Usefulness of transnasal argon plasma coagulation for esophageal varices compared with the peroral method: a randomized and prospective clinical study.

BACKGROUND: Argon plasma coagulation (APC) is very useful as a consolidation treatment for reducing the recurrence of esophageal varices (EVs). However, repeated sedation in endoscopic treatment has the risk of prolonging hepatic encephalopathy and affects the respiratory state of liver cirrhosis (LC) patients, in whom pulmonary arteriovenous shunts are observed. We evaluated prospectively whether transnasal endoscopic APC without sedation is more effective than peroral endoscopic APC with sedation. PATIENTS AND METHODS: LC patients (n = 101), treated by endoscopic injection sclerotherapy to eradicate EVs, were randomly divided into a transnasal APC group (n = 50) and a peroral APC group (n = 51). The primary efficacy endpoint was the cumulative recurrence rate of EVs. The secondary endpoints were blood pressure (BP), heart rate, oxygen saturation during APC and complications. RESULTS: There was no significant difference in the cumulative recurrence rate of EVs at 36 months between the transnasal APC and peroral APC groups (35.0 vs. 40.8%, p = 0.39, log-rank test), indicating that transnasal APC is not inferior to peroral APC. The transnasal APC group showed more stable intraoperative BP and oxygen saturation values, and a lower incidence of epigastralgia (56.0 vs. 74.5%, p = 0.04). CONCLUSION: The efficacy of reducing the recurrence of EVs in the transnasal APC group was not significantly different from that in the peroral APC group. Transnasal APC caused less distress and required no sedation. Therefore, this method was more advantageous for LC patients at risk of suffering from prolongation of hepatic encephalopathy.

Noninvasive diagnostic method for idiopathic portal hypertension based on measurements of liver and spleen stiffness by ARFI elastography.

BACKGROUND: Acoustic radiation force impulse (ARFI) elastography is an ultrasound technique that is capable of measuring tissue stiffness noninvasively. It is difficult to differentiate idiopathic portal hypertension (IPH) from liver cirrhosis (LC) or chronic hepatitis (CH), and liver biopsy is essential. We investigated whether it would be possible to noninvasively diagnose IPH by measuring the stiffness of the liver and spleen by ARFI. METHODS: The subjects were 17 IPH patients, 25 LC patients, 20 CH patients, and 20 normal controls (NC). We measured liver stiffness, spleen stiffness, and the spleen/liver stiffness ratio, and plotted ROC curves. RESULTS: The median value of liver stiffness in the IPH group was lower than that in the LC group (p = 0.00077) and about the same as in the CH group (p = 0.79). The median value of spleen stiffness was highest in the IPH group (IPH vs. LC group, p = 0.003; IPH vs. CH group, p < 0.00001). The spleen/liver stiffness ratio was lower in the LC group and in the CH group, and higher in the IPH group (p < 0.001, respectively). When an ROC curve of spleen/liver stiffness ratios was plotted to differentiate between the IPH group and the combined group of patients with other liver diseases (LC + CH group), when a cutoff value of 1.71 was used, the AUROC was 0.933 sensitivity 0.941, specificity 0.800, and accuracy 0.839. CONCLUSION: Measuring the spleen/liver stiffness ratio by ARFI made it possible to noninvasively, specifically, and accurately diagnose IPH.

Flexible imaging color enhancement improves visibility of transnasal endoscopic images in diagnosing esophageal varices: a multicenter prospective blinded study.

OBJECTIVE: To clarify the usefulness of transnasal esophagogastroduodenoscope (N-EGD) with all flexible imaging color enhancement (FICE) patterns (0-9) for the diagnosis of esophageal varices (EV). METHODS: A total of 50 patients with EV were examined during the same period by N-EGD without sedation and by peroral endoscopy (O-EGD) with sedation. The visibility of treatment scars, microvessels, recurrent EV and red color sign (RCS) were measured. Visibility was evaluated by five blinded observers (poor-good: 0-10), and the effect of both endoscopic examinations on the cardiorespiratory function of the patients was measured. RESULTS: The image scores for O-EGD and N-EGD with ordinary mode and N-EGD with FICE were 7.3 ± 1.2, 6.1 ± 1.0 and 6.9 ± 1.0 for treatment scars; 7.2 ± 1.4, 6.2 ± 1.2 and 7.3 ± 1.0 for microvessels; 7.2 ± 1.2, 6.1 ± 1.0 and 7.1 ± 1.0 for recurrent EV and 7.2 ± 1.3, 6.1 ± 1.3, and 7.2 ± 1.2 for RCS, respectively (intraclass correlation coefficients > 0.6). When FICE patterns 2, 6 and 9 were used, visibility was much improved. Ten minutes after insertion, the double product values in the N-EGD with the FICE group were significantly better (P < 0.05). CONCLUSIONS: N-EGD with FICE is very useful for the diagnosis of EV and can improve the visibility of N-EGD on each lesion to the same level as that of O-EGD. N-EGD with FICE does not require sedation and may reduce the risk of hepatic encephalopathy.

Analysis of intrahepatic vascular morphological changes of chronic liver disease for assessment of liver fibrosis stages by micro-flow imaging with contrast-enhanced ultrasound: preliminary experience.

OBJECTIVE: To assess morphological vascular changes due to an increase in liver fibrosis by using micro-flow imaging (MFI) of contrast-enhanced ultrasound. METHODS: MFI was performed in 47 patients who underwent liver biopsy, and in 10 normal cases. For 27/57 cases, we performed MFI twice in order to assess the reproducibility of the examination, thus yielding a total of 84 examinations. Seven physicians interpreted each case individually by assigning confidence levels for the presence or absence of three imaging features that were related to alteration of portal vein morphology: angle widening, tapering/interruption and tortuosity. RESULTS: Pearson's correlation coefficient between the average rating scores based on tortuosity and the histological fibrosis stage was 0.806 (p < 0.001). The diagnostic accuracy of the average area under the ROC curve, which was estimated by use of the confidence levels of tapering/interruption, tortuosity and angle widening, was 0.964 for F1 vs. F2-4, 0.968 for F1-2 vs. F3-4 and 0.910 for F1-3 vs. F4. The average correlation coefficient between the ratings on different images from the same patients was 0.838. CONCLUSION: Assessment of morphological intrahepatic vascular changes on MFI may be useful for grading liver fibrosis.

[A case of splenic inflammatory pseudotumor].

A 74-year-old woman underwent abdominal echography at a local clinic and a splenic mass was found. She was hospitalized for detailed examinations and treatment. Splenectomy was performed to make a definite diagnosis and for treatment because a definitive diagnosis could not be made, despite various examinations. Histopathological examination revealed that the lesion was infiltrated by polyclonal lymphoid cells and contained proliferating spindle-shaped fibroblasts without any atypical cells, so the splenic mass was diagnosed as an inflammatory pseudotumor. Because some cases of inflammatory pseudotumor can be diagnosed from the clinical course and imaging findings, this possibility should also be considered in the differential diagnosis of a splenic mass.