Enhancing Detection of Small Esophageal Varices by PillCam ESO
Enhancing Detection of Small Esophageal Varices by PillCam ESO
Increasing intra-abdominal pressure (IAP) with an abdominal binder will increase pressure
 within smaller esophageal varices which will therefore enhance the ability of capsule
 endoscopy to detect these varices better.

 Therefore, the aims of the investigators' study are as follows:

 1. To determine if using an abdominal binder to increase IAP can increase the detection
 rate of small esophageal varices when using capsule endoscopy.

 2. To determine if using an abdominal binder to increase IAP during capsule endoscopy has a
 comparable detection rate of small esophageal varices to conventional endoscopy.
Esophageal variceal bleeding is a common and life-threatening complication of portal
 hypertension in patients with cirrhosis of liver. It is associated with a mortality rate of
 up to 50% in these patients. Prophylactic treatments to prevent variceal bleeding, therefore,
 assume paramount clinical significance. Currently, primary prophylactic treatments using
 pharmacologic agents with non-selective beta blockers as well as endoscopic variceal ligation
 (EVL) are effectively employed in preventing variceal bleeding. The American Association for
 the Study of Liver Disease (AASLD) guidelines recommend that patients with Child's stage A
 cirrhosis and portal hypertension with platelet count less than 140,000/mmq or portal vein
 diameter > 13mm and those patients classified as Child's B and C cirrhosis should undergo
 screening endoscopy for esophageal varices. Patients with cirrhosis and no esophageal varices
 detected during screening should undergo endoscopy ever three years. Patients with small
 esophageal varices are recommended to be screened endoscopically every 1 to 2 years.

 Currently, esophagogastroduodenoscopy (EGD) under conscious sedation is the gold standard for
 variceal screening. However, EGD has certain limitations especially when used in patients
 with cirrhosis of the liver. Prolonged conscious sedation may have an adverse effect on
 encephalopathy. EGD also may not be cost effective for screening esophageal varices.

 The use of PillCam ESO capsule endoscopy to detect esophageal varices has become an
 attractive alternative to conventional endoscopy especially in patients unwilling to undergo
 EGD. Identifying patients with small varices, which have the potential for progression to
 large varices and bleeding, is an important clinical issue to address.
Inclusion Criteria:

 -  patients identified with grade I and grade II esophageal varices by conventional
 endoscopy who are returning for screening or surveillance

 -  patients who have had endoscopic banding of varices in the past

 -  patients aged 18 years or older

 -  patients able to give consent

 -  patients eligible and willing to undergo upper endoscopy and PillCam ESO capsule
 endoscopy

 Exclusion Criteria:

 -  dysphagia

 -  Zenker's diverticulum

 -  pregnancy

 -  esophageal stricture

 -  gastric or intestinal obstruction

 -  multiple abdominal surgeries

 -  cardiac pacemakers

 -  implanted electronic medical devices

 -  cognitive impairment

 -  also, patients found to have bleeding, requiring banding, or other complications on
 screening EGD the day of the trial will not proceed to capsule endoscopy

 -  urine pregnancy test will be conducted prior to participation; this is part of the
 standard procedure for women of child-bearing age undergoing upper endoscopy in the GI
 lab

 -  all patients being evaluated for the current study will be evaluated for the presence
 or absence of overt portosystemic encephalopathy:

 -  Those found to have overt portosystemic encephalopathy will then be graded based
 on the standard scale of grade 1 through 4 portosystemic encephalopathy.
 Assessment of whether patients with liver disease and hepatocellular carcinoma
 possess decisional capacity is essentially the same as for other subjects with
 the exception that due diligence must be used to address whether there is any
 evidence of active ongoing overt portosystemic encephalopathy. From the available
 data and current standards of care, patients with stage 1 overt hepatic
 encephalopathy are decisional but may have minimal impairment in their cognitive
 skills particularly in the domains of attention and sleep. Decisional capacity in
 patients with grades 2-4 overt portosystemic encephalopathy is impaired and will
 lead to them bring excluded from the study.