Update of endoscopy in liver disease: more than just treating varices

Abstract

The management of complications in liver disease is often complex and challenging. Endoscopy has undergone a period of rapid expansion with numerous novel and specialized endoscopic modalities that are of increasing value in the investigation and management of the patient with liver disease. In this review, relevant literature search and expert opinions have been used to provide a brief overview and update of the current endoscopic management of patients with liver disease and portal hypertension. The main areas covered are safety of endoscopy in patients with liver disease, the use of standard endoscopy for the treatment of varices and the role of new endoscopic modalities such as endoscopic ultrasound, esophageal capsule, argon plasma coagulation, spyglass and endomicroscopy in the investigation and treatment of liver-related gastrointestinal and biliary pathology. It is clear that the role of the endoscopy in liver disease is well beyond that of just treating varices. As the technology in endoscopy expands, so does the role of the endoscopist in liver disease.

Keywords: Cirrhosis; Endomicroscopy; Endoscopic retrograde cholangiopancreatography; Endoscopic ultrasound; Esophageal capsule; Portal hypertension; Spyglass; Varices.

Figure 1

Endoscopic images of fundic gastric varices before (A), during (B, C) and after (D) thrombin injection.

Figure 2

Endoscopic image. A: Gastric antral vascular ectasia (GAVE) (diffuse type) with active bleeding prior to argon plasma coagulation (APC) treatment; B: GAVE (diffuse type) immediately after APC treatment.

Figure 3

Endoscopic image. A: Gastric antral vascular ectasia-induced symptomatic anemia; B: Endoscopic image of the same patient 2 years later, after several argon plasma coagulation sessions. The number of angioectatic lesions in the gastric outlet had dramatically decreased.

Figure 4

Endoscopic image of gastric irregular submucosal lesion. A: Gastric irregular submucosal lesion in a patient with portal hypertension; B: The same lesion examined under color Doppler endoscopic ultrasound. The submucosal lesion was hypervascular and represented a gastric varix.

Figure 5

Color doppler endoscopic ultrasound image of duodenal varices after thrombin injection. The absence of blood flow and the speckled appearances were suggestive of thrombus formation.

Figure 6

Small bowel capsule image of portal hypertensive enteropathy and stigmata of recent bleeding. Engorged small bowel villi and micro-hemorrhagic spots were visible.

Figure 7

Small bowel capsule image of portal hypertensive enteropathy with snake-skin-like appearance of the mucosa and red spots as stigmata of recent bleeding.

Figure 8

Endomicroscopy image. A: Image from Cellvizio^® bile duct endomicroscopy. The regular reticular pattern of thin dark structures with low signal (dark) characterized the normal bile duct (Image courtesy of www. cellvizio.net); B: Abnormal bile duct appearances in Cellvizio^® endomicroscopy; isolated blood vessels with very strong signal (with strands) suggestive of tumor neovascularization of cholangiocarcinoma (Image courtesy of www.cellvizio.net); C: Reticular pattern of dark bands and dark clumps or glands suggestive of cholangiocarcinoma (Image courtesy of www.cellvizio.net).