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Utility of endoscopic procedures in the evaluation of liver transplant candidates
Presented by: John J. DeGuide, MD
Affiliation: Wilford Hall Medical Center, Lackland AFB, Texas
Although hundreds of patients undergo liver transplants each year in the US, there is still considerable controversy over the best way to determine if these patients have underlying problems that may affect their post-surgical outcome.
Dr. DeGuide and his colleagues wanted to determine if the routine endoscopic evaluation of patients undergoing liver transplant could detect abnormalities that may affect their candidacy or pre-transplant management. Because there is a critical shortage of donor organs, it is important to be able to optimize the outcome of liver transplantation. Obviously, poorer outcomes occur in more severely ill patients, and endoscopy might identify gastrointestinal lesions that may complicate recovery following transplant.Patients who were referred to Dr. DeGuide’s clinic for as candidates for liver transplantation underwent routine esophagogastroduodenoscopy (EGD) if this had not been performed in the previous 6 months. Colonoscopy (CSP) was also performed in patients who were over the age of 50 years, anemic, or if there was a history of colonic pathology or gastrointestinal hemorrhage. 118 adults were evaluated during 1995. None had symptoms that suggested the presence of active gastrointestinal disease. The average age was 49 years; liver disease was alcohol-related in 36% of the patients, related to chronic hepatitis B and C infection in 27%, and due to a mix of other etiologies in the remaining patients. EGD was performed in 74 patients.
Endoscopy identified a variety of gastrointestinal lesions including esophageal varices (EV) in 47 patients, portal hypertensive gastropathy in 21, gastric ulcers in 7 and duodenal ulcers in 3. Gastric varices were discovered in 7 patients. Variceal sclerotherapy or ligation was performed in 9 patients. Beta-blocker therapy was started in 26 patients with EV. One patient was found to have esophageal and gastric cancer. This relatively high incidence of pathology could have been related to the fact that more than one-third of the patients had a history of alcohol abuse.
Colonoscopy was performed in 56 patients. Adenomatous polyps were discovered in 24 patients and polypectomy was done in 21. One patient was found to have colon cancer and one with ulcerative colitis underwent colectomy because of the discovery of a space-occupying lesion. Inflammatory bowel disease was found in 3 patients. Most significantly, 44% of the procedures performed led to a change in patient management.
For example, three patients were precluded from receiving a liver transplant because of the presence of a malignancy.
Dr. DeGuide concluded that performing endoscopy in patients who are candidates for liver transplantation, frequently reveals important abnormalities and otherwise unrecognized underlying diseases that could significantly impact patient management.
