Unsedated Peroral Thin Scope Endoscopy for Screening of Esophageal Varices in Endoscopy-Naïve Child-Pugh A Cirrhotics

Abstract

Introduction: Bleeding esophageal varices cause significant morbidity and mortality in patients with cirrhosis. While various non-invasive strategies for variceal screening have been proposed, current guidelines recommend conventional esophagogastroduodenoscopy (EGD). The drawbacks of this approach include cost and risk of adverse events. Therefore, we propose the use of unsedated peroral thin scope endoscopy (TSE) as an alternative, minimally-invasive strategy. Methods: We retrospectively reviewed the 168 endoscopy-naïve patients with Child-Pugh A cirrhosis who underwent TSE for variceal screening at the University of Calgary outpatient liver clinic between September 2011 and July 2013. Baseline characteristics collected included diagnosis, age, sex, AST, platelet count, spleen size, and liver stiffness by transient elastography (FibroScan®). The MELD score, platelet count to spleen ratio (PSR), AST to platelet ratio index (APRI), and liver stiffness-spleen diameter to platelet ratio score (LSPS) were calculated for each patient. The tolerability of TSE was recorded. Findings of TSE, including the presence and size of varices, and the presence of non-variceal phenomena, were documented. Results: TSE was well-tolerated in 94% of cases, and no adverse events were reported. The rates of no, small, and medium/large esophageal varices were 72.0%, 17.9%, and 10.1%, respectively. Medium/large varices with high-risk stigmata were seen in 1.8% of patients screened. Portal hypertensive gastropathy was seen in 36.3% of patients. Gastric or duodenal ulcers were seen in 13.7% of patients, but none warranted intervention. Patients with varices did not have higher MELD scores than those with no varices (p=0.48). LSPS was the single best noninvasive predictor of patients with medium/large esophageal varices (area under the receiver operating characteristic, 0.83; 95% confidence interval, 0.72-0.93; p<0.001). Conclusion: TSE for the screening of esophageal varices in endoscopy-naïve patients with Child-Pugh A cirrhosis is safe and well tolerated. Varices were found in 28% of patients, but most did not require further endoscopic intervention. In-hospital sedated EGD was avoided in 88% of patients screened. LSPS may be able to descriminate between patients suitable for TSE, and those who should proceed directly to EGD.