Clin Endosc.  2018 Nov;51(6):563-569. 10.5946/ce.2018.041.

Mucosal Changes in the Small Intestines in Portal Hypertension: First Study Using the Pillcam SB3 Capsule Endoscopy System

• Goenka MK
• Shah BB
• Rai VK
• Jajodia S
• Goenka U

• KMID: 2430399
• DOI: http://doi.org/10.5946/ce.2018.041

Abstract

BACKGROUND/AIMS
To evaluate patients with portal hypertension (PH) of varied etiologies for portal hypertensive enteropathy (PHE) using the PillCam SB3 capsule endoscopy (CE) system.
METHODS
Consecutive patients with PH presenting with unexplained anemia and/or occult gastrointestinal bleeding were evaluated using the PillCam SB3 CE system. Abnormal findings were categorized as vascular or non-vascular. The patients with ongoing bleeding caused by PHE were treated. The correlation of the CE scores of PHE with the clinical, laboratory, and endoscopic features was determined.
RESULTS
Of the 43 patients included in the study, 41 (95.3%) showed PHE findings. These included varices (67.4%), red spots (60.5%), erythema (44.2%), villous edema (46.5%), telangiectasia (16.3%), and polyps (16.3%). The CE scores varied from 0 to 8 (mean±standard deviation, 4.09±1.8). Five patients (11.6%) showed evidence of ongoing or recent bleeding due to PHE. Three of these five patients underwent endotherapy, and one patient underwent radiological coil placement.
CONCLUSIONS
The PillCam SB3 CE system revealed a high prevalence of PHE in the patients with PH. Using this system, evidence of bleeding due to PHE was found in a small but definite proportion of the patients.

Keyword

Capsule endoscopy; Intestine, small; Hypertension, portal; Cirrhosis; PillCam SB3

MeSH Terms

Anemia
Capsule Endoscopy*
Edema
Erythema
Fibrosis
Hemorrhage
Humans
Hydrogen-Ion Concentration
Hypertension, Portal*
Intestine, Small*
Polyps
Prevalence
Telangiectasis
Varicose Veins

Figure

• 

  Fig. 1. Vascular changes seen on capsule endoscopy: (A) red spot, (B) telangiectasia, and (C) to (E) varices.

• 

  Fig. 2. Non-vascular (inflammatory) changes seen on capsule endoscopy: (A) villous edema, (B) and (C) erythema, and (D) and (E) polyp.

• 

  Fig. 3. Capsule endoscopy showing blood in the lumen and evidence of ulcer (arrow).

Reference

1. Bornman PC, Krige JE, Terblanche J. Management of oesophageal varices. Lancet. 1994; 343:1079–1084.

2. McCormack TT, Sims J, Eyre-Brook I, et al. Gastric lesions in portal hypertension: inflammatory gastritis or congestive gastropathy? Gut. 1985; 26:1226–1232.

3. Ganguly S, Sarin SK, Bhatia V, Lahoti D. The prevalence and spectrum of colonic lesions in patients with cirrhotic and noncirrhotic portal hypertension. Hepatology. 1995; 21:1226–1231.

4. Goenka MK, Kochhar R, Nagi B, Mehta SK. Rectosigmoid varices and other mucosal changes in patients with portal hypertension. Am J Gastroenterol. 1991; 86:1185–1189.

5. Chen LS, Lin HC, Lee FY, Hou MC, Lee SD. Portal hypertensive colopathy in patients with cirrhosis. Scand J Gastroenterol. 1996; 31:490–494.

6. Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal varices, haemorrhoids, and portal hypertension. Lancet. 1989; 1:349–352.

7. Misra V, Misra SP, Dwivedi M, Gupta SC. Histomorphometric study of portal hypertensive enteropathy. Am J Clin Pathol. 1997; 108:652–657.

8. Nagral AS, Joshi AS, Bhatia SJ, Abraham P, Mistry FP, Vora IM. Congestive jejunopathy in portal hypertension. Gut. 1993; 34:694–697.

9. Viggiano TR, Gostout CJ. Portal hypertensive intestinal vasculopathy: a review of the clinical, endoscopic, and histopathologic features. Am J Gastroenterol. 1992; 87:944–954.

10. Misra SP, Dwivedi M, Misra V, Gupta M. Ileal varices and portal hypertensive ileopathy in patients with cirrhosis and portal hypertension. Gastrointest Endosc. 2004; 60:778–783.

11. Ohtani T, Kajiwara E, Suzuki N, et al. Ileal varices associated with recurrent bleeding in a patient with liver cirrhosis. J Gastroenterol. 1999; 34:264–268.

12. Lewis P, Warren BF, Bartolo DC. Massive gastrointestinal haemorrhage due to ileal varices. Br J Surg. 1990; 77:1277–1278.

13. Arst HF, Reynolds JD. Acute ileal variceal hemorrhage secondary to esophageal sclerotherapy. J Clin Gastroenterol. 1986; 8:603–604.

14. Chandrasekar TS, Janakan GB, Chandrasekar VT, Kalamegam RY, Suriyanarayanan S, Sanjeevaraya PM. Spectrum of small-bowel mucosal abnormalities identified by capsule endoscopy in patients with portal hypertension of varied etiology. Indian J Gastroenterol. 2017; 36:32–37.

15. Dabos KJ, Yung DE, Bartzis L, Hayes PC, Plevris JN, Koulaouzidis A. Small bowel capsule endoscopy and portal hypertensive enteropathy in cirrhotic patients: results from a tertiary referral centre. Ann Hepatol. 2016; 15:394–401.

16. Aoyama T, Oka S, Aikata H, et al. Major predictors of portal hypertensive enteropathy in patients with liver cirrhosis. J Gastroenterol Hepatol. 2015; 30:124–130.

17. Jeon SR, Kim JO, Kim JB, et al. Portal hypertensive enteropathy diagnosed by capsule endoscopy in cirrhotic patients: a nationwide multicenter study. Dig Dis Sci. 2014; 59:1036–1041.

18. Abdelaal UM, Morita E, Nouda S, et al. Evaluation of portal hypertensive enteropathy by scoring with capsule endoscopy: is transient elastography of clinical impact? J Clin Biochem Nutr. 2010; 47:37–44.

19. Akyuz F, Pinarbasi B, Ermis F, et al. Is portal hypertensive enteropathy an important additional cause of blood loss in portal hypertensive patients? Scand J Gastroenterol. 2010; 45:1497–1502.

20. Kovács M, Pák P, Pák G, Fehér J, Rácz I. Small bowel alterations in portal hypertension: a capsule endoscopic study. Hepatogastroenterology. 2009; 56:1069–1073.

21. Goulas S, Triantafyllidou K, Karagiannis S, et al. Capsule endoscopy in the investigation of patients with portal hypertension and anemia. Can J Gastroenterol. 2008; 22:469–474.

22. Figueiredo P, Almeida N, Lérias C, et al. Effect of portal hypertension in the small bowel: an endoscopic approach. Dig Dis Sci. 2008; 53:2144–2150.

23. De Palma GD, Rega M, Masone S, et al. Mucosal abnormalities of the small bowel in patients with cirrhosis and portal hypertension: a capsule endoscopy study. Gastrointest Endosc. 2005; 62:529–534.

24. Monteiro S, de Castro FD, Carvalho PB, Moreira MJ, Rosa B, Cotter J. PillCam^® SB3 capsule: does the increased frame rate eliminate the risk of missing lesions? World J Gastroenterol. 2016; 22:3066–3068.

25. Kunihara S, Oka S, Tanaka S, et al. Third-generation capsule endoscopy outperforms second-generation based on the detectability of esophageal varices. Gastroenterol Res Pract. 2016; 2016:9671327.

26. Eliakim R. Where do I see minimally invasive endoscopy in 2020: clock is ticking. Ann Transl Med. 2017; 5:202.

27. Mekaroonkamol P, Cohen R, Chawla S. Portal hypertensive enteropathy. World J Hepatol. 2015; 7:127–138.

28. Kodama M, Uto H, Numata M, et al. Endoscopic characterization of the small bowel in patients with portal hypertension evaluated by double balloon endoscopy. J Gastroenterol. 2008; 43:589–596.

29. Højhus JH, Pedersen SA. Cirrhosis and bleeding ileal varices without previous intraabdominal surgery. A case report. Acta Chir Scand. 1986; 152:479–480.

30. Varanasi RV, Fleisher AS, Darwin PE, King CE, Haluszka O. Colonoscopic sclerotherapy of ileal varices. Gastrointest Endosc. 2000; 52:109–111.

31. Norton ID, Andrews JC, Kamath PS. Management of ectopic varices. Hepatology. 1998; 28:1154–1158.

32. Koo SM, Jeong SW, Jang JY, et al. Jejunal variceal bleeding successfully treated with percutaneous coil embolization. J Korean Med Sci. 2012; 27:321–324.

33. Lemmers A, Evrard S, Demetter P, et al. Gastrointestinal polypoid lesions: a poorly known endoscopic feature of portal hypertension. United European Gastroenterol J. 2014; 2:189–196.

34. Guth E, Katz MD, Hanks SE, Teitelbaum GP, Ralls P, Korula J. Recurrent bleeding from ileal varices treated by transjugular intrahepatic portosystemic shunt: value of Doppler ultrasonography in diagnosis and follow-up. J Ultrasound Med. 1996; 15:67–69.

35. Haskal ZJ, Scott M, Rubin RA, Cope C. Intestinal varices: treatment with the transjugular intrahepatic portosystemic shunt. Radiology. 1994; 191:183–187.

36. Lu Y, Gao R, Liao Z, Hu LH, Li ZS. Meta-analysis of capsule endoscopy in patients diagnosed or suspected with esophageal varices. World J Gastroenterol. 2009; 15:1254–1258.

37. Chavalitdhamrong D, Jensen DM, Singh B, et al. Capsule endoscopy is not as accurate as esophagogastroduodenoscopy in screening cirrhotic patients for varices. Clin Gastroenterol Hepatol. 2012; 10:254–258. e1.