Of the 43 patients included in the study, 41 (95.3%) showed PHE findings. These included varices (67.4%), red spots (60.5%), erythema (44.2%), villous edema (46.5%), telangiectasia (16.3%), and polyps (16.3%). The CE scores varied from 0 to 8 (mean±standard deviation, 4.09±1.8). Five patients (11.6%) showed evidence of ongoing or recent bleeding due to PHE. Three of these five patients underwent endotherapy, and one patient underwent radiological coil placement.

CONCLUSION

The PillCam SB3 CE system revealed a high prevalence of PHE in the patients with PH. Using this system, evidence of bleeding due to PHE was found in a small but definite proportion of the patients.

Clinical significance of small-bowel villous edema in patients with liver cirrhosis: A capsule endoscopy study

BACKGROUND AND AIM

The relationship between the presence of villous edema (VE) in portal hypertensive enteropathy and clinical factors remains unclear. The aim of this study was to reveal the clinical factors related to VE in patients with liver cirrhosis (LC), and investigate the clinical significance of VE.

METHODS

Between February 2009 and September 2016, 363 consecutive patients with LC underwent capsule endoscopy for diagnosing portal hypertensive enteropathy at Hiroshima University Hospital. We evaluated the relationship between the presence of VE and patients' clinical characteristics, findings of esophagogastroduodenoscopy and computed tomography, and survival time.

RESULTS

Villous edema was observed in 131 patients (36%), and severe lesions were found in 71 (20%). The presence of VE was significantly greater in patients with Child-Pugh classification B or C, esophageal varices, portal hypertensive gastropathy (PHG), ascites, portal vein thrombosis (PVT), and splenomegaly. In multivariate analysis, Child-Pugh class B or C, esophageal varices, PVT, and splenomegaly were significant predictive factors for the presence of VE. Severe VE was significantly greater in patients with Child-Pugh class B or C, serum albumin level ≤ 3.2 mg/dL, PHG, and PVT. In multivariate analysis, PHG, Child-Pugh class B or C, PVT, were significant predictive factors for severe VE.

CONCLUSIONS

Clinical factors related to portal hypertension were significantly correlated with VE. In particular PVT was correlated with the appearance and exacerbation of VE. Periodic capsule endoscopy in LC patients may lead to early detection of portal hypertension and PVT.

Diagnostic and therapeutic features of small bowel involvement in portal hypertension

Enteropathy is a lesser known complication of portal hypertension and consists of different changes in the mucosal layer of the small bowel which lead to the appearance of vascular and inflammatory lesions. It can be an important co-factor in the development of anemia in the cirrhotic population, and nowadays an easy and non-invasive diagnosis can be made thanks to capsule endoscopy. However, it is rarely considered in the management of patients with portal hypertension. Some aspects such as pathogenesis or incidence remain unclear and no specific recommendations are included in the guidelines regarding diagnosis or treatment. A review of the available literature was performed with regards to the most relevant aspects of this entity.

Re-bleeding events in patients with small intestinal vascular malformation: Risk factors and effect of treatment with thalidomide

AIM

To investigate the risk factors for re-bleeding events in patients with small intestinal vascular malformation and assess the influence of thalidomide on the re-bleeding rate.

METHODS

This study involved patients with gastrointestinal bleeding referred to the First Affiliated Hospital of Zhengzhou University for capsule endoscopy (CE) and enteroscopy between January 2012 and December 2014. Only patients with small intestinal vascular malformation were included in the study. Follow-up data were obtained through medical records review, telephone interviews or follow-up clinic visits to identify the risk factors associated with re-bleeding. Based on the follow-up data, the re-bleeding rate was compared between patients who had been treated with thalidomide and those who had not.

RESULTS

A total of 156 patients were included in the study, and all of them completed the follow-up, with a mean follow-up duration of 10.78 ± 7.64 mo. Multiple regression analysis identified that presence of hypertension (HR = 1.994, 95%CI: 1.236-3.125, P = 0.005), multiple lesions (≥3) (HR = 1.644, 95%CI: 1.002-2.703, P = 0.049) and liver cirrhosis (HR = 2.116, 95%CI: 1.063-4.212, P = 0.033) were significant independent predictors of re-bleeding, while treatment with thalidomide was a protecting factor (HR = 0.497, 95%CI: 0.303-0.816, P = 0.006). The cumulative re-bleeding rates in patients who were treated with thalidomide and those who were not were 35.71% and 54.65%, respectively, and the difference reached statistical significance (P < 0.05).

CONCLUSION

The re-bleeding rate in patients with small bowel vascular malformation is relatively high, especially those with hypertension, multiple lesions (≥3) and liver cirrhosis. Repeated CE or enteroscopy is recommended for those patients with risk factors for re-bleeding within 2 years. Treatment with thalidomide for patients without contraindication can reduce the re-bleeding rate.

Small bowel capsule endoscopy and portal hypertensive enteropathy in cirrhotic patients: results from a tertiary referral centre

BACKGROUND AND RATIONALE

Portal hypertensive enteropathy (PHE) remains difficult to diagnose in patients with cirrhosis and portal hypertension. Limited test choices exist for the inspection of the small bowel in these patients. Small bowel capsule endoscopy (SBCE) is ideal in this situation but rarely performed. We aimed to determine the prevalence of PHE using SBCE in a cirrhotic patient population and correlate its presence with clinical and CT imaging findings.

MATERIAL AND METHODS

We retrospectively analysed data from cirrhotic patients who underwent SBCE at our unit. Studies were evaluated for the presence of cirrhosis-related findings in the oesophagus, stomach and small-bowel. The relationships between PHE and patients' clinical characteristics were evaluated.

RESULTS

53 patients with cirrhosis underwent SCBE. We used PillCam®SB on 36 patients and MiroCam® capsule on 17. Thirty patients were referred for iron deficiency anaemia, 15 for obscure gastrointestinal bleeding, and 4 for other indications. Four data sets were not available for review, leaving 49 patients. Mean age was 61.19 ± 14.54 years (M/F = 27/22). Six SBCE examinations were incomplete. Thirty three patients had evidence of portal hypertensive gastropathy (PHG) and 17 had evidence of oesophageal varices. In total, 29 patients had SCBE evidence of PHE (57%). 28/29 (96.5%) patients with PHE had also evidence of PHG. 13/17 (76.4%) patients with oesophageal varices had also evidence of PHE.

CONCLUSIONS

The prevalence of PHE in our study was 57%. SBCE is a useful tool in evaluating PHE in cirrhotic patients irrespective of aetiology.

Association between fatty liver and small intestinal mucosal lesions

AIM: To assess the association between fatty liver and small intestinal mucosal lesions.

METHODS: After obtaining approval from the ethical review committee of the First Affiliated Hospital of Guangdong Pharmaceutical University, from August 2011 to August 2015, patients who were excluded as having cancer or primary intestinal disease and NSAID takers were divided into a fatty liver group (case group) and a group without liver disease (control group). Intestinal lesions were detected by capsule endoscopy, and the correlation of capsule endoscopy scoring index with fatty liver index was analyzed.

RESULTS: Of 350 individuals, 60 diagnosed with fatty liver by CT or B ultrasound were included in the case group, and 290 without liver diseases were included in the control group. The incidence of small bowel mucosal lesions and the Lewis score in the case group were significantly higher than those in the control group (75.0% vs 33.8%, P < 0.001; 121.00 ± 178.51 vs 61.08 ± 144.10, P = 0.005). In fatty liver patients, the incidence rates of small intestinal edema in the upper, middle and lower third were 7.1%, 15.7%, and 4.3% (P < 0.001), respectively, and the incidence rates of small intestinal ulcers were 2.0%, 2.6%, and 3.4% (P = 0.498), respectively. Liver noninvasive NAFLD-FS score was positively correlated with the small intestinal mucosa damage score (r = 0.108, P = 0.043). Insulin resistance index was positively correlated with small intestinal damage score (r = 0.162, P = 0.034).

CONCLUSION: Fatty liver disease may be related to the small intestine lesions, and triglycerides may be an important factor. Most lesions are located in the proximal or middle small bowel.

Capsule Endoscopy for Portal Hypertensive Enteropathy

Portal hypertensive enteropathy (PHE) is a mucosal abnormality of the small bowel that is observed in patients with portal hypertension (PH) and can lead to gastrointestinal bleeding and anemia. The pathogenesis is still not completely understood. The introduction of new endoscopic methods, including capsule endoscopy (CE) or balloon-assisted enteroscopy, has increased the detection of these abnormalities. CE can also serve as a road map for deciding subsequent interventions and evaluating the treatment effect. The prevalence of PHE is reportedly 40-70% in patients with PH. Endoscopic findings can be roughly divided into vascular and nonvascular lesions such as inflammatory-like lesions. Traditionally, PHE-associated factors include large esophageal varices, portal hypertensive gastropathy or colopathy, Child-Turcotte-Pugh class B or C, a history of variceal treatment, and acute gastrointestinal bleeding. More recently, on using scoring systems, a high computed tomography or transient elastography score was reportedly PHE-related factors. However, the prevalence of PHE and its related associated factors remain controversial. The management of PHE has not yet been standardized. It should be individualized according to each patient's situation, the availability of therapy, and each institutional expertise.

Major predictors and management of small-bowel angioectasia

Background

Small-bowel angioectasias are frequently diagnosed with capsule endoscopy (CE) or balloon endoscopy however, major predictors have not been defined and the indications for endoscopic treatment have not been standardized. The aim of this study was to evaluate the predictors and management of small-bowel angioectasia.

Methods

Among patients with obscure gastrointestinal bleeding (OGIB) who underwent both CE and double-balloon endoscopy at our institution, we enrolled 64 patients with small-bowel angioectasia (angioectasia group) and 97 patients without small-bowel angioectasia (non-angioectasia group). The angioectasia group was subdivided into patients with type 1a angioectasia (35 cases) and type 1b angioectasia (29 cases) according to the Yano-Yamamoto classification. Patient characteristics, treatment, and outcomes were evaluated.

Results

Age (P = 0.001), cardiovascular disease (P = 0.002), and liver cirrhosis (P = 0.003) were identified as significant predictors of small-bowel angioectasia. Multivariate logistic regression analysis identified cardiovascular disease (odds ratio 2.86; 95 % confidence interval, 1.35–6.18) and liver cirrhosis (odds ratio 4.81; 95 % confidence interval, 1.79–14.5) as independent predictors of small-bowel angioectasia. Eleven type 1a cases without oozing were treated conservatively, and 24 type 1a cases with oozing were treated with polidocanol injection (PDI). Re-bleeding occurred in two type 1a cases (6 %). Seventeen type 1b cases were treated with PDI and 12 type 1b cases were treated with PDI combined with argon plasma coagulation (APC) or clipping. Re-bleeding occurred in five type 1b cases (17 %) that resolved after additional endoscopic hemostasis in all cases. There was one adverse event from endoscopic treatment (1.6 %).

Conclusions

Cardiovascular disease and liver cirrhosis were significant independent major predictors of small-bowel angioectasia. Type 1a angioectasias with oozing are indicated for PDI and type 1b angioectasias are indicated for PDI with APC or clipping.

Portal hypertensive enteropathy

Portal hypertensive enteropathy (PHE) is a condition that describes the pathologic changes and mucosal abnormalities observed in the small intestine of patients with portal hypertension. This entity is being increasingly recognized and better understood over the past decade due to increased accessibility of the small intestine made possible by the introduction of video capsule endoscopy and deep enteroscopy. Though challenged by its diverse endoscopic appearance, multiple scoring systems have been proposed to classify the endoscopic presentation and grade its severity. Endoscopic findings can be broadly categorized into vascular and non-vascular lesions with many subtypes of both categories. Clinical manifestations of PHE can range from asymptomatic incidental findings to fatal gastrointestinal hemorrhage. Classic endoscopic findings in the setting of portal hypertension may lead to a prompt diagnosis. Occasionally histopathology and cross sectional imaging like computed tomography or magnetic resonance imaging may be helpful in establishing a diagnosis. Management of overt bleeding requires multidisciplinary approach involving hepatologists, endoscopists, surgeons, and interventional radiologists. Adequate resuscitation, reduction of portal pressure, and endoscopic therapeutic intervention remain the main principles of the initial treatment. This article reviews the existing evidence on PHE with emphasis on its classification, diagnosis, clinical manifestations, endoscopic appearance, pathological findings, and clinical management. A new schematic management of ectopic variceal bleed is also proposed.

Major predictors of portal hypertensive enteropathy in patients with liver cirrhosis

BACKGROUND AND AIM

Portal hypertensive enteropathy (PHE) is acknowledged as a source of bleeding, and predicting its presence has become more important. We assessed PHE using capsule endoscopy (CE) and investigated factors that may predict its presence, including portosystemic shunts (PSs).

METHODS

We analyzed data from 134 consecutive patients with liver cirrhosis, from February 2009 to September 2013. All patients had undergone dynamic computed tomography and esophagogastroduodenoscopy before CE examination. The frequencies and types of PHE lesions, and the relationships between the presence of PHE and patients' clinical characteristics were evaluated. The distribution of the lesions was also determined.

RESULTS

PHE was found in 91 (68%), erythema in 70 (52%), erosions in 25 (19%), angioectasia in 24 (18%), villous edema in 18 (13%), and varices in 10 (7%) patients. Most lesions were located in the jejunum. The clinical characteristics associated with the presence of PHE were a Child-Pugh grade of B or C (P = 0.0058), and the presence of PSs (P < 0.0001), ascites (P = 0.0017), portal thrombosis (P = 0.016), esophageal varices (P = 0.0017), and portal hypertensive gastropathy (P = 0.0029). The presence of PSs was an independent predictor of PHE (odds ratio [OR]: 3.15; 95% confidence interval [CI]: 1.27-7.95). Among the shunt types, left gastric vein (OR: 5.31; 95% CI: 1.97-17.0) and splenorenal shunts (OR: 4.26; 95% CI: 1.29-19.4) were independent predictors of PHE.

CONCLUSION

PSs, especially left gastric vein and splenorenal shunts, appear to reliably predict the presence of PHE.

Portal hypertensive enteropathy diagnosed by capsule endoscopy in cirrhotic patients: a nationwide multicenter study

BACKGROUND AND AIM

Due to the limited data on portal hypertensive enteropathy (PHE), the prevalence of and clinical factors related to PHE remain unclear. This study determined the prevalence of PHE using capsule endoscopy (CE) and PHE-related clinical factors.

METHODS

This was a retrospective multicenter study using the Capsule Endoscopy Nationwide Database Registry. From 2,879 cases that underwent CE, 45 cirrhosis patients with portal hypertension (PH) were enrolled and divided into PHE (n = 18) and non-PHE (n = 27) groups. From computed tomography (CT) images, six secondary changes due to PH were scored to give a total CT score of 0-6. The main outcome variable was the prevalence of PHE and PHE-related clinical factors.

RESULTS

The prevalence of PHE was 40 %. Comparing the PHE and non-PHE groups, the most common findings were angiodysplasias in 55.7 % (vs. 7.4 %, p = 0.001) and varices in 38.9 % (vs. 0 %, p = 0.001). Active bleeding was observed in 16.6 and 3.7 %, respectively, but this difference was not significant. In the univariate analysis, Child-Turcotte-Pugh class C (p = 0.002) and a high CT score (≥3 vs. <3, p = 0.004) were significantly associated with PHE. However, only a high CT score was significant in the multivariate analysis (odds ratio 11.19; 95 % confidence interval, 1.59-infinity; p = 0.040).

CONCLUSIONS

The prevalence of PHE was 40 %, and it might be more prevalent in cirrhosis patients with PH who have a high CT score. CE is a useful diagnostic tool for evaluating PHE in cirrhosis patients with PH.

Is small-bowel capsule endoscopy effective for diagnosis of esophagogastric lesions related to portal hypertension?

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.

Small bowel abnormalities in patients with compensated liver cirrhosis

BACKGROUND

Although capsule endoscopy is available as a minimally invasive imaging technique that contributes significantly to the detection of small bowel lesions, there are only a very few published descriptions of small bowel abnormalities in patients with portal hypertension.

AIMS

The aim of this study was to characterize the occurrence of small bowel lesions by means of capsule endoscopy in patients with portal hypertension, particularly those with compensated liver cirrhosis and associated anemia.

METHODS

Sixty consecutive patients who met our criteria underwent capsule endoscopy. The frequency, type, and distribution of small bowel lesions were determined, and clinical factors associated with the lesions were examined.

RESULTS

Small bowel abnormalities were found in 40 patients (67 %), including erythema (n = 32, 53 %), erosion (n = 10, 17 %), angioectasia (n = 9, 15 %), varices (n = 4, 7 %), and villous edema (n = 4, 7 %). Most lesions were located in the proximal or middle small bowel. Factors associated with the lesions were Child-Pugh class B (vs. class A, P = 0.0023), ascites (vs. no ascites, P = 0.0085), and portal hypertensive gastropathy (vs. no portal hypertensive gastropathy, P = 0.0434).

CONCLUSIONS

We found capsule endoscopy to be a useful diagnostic modality for detecting clinically significant small bowel lesions in patients with compensated liver cirrhosis. Based on our results, we suggest that this procedure should be especially considered for patients with Child-Pugh class B disease, ascites, and/or portal hypertensive gastropathy if they show evidence of gastrointestinal blood loss and/or iron-deficiency anemia.

Effects of transjugular intrahepatic portosystemic shunt on changes in the small bowel mucosa of cirrhotic patients with portal hypertension

BACKGROUND

The introduction of capsule endoscopy (CE) has facilitated the detection of mucosal changes in the small bowel, and such mucosal changes have been noted in cirrhotic patients with portal hypertension; these changes are described as portal hypertensive enteropathy. The aim of this study was to assess the effects of transjugular intrahepatic portosystemic shunt (TIPS) on the small bowel mucosal changes detected by CE in cirrhotic patients with portal hypertension.

METHODS

TIPS was performed in fifteen cirrhotic patients with portal hypertension. All patients underwent CE before and 2 weeks after TIPS. The small bowel mucosal changes were defined as edema, angiodysplasia-like lesions, red spots, and small bowel varices. Changes in the portosystemic pressure gradient (PSG) and CE findings were evaluated.

RESULTS

Before TIPS, small bowel edema was detected in all 15 patients, angiodysplasia-like lesions in 7, and red spots in 14 patients. The PSG decreased significantly, from 21.2 ± 2.6 before TIPS to 8.9 ± 3.3 mmHg (p < 0.001) after the procedure. After TIPS, the small bowel edema was attenuated in 8 of the 15 patients. In two patients with angiodysplasia-like lesions and 4 with red spots, these lesions were attenuated after TIPS. The average score for small bowel edema and the grade of red spots were reduced significantly after TIPS (2.3 ± 0.7-1.8 ± 0.6, p < 0.005 and 1.6 ± 0.9-1.3 ± 0.7, p < 0.05, respectively). Small bowel varices were seen in 4 patients before TIPS and all these varices disappeared after TIPS.

CONCLUSIONS

In cirrhotic patients with portal hypertension, small bowel edema, red spots, and small bowel varices were attenuated after TIPS. Portal hypertension may be an important factor in the development of small bowel mucosal changes.

Mesocaval shunt for portal hypertensive small bowel bleeding documented with intraoperative enteroscopy

INTRODUCTION

Besides upper gastrointestinal tract, small bowel has also been implicated as a potential source of hemorrhage in patients with portal hypertension.

PRESENTATION OF CASE

We report an interesting case of recurrent massive small intestinal bleeding in a patient with portal hypertension secondary to liver cirrhosis treated with a mesocaval shunt. Endoscopic assessment with gastroscopy and colonoscopy failed to identify the source of hemorrhage. An intraoperative enteroscopy was conducted which revealed a diffuse bleeding pattern from the small bowel mucosa.

DISCUSSION

An interposition mesocaval shunt procedure was successfully carried out on an emergency basis that eventually managed to control bleeding.

CONCLUSION

In cases, where a diffuse pattern of hemorrhage exist or non-operative measures fail emergency mesocaval shunting seems to be an efficacious alternative treatment approach for portal hypertension related intestinal bleeding.