RESEARCH RESEARCH MONTHMONTH

Tamar MeszarosTamar MeszarosPGY-3PGY-3

July 24, 2006July 24, 2006

Preparing for the MonthPreparing for the Month

Find a mentorFind a mentor AttendingAttending FellowFellowFind a ProjectFind a Project TopicTopic CaseCase

Research ProjectResearch Project

Formulate a Formulate a QuestionQuestionLiterature SearchLiterature SearchDevelop a Develop a ProtocolProtocolIRB ApprovalIRB Approval

QUESTIONQUESTION

Is Video Capsule Endoscopy a Is Video Capsule Endoscopy a reasonable alternative to EGD in the reasonable alternative to EGD in the

detection of esophageal varices in the detection of esophageal varices in the cirrhotic patient?cirrhotic patient?

The PillCam ESO Capsule The PillCam ESO Capsule Endoscope Endoscope

Relevant QRelevant Q

Attractive alternative to EGD Attractive alternative to EGD Less risks Less risks

CoagulopathyCoagulopathyEncephalopathy with sedationEncephalopathy with sedation

More comfortable More comfortable Few contraindicationsFew contraindications

To date, there is no published study To date, there is no published study showing it’s efficacy in the detection of showing it’s efficacy in the detection of esophageal varices.esophageal varices.

Esopahgeal Capsule EndoscopyEsopahgeal Capsule Endoscopy

Prospective multicenter, international study Prospective multicenter, international study 66 of 106 patients had + esophageal findings66 of 106 patients had + esophageal findingsECE identified esophageal abnormalities in 61 ECE identified esophageal abnormalities in 61 (sensitivity, 92%; specificity, 95%). (sensitivity, 92%; specificity, 95%). The per-protocol sensitivity, specificity, PPV, and The per-protocol sensitivity, specificity, PPV, and NPV of ECE for Barrett esophagus were 97%, NPV of ECE for Barrett esophagus were 97%, 99%, 97%, and 99%, respectively99%, 97%, and 99%, respectivelyEsophagitis 89%, 99%, 97%, and 94%,Esophagitis 89%, 99%, 97%, and 94%,ECE was preferred over EGD by all patientsECE was preferred over EGD by all patientsNo adverse events related to ECE. No adverse events related to ECE.

Journal of Clinical GastroenterologyJournal of Clinical Gastroenterology. A Prospective Study of the Diagnostic Accuracy of . A Prospective Study of the Diagnostic Accuracy of PillCam ESO Esophageal Capsule Endoscopy Versus Conventional Upper Endoscopy PillCam ESO Esophageal Capsule Endoscopy Versus Conventional Upper Endoscopy in Patients With Chronic Gastroesophageal Reflux Diseases August 2005; 39(7): 572-578in Patients With Chronic Gastroesophageal Reflux Diseases August 2005; 39(7): 572-578

VCE in small bowel dzVCE in small bowel dz

Review articles from Israel & Review articles from Israel & NetherlandsNetherlands Wireless capsule video endoscopy: three years Wireless capsule video endoscopy: three years

of experienceof experience Video capsule endoscopy: procedure, Video capsule endoscopy: procedure,

indications and diagnostic yield.indications and diagnostic yield. More sensitive diagnostic tool than More sensitive diagnostic tool than

enteroscopy, CT and SBFT for small enteroscopy, CT and SBFT for small bowel disease.bowel disease.

AlternativesAlternatives

Some alternatives have been studiedSome alternatives have been studied Transnasal endoluminal ultrasound. Transnasal endoluminal ultrasound. Compared transnasal endoscopy to EGD. Compared transnasal endoscopy to EGD. Concluded it to be a safe and good Concluded it to be a safe and good

alternative. alternative. Study was small.Study was small. No follow up studies to date.No follow up studies to date.

Saelan K. et al. Unsedated Transnasal Endoscopy: a New Technique Saelan K. et al. Unsedated Transnasal Endoscopy: a New Technique for Accurately Detecting and Grading Esophageal Varices in for Accurately Detecting and Grading Esophageal Varices in Cirrhotic atients. The American Journal of Gastroenterology Sept Cirrhotic atients. The American Journal of Gastroenterology Sept 2002; 97: 2246-22492002; 97: 2246-2249

Background:Background:Varices in the CirrhoticVarices in the Cirrhotic

2/3 of patients will develop varices.2/3 of patients will develop varices.Prevalence as high as eighty to ninety Prevalence as high as eighty to ninety percent reported in newer studies.percent reported in newer studies.The mortality rate after the first episode of The mortality rate after the first episode of bleeding is twenty to thirty five percent. bleeding is twenty to thirty five percent.

Dennis M Jensen. Endoscopic Screening for Varices in Dennis M Jensen. Endoscopic Screening for Varices in cirrhosis: findings, implications and Outcomes. cirrhosis: findings, implications and Outcomes. Gastroenterology 2002;122:1620-1630.Gastroenterology 2002;122:1620-1630.

Methods/MaterialsMethods/Materials

A randomized selection of cirrhotic patients A randomized selection of cirrhotic patients from Dr. Lewis’ liver clinic.from Dr. Lewis’ liver clinic.Both pill endoscopy and EGD will be performed Both pill endoscopy and EGD will be performed on the same day on the same day Pill endoscopy will be performed first, followed Pill endoscopy will be performed first, followed by EGD. by EGD. Dr. Bull Henry to interpret the pill endoscopy Dr. Bull Henry to interpret the pill endoscopy Both Dr. Bull-Henry and Dr. Lewis will be Both Dr. Bull-Henry and Dr. Lewis will be blinded to results of the other clinician’s blinded to results of the other clinician’s procedure as well as the patient’s history.procedure as well as the patient’s history.

Methods/MaterialsMethods/Materials

Northern Italian System Northern Italian System Dr. Bull-Henry will describe the varicesDr. Bull-Henry will describe the varices there is no established grading system for there is no established grading system for

varices seen by pill endoscopy at this time. varices seen by pill endoscopy at this time.

Correlation to the EGD results determined Correlation to the EGD results determined in order to evaluate the pill’s efficacy in in order to evaluate the pill’s efficacy in variceal detection. variceal detection. Ultimate GoalUltimate Goal conduct a larger study if the results are conduct a larger study if the results are

statistically significant. statistically significant.

Reality Check!!Reality Check!!

Insurance would not Insurance would not cover both pill cover both pill endoscopy and EGD. endoscopy and EGD. Back to the drawing Back to the drawing board!!board!!

Patient SelectionPatient Selection

Patients with known cirrhotic Patients with known cirrhotic liver dzliver dzEGD performed by Dr. Lewis EGD performed by Dr. Lewis within the last 6 monthswithin the last 6 monthsPill endoscopy results to be Pill endoscopy results to be read by Dr. Bull-Henryread by Dr. Bull-Henry

N e w S n a g ! !N e w S n a g ! !

Dr. Lewis did not receive the 20 Dr. Lewis did not receive the 20 free pills as promised!free pills as promised!Working with Maria Bertagnolli Working with Maria Bertagnolli on finding funding!on finding funding!

In the meantime……..In the meantime……..

Prospective StudyProspective Study Dr. CharabatyDr. Charabaty VCE in the Crohn’s patientVCE in the Crohn’s patient

Case ReportCase Report WHCWHC Pancreatitis and PPIPancreatitis and PPI

CITATIONSCITATIONSDennis M Jensen. Dennis M Jensen. Endoscopic Screening for Varices in cirrhosis: findings, Endoscopic Screening for Varices in cirrhosis: findings, implications and Outcomes.implications and Outcomes. Gastroenterology 2002;122:1620-1630. Gastroenterology 2002;122:1620-1630.Saelan K. et al. Saelan K. et al. Unsedated Transnasal Endoscopy: a New Technique for Unsedated Transnasal Endoscopy: a New Technique for Accurately Detecting and Grading Esophageal Varices in Cirrhotic Patients.Accurately Detecting and Grading Esophageal Varices in Cirrhotic Patients. The American Journal of Gastroenterology Sept 2002; 97: 2246-2249.The American Journal of Gastroenterology Sept 2002; 97: 2246-2249.Rami Eliakim. Rami Eliakim. Wireless capsule video endoscopy: three years of Wireless capsule video endoscopy: three years of experience.experience. World J Gastroenterology 2004; 10(9): 1238-1239. World J Gastroenterology 2004; 10(9): 1238-1239.S.A.C. van Tuyl et al. S.A.C. van Tuyl et al. Video capsule endoscopy: procedure, indications and Video capsule endoscopy: procedure, indications and diagnostic yield.diagnostic yield. The Netherlands Journal of Medicine July 2004; The Netherlands Journal of Medicine July 2004; 62(7):225-228.62(7):225-228.Gastroenterology & Hepatology. Gastroenterology & Hepatology. Technology Insight: current status of video Technology Insight: current status of video capsule endoscopycapsule endoscopy. 2006 Mar;3(3):158-64 . 2006 Mar;3(3):158-64 Journal of Clinical GastroenterologyJournal of Clinical Gastroenterology. A Prospective Study of the Diagnostic . A Prospective Study of the Diagnostic Accuracy of PillCam ESO Esophageal Capsule Endoscopy Versus Accuracy of PillCam ESO Esophageal Capsule Endoscopy Versus Conventional Upper Endoscopy in Patients With Chronic Gastroesophageal Conventional Upper Endoscopy in Patients With Chronic Gastroesophageal Reflux Diseases August 2005; 39(7): 572-578.Reflux Diseases August 2005; 39(7): 572-578.