Detachable String Magnetically Controlled Capsule Endoscopy Vs.Esophagogastroduodenoscopy For Diagnosing Gastroesophageal Varices In Patients With Liver Cirrhosis

Background: Variceal bleeding is the most common lethal complication of liver cirrhosis(LC).Current guidelines recommended that all patients with cirrhosis should undergo esophagogastroduodenoscopy(EGD)screening and periodic surveillance.EGD is,however,an unpleasant invasive procedure with potential procedure-related complications.The new device of detachable string magnetically controlled capsule endoscopy(ds-MCE)makes it possible to comfortably,actively control the capsule in the esophagus and stomach,and the more than 8 hours battery life of the ds-MCE enables a further examination of the small bowel.Aims: The aim of the current study is to assess the accuracy of ds-MCE in identifying gastroesophageal varices(GEV),grading esophageal varices(EV),identifying high-risk EVs and portal hypertensive gastropathy(PHG)in LC patients using EGD as the gold standard,and to define the mucosal abnormalities of portal hypertensive enteropathy(PHE).Methods: Adult patients with LC underwent ds-MCE examination followed by EGD within 48 hours.The endoscopist who performed the EGD was blinded to the ds-MCE results.Data collected on each patient included baseline characteristics,feasibility and duration of ds-MCE procedure,the presence of esophageal varices,the grade of esophageal varices,the detection of red sign,the presence of gastric varices,portal hypertension gastropathy and portal hypertension enteropathy.Results:(1)A total of 55 participants who satisfied the inclusion/exclusion criteria were enrolled in the study between June 2019 and January 2020.Two patients were subsequently excluded from the analysis.Therefore 53 patients(43 males,10 females;average age 46.8±10.7 years)were included in the analyses.(2)The capsule endoscopy completion rate for small bowel was 92%.The median esophageal recording time was 2.72 minutes.The median gastric examination time was 14.23 minutes.The median gastric transit time was 93.33 minutes.The median small bowel examination time was 5.26 hours.The median total transit time for ds-MCE was 11.09 hours.(3)For detecting GOVs,using EGD as the gold standard,ds-MCE had a sensitivity,specificity,positive predictive value(PPV),and negative predictive value(PPV)of 94%,94%,97 %,and 89%,respectively,and the overall agreement was 94% with kappa score of 0.87.(4)For detecting esophageal varices,using EGD as the gold standard,ds-MCE had a sensitivity,specificity,PPV,and NPV of 97%,95%,97 %,and 95%,respectively,and the overall agreement was 96% with kappa score of 0.92.(5)In differentiating between medium/large varices,the sensitivity,specificity,PPV,and NPV were 96%,100%,100%,and 97% respectively,and the overall agreement was 98% with kappa score of 0.96.(6)In differentiating high-risk EVs,the sensitivity,specificity,PPV,and NPV were 100%,96%,96%,and 100% respectively,and the overall accuracy was 98% with kappa score of 0.96.(7)For detecting gastric varices,using EGD as the gold standard,ds-MCE had a sensitivity,specificity,PPV,and NPV of 86%,95%,86%,and 95%,respectively,and the overall accuracy was 92% with kappa score of 0.81.(8)For detecting portal hypertension gastropathy,using EGD as the gold standard,ds-MCE had a sensitivity,specificity,PPV,and NPV of 100%,100%,100%,and 100%,respectively,and the overall accuracy was 100% with kappa score of 1.00.(9)Mucosal changes were found in 26(49%)cirrhotic patients.The lesions included edema in 14 patients,erythema in 20 patients,red spots in 5 patients,telangiectasias in 1 patient,angiodysplasia-like lesions in 2 patients,and varices in 11 patients.Eighteen patients had more than one lesion during observation by ds-MCE.A comparison of patients with and those without PHE showed that decompensated cirrhosis,the presence of esophageal varices,medium/large esophageal varices,high-risk esophageal varices,and portal gastropathy were all significantly associated with PHE.(10)The mean overall comfort score of ds-MCE in the 53 patients was 3.74±0.45(range 0-4),the comfort score of EGD under general anesthesia was 3.57±0.53(0-4),and the comfort score of traditional EGD was 1.87 ±0.72(0-4).Meanwhile,47(87%)subjects preferred ds-MCE compared with EGD.During the EGD and ds-MCE examination,no complications such as capsule endoscopic retention,bleeding from gastroesophageal varices occurred.Conclusion: The new method of ds-MCE is a well-tolerated and safe procedure in LC.Using EGD as gold standard,ds-MCE is of high accuracy in detecting gastroesophageal varices with the advantage of further detecting the mucosal lesions in small bowels.ds-MCE is expected to be the first-line method in screening and surveillance of gastroesophageal varices in patients with LC.