Studies Test Non-Invasive Procedure to Detect Esophageal Bleeding

The May issue of Hepatology reports new progress in the quest for a better way to screen for esophageal varices, the extremely dilated veins that are particularly prone to bleeding and commonly seen with cirrhosis. Two studies examine endoscopy alternatives and report promising results. Hepatology is a journal published by John Wiley & Sons on behalf of the American Association for the Study of Liver Diseases (AASLD).

About one in four cirrhotic patients with esophageal varices will suffer variceal bleeding, which causes death within six weeks for up to 20 percent of sufferers. Because of this risk, practice guidelines recommend screening for varices in all patients with cirrhosis. People with medium to large varices can be treated with beta-blockers or band ligation to reduce their risk of bleeding by 50 percent. Currently, endoscopy is the gold standard for screening for varices. However, it is uncomfortable, invasive, expensive and perhaps unnecessary for the patients who don’t develop varices. Researchers have been seeking alternative ways to screen for the condition.

Researchers led by Roberto de Franchis of Milan tested esophageal capsule endoscopy in 290 patients with portal hypertension, most of whom were scheduled for esophago-gastro-duodenoscopy (EGD). They then compared the diagnostic results of both procedures. They found that the difference in diagnosing esophageal varices was 15.6 percent in favor of EGD.

"We recommend that EGD be used to screen patients with cirrhosis for large esophageal varices. However, the minimal invasiveness, good tolerance and good agreement of capsule endoscopy with EGD might increase adherence to screening programs," they conclude.

In a similar study, researchers led by Roman Perri of the Mayo Clinic prospectively compared computerized tomographic (CT) scanning to endoscopic screening in 102 patients. "CT was found to have an approximately 90 percent sensitivity in the identification of esophageal varices determined to be large on endoscopy, but only about 50 percent specificity," they report. "The sensitivity of CT in detecting gastric varices was 87 percent." They also found that patients preferred CT to endoscopy, and that the former procedure was significantly more cost-effective.

According to an accompanying editorial by Didier Lebrec of Hopital Beaujon and colleagues, both studies were well-
designed and showed that both capsule endoscopy and CT could be good screening tools. However, neither showed adequate sensitivity for detecting large varices. "One-third of the patients with large varices would have been misdiagnosed by CT, and sensitivity for the capsule was only 78 percent, which is insufficient," they write. "Therefore replacing endoscopy with one of these two techniques would result in more misdiagnosed patients with large varices, which is not reasonable."

The best non-invasive tool to replace endoscopy has not yet been found, say Lebrec and colleagues. "Physicians and patients must accept this uncertainty and efforts must continue to find indexes and associate non-invasive methods to screen patients for varices without endoscopy."

Another article in the same issue of Hepatology summarizes the results of a recent Endpoints Single Topic Conference on portal hypertension and variceal bleeding that was jointly sponsored by the American Association for the Study of Liver Disease and its European counterpart. The participating experts prioritized areas for future research, including definition of surrogate outcomes and classification of patients into different risk groups, and put forth practice recommendations in areas in which no further trials were necessary or plausible.

Source: John Wiley & Sons, Inc.