Bleeding from esophageal varices (EV) is a serious consequence of portal hypertension. Current guidelines recommend screening patients with cirrhosis with esophagogastroduodenoscopy (EGD) to detect varices. However, the unpleasantness and need for sedation of EGD may limit adherence to screening programs. Pilot studies have shown good performance of esophageal capsule endoscopy in detecting varices. This multicenter trial was designed to assess the diagnostic performance of capsule endoscopy in comparison with EGD. Patients undergoing EGD for screening or surveillance of EV underwent a capsule study previously. The study was designed as an equivalence study, assuming that a difference of <10% between capsule endoscopy and EGD in diagnosing EV would demonstrate equivalence. Two hundred eighty-eight patients were enrolled. Endoscopy was for screening in 195 patients and for surveillance of known EV in 93. Overall agreement for detecting EV between EGD and capsule endoscopy was 85.8%; the kappa score was 0.73. Capsule endoscopy had a sensitivity, specificity, positive predictive value, and negative predictive value of 84%, 88%, 92%, and 77%, respectively. The difference in diagnosing EV was 15.6% in favor of EGD. There was complete agreement on variceal grade in 227 of 288 cases (79%). In differentiating between medium/large varices requiring treatment and small/ absent varices requiring surveillance, the sensitivity, specificity, positive predictive value, and negative predictive value for capsule endoscopy were 78%, 96%, 87%, and 92%, respectively. Overall agreement on treatment decisions based on EV size was substantial at 91% (kappa ‫؍‬ 0.77). Conclusion: We recommend that EGD be used to screen patients with cirrhosis for large EV. However, the minimal invasiveness, good tolerance, and good agreement of capsule endoscopy with EGD might increase adherence to screening programs. Whether this is the case needs to be determined. (HEPATOLOGY 2008;47:1595-1603 See Editorial on Page 1434 T he average risk of variceal bleeding in unselected populations of patients with cirrhosis with esophageal varices is about 25%. 1 Such bleeding carries a mortality of 10%-20% within 6 weeks of the bleeding episode. [2][3][4] The risk of bleeding is related to the size of varices, the presence of "red signs" on varices, and the degree of liver insufficiency as evaluated by the ChildPugh score. 5 Because nonselective beta blockers and band ligation decrease the relative risk of bleeding by about 50% in patients with medium or large varices, 1,6 practice guide-

ERCP and EUS are complementary techniques in the management of biliary and pancreatic diseases. Combination of these two techniques can reach different levels of complexity with increasing rates of adverse events. In this article we propose a categorization of the relationship between EUS and ERCP based on whether EUS indicates, complements, facilitates or replaces ERCP. It has implications for the complexity of the technique, the training of the endoscopist and the necessary hospital resources. This classification can also be useful in planning endoscopist training and patient management.

In our series, an AD was found on upper endosonography in 38.5% of the patients studied, and a SAD in 11.3%. The probability of finding a SAD on EUS is not influenced by previous endoscopic or radiologic explorations.

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