It is recommended that adult patients with portal hypertension (PH) undergo screening for varices, especially in order to prevent the complication of variceal hemorrhage. There is variably in PH management in children, often due to complicating factors such as a child’s smaller size. Capsule endoscopy, specifically the esophageal capsule (EC) that captures images on both ends of the capsule at a rapid frequency, has been used to assess for esophageal varices in adults. Although EC has no therapeutic ability, it can screen for variceal formation in patients without the requirement of anesthesia. Minimal data on EC use in children with portal hypertension is available, and the authors performed a single-center, retrospective study to assess the capability of EC for variceal screening in a specific pediatric population with PH.
A 12-year chart review occurred to identify children with a diagnosis of PH who had underwent screening using EC. Patients had to be able to swallow an EC, and children with prior abdominal surgery or pacemaker placement were excluded. Three models of EC capsules (PillCam ESO, PillCam ESO2, and PillCam UGI Capsule made by Given Imaging Ltd, Yoqneam, Israel/Medtronic) were utilized. After a patient swallowed the EC by standard protocol, esophageal varices were described in regards to esophageal location (proximal, mid, or distal esophagus) and size (small, medium, or large). The electronic medical record was reviewed on each included patient to determine various aspects including testing indications for PH as well as medication use. The clinical status for each patient was defined as compensated cirrhosis, decompensated cirrhosis (cirrhosis with complications such as ascites, encephalopathy, variceal hemorrhage, or hepatopulmonary syndrome), noncirrhotic portal hypertension, cardiac cirrhosis (such as from congenital heart failure), and suspected PH.
A total of 98 patients were included in the study (57.1% male), and 146 completed EC studies were performed. The average age at the time of EC was 16 years with a median interquartile range of 13.7 – 18.5 years. Compensated cirrhosis was present in 57% of patients; noncirrhotic portal hypertension was present in 19.5% of patients. EC was used as a screening modality in 66.5% of studies and for surveillance for known varices in 33.5% of patients. No portal hypertension changes were seen in 74 EC studies, and 64 EC studies demonstrated variceal formation (59 esophageal, 17 gastric, 6 duodenal). Other findings included blood flecks (23% of studies), erosions (22.5%), portal gastropathy (18.1%), esophagitis (14.5%), heterotopic tissue (9.4%), scarring from prior ligation (12.3%), and ulcer formation (3.6%). Most identified varices were in the esophagus (59 studies), specifically in the distal esophagus (56 studies), and most varices were described as small (40 studies). The authors noted that 12 of the EC studies led to new medication use while 11 esophagogastroduodenoscopies were performed as a result of EC studies (mostly esophageal variceal band placement). Finally, a total of 4 patients had an episode of GI bleeding within 1 year of their EC study; however, none of these patients had a bleeding event due to missed findings on EC.
This study demonstrated that EC is an effective screening and surveillance tool for varices in children with portal hypertension. The safety of EC use makes it a potential quick tool for determining variceal formation, and it has the potential to be used for screening / surveillance in children who cannot tolerate anesthesia.
Pai A, Jonas M, Fox V. Esophageal capsule endoscopy in children and young adults with portal hypertension. Journal of Pediatric Gastroenterology and Nutrition. 2019; 69: 641-647
John Pohl, M.D., Book Editor, is on the Editorial Board of Practical Gastroenterology