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Hirata I, Tsuboi A, Matsubara Y, Sumioka A, Takasago T, Tanaka H, Yamashita K, Takigawa H, Kotachi T, Yuge R, Urabe Y, Oka S. Long-term outcomes of patients with obscure gastrointestinal bleeding after negative capsule endoscopy. J Gastroenterol Hepatol 2024; 39:165-171. [PMID: 37837361 DOI: 10.1111/jgh.16379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND AND AIM Although small-bowel capsule endoscopy (CE) is widely used for obscure gastrointestinal bleeding (OGIB), long-term outcomes for OGIB patients after negative CE remain unclear. Herein, we defined negative CE as P0 (no bleeding potential) or P1 (less likely to bleed), based on the P classification using CE. We aimed to clarify long-term outcomes of patients with OGIB after negative CE. METHODS This single-center observational study enrolled 461 consecutive patients with OGIB who underwent CE from March 2014 to October 2021 and were followed up for >1 year. We examined rebleeding rates and predictive factors. RESULTS Two hundred and twenty-four (49%) patients had P0, and 237 (51%) had P1 findings. Rebleeding occurred in 9% and 16% of patients in the P0 and P1 groups, respectively. Two patients in the P0 group and 15 in the P1 group showed rebleeding from the small bowel. The rate of small-bowel rebleeding was significantly lower in the P0 group than that in the P1 group (1% vs 6%, P = 0.002), as was the cumulative rebleeding rate (P = 0.004). In the multivariate analysis, history of endoscopic hemostasis (hazard ratio [HR] = 15.958, 95% confidence interval [CI]:4.950-51.447, P < 0.001) and P1 CE findings (HR = 9.989, 95% CI: 2.077-48.030, P = 0.004) were independently predicted small-bowel rebleeding. CONCLUSIONS OGIB with P0 CE findings rarely showed rebleeding from the small bowel. Rebleeding may occur in patients with OGIB. Patients with history of endoscopic hemostasis for small-bowel lesions or P1 CE findings should be followed up intensively.
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Affiliation(s)
- Issei Hirata
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuka Matsubara
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takeshi Takasago
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidenori Tanaka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ken Yamashita
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hidehiko Takigawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Takahiro Kotachi
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Ryo Yuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastrointestinal Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Hirata I, Tsuboi A, Oka S, Sumioka A, Iio S, Hiyama Y, Kotachi T, Yuge R, Hayashi R, Urabe Y, Tanaka S. Diagnostic yield of proximal jejunal lesions with third-generation capsule endoscopy. DEN OPEN 2022; 3:e134. [PMID: 35898830 PMCID: PMC9307735 DOI: 10.1002/deo2.134] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 05/13/2022] [Accepted: 05/15/2022] [Indexed: 12/09/2022]
Abstract
Objectives Capsule endoscopy (CE) has been shown to have poor diagnostic performance when the capsule passes quickly through the small bowel, especially the proximal jejunum. This study aimed to evaluate the diagnostic yield of proximal jejunal lesions with third-generation CE technology. Methods We retrospectively examined 138 consecutive patients, 76 (55.0%) of whom were men. The patients' median age was 70 years, and proximal jejunal lesions were detected by CE and/or double-balloon endoscopy at Hiroshima University Hospital between January 2011 and June 2021. We analyzed the diagnostic accuracy of CE for proximal jejunal lesions and compared the characteristics of the discrepancy between the use of CE and double-balloon endoscopy with Pillcam SB 2 (SB2) and Pillcam SB 3 (SB3). Results SB2 and SB3 were used in 48 (35%) and 90 (65%) patients, respectively. There was no difference in baseline characteristics between these groups. Small-bowel lesions in the proximal jejunum comprised 75 tumors (54%), 50 vascular lesions (36%), and 13 inflammatory lesions (9%). The diagnostic rate was significantly higher in the SB3 group than in the SB2 group for tumors (91% vs. 72%, p < 0.05) and vascular lesions (97% vs. 69%, p < 0.01). For vascular lesions, in particular, the diagnostic rate of angioectasia improved in the SB3 group (100%) compared with that in the SB2 group (69%). Conclusions SB3 use improved the detection of proximal jejunal tumors and vascular lesions compared with SB2 use.
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Affiliation(s)
- Issei Hirata
- Department of Gastroenterology and MetabolismHiroshima University HospitalHiroshimaJapan
| | - Akiyoshi Tsuboi
- Department of EndoscopyHiroshima University HospitalHiroshimaJapan
| | - Shiro Oka
- Department of Gastroenterology and MetabolismHiroshima University HospitalHiroshimaJapan
| | - Akihiko Sumioka
- Department of Gastroenterology and MetabolismHiroshima University HospitalHiroshimaJapan
| | - Sumio Iio
- Department of Gastroenterology and MetabolismHiroshima University HospitalHiroshimaJapan
| | - Yuichi Hiyama
- Department of Center for Integrated Medical ResearchHiroshima University HospitalHiroshimaJapan
| | - Takahiro Kotachi
- Department of EndoscopyHiroshima University HospitalHiroshimaJapan
| | - Ryo Yuge
- Department of EndoscopyHiroshima University HospitalHiroshimaJapan
| | - Ryohei Hayashi
- Department of EndoscopyHiroshima University HospitalHiroshimaJapan
| | - Yuji Urabe
- Division of Regeneration and Medicine Center for Translational and Clinical ResearchHiroshima University HospitalHiroshimaJapan
| | - Shinji Tanaka
- Department of EndoscopyHiroshima University HospitalHiroshimaJapan
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Abstract
PURPOSE OF REVIEW Gastroesophageal varices are common complications of chronic liver diseases (CLDs) and portal hypertension. Small varices have the risk of progressing to larger varices, causing bleeding or even death. Thus, early detection and appropriate management of small varices are necessary. The purpose of this review is to summarize the advance in the recent 5years about diagnosing and managing the small varices in CLDs. RECENT FINDINGS The diagnosing methods of small varices in recent studies include improved endoscopic examinations, such as capsule endoscopy, and many noninvasive methods, including blood tests, ultrasound, computed tomography and magnetic resonance. For the management of small varices, though it is controversial, prevention using nonselective beta-blockers is still an essential part. SUMMARY In this review, we summarize the classification of varices, the invasive and noninvasive diagnostic methods, their performances, and the emerging progression in the management of small varices in the recent 5 years. We hope that this review provides relevant information to understand better and appropriately manage small varices.
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Affiliation(s)
- Ying Zhu
- Department of Infectious Diseases, The First Affiliated Hospital of Dalian Medical University, Dalian
| | - Hui Cheng
- Department of Infectious Diseases, The First Affiliated Hospital of Dalian Medical University, Dalian
- Department of Gastroenterology, The Second Affiliated Hospital of Dalian Medical University, Dalian
| | - Jianyong Chen
- Department of Gastroenterology, Jiangxi Provincial People's Hospital, Nanchang
| | - Yifei Huang
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
| | - Hao Liu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xiaolong Qi
- CHESS Center, Institute of Portal Hypertension, The First Hospital of Lanzhou University, Lanzhou, China
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Enomoto M, Takaya H, Namisaki T, Fujinaga Y, Nishimura N, Sawada Y, Kaji K, Kawaratani H, Moriya K, Akahane T, Inoue T, Matsumoto M, Yoshiji H. Ratio of von Willebrand factor antigen to ADAMTS13 activity is a useful biomarker for acute-on-chronic liver failure development and prognosis in patients with liver cirrhosis. Hepatol Res 2022; 52:390-400. [PMID: 34964539 DOI: 10.1111/hepr.13743] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/06/2021] [Accepted: 12/26/2021] [Indexed: 01/21/2023]
Abstract
AIM Acute-on-chronic liver failure (ACLF) is associated with a high risk of short-term mortality after progression to multiple organ failure. A disintegrin-like and metalloproteinase with thrombospondin type-1 motifs 13 (ADAMTS13) is a metalloproteinase that specifically cleaves multimeric von Willebrand factor (VWF). An imbalance between ADAMTS13 enzyme and VWF substrate is associated with liver cirrhosis progression that induces ACLF. This study examined the relationship between ADAMTS13 and VWF and ACLF development to determine whether ADAMTS13 and VWF are useful predictive biomarkers for ACLF development and prognosis of patients with liver cirrhosis. METHODS The study enrolled 67 patients with Child-Pugh class A and B liver cirrhosis. ADAMTS13 activity (ADAMTS13:AC) and VWF antigen (VWF:Ag) were measured using enzyme-linked immunosorbent assays. The ratio of VWF:Ag to ADAMTS13:AC (VWF:Ag/ADAMTS13:AC) was used to divide patients into two groups according to the classification and regression tree based on Gray model survival analysis. RESULTS Compared with patients with Child-Pugh class A liver cirrhosis, class B patients had a higher VWF:Ag/ADAMTS13:AC and a higher risk of ACLF development. Cumulative incidence of ACLF was significantly higher in patients with high (>7.9) versus low (≤7.9) VWF:Ag/ADAMTS13:AC (hazard ratio [HR], 6.50; 95% CI, 2.31-18.29; p < 0.001). Cumulative survival was significantly lower in cirrhotic patients with high versus low VWF:Ag/ADAMTS13:AC (HR 5.11; 95% CI, 1.85-14.14; p = 0.002). CONCLUSIONS For patients with liver cirrhosis, VWF:Ag/ADAMTS13:AC is associated with functional liver reserve and predicts the development of ACLF and the prognosis.
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Affiliation(s)
- Masahide Enomoto
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Hiroaki Takaya
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Tadashi Namisaki
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Yukihisa Fujinaga
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Norihisa Nishimura
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuhiko Sawada
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Kosuke Kaji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Hideto Kawaratani
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Kei Moriya
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Takemi Akahane
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
| | - Takashi Inoue
- Institute for Clinical and Translational Science, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, Kashihara, Nara, Japan
| | - Hitoshi Yoshiji
- Department of Gastroenterology, Nara Medical University, Kashihara, Nara, Japan
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Iio S, Oka S, Tanaka S, Sumioka A, Tsuboi A, Nojima T, Hirata S, Matsuo Y, Sugiyama E, Hide M, Arihiro K, Chayama K. Capsule endoscopy findings reflect the gastrointestinal conditions of patients with systemic sclerosis. Sci Rep 2021; 11:20163. [PMID: 34635790 PMCID: PMC8505447 DOI: 10.1038/s41598-021-99775-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/01/2021] [Indexed: 11/23/2022] Open
Abstract
Systemic sclerosis (SSc) is characterized by fibrosis of the skin and various internal organs. However, there is limited knowledge concerning small-bowel lesions. We evaluated the clinical state of patients with SSc according to the capsule endoscopy (CE) findings. Sixty-five consecutive patients with SSc (61 females; mean age, 64.3 years) underwent CE at Hiroshima University Hospital between April 2012 and December 2019. SSc was subclassified into diffuse and limited cutaneous SSc. Among the 65 patients, 55 (51 females; mean age, 64.5 years; diffuse cutaneous SSc, 27 patients) were evaluated for the presence of fibrosis in the gastrointestinal tract by biopsy. Small-bowel lesions were detected in 27 (42%) patients with SSc. Type 1b angioectasia (Yano-Yamamoto classification) was more frequent in limited cutaneous SSc patients (p = 0.0071). The average capsule transit time of the esophagus was significantly longer in diffuse cutaneous SSc patients (p = 0.0418). There were more cases of Type 1a angioectasia in SSc patients without fibrosis. The average capsule transit time of the esophagus was significantly longer in SSc patients with fibrosis. Thus, this study revealed that the frequency of small-bowel angioectasia and gastrointestinal motility in patients with SSc differed depending on SSc subclassification and the presence of fibrosis.
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Affiliation(s)
- Sumio Iio
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takaki Nojima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshimi Matsuo
- Department of Dermatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Michihiro Hide
- Department of Dermatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
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Takaya H, Namisaki T, Sato S, Kaji K, Tsuji Y, Kaya D, Fujinaga Y, Sawada Y, Shimozato N, Kawaratani H, Moriya K, Akahane T, Mitoro A, Yoshiji H. Increased Endotoxin Activity Is Associated with the Risk of Developing Acute-on-Chronic Liver Failure. J Clin Med 2020; 9:jcm9051467. [PMID: 32422875 PMCID: PMC7290888 DOI: 10.3390/jcm9051467] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/06/2020] [Accepted: 05/12/2020] [Indexed: 02/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) leads to systematic inflammatory response syndrome and multiple organ failure. This study investigated the relationship between endotoxin (Et) and ACLF with the aim of determining whether Et activity (EA) is useful as a predictive biomarker of ACLF development and whether rifaximin treatment decreased the risk of ACLF development. Two hundred forty-nine patients with liver cirrhosis were enrolled in this study. Et concentration was determined in the whole blood by a semiquantitative EA assay. Predictive factors of ACLF development and the risk of ACLF development with and without rifaximin treatment were identified by univariate and multivariate analysis using Fine and Gray’s proportional subhazards model. EA level was higher in Child-Pugh class B than in class A patients, and class B patients had an increased risk of ACLF development compared with class A patients. Multivariate analysis showed that EA level was a predictive factor independently associated with ACLF development. Rifaximin decreased EA level and the risk of ACLF development in Child-Pugh class B patients. Et levels were associated with functional liver capacity and were predictive of ACLF development in cirrhotic patients. Rifaximin decreased Et level and the risk of ACLF development in advanced cirrhotic patients.
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Clinical Utility of Emergency Capsule Endoscopy for Diagnosing the Source and Nature of Ongoing Overt Obscure Gastrointestinal Bleeding. Gastroenterol Res Pract 2019; 2019:5496242. [PMID: 31885542 PMCID: PMC6914955 DOI: 10.1155/2019/5496242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 10/26/2019] [Accepted: 11/04/2019] [Indexed: 02/07/2023] Open
Abstract
Background and Aims In patients with ongoing overt obscure gastrointestinal bleeding (OGIB), prompt detection of the bleeding source is crucial to treatment success. However, there is no consensus on the optimal timing of diagnostic capsule endoscopy (CE). We investigated the clinical utility of emergency CE for detecting the source of ongoing overt OGIB. Methods We retrospectively evaluated 146 consecutive patients who, between February 2009 and July 2018, underwent emergency CE at Hiroshima University Hospital to detect the source of ongoing overt OGIB. Patients with a bleeding source located outside the small bowel were excluded. The remaining 127 patients were stratified according to the timing of CE relative to the onset of bleeding: patients in group A (n = 15, 12 men; mean age: 75 years; age range: 62–83 years) underwent CE within 48 hours of bleeding onset, whereas patients in group B (n = 112, 73 men; mean age: 65 years; age range: 17–88 years) underwent CE at >48 hours after bleeding onset. All patients underwent double-balloon endoscopy, and the final diagnosis was compared against the CE findings. Results The CE lesion detection rate was significantly higher in group A (12/15 patients, 80%) than in group B (53/112 patients, 47%) (p = 0.0174). There was no significant difference between the two groups regarding the patients' background characteristics. Vascular lesions were the most frequent finding in both groups. The diagnostic concordance rate between emergency CE and double-balloon endoscopy was 100% in group A and 92.9% in group B. Rebleeding after endoscopic treatment was confirmed in only one patient in group B. Conclusions Emergency CE represents a useful diagnostic modality in patients with ongoing overt OGIB, potentially improving detection rates and reducing rebleeding risk.
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Tsuboi A, Oka S, Tanaka S, Iio S, Otani I, Kunihara S, Chayama K. The Clinical Usefulness of the PillCam Progress Indicator for Route Selection in Double Balloon Endoscopy. Intern Med 2019; 58:1375-1381. [PMID: 30626833 PMCID: PMC6548919 DOI: 10.2169/internalmedicine.2043-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective The utility of capsule endoscopy (CE) findings in the route selection for double balloon endoscopy (DBE) has not been adequately discussed. The PillCam Progress Indicator in the RAPID 6.5 software program graphically demonstrates the progress of the capsule endoscope through the small-bowel. This study aimed to clarify the usefulness of the PillCam Progress Indicator in choosing the initial DBE route. Methods We retrospectively examined 50 consecutive patients with 50 target lesions detected on both CE and DBE at Hiroshima University Hospital from January 2011 to February 2018. In this study, we selected antegrade DBE on the basis of % Capsule Progress <50% as a clinical trial. The association between the PillCam Progress Indicator data and the DBE route to the target lesion was analyzed. Results The target lesion was reached via the initial DBE route in 96% (48/50) of cases. The cutoff values for selecting an antegrade route for DBE were 50% for % Capsule Progress and 42% for % SB Time. At the cutoff value, the sensitivity, specificity, and positive and negative predictive values for route selection were 100%, 91%, 93%, and 100% for % Capsule Progress and 96%, 91%, 93%, and 95% for % SB Time. Conclusion The PillCam Progress Indicator was useful for determining the appropriate initial DBE route.
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Affiliation(s)
- Akiyoshi Tsuboi
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Japan
| | - Sumio Iio
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Ichiro Otani
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Japan
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Aasen TD, Wilhoite D, Rahman A, Devani K, Young M, Swenson J. No significant difference in clinically relevant findings between Pillcam ® SB3 and Pillcam ® SB2 capsules in a United States veteran population. World J Gastrointest Endosc 2019; 11:124-132. [PMID: 30788031 PMCID: PMC6379749 DOI: 10.4253/wjge.v11.i2.124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 01/20/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Capsule endoscopy (CE) allows for a non-invasive small bowel evaluation for a wide range of gastrointestinal (GI) symptoms and diseases. Capsule technology has been rapidly advancing over recent years, often improving image frequency and quality. The Pillcam® SB3 (SB3) capsule is one such technology that offers an adaptive frame rate advantage over the previous versions of the capsule the Pillcam® SB2 (SB2). Some have proposed that this improvement in capsule technology may lead to increased diagnostic yields; however, real world clinical data is currently lacking.
AIM To evaluate the clinically relevant findings of SB3 and SB2 capsules in a population of United States veterans.
METHODS A retrospective analysis of 260 consecutive CE studies was performed including 130 SB3 and 130 SB2 capsule studies. Recorded variables included: age, gender, type of capsule, body mass index, exam completion, inpatient status, opioid use, diabetes, quality of preparation, gastric transit time, small bowel transit time, indication, finding, and if the exam resulted in a change in clinical management. The primary outcome measured was the detection of clinically relevant findings between SB3 and SB2 capsules.
RESULTS Mean age of the study population was 67.1 ± 10.4 years and 94.2% of patients were male. Of these 28.1% were on opioid users. The most common indications for capsule procedure were occult GI bleeding (74.6%) and overt GI bleeding (14.6%). Rates of incomplete exam were similar between SB3 and SB2 groups (16.9% vs 9.2%, P = 0.066). The overall rate of clinically relevant finding was 48.9% in our study. No significant difference was observed in SB3 vs SB2 capsules for clinically relevant findings (46.2% vs 51.5%, P = 0.385) or change in clinical management (40.8% vs 50.0%, P = 0.135).
CONCLUSION Our study found no significant difference in clinically relevant findings between SB3 and SB2 capsules.
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Affiliation(s)
- Tyler D Aasen
- Gastroenterology Section, East Tennessee State University Quillen College of Medicine, Johnson City, TN 37604, United States
| | - David Wilhoite
- Gastroenterology Section, East Tennessee State University Quillen College of Medicine, Johnson City, TN 37604, United States
| | - Aynur Rahman
- Gastroenterology Section, East Tennessee State University Quillen College of Medicine, Johnson City, TN 37604, United States
| | - Kalpit Devani
- Gastroenterology Section, East Tennessee State University Quillen College of Medicine, Johnson City, TN 37604, United States
| | - Mark Young
- Gastroenterology Section, East Tennessee State University Quillen College of Medicine, Johnson City, TN 37604, United States
| | - James Swenson
- Gastroenterology Section, Mountain Home Veterans Affairs Healthcare System, Mountain Home, TN 37684, United States
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10
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Nam SJ, Kim JH, Park SC. The Usefulness of New-Generation Capsule Endoscopy in Patients with Portal Hypertensive Enteropathy. Clin Endosc 2018; 51:505-507. [PMID: 30449077 PMCID: PMC6283760 DOI: 10.5946/ce.2018.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/31/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Seung-Joo Nam
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Ji Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sung Chul Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
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Kunihara S, Oka S, Tanaka S, Otani I, Igawa A, Nagaoki Y, Aikata H, Chayama K. Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study. Digestion 2018; 98:33-40. [PMID: 29672296 DOI: 10.1159/000486666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/08/2018] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy and Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Ichiro Otani
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Atsushi Igawa
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuko Nagaoki
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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12
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Goenka MK, Shah BB, Rai VK, Jajodia S, Goenka U. Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System. Clin Endosc 2018; 51:563-569. [PMID: 30300988 PMCID: PMC6283757 DOI: 10.5946/ce.2018.041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 07/18/2018] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
| | - Bhavik Bharat Shah
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Vijay Kumar Rai
- Institute of Gastro-Sciences, Apollo Gleneagles Hospitals, Kolkata, India
| | - Surabhi Jajodia
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
| | - Usha Goenka
- Department of Clinical Imaging and Interventional Radiology, Apollo Gleneagles Hospitals, Kolkata, India
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13
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Kunihara S, Oka S, Tanaka S, Tsuboi A, Otani I, Chayama K. Management of occult obscure gastrointestinal bleeding patients based on long-term outcomes. Therap Adv Gastroenterol 2018; 11:1756284818787408. [PMID: 30034534 PMCID: PMC6048613 DOI: 10.1177/1756284818787408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/15/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There is no consensus regarding the management of occult obscure gastrointestinal bleeding (OGIB) patients without a confirmed bleeding source. This study aimed to consider the management of occult OGIB patients based on their long-term outcomes. METHODS We retrospectively enrolled 357 consecutive occult OGIB patients (203 men; mean age: 59.7 years) who underwent capsule endoscopy (CE) at Hiroshima University Hospital, Japan and were followed up for more than 12 months (mean follow-up period; 50.2 months). Patients were divided into three groups as follows: Group A consisted of 98 of 157 patients who had positive findings and indication for treatment, Group B consisted of 59 of 157 patients who had positive findings but no indication for treatment, and Group C consisted of 200 patients who had negative small-bowel findings. We examined the rate of positive CE findings, detection rate and details of bleeding sources, overt bleeding rate, the rate of anemia exacerbation, 5-year anemia exacerbation rate, and overall survival rate. RESULTS The positive CE findings rate was 44% (157/357) and detection rate of bleeding source was 27% (98/357). The details of Group A were as follows: angioectasia (n = 61), nonspecific ulceration (n = 10), nonsteroidal anti-inflammatory drug-induced ulcer (n = 8), and others (n = 19). The details of Group B were as follows: erythema (n = 31), angioectasia (n = 25), and others (n = 3). There were no patients with overt bleeding in Group B. Although six patients had anemia exacerbation in Group B, they had angioectasia without a bleeding source. CONCLUSION The long-term outcomes of occult OGIB patients were good. Occult OGIB patients without bleeding source lesions may not require follow-up CE.
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Affiliation(s)
- Sayoko Kunihara
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
| | | | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University
Hospital, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
| | - Ichiro Otani
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism,
Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima,
Japan
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14
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Omori T, Hara T, Sakasai S, Kambayashi H, Murasugi S, Ito A, Nakamura S, Tokushige K. Does the PillCam SB3 capsule endoscopy system improve image reading efficiency irrespective of experience? A pilot study. Endosc Int Open 2018; 6:E669-E675. [PMID: 29868632 PMCID: PMC5979195 DOI: 10.1055/a-0599-5852] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 02/20/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS The aim of this study was tp compare the diagnostic efficiency of the PillCam SB3 capsule endoscopy (CE) system with the older system, PillCam SB2, taking into consideration the experience of the image reader. PATIENTS AND METHODS Small intestinal CE was conducted on 64 patients around May 2014 when the SB3 was introduced in our hospital. Data obtained from 20 patients (SB2: 10 and SB3: 10) based on transit time were assessed by junior (experience: 20 images), intermediate (> 50), and expert readers (> 600). RESULTS Reading time with the CE down to the end of the small intestine was shorter in the SB3 group for each reader (SB2 vs. SB3: junior, 40.2 ± 10.1 vs. 23.7 ± 6.7 [ P = 0.0009]; intermediate, 21.4 ± 4.9 vs. 10.3 ± 2.9 [ P = 0.0003]; expert, 23.2 ± 5.6 vs. 11.1 ± 2.9 min [ P = 0.0002]). Interpretation agreement rates between the findings by junior and intermediate readers and those by the expert reader were 84.6 % and 92.3 %, respectively. For the junior reader, rates of agreement using the SB2 and SB3 systems with those by the expert reader were 85.7 % and 83.3 %, respectively; no significant difference was noted between the two systems. Similarly, for the intermediate reader, the respective agreement rates using the SB2 and SB3 systems were 85.7 % and 100 %, respectively. CONCLUSIONS The PillCam SB3 reduces the time burden on readers irrespective of their experience.
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Affiliation(s)
- Teppei Omori
- Institute of Gastroenterology, Tokyo Women’s University, Tokyo, Japan,Corresponding author Teppei Omori, MD Institute of GastroenterologyTokyo Women’s Medical University8-1 Kawada-choShinjuku-kuTokyo 162-8666Japan+81-3-5269-7507
| | - Toshifumi Hara
- Institute of Gastroenterology, Tokyo Women’s University, Tokyo, Japan
| | - Sachiyo Sakasai
- Central Clinical Laboratory, Tokyo Women’s Medical University, Tokyo, Japan
| | | | - Shun Murasugi
- Institute of Gastroenterology, Tokyo Women’s University, Tokyo, Japan
| | - Ayumi Ito
- Institute of Gastroenterology, Tokyo Women’s University, Tokyo, Japan
| | - Shinichi Nakamura
- Institute of Gastroenterology, Tokyo Women’s University, Tokyo, Japan
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15
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Otani I, Oka S, Tanaka S, Tsuboi A, Kunihara S, Nagaoki Y, Aikata H, Chayama K. Clinical significance of small-bowel villous edema in patients with liver cirrhosis: A capsule endoscopy study. J Gastroenterol Hepatol 2018; 33:825-830. [PMID: 29023961 DOI: 10.1111/jgh.14016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/15/2017] [Accepted: 09/25/2017] [Indexed: 12/09/2022]
Abstract
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.
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Affiliation(s)
- Ichiro Otani
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Sayoko Kunihara
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuko Nagaoki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroshi Aikata
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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16
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Pateu E, Oberti F, Calès P. The noninvasive diagnosis of esophageal varices and its application in clinical practice. Clin Res Hepatol Gastroenterol 2018; 42:6-16. [PMID: 28870440 DOI: 10.1016/j.clinre.2017.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 02/04/2023]
Abstract
Here, we review recent improvements made to different noninvasive tests used for the diagnosis of esophageal varices (EV) in the light of the recent Baveno VI recommendation and with an emphasis on clinical application. Like for fibrosis tests, these noninvasive EV tests can be classified as direct markers when they provide a visualization of EV (including all imaging procedures like endoscopy or radiology) and as indirect markers when they do not (blood markers or elastometry). Clinical descriptors expressed as percentages, especially the spared endoscopy rate and the missed high-risk esophageal varices (HREV) rate, are more eloquent in this setting than classical statistical descriptors like accuracy. Single biomarkers are insufficient, generally due to a missed HREV rate exceeding the acceptable limit of 5% indicated in the Baveno VI consensus. Thus, biomarker combinations are currently garnering the most interest. The Baveno VI recommendation states that in alcoholic and viral cirrhoses, screening endoscopy can be safely set aside for patients with liver stiffness<20kPa and platelets>150G/L. The Baveno rule's mean missed HREV rate is<5% but its spared endoscopy rate is<20%. New combinations or stepwise algorithms show promise but must be validated. Going forward, the Baveno rule provides a simple noninvasive method to rule out HREV in clinical practice but the need for further research continues. The noninvasive diagnosis of HREV will be significantly improved by new, simple and affordable combinations.
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Affiliation(s)
- Etienne Pateu
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France
| | - Frédéric Oberti
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France
| | - Paul Calès
- Hepato-Gastroenterology Department, University Hospital, 49933 Angers, France; HIFIH Laboratory, University Angers, Bretagne-Loire University, 49045 Angers, France.
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17
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Calès P, Sacher-Huvelin S, Valla D, Bureau C, Olivier A, Oberti F, Boursier J, Galmiche JP. Large oesophageal varice screening by a sequential algorithm using a cirrhosis blood test and optionally capsule endoscopy. Liver Int 2018. [PMID: 28622450 DOI: 10.1111/liv.13497] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Large oesophageal varice (LEV) screening is recommended in cirrhosis. We performed a prospective study to improve non-invasive LEV screening. DESIGN 287 patients with cirrhosis had upper gastrointestinal endoscopy (LEV reference), oesophageal capsule endoscopy (ECE), liver elastography and blood marker analyses. CirrhoMeter (cirrhosis blood test), the most accurate non-invasive LEV test, was segmented for cirrhosis (reference comparator) or LEV. VariScreen, a sequential and partially minimally invasive diagnostic algorithm, was developed by multivariate analysis. It uses CirrhoMeter first, then ECE if CirrhoMeter cannot rule LEV out or in, and finally endoscopy if CirrhoMeter+ECE combination remains uninformative. RESULTS Diagnostic effectiveness rates for LEV were: cirrhosis-segmented CirrhoMeter: 14.6%, LEV-segmented CirrhoMeter: 34.6%, ECE: 60.6% and VariScreen: 66.4% (P ≤ .001 for overall or pair comparison). The respective missed LEV rates were: 2.8%, 5.6%, 8.3% and 5.6% (P = .789). Spared endoscopy rates were, respectively: 15.6%, 36.0%, 70.6% and 69%, (P < .001 for overall or paired comparison except ECE vs VariScreen: P = .743). VariScreen spared 38% of ECE and reduced missed LEV by 87% compared to classical ECE performed in all patients. Excepting cirrhosis-segmented CirrhoMeter, these spared endoscopy rates were significantly higher than that of the Baveno VI recommendation (using platelets and Fibroscan): 18.4% (P < .001). Ascites and Child-Pugh class independently predicted endoscopy sparing by VariScreen: from 86.0% in compensated Child Pugh class A to 24.1% in Child-Pugh class C with ascites. CONCLUSION VariScreen algorithm significantly reduced the missed LEV rate with ECE by 87%, ECE use by 38% and endoscopy requirement by 69%, and even 86% in compensated cirrhosis.
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Affiliation(s)
- Paul Calès
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Sylvie Sacher-Huvelin
- CIC 1413, INSERM, CHU, Nantes, France.,Department of Gastroenterology, IMAD, CHU and UNIV Nantes, Bretagne Loire University, Nantes, France
| | - Dominique Valla
- Liver Unit, DHU UNITY, Beaujon Hospital, HUPNVS, APHP, INSERM UMR U1149, University Paris Diderot, Clichy, France
| | | | - Anne Olivier
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Frédéric Oberti
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Jérôme Boursier
- Department of Liver-Gastroenterology, University Hospital, HIFIH Laboratory, UNIV Angers, Bretagne Loire University, Angers, France
| | - Jean Paul Galmiche
- Department of Gastroenterology, IMAD, CHU and UNIV Nantes, Bretagne Loire University, Nantes, France
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