One-stop shop for variceal surveillance: integration of unsedated ultrathin endoscopy into the routine clinic visit.
cirrhosis
clinical decision making
endoscopy
health economics
oesophageal varices
Journal
Frontline gastroenterology
ISSN: 2041-4137
Titre abrégé: Frontline Gastroenterol
Pays: England
ID NLM: 101528589
Informations de publication
Date de publication:
2021
2021
Historique:
received:
17
09
2020
revised:
01
12
2020
accepted:
15
12
2020
entrez:
20
12
2021
pubmed:
21
12
2021
medline:
21
12
2021
Statut:
epublish
Résumé
The endoscopic appearance of oesophageal varices determines the need for prophylaxis. However, as the point prevalence of varices is low (25%), the majority of surveillance endoscopies are unnecessary and costly. Narrow diameter, ultrathin (UT) endoscopes are more tolerable than conventional upper gastrointestinal (UGI) endoscopes and can be used without sedation. We hypothesised that unsedated UT endoscopy for variceal surveillance could be implemented during the routine outpatient clinic visit allowing accurate diagnosis of varices and the timely provision of prophylaxis. Patients with cirrhosis awaiting surveillance endoscopy were identified. UT endoscopy was scheduled during routine clinic review at the same time as ultrasound surveillance for hepatocellular carcinoma. UGI endoscopy was performed unsedated using the E.G Scan II disposable endoscope. Varices were graded using the modified Paquet classification. Video recordings of procedures were reviewed by blinded assessors and agreement was assessed using the kappa statistic. 40 patients (80% male) underwent unsedated UT endoscopy. All procedures were successful and tolerated well in 98% of cases. Median procedure time was 2 min (IQR 1-3). Varices were found in 37.5% (17.5% grade 1 and 20% grade 2). Patients with grade 2 varices were prescribed non-selective beta blockers at the clinic appointment. Kappa statistic for the finding of any varices was 0.636 (p=0.001) and 0.8-1.0 for diagnosis of grade 2 varices (p<0.0001). Outpatient unsedated ultrathin endoscopy in patients with cirrhosis is accurate, safe and feasible. This integrative care model is convenient, particularly for regional communities, and is likely to result in significant cost savings associated with variceal surveillance.
Sections du résumé
BACKGROUND
BACKGROUND
The endoscopic appearance of oesophageal varices determines the need for prophylaxis. However, as the point prevalence of varices is low (25%), the majority of surveillance endoscopies are unnecessary and costly. Narrow diameter, ultrathin (UT) endoscopes are more tolerable than conventional upper gastrointestinal (UGI) endoscopes and can be used without sedation. We hypothesised that unsedated UT endoscopy for variceal surveillance could be implemented during the routine outpatient clinic visit allowing accurate diagnosis of varices and the timely provision of prophylaxis.
METHODS
METHODS
Patients with cirrhosis awaiting surveillance endoscopy were identified. UT endoscopy was scheduled during routine clinic review at the same time as ultrasound surveillance for hepatocellular carcinoma. UGI endoscopy was performed unsedated using the E.G Scan II disposable endoscope. Varices were graded using the modified Paquet classification. Video recordings of procedures were reviewed by blinded assessors and agreement was assessed using the kappa statistic.
RESULTS
RESULTS
40 patients (80% male) underwent unsedated UT endoscopy. All procedures were successful and tolerated well in 98% of cases. Median procedure time was 2 min (IQR 1-3). Varices were found in 37.5% (17.5% grade 1 and 20% grade 2). Patients with grade 2 varices were prescribed non-selective beta blockers at the clinic appointment. Kappa statistic for the finding of any varices was 0.636 (p=0.001) and 0.8-1.0 for diagnosis of grade 2 varices (p<0.0001).
CONCLUSIONS
CONCLUSIONS
Outpatient unsedated ultrathin endoscopy in patients with cirrhosis is accurate, safe and feasible. This integrative care model is convenient, particularly for regional communities, and is likely to result in significant cost savings associated with variceal surveillance.
Identifiants
pubmed: 34925746
doi: 10.1136/flgastro-2020-101680
pii: flgastro-2020-101680
pmc: PMC8640389
doi:
Types de publication
Journal Article
Langues
eng
Pagination
545-549Informations de copyright
© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.
Déclaration de conflit d'intérêts
Competing interests: None declared.
Références
Hepatology. 2016 Jun;63(6):1968-76
pubmed: 26599983
Gastroenterol Clin Biol. 1989 Dec;13(12):967-73
pubmed: 2696663
Hepatology. 1990 Mar;11(3):341-7
pubmed: 2312048
J Clin Gastroenterol. 2017 Feb;51(2):174-182
pubmed: 27548729
J Hepatol. 2016 Nov;65(5):899-905
pubmed: 27388923
Aliment Pharmacol Ther. 2019 Jun;49(12):1464-1473
pubmed: 31059160
Gastroenterology. 2003 Dec;125(6):1606-12
pubmed: 14724812
World J Gastroenterol. 2007 Feb 14;13(6):906-11
pubmed: 17352021
Gut. 1992 Oct;33(10):1381-5
pubmed: 1446864
Arch Intern Med. 2010 Oct 25;170(19):1752-7
pubmed: 20975024
J Hepatol. 2015 Sep;63(3):743-52
pubmed: 26047908
Dig Liver Dis. 2006 Dec;38(12):899-904
pubmed: 17005458
J Gastroenterol Hepatol. 1998 Jun;13(6):579-84
pubmed: 9715399
Gastrointest Endosc. 2017 Jun;85(6):1212-1217
pubmed: 27894929
Hepatology. 1997 Jun;25(6):1346-50
pubmed: 9185751
Clin Liver Dis. 1997 May;1(1):31-44, x
pubmed: 15562666
Lancet. 2003 Mar 15;361(9361):952-4
pubmed: 12648985