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Comparison of esophageal capsule endoscopy and esophagogastroduodenoscopy for diagnosis of esophageal varices  [cached]
Catherine T Frenette, John G Kuldau, Donald J Hillebrand, Jill Lane, Paul J Pockros
World Journal of Gastroenterology , 2008,
Abstract: AIM: To investigate the utility of esophageal capsule endoscopy in the diagnosis and grading of esophageal varices.METHODS: Cirrhotic patients who were undergoing esophagogastroduodenoscopy (EGD) for variceal screening or surveillance underwent capsule endoscopy. Two separate blinded investigators read each capsule endoscopy for the following results: variceal grade, need for treatment with variceal banding or prophylaxis with beta-blocker therapy, degree of portal hypertensive gastropathy, and gastric varices.RESULTS: Fifty patients underwent both capsule and EGD. Forty-eight patients had both procedures on the same day, and 2 patients had capsule endoscopy within 72 h of EGD. The accuracy of capsule endoscopy to decide on the need for prophylaxis was 74%, with sensitivity of 63% and specificity of 82%. Inter-rater agreement was moderate (kappa = 0.56). Agreement between EGD and capsule endoscopy on grade of varices was 0.53 (moderate). Inter-rater reliability was good (kappa = 0.77). In diagnosis of portal hypertensive gastropathy, accuracy was 57%, with sensitivity of 96% and specificity of 17%. Two patients had gastric varices seen on EGD, one of which was seen on capsule endoscopy. There were no complications from capsule endoscopy.CONCLUSION: We conclude that capsule endoscopy has a limited role in deciding which patients would benefit from EGD with banding or beta-blocker therapy. More data is needed to assess accuracy for staging esophageal varices, PHG, and the detection of gastric varices.
Towards Noninvasive Detection of Oesophageal Varices  [PDF]
Kara Rye,Robert Scott,Gerri Mortimore,Adam Lawson,Andrew Austin,Jan Freeman
International Journal of Hepatology , 2012, DOI: 10.1155/2012/343591
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.
Meta-analysis of capsule endoscopy in patients diagnosed or suspected with esophageal varices  [cached]
Daniel Ahn, Praveen Guturu
World Journal of Gastroenterology , 2010,
Abstract: The PillCam ESO (Given Imaging, Israel) or esophageal capsule endoscopy (ECE) is a novel technique used in the diagnostic evaluation of esophagus. Many studies have been performed to compare the accuracy of ECE against the current gold standard esophago-gastro-duodenoscopy and a meta-analysis recently published by Lu et al suggests that ECE may have an acceptable sensitivity and specificity in detecting esophageal varices. We would like to discuss the importance and implication of publication bias in this meta-analysis.
Meta-analysis of capsule endoscopy in patients diagnosed or suspected with esophageal varices  [cached]
Yi Lu, Rui Gao, Zhuan Liao, Liang-Hao Hu, Zhao-Shen Li
World Journal of Gastroenterology , 2009,
Abstract: AIM: To review the literature on capsule endoscopy (CE) for detecting esophageal varices using conventional esophagogastroduodenoscopy (EGD) as the standard.METHODS: A strict literature search of studies comparing the yield of CE and EGD in patients diagnosed or suspected as having esophageal varices was conducted by both computer search and manual search. Data were extracted to estimate the pooled diagnostic sensitivity and specificity.RESULTS: There were seven studies appropriate for meta-analysis in our study, involving 446 patients. The pooled sensitivity and specificity of CE for detecting esophageal varices were 85.8% and 80.5%, respectively. In subgroup analysis, the pooled sensitivity and specificity were 82.7% and 54.8% in screened patients, and 87.3% and 84.7% in the screened/patients under surveillance, respectively.CONCLUSION: CE appears to have acceptable sensitivity and specificity in detecting esophageal varices. However, data are insufficient to determine the accurate diagnostic value of CE in the screen/surveillance of patients alone.
Towards Noninvasive Detection of Oesophageal Varices  [PDF]
Kara Rye,Robert Scott,Gerri Mortimore,Adam Lawson,Andrew Austin,Jan Freeman
International Journal of Hepatology , 2012, DOI: 10.1155/2012/343591
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. 1. Introduction Cirrhosis is the end stage of every chronic liver disease, resulting in formation of fibrous tissue, disorganization of liver architecture, and nodule formation, which interferes with liver function and results in portal hypertension. Portal hypertension is associated with development of a hyperdynamic circulation and complications such as ascites, hepatic encephalopathy, and oesophago-gastric varices. Patients with cirrhosis and gastro-oesophageal varices have a hepatic venous pressure gradient during haemodynamic catheterization of at least 10–12?mmHg [1]. Oesophageal varices are present at diagnosis in approximately 50% of cirrhotic patients, being more common in Child-Pugh class C patients compared to Child-Pugh class A patients (85% versus 40%) [1, 2]. De novo formation of varices occurs at a rate of 5% per year, with a higher incidence in patients continuing to consume alcohol or with worsening liver function [2]. Once varices form, they enlarge from small to large at a rate of 5–12% per year [2] and bleed at a rate of 5–15% per year. The greatest bleeding risk is seen in large varices classified as being >5?mm diameter and is also influenced by liver disease severity as assessed by Child-Pugh score, and by the presence of red wale markings on varices at endoscopy. Therefore, these factors should also be taken into consideration to classify “high-risk varices” [3]. Reports from the 1940’s to the 1980’s demonstrate poor outcomes from variceal bleeding with mortality rates between 30–60% [4–6], but studies suggest that the outcomes have improved
Three benefits of microcatheters for retrograde transvenous obliteration of gastric varices
Tetsuo Sonomura,Wataru Ono,Morio Sato,Shinya Sahara
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i12.1373
Abstract: AIM: To evaluate the usefulness of the microcatheter techniques in balloon-occluded retrograde transvenous obliteration (BRTO) of gastric varices. METHODS: Fifty-six patients with gastric varices underwent BRTOs using microcatheters. A balloon catheter was inserted into gastrorenal or gastrocaval shunts. A microcatheter was navigated close to the varices, and sclerosant was injected into the varices through the microcatheter during balloon occlusion. The next morning, thrombosis of the varices was evaluated by contrast enhanced computed tomography (CE-CT). In patients with incomplete thrombosis of the varices, a second BRTO was performed the following day. Patients were followed up with CE-CT and endoscopy. RESULTS: In all 56 patients, sclerosant was selectively injected through the microcatheter close to the varices. In 9 patients, microcoil embolization of collateral veins was performed using a microcatheter. In 12 patients with incomplete thrombosis of the varices, additional injection of sclerosant was performed through the microcatheter that remained inserted overnight. Complete thrombosis of the varices was achieved in 51 of 56 patients, and the remaining 5 patients showed incomplete thrombosis of the varices. No recurrence of the varices was found in the successful 51 patients after a median follow up time of 10.5 mo. We experienced one case of liver necrosis, and the other complications were transient. CONCLUSION: The microcatheter techniques are very effective methods for achieving a higher success rate of BRTO procedures.
Human thrombin for the treatment of gastric and ectopic varices  [cached]
Norma C McAvoy,John N Plevris,Peter C Hayes
World Journal of Gastroenterology , 2012, DOI: 10.3748/wjg.v18.i41.5912
Abstract: AIM: To evaluate the efficacy of human thrombin in the treatment of bleeding gastric and ectopic varices. METHODS: Retrospective observational study in a Tertiary Referral Centre. Between January 1999-October 2005, we identified 37 patients who were endoscopically treated with human thrombin injection therapy for bleeding gastric and ectopic varices. Patient details including age, gender and aetiology of liver disease/segmental portal hypertension were documented. The thrombin was obtained from the Scottish National Blood Transfusion Service and prepared to give a solution of 250 IU/mL which was injected via a standard injection needle. All patient case notes were reviewed and the total dose of thrombin given along with the number of endoscopy sessions was recorded. Initial haemostasis rates, rebleeding rates and mortality were catalogued along with the incidence of any immediate complications which could be attributable to the thrombin therapy. The duration of follow up was also listed. The study was conducted according to the United Kingdom research ethics guidelines. RESULTS: Thirty-seven patients were included. 33 patients (89%) had thrombin (250 U/mL) for gastric varices, 2 (5.4%) for duodenal varices, 1 for rectal varices and 1 for gastric and rectal varices. (1) Gastric varices, an average of 15.2 mL of thrombin was used per patient. Re-bleeding occurred in 4 patients (10.8%), managed in 2 by a transjugular intrahepatic portosystemic shunt (TIPSS) (one unsuccessfully who died) and in other 2 by a distal splenorenal shunt; (2) Duodenal varices (or type 2 isolated gastric varices), an average of 12.5 mL was used per patient over 2-3 endoscopy sessions. Re-bleeding occurred in one patient, which was treated by TIPSS; and (3) Rectal varices, an average of 18.3 mL was used per patient over 3 endoscopy sessions. No re-bleeding occurred in this group. CONCLUSION: Human thrombin is a safe, easy to use and effective therapeutic option to control haemorrhage from gastric and ectopic varices.
Non-invasive predictors of esophageal varices  [cached]
Cherian Jijo,Deepak Nandan,Ponnusamy Rajesh,Somasundaram Aravindh
Saudi Journal of Gastroenterology , 2011,
Abstract: Background/Aim: Current guidelines recommend screening cirrhotic patients with an endoscopy to detect esophageal varices and to institute prophylactic measures in patients with large esophageal varices. In this study, we aimed at identifying non-endoscopic parameters that could predict the presence and grades of esophageal varices. Patients and Methods: In a prospective study, 229 newly diagnosed patients with liver cirrhosis, without a history of variceal bleeding, were included. Demographic, clinical, biochemical and ultrasonographic parameters were recorded. Esophageal varices were classified as small and large, at endoscopy. Univariate analysis and multivariate logistic regression analysis were done to identify independent predictors for the presence and grades of varices. Results: Of the 229 patients (141 males; median age 42 years; range 17-73 years) with liver cirrhosis, 97 (42.3%) had small and 81 (35.4%) had large varices. On multivariate analysis, low platelet count (Odd′s Ratio [OR], 4.3; 95% confidence interval [CI], 1.2-14.9), Child Pugh class B/C (OR, 3.3; 95% CI, 1.8-6.3), spleen diameter (OR, 4.3; 95% CI, 1.6-11.9) and portal vein diameter (OR, 2.4; 95% CI, 1.1-5.3) were independent predictors for the presence of varices. Likewise, for the presence of large esophageal varices, low platelet count (OR, 2.7; 95% CI, 1.4-5.2), Child Pugh class B/C (OR, 3.8; 95% CI, 2.3-6.5) and spleen diameter (OR, 3.1; 95% CI, 1.6-6.0) were the independent risk factors. Conclusion: The presence and higher grades of varices can be predicted by a low platelet count, Child-Pugh class B/C and spleen diameter. These may be considered as non-endoscopic predictors for the diagnosis and management of large grade varices.
Bleeding from gastric body varices effectively treated with endoscopic band ligation  [cached]
Sato T,Kitagawa S
International Medical Case Reports Journal , 2012,
Abstract: Takahiro Sato, Sho KitagawaDepartment of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, JapanAbstract: A 55-year-old man with alcoholic liver cirrhosis was admitted to hospital with tarry stools. Videoendoscopy examination on admission revealed blood oozing from the greater curvature of the gastric body (ectopic varices). Endoscopic ultrasonography and computed tomography were used in making the diagnosis. Endoscopic band ligation (EBL) was performed for the bleeding site of these varices. The patient experienced no further episodes of bleeding during the 6 months following treatment with EBL. EBL was very effective in treating the bleeding from gastric body varices.Keywords: ectopic varices, endoscopic band ligation, gastric body varices, portal hypertension
Serum type IV collagen level is predictive for esophageal varices in patients with severe alcoholic disease  [cached]
Satoshi Mamori, Yasuyuki Searashi, Masato Matsushima, Kenichi Hashimoto, Shinichiro Uetake, Hiroshi Matsudaira, Shuji Ito, Hisato Nakajima, Hisao Tajiri
World Journal of Gastroenterology , 2008,
Abstract: AIM: To determine factors predictive for esophageal varices in severe alcoholic disease (SAD).METHODS: Abdominal ultrasonography (US) was performed on 444 patients suffering from alcoholism. Forty-four patients found to have splenomegaly and/or withering of the right liver lobe were defined as those with SAD. SAD patients were examined by upper gastrointestinal (UGI) endoscopy for the presence of esophageal varices. The existence of esophageal varices was then related to clinical variables.RESULTS: Twenty-five patients (56.8%) had esophageal varices. A univariate analysis revealed a significant difference in age and type IV collagen levels between patients with and without esophageal varices. A logistic regression analysis identified type IV collagen as the only independent variable predictive for esophageal varices (P = 0.017). The area under the curve (AUC) for type IV collagen as determined by the receiver operating characteristic (ROC) for predicting esophageal varices was 0.78.CONCLUSION: This study suggests that the level of type IV collagen has a high diagnostic accuracy for the detection of esophageal varices in SAD.
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