Introduction

Esophageal variceal (EV) bleeding is a severe complication of portal hypertension with significant morbidity and mortality. Guidelines for the American Association for the Study of Liver Diseases (AASLD) currently recommend endogastroduodenoscopy (EGD) at the time of diagnosis of cirrhosis. Traditionally, screening and grading of EV is performed by EGD. However, EGD is an invasive procedure and not risk-free; it is mostly performed using intravenous conscious sedation increasing its risks by adding the effects of sedative drugs in the cirrhotic population. Wired magnetic-assisted capsule endoscopy (MACE) uses a wire-connected capsule steerable by an external magnet and allows examination of the upper GI tract. However, its potential usefulness in diagnosing esophageal varices in patients with liver cirrhosis has not been assessed.

Aims & Methods

Method: We prospectively enrolled patients with cirrhosis and indications to receive EGD for screening or surveillance for esophageal varices. A wired MACE study was performed followed by an EGD which was performed by one experienced endoscopist within 6 hours. Capsule videos were assessed by two investigator who were blinded to the patients’ medical history and EGD findings. The diagnostic yield of wired MACE and EGD were compared. Patients’ tolerance and acceptance of wired MACE and EGD were also assessed.

Results

Thirty-two patients were included for analysis (mean age: 64 years, range: 41-83 years; 59.4% male); the clinical characteristics of enrolled patients were listed in Table1 and only 6 patients (18.8%) received sedated EGD. The mean examination time of wired MACE and EGD (including time of endoscopic variceal ligation) was 7.9 mins and 10.9 mins respectively. The combined sensitivity, specificity and accuracy of diagnosing EV by wire-MACE was 92.1% [95% confidence interval(CI): 78.6-98.3%], 88.5% (95% CI: 69.9-97.6%) and 90.6% (95% CI: 80.7-96.5%) respectively with good interobserver agreement (kappa=0.87). The combined sensitivity, specificity and accuracy of predicting the need for endoscopic variceal ligation (EVL) by wire-MACE was 70.0% (95% CI: 34.8-93.3%), 94.4% (95% CI: 84.6-98.8%) and 90.6% (95% CI: 80.7-96.5%) respectively with moderate interobserver agreement (kappa=0.54). Wired MACE has lower scores of discomfort (2.1 vs 4.4, p < 0.0001) and better scores of acceptance (4.2 vs 3.2, p <0.01) than that of EGD.

Conclusion

Wired MACE has good accuracy in diagnosing EV and predicting the need of prophylactic EVL; moreover, it has less discomfort and better acceptance than EGD.

References

Garcia-Tsao, G., et al., Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Am J Gastroenterol, 2007. 102(9): p. 2086-102.
2.Stipho, S., et al., String capsule endoscopy for screening and surveillance of esophageal varices in patients with cirrhosis. J Interv Gastroenterol, 2012. 2(2): p. 54-60.
3.Sacher-Huvelin, S., et al., Screening of esophageal varices by esophageal capsule endoscopy: results of a French multicenter prospective study. Endoscopy, 2015. 47(6): p. 486-92.
4.Ishiguro, H., et al., Esophageal Capsule Endoscopy for Screening Esophageal Varices among Japanese Patients with Liver Cirrhosis. Gastroenterol Res Pract, 2012. 2012: p. 946169.
5.Chavalitdhamrong, D., et al., Capsule endoscopy is not as accurate as esophagogastroduodenoscopy in screening cirrhotic patients for varices. Clin Gastroenterol Hepatol, 2012. 10(3): p. 254-8.e1.
6.McCarty, T.R., Y. Afinogenova, and B. Njei, 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(2): p. 174-182.

Introduction

Erosive esophagitis (EE) is a clinically significant manifestation of gastroesophageal reflux disease (GERD), characterized by endoscopically visible mucosal breaks due to chronic gastric acid exposure. EE increases the risk of complications such as Barrett’s esophagus and esophageal adenocarcinoma. Although esophagogastroduodenoscopy (EGD) remains the diagnostic gold standard, it is invasive and often requires sedation. Wired magnetic-assisted capsule endoscopy (MACE) is a novel, minimally invasive technique using a magnetically navigable capsule tethered via a soft wire, enabling upper gastrointestinal tract examination. However, its diagnostic value for EE remains underexplored.

Aims & Methods

From February 2021 to November 2024, 85 patients underwent wired MACE followed by EGD within six hours at National Taiwan University Hospital. Indications included acute upper gastrointestinal bleeding (n=30), esophageal varices screening (n=33), and pre-bariatric surgery assessment (n=22). Diagnostic accuracy of wired MACE for EE was assessed using EGD as the reference. Patient-reported discomfort (0–10 scale) and acceptance (0–5 scale) were compared between the two modalities.

Results

The mean age was 57.8 years (SD 15.2; range 23–83), with 62.4% male. EGD was performed without sedation in 92.9% of cases. Wired MACE showed a sensitivity of 86.4% (95% CI: 76.2–97.0%), specificity of 82.9% (95% CI: 71.4–94.0%), PPV of 84.4%, NPV of 85.0%, and overall accuracy of 84.7%. Agreement with EGD was substantial (κ = 0.69). MACE was associated with lower mean discomfort scores (1.9 vs. 5.5, p < 0.0001) and higher acceptance scores (4.2 vs. 2.3, p < 0.01), indicating superior tolerability.

Conclusion

Wired MACE demonstrated high diagnostic accuracy and substantial agreement with EGD in detecting EE. Its significantly lower discomfort and higher patient acceptance support its potential as a less invasive, better-tolerated diagnostic alternative to conventional endoscopy.

References

Sharma, P., et al., The Diagnostic Accuracy of Esophageal Capsule Endoscopy in Patients With Gastroesophageal Reflux Disease and Barrett's Esophagus: A Blinded, Prospective Study. Official journal of the American College of Gastroenterology | ACG, 2008. 103(3): p. 525-532.
Lien, G.S., et al., Feasibility and safety of a novel magnetic-assisted capsule endoscope system in a preliminary examination for upper gastrointestinal tract. Surg Endosc, 2018. 32(4): p. 1937-1944.

Clinical Case Summary

An 82-year-old man with Child B alcoholic cirrhosis, complicated by portal hypertension, underwent surveillance upper digestive endoscopy (UDE), revealing large esophageal varices and a 20 mm exophytic lesion, 40 cm from the dental arch, with an infiltrative and ulcerated appearance. Biopsies were inconclusive. Endoscopic ultrasound identified a heterogeneous, amorphous lesion with poorly defined borders and disruption of all wall layers, complicated by numerous large varices, preventing biopsy due to hemorrhagic risk. Computed tomography revealed parietal thickening in the distal esophagus and multiple varices, complicating lesion delineation. An oncology consultation recommended clinical surveillance, considering the patient's age, comorbidities, indeterminate nature of the esophageal lesion, and low suspicion for adenocarcinoma on ultrasound. One year later, surveillance UDE showed regression of the lesion.Histological samples were reviewed, revealing changes consistent with pyogenic granuloma. Pyogenic granuloma is a rapidly growing capillary hemangioma that may occur within the lumen of a pre-existing vessel (intravascular variant). The case is supported by appropriate iconography.

This case is presented with imaging, highlighting the challenge due to the macroscopic appearance suggestive of a neoplastic lesion and the pyogenic granuloma's growth within esophageal varices, limiting diagnostic and therapeutic management.

References

Introduction

Variceal bleeding is a common and life-threatening complication of liver cirrhosis, with endoscopic therapy being an important treatment modality [1]. There are several endoscopic techniques available for the management of variceal bleeding, including band ligation, sclerotherapy, tissue adhesives, and endoscopic ultrasound-guided variceal obturation (EUS-VO) [2].

Aims & Methods

This meta-analysis aimed to compare the efficacy and safety of different endoscopic modalities for the prevention and management of variceal bleeding in patients with liver cirrhosis. A systematic literature search was conducted in several databases, including PubMed, Embase, and Cochrane Library, from inception to September 2022. Randomized controlled trials, cohort studies, and case-control studies that compared different endoscopic modalities for the management of variceal bleeding in patients with liver cirrhosis were included. The primary outcomes of interest were initial hemostasis rates, rebleeding rates, and adverse events.

Results

A total of 15 studies (n = 1,742) met the inclusion criteria and were included in the meta-analysis. The pooled results showed that band ligation was associated with lower rebleeding rates compared to sclerotherapy (OR 0.59, 95% CI 0.44-0.79, p = 0.001), while sclerotherapy was associated with a higher risk of adverse events (OR 3.21, 95% CI 1.69-6.11, p < 0.001). Tissue adhesives, such as N-butyl-2-cyanoacrylate, were associated with higher initial hemostasis rates compared to other endoscopic therapies (OR 1.82, 95% CI 1.30-2.55, p = 0.001) and lower rebleeding rates (OR 0.39, 95% CI 0.20-0.77, p = 0.006). EUS-VO was associated with higher initial hemostasis rates (OR 1.93, 95% CI 1.08-3.43, p = 0.027) and lower rebleeding rates (OR 0.43, 95% CI 0.26-0.71, p = 0.001) compared to traditional endoscopic therapies.

Conclusion

Our meta-analysis suggests that band ligation and tissue adhesives may be superior to sclerotherapy for the prevention and management of variceal bleeding in patients with liver cirrhosis. EUS-VO may be a promising alternative to traditional endoscopic therapies, although further studies are needed to confirm its efficacy and safety. The choice of endoscopic technique should be individualized based on patient factors and physician expertise.

References

1-Tang L, Li X, Cui J, Huang LY. EUS-guided coil placement and cyanoacrylate glue injection for gastric variceal bleeding with obvious spontaneous portosystemic shunts. Endosc Ultrasound. 2023 Jan-Feb;12(1):84-89. doi: 10.4103/EUS-D-22-00006. PMID: 36510864.
2-Huang Z, Zhang W, Lv F, Ma L, Xiao Y, Gao S, Zhang M, Wang Y, Li P, Zhao H, Yu H, Cao J, Ke G, Wang Y, Chen M. Efficacy and safety of EUS-guided coil embolization combined with endoscopic cyanoacrylate injection versus balloon-occluded retrograde transvenous obliteration for gastric varices with high-risk ectopic embolism: A multicenter and retrospective cohort study. Endosc Ultrasound. 2023 Jan-Feb;12(1):74-83. doi: 10.4103/EUS-D-21-00260. PMID: 36510863.

Introduction

Varices are present in 30-40 % of patients with compensated cirrhosis (Child-Pugh class A). Although screening endoscopy for esophageal varices(O.V.) is recommended to all patients with cirrhosis, this recommendation is not a result of evidence-based data. We studied the association of (platelet count/spleen diameter ratio, insulin resistance and splenoportal index) and the presence of O.V. in patients with compensated cirrhosis.

Aims & Methods

124 patients with compensated liver cirrhosis due to chronic hepatitis C virus were studied. After clinical, laboratory ultrasound examinations, all patients underwent screening endoscopy and O.V were reported as present or absent. According to presence or absence of varices; two groups were described: group I without varicesand group II with varices.

Results

Among 124 patients with mean age of (51.81±12.94), 2 groups were described: group I (30 patients) and group II (94 patients) with a male majority (20 patients in group I and 66 patients in group II). In group I and group II: the mean platelet count/spleen diameter ratio was (1022.6±73.36, 608.76±58.44) respectively, the mean insulin resistance value was (2.426±0.618, 3.081±0.474) respectively. The mean splenoportalindex (SPI) value was (2.878±0.870, 6.349±0.514) respectively.For platelet count/spleen diameter ratio and SPI, the sensitivity was (95.7%), specificity (83.3%) and accuracy (92.7%). For platelet count/spleen diameter ratio andinsulin resistance(IR), the sensitivity was (70.2%), specificity (86.7%) and accuracy (74.1%). For IR and SPI, the sensitivity was (70.2%), specificity (76.7%) and accuracy (71.7%).For the three predictors combined, the sensitivity was (78.7%), specificity (82.2%) and accuracy (79.5%).

Table (1) shows the sensitivity, specificity, positive predictive value, negative predictive value and accuracy when we combine (Platelet count /spleen diameter ratio & Splenoportal index), (Platelet count /spleen diameter ratio & IR) and (IR& Splenoportal index).

Conclusion

Low platelet count/spleen ratio and high SPI are very useful non invasive predictors for the presence of O.V. that could be used either separately or combined to decrease the number of upper GIT endoscopies needed in cirrhotic patients management, However, IR as a non invasive predictor is still in need for further evaluation.

References

Berzigotti A, Gilabert R, Abraldes JG, Nicolau C, Bru C, Bosch J, et al. Noninvasive prediction of clinically
significant portal hypertension and esophageal varices in patients with compensated liver cirrhosis. Am J
Gastroenterol 2008; 103:1159-67.
Bolondi L, Zironi G, Gaiani S, Li Bassi S, Benzi G, Barbara L. Caliber of splenic and hepatic arteries and spleen size in cirrhosis of different etiology. Liver 1991; 11:198– 205.
Bressler B, Pinto R, El-Ashry D, Heathcote EJ. Which patients with primary biliary cirrhosis or primary sclerosing
cholangitis should undergo endoscopic screening for oesophageal varices detection? Gut 2005; 54:407-10.
Camma` C, Petta S, Vito Di Marco, Fabrizio Bronte, Stefania Ciminnisi, Giusalba Licata, Sergio Peralta, Fabio
Simone, Giulio Marchesini, and Antonio Crax. Insulin Resistance Is a Risk Factor for Esophageal Varices in Hepatitis C
Virus Cirrhosis. Hepatology 2009; 49:195- 203.

Introduction

Endoscopic ultrasound (EUS) and positron emission tomography (PET) have been widely recognized as valuable imaging modalities for tumor-node-metastasis (TNM) staging and treatment decision-making in patients with esophageal cancer. However, the accuracy of EUS and PET in esophageal cancer patients following neoadjuvant concurrent chemoradiotherapy (CCRT) remains inconsistent. Our objective was to conduct a comparative study between EUS and PET to evaluate their accuracy in staging post-CCRT patients who underwent resection surgery and were diagnosed with tumor complete remission.

Aims & Methods

The subjects of this study comprised patients diagnosed with esophageal squamous cell carcinoma and treated with CCRT before surgery at National Taiwan University Hospital (NTUH). Data were collected from May 1, 2007, to May 31, 2022, from a database of 828 esophageal cancer patients who underwent both EUS and PET before and after CCRT, and subsequently underwent resection surgery with pathologically complete response, resulting in a total of 231 patients. After excluding 14 patients who did not receive CCRT, 217 patients were enrolled for further study. The analysis focused on the T and N stages of esophageal cancer as reported by EUS and PET before and after CCRT, correlating clinical stages with pathologic stages. Using pathological diagnosis as the criterion standard, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of EUS and PET were calculated. Patients who did not receive EUS or PET before CCRT and those who did not receive EUS or PET after CCRT (n=87) were excluded, resulting in a final inclusion of 128 cases for analysis.

Results

Among the 128 recruited patients, the overall accuracy of EUS for T-stage was 6.3%, while PET exhibited an accuracy of 13.3%. For N-stage, the accuracy of EUS was 20.3%, whereas PET demonstrated an accuracy of 33.6%.

Conclusion

In post-CCRT esophageal patients who achieved complete pathological remission, PET exhibited superior accuracy compared to EUS for both T and N staging; however, neither modality attained satisfactory levels of accuracy.

References

• 1. Yen, T. J., et al. (2012). "Comparative study between endoscopic ultrasonography and positron emission tomography-computed tomography in staging patients with esophageal squamous cell carcinoma." Dis Esophagus 25(1): 40-47
• 2. Ajani, J. A., et al. (2019). "Esophageal and Esophagogastric Junction Cancers, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology." Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 17(7): 855-883.
• 3. Rice, T. W., et al. (2017). "8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction: application to clinical practice." Ann Cardiothorac Surg 6(2): 119-130.