Predictive Factors of Portal Hypertensive Enteropathy Exacerbation in Patients with Liver Cirrhosis: A Capsule Endoscopy Study.

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.

Evaluation for the Clinical Efficacy of Colon Capsule Endoscopy in the Detection of Laterally Spreading Tumors.

BACKGROUND AND AIM: The manner in which colorectal lesions are being detected with PillCam COLON2 capsule endoscopy (CCE2) has markedly improved in recent days. However, limited data are available on CCE2 for detecting laterally spreading tumors (LSTs). The aim of this study was to compare CCE2 with optical colonoscopy (OC), which is currently the gold standard used in the detection of LSTs. METHODS: We performed a prospective, single-academic center study comparing CCE2 with OC in patients with LSTs diagnosed using OC, which was performed during the 3-month period prior to CCE2. We focused on the sensitivity and specificity of CCE2 for detecting LSTs. LSTs were classified into the LST-granular type (LST-G) or the LST-non-granular type (LST-NG). RESULTS: Thirty patients (mean age 59.5 years) were enrolled. Of them, 21 LSTs (7 LST-Gs and 14 LST-NGs) were evaluated in this study. The mean diameter of the LSTs was 27 ± 15 mm (range 10-60 mm). Histopathological diagnoses of the LSTs were as follows: tubular adenoma, 12 cases (57%); sessile serrated adenoma/polyp (SSA/P), 4 cases (19%); Tis carcinoma, 1 case (5%); and T1 carcinoma, 4 cases (19 LSTs were found in the following locations: cecum, 1 case (5%); ascending colon, 6 cases (29%); transverse colon, 6 cases, (29%); descending colon, 1 case (5%); sigmoid colon, 3 cases (13%); and rectum, 4 cases (19%). The colon cleansing level was adequate in all cases. The sensitivity and specificity of CCE2 for detecting LSTs were 81 and 100% respectively. For detecting LST-Gs and LST-NGs, the sensitivity and specificity were 71 and 100%, and 86 and 100%, respectively. There were 4 false-negative cases (LST-G (18 mm), cecum; LST-G (20 mm), sigmoid colon; LST-NG (25 mm), transverse colon; LST-NG (20 mm), transverse colon). CONCLUSIONS: The sensitivity for detecting LSTs is lower with CCE2 than it is with OC, especially for LSTs located on the right colon or for SSA/P.

Third-Generation Capsule Endoscopy Outperforms Second-Generation Based on the Detectability of Esophageal Varices.

Background and Aim. The third-generation capsule endoscopy (SB3) was shown to have better image resolution than that of SB2. The aim of this study was to compare SB2 and SB3 regarding detectability of esophageal varices (EVs). Methods. Seventy-six consecutive liver cirrhosis patients (42 men; mean age: 67 years) received SB3, and 99 (58 men; mean age, 67 years old) received SB2. All patients underwent esophagogastroduodenoscopy within 1 month prior to capsule endoscopy as gold standard for diagnosis. The diagnosis using SB3 and SB2 for EVs was evaluated regarding form (F0-F3), location (Ls, Lm, and Li), and the red color (RC) sign of EVs. Results. SB2 and SB3 did not significantly differ on overall diagnostic rates for EV. Sensitivity, specificity, positive predictive value, and negative predictive value of SB2/SB3 for EV diagnosis were, respectively, 65%/81%, 100%/100%, 100%/100%, and 70%/62%. However, the diagnostic rates for EV form F1 were 81% using SB3 and 52% using SB2 (P = 0.009). Further, the diagnostic rates for Ls/Lm varices were 79% using SB3 and 81% using SB2, and, for Li, varices were 84% using SB3 and 52% using SB2 (P = 0.02). Conclusion. SB3 significantly improved the detectability of EVs compared with SB2.

Polidocanol injection therapy for small-bowel hemangioma by using double-balloon endoscopy.

BACKGROUND AND AIMS: Small-bowel hemangioma is a rare disease that often causes active bleeding. The standard therapeutic method for small-bowel hemangioma is surgical resection. The aim of this study was to evaluate the usefulness of polidocanol injection (PDI) for small-bowel hemangiomas. METHODS: This study included 12 patients with obscure GI bleeding (6 male; mean age 62 years) with 39 small-bowel hemangiomas; patients were treated with PDI by using double-balloon endoscopy (DBE). EUS with DBE was performed before PDI. The lesions were divided into 2 groups according to tumor size: Group A (size <10 mm; 20 lesions) and group B (size ≥10 mm; 19 lesions). The outcomes of PDI treatment for small-bowel hemangioma were evaluated between the 2 groups. Additionally, in order to standardize the amount of PDI injected, the total amount of polidocanol according to lesion size was calculated. RESULTS: There was no difference in the location of lesions and treatment times between the 2 groups. Group B had a significantly higher injection time per lesion (P < .05) and amount of polidocanol per lesion than group A (P < .01). Rebleeding occurred in only 1 case (8%). There were no adverse events related to PDI. The contribution ratio between the lesion size and amount of polidocanol showed a correlation (r = 0.77). The optimal amount of polidocanol for small-bowel hemangioma was determined to be 0.2 mL/mm. CONCLUSIONS: PDI is an easy, safe, and effective method to treat small-bowel hemangiomas.

Major predictors and management of small-bowel angioectasia.

BACKGROUND: Small-bowel angioectasias are frequently diagnosed with capsule endoscopy (CE) or balloon endoscopy however, major predictors have not been defined and the indications for endoscopic treatment have not been standardized. The aim of this study was to evaluate the predictors and management of small-bowel angioectasia. METHODS: Among patients with obscure gastrointestinal bleeding (OGIB) who underwent both CE and double-balloon endoscopy at our institution, we enrolled 64 patients with small-bowel angioectasia (angioectasia group) and 97 patients without small-bowel angioectasia (non-angioectasia group). The angioectasia group was subdivided into patients with type 1a angioectasia (35 cases) and type 1b angioectasia (29 cases) according to the Yano-Yamamoto classification. Patient characteristics, treatment, and outcomes were evaluated. RESULTS: Age (P = 0.001), cardiovascular disease (P = 0.002), and liver cirrhosis (P = 0.003) were identified as significant predictors of small-bowel angioectasia. Multivariate logistic regression analysis identified cardiovascular disease (odds ratio 2.86; 95% confidence interval, 1.35-6.18) and liver cirrhosis (odds ratio 4.81; 95% confidence interval, 1.79-14.5) as independent predictors of small-bowel angioectasia. Eleven type 1a cases without oozing were treated conservatively, and 24 type 1a cases with oozing were treated with polidocanol injection (PDI). Re-bleeding occurred in two type 1a cases (6%). Seventeen type 1b cases were treated with PDI and 12 type 1b cases were treated with PDI combined with argon plasma coagulation (APC) or clipping. Re-bleeding occurred in five type 1b cases (17%) that resolved after additional endoscopic hemostasis in all cases. There was one adverse event from endoscopic treatment (1.6%). CONCLUSIONS: Cardiovascular disease and liver cirrhosis were significant independent major predictors of small-bowel angioectasia. Type 1a angioectasias with oozing are indicated for PDI and type 1b angioectasias are indicated for PDI with APC or clipping.

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.

Comparison of small-bowel mucosal injury between low-dose aspirin and non-aspirin non-steroidal anti-inflammatory drugs: a capsule endoscopy study.

BACKGROUND/AIMS: The differences in the severity of small-bowel toxicity induced by aspirin and non-aspirin non-steroidal anti-inflammatory drugs (NSAIDs) remain unclear. This study aimed at clarifying these differences in small-bowel mucosal injury by using capsule endoscopy (CE). METHODS: We retrospectively compared the records of 78 and 40 obscure gastrointestinal bleeding patients receiving low-dose aspirin (LDA) and non-aspirin NSAIDs, respectively. All patients were found to have small-bowel mucosal injuries on CE. The two groups were compared for the number of small-bowel mucosal injuries and CE scores on the basis of the findings of CE. RESULTS: The mean numbers of reddened lesions in the LDA group and non-aspirin NSAID group were 2.49 ± 3.15 and 1.65 ± 3.04; the mean numbers of erosions/ulcers 1.56 ± 3.75 and 6.08 ± 10.4, and the mean CE scores 154 ± 294 and 520 ± 758, respectively. The mean number of reddened lesions was significantly higher and the mean number of erosions/ulcers and CE scores significantly lower in the LDA group than in the other non-aspirin NSAID group. CONCLUSION: Small-bowel mucosal injuries were significantly milder in the LDA group than in the non-aspirin NSAID group, though reddened lesions were more frequent in the LDA group.