Surveillance of small intestinal abnormalities in patients with hepatocellular carcinoma: a prospective capsule endoscopy study

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.

Utility of endoscopic ultrasound and endoscopy in diagnosis and management of hepatocellular carcinoma and its complications: What does endoscopic ultrasonography offer above and beyond conventional cross-sectional imaging?

Hepatocellular carcinoma constitutes over 90% of the primary liver tumors, the rest being cholangiocarcinoma. It has an insidious presentation, which is responsible for the delayed presentation. Hence, the management strategy relies on screening to diagnose it an early stage for curative resection and/or treatment with local ablative techniques or chemotherapy. However, even with different screening programs, more than 60% of tumors are still detected at an advanced stage, leading to an unchanged mortality rate, thereby implying a room for improvement in the screening and diagnostic process. In the last few years, there has been evolution of utility of endoscopy, specifically endoscopic ultrasonography along with Fine needle aspiration, for this purpose, which we comprehensively review in this article.

Clinical Practice Guideline for Enteroscopy

Management of small bowel diseases has evolved since the advent of capsule endoscopy (CE) and balloon-assisted enteroscopy (BAE). One of the most common indications for enteroscopy is obscure gastrointestinal bleeding (OGIB), followed by small bowel stenosis, tumors, and inflammatory bowel disease. Although enteroscopes have been regarded as useful tools, correct guidelines are required to ensure that we manipulate these enteroscopes safely and efficiently in clinical practice. Herein, the Japanese Gastroenterological Endoscopy Society has developed 'Clinical Practice Guidelines for Enteroscopy' in collaboration with the Japanese Society of Gastroenterology, the Japanese Gastroenterological Association, and the Japanese Association for Capsule Endoscopy. These guidelines are based on the evidence available until now, but small bowel endoscopy is a relatively new technology, so the guidelines include recommendations based on a consensus reached among experts when the evidence has not been considered sufficient. These guidelines were not designed to be disease-based, but focus on how we should use small bowel CE and BAE in everyday clinical practice.

Impact of serum ferritin level on hepatocarcinogenesis in chronic hepatitis C patients

AIM

To elucidate the impact of the serum ferritin level, a surrogate indicator of hepatic iron accumulation, on hepatocarcinogenesis in chronic hepatitis C patients.

METHODS

Serum ferritin was measured in 487 chronic hepatitis C patients without history of hepatocellular carcinoma (HCC) after excluding patients in phlebotomy, those with overt chronic gastrointestinal bleeding and those who achieved sustained virological response before enrollment. Patients were divided into four groups (G1-G4) by quartile points of serum ferritin, with sexes separated.

RESULTS

The serum ferritin level was positively correlated with total bilirubin, aspartate aminotransferase, alanine aminotransferase (ALT), γ-glutamyltransferase, hemoglobin and AFP, and inversely correlated with prothrombin activity in both sexes. A significant difference in HCC incidence was observed only in male patients; the incidence was higher in G1 (≤80 ng/mL, n = 54) and G4 (≥323 ng/mL, n = 54) compared with that of G2 (81-160 ng/mL, n = 54) and G3 (161-322 ng/mL, n = 52). The spline curve indicating the relationship between the hazard ratio and serum ferritin level took the form of a J-shape for male patients. In multivariate analysis, G1 and G4 showed higher incidence of HCC among men with a hazard ratio of 2.19 (95% confidence interval, 1.02-4.70; P = 0.045) compared with G2 and G3, together with older age, lower serum albumin and ALT above the normal upper limit.

CONCLUSION

The serum ferritin level is an independent risk factor for HCC development in male patients with chronic hepatitis C when the level is extremely high or low.

Risk factors for small bowel angioectasia: The impact of visceral fat accumulation

AIM: To investigate visceral fat accumulation in association with the risk of small bowel angioectasia.

METHODS: We retrospectively investigated 198 consecutive patients who underwent both capsule endoscopy and CT for investigation of obscure gastrointestinal bleeding (OGIB) from January 2009 to September 2013. The visceral fat area (VFA) and subcutaneous fat area were measured by CT, and information on comorbidities, body mass index, and medications was obtained from their medical records. Logistic regression analysis was used to evaluate associations.

RESULTS: Capsule endoscopy revealed small bowel angioectasia in 18/198 (9.1%) patients with OGIB. Compared to patients without small bowel angioectasia, those with small bowel angioectasia had a significantly higher VFA (96 ± 76.0 cm²vs 63.4 ± 51.5 cm², P = 0.016) and a higher prevalence of liver cirrhosis (61% vs 22%, P < 0.001). The proportion of patients with chronic renal failure was higher in patients with small bowel angioectasia (22% vs 9%, P = 0.11). There were no significant differences in subcutaneous fat area or waist circumference. The prevalence of small bowel angioectasia progressively increased according to the VFA. Multivariate analysis showed that the VFA [odd ratio (OR) for each 10-cm² increment = 1.1; [95% confidence interval (CI): 1.02-1.19; P = 0.021] and liver cirrhosis (OR = 6.1, 95%CI: 2.2-18.5; P < 0.001) were significant risk factors for small bowel angioectasia.

CONCLUSION: VFA is positively associated with the prevalence of small bowel angioectasia, for which VFA and liver cirrhosis are independent risk factors in patients with OGIB.

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.

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.

Percutaneous transhepatic sclerotherapy for recurrent bleeding ileal varices diagnosed by capsule endoscopy and computed tomography during percutaneous transhepatic venography

We report a case of acute uncontrolled gastrointestinal bleeding in a patient with liver cirrhosis. A 64-year-old man was admitted to our hospital for further investigation of blood in stools. Preliminary examination by computed tomography (CT) as well as upper and lower endoscopy could not detect the bleeding source. Exploratory laparotomy was considered difficult due to potential easy bleeding and adhesions caused by past abdominal surgery. The hemoglobin level was normalized by blood transfusion. Capsule endoscopy (CE) identified ileal varices. The top of these ileal varices was red, prompting their identification as the source of bleeding. Percutaneous transhepatic venography (PTV) confirmed the presence of many varices in the branch of the superior mesenteric vein, although the bleeding source could not be identified. CT during PTV identified varices protruding into the ileal lumen, which were managed subsequently by percutaneous transhepatic sclerotherapy (PTS). The procedure stopped the bleeding completely. CE proved less invasive and effective in detecting obscure gastrointestinal bleeding. CT during PTV followed by PTS is suitable for diagnosis and treatment of bleeding varices in patients with portal hypertension.