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RESEARCH MONTH

RESEARCH MONTH

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RESEARCH MONTH

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  1. RESEARCH MONTH Tamar Meszaros PGY-3 July 24, 2006

  2. Preparing for the Month • Find a mentor • Attending • Fellow • Find a Project • Topic • Case

  3. Research Project • Formulate a Question • Literature Search • Develop a Protocol • IRB Approval

  4. QUESTION Is Video Capsule Endoscopy a reasonable alternative to EGD in the detection of esophageal varices in the cirrhotic patient?

  5. The PillCam ESO Capsule Endoscope

  6. Relevant Q • Attractive alternative to EGD • Less risks • Coagulopathy • Encephalopathy with sedation • More comfortable • Few contraindications • To date, there is no published study showing it’s efficacy in the detection of esophageal varices.

  7. Esopahgeal Capsule Endoscopy • Prospective multicenter, international study • 66 of 106 patients had + esophageal findings • ECE identified esophageal abnormalities in 61 (sensitivity, 92%; specificity, 95%). • The per-protocol sensitivity, specificity, PPV, and NPV of ECE for Barrett esophagus were 97%, 99%, 97%, and 99%, respectively • Esophagitis 89%, 99%, 97%, and 94%, • ECE was preferred over EGD by all patients • No adverse events related to ECE. Journal of Clinical Gastroenterology. A Prospective Study of the Diagnostic Accuracy of PillCam ESO Esophageal Capsule Endoscopy Versus Conventional Upper Endoscopy in Patients With Chronic Gastroesophageal Reflux Diseases August 2005; 39(7): 572-578

  8. VCE in small bowel dz • Review articles from Israel & Netherlands • Wireless capsule video endoscopy: three years of experience • Video capsule endoscopy: procedure, indications and diagnostic yield. • More sensitive diagnostic tool than enteroscopy, CT and SBFT for small bowel disease.

  9. Alternatives • Some alternatives have been studied • Transnasal endoluminal ultrasound. • Compared transnasal endoscopy to EGD. • Concluded it to be a safe and good alternative. • Study was small. • No follow up studies to date. Saelan K. et al. Unsedated Transnasal Endoscopy: a New Technique for Accurately Detecting and Grading Esophageal Varices in Cirrhotic atients. The American Journal of Gastroenterology Sept 2002; 97: 2246-2249

  10. Background:Varices in the Cirrhotic • 2/3 of patients will develop varices. • Prevalence as high as eighty to ninety percent reported in newer studies. • The mortality rate after the first episode of bleeding is twenty to thirty five percent. Dennis M Jensen. Endoscopic Screening for Varices in cirrhosis: findings, implications and Outcomes. Gastroenterology 2002;122:1620-1630.

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

  12. Methods/Materials • Northern Italian System • Dr. Bull-Henry will describe the varices • there is no established grading system for varices seen by pill endoscopy at this time. • Correlation to the EGD results determined in order to evaluate the pill’s efficacy in variceal detection. • Ultimate Goal • conduct a larger study if the results are statistically significant.

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

  14. Patient Selection • Patients with known cirrhotic liver dz • EGD performed by Dr. Lewis within the last 6 months • Pill endoscopy results to be read by Dr. Bull-Henry

  15. New Snag!!

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

  17. In the meantime……..

  18. Prospective Study • Dr. Charabaty • VCE in the Crohn’s patient • Case Report • WHC • Pancreatitis and PPI

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