Screening for Esophageal Varices in End Stage Liver Disease: Utility of Esophageal Capsule Endoscopy

Abstract

Background: Esophageal varices are a major complication of liver cirrhosis. 50% of patients with esophageal varices will eventually bleed and this is associated with 20% mortality at about 6 weeks. Current AASLD guidelines recommend screening for esophageal varices in patients with cirrhosis. This should be done yearly and every 2-3 years in patients with and without varices respectively. Esophagogastroduodenoscopy (EGD) has been the standard tool used for this evaluation. We describe our experience with the esophageal capsule endoscope (ECE). Methods: A prospective observational study was conducted on 217 consecutive patients in an outpatient hepatology/liver transplantation setting. The Pillcam Eso esophageal capsule was used on all the patients. This device acquires 14 images/second (7 frames/second/end). All patients fasted prior to the procedure and data was collected on all 217 patients. The video capsule images were evaluated by a trained investigator. Results: The average age was 57.1 and 50.2 % of the patients were male. Esophageal varices were seen in 38% (83/217). Other findings include gastric varices 1.3% (3/217), portal hypertensive gastropathy 11% (24/217). Barrett's esophagus and esophageal erosion was seen 2 and 1 patient respectively. The mean esophageal transit time was 3.8 ± 3.7 minutes. Stigmata of recent bleed were seen in 8.8% (19/217). Esophageal ring was seen in 3 patients and in 10 patients the capsule did not reach the stomach during the 20 minutes of study. Gastric visualization was obscured in 5 patients with retained food in the stomach. Conclusion: Our study shows that ECE is a valuable screening tool for esophageal varices in cirrhotic patients. Other findings in this study suggest it may also be useful for diagnosis of other co-existent esophageal and gastric pathologies. Failure rate was very low as the capsule failed to reach the stomach within the study period in only 10 patients. Studies have estimated the sensitivity and specificity of the esophageal capsule endoscopy to be 92-97% and 95-100% respectively. The overall concordance between ECE and EGD for diagnosis esophageal varices has been estimated to be 96.9%. Relative ease of swallow and convenience may make this a more attractive alternative for patients In future.