“Bread & Butter” Issues in Endoscopy

1. “Bread & Butter” Issues in Endoscopy The New England Team Alain Ades, MD Steven Brandwein, MD Pamela Connors, MD Mark Lena, MD Jeffry Potash, MD Gary Shapiro, MD

2. “Bread & Butter” Issues in Endoscopy • Your favorite internist refers a 70 yo male who winters in Florida with iron deficiency anemia (HCT 25, MCV 71, Fe 9, TIBC 500 and 4.5% Fe saturation) • Recent evaluation in Florida included a normal EGD and Colon. • He initially responded to Iron theapy • Physical exam is normal, FOBT (-)

3. “Bread & Butter” Issues in Endoscopy • What is the next step in the evaluation? • When do you consider repeating either the EGD or the Colon? • What is the miss rate of for EGD or Colonoscopy? • What about missed AVM’s that could be treated? • What if you find a missed colon cancer?

4. “Bread & Butter” Issues in Endoscopy • 52yo WF referred for screening colonoscopy with longstanding chronic constipation and FOBT (-). • She has had two prior pelvic surgeries including a TAH/BSO and bladder suspension • No family history of colon cancer, breast, or pancreatic cancer • She asks about the alternatives having heard about virtual colonoscopy and the risks and benefits of colonoscopy.

5. “Bread & Butter” Issues in Endoscopy • Virtual colonoscopy: where, who, when, what about the radiation exposure • Colonoscopy risk? • Does her constipation have you choose an alternative preparation? • You pass the scope through the tortuous colon fixed by adhesions only to the level of the ICV with 50 % of the cecum seen. What now?

6. “Bread & Butter” Issues in Endoscopy • 62 yo male with a hx of two less than 1 cm adenomatous polyps removed 3yrs ago in Arizona. Pathology report confirms the polyps were adenomas. The patient has a significant family history of colon cancer with a father who died of metastatic colon cancer at age 75. He is otherwise well when does he need his next colonoscopy?

7. “Bread & Butter” Issues in Endoscopy • How do we determine the recall time? • How hard do we try to find them and get them back? • Is 10 years safe for EVERYBODY? • Have we been doing screening colonoscopy long enough to determine appropriate subsets?

8. “Bread & Butter” Issues in Endoscopy • 42 yo female with newly diagnosed crohn’s disease with small bowel fistula disease without abscess. Compliant with Pentasa 4 QID and on her second steroid taper with a flare of pain and diarrhea. • Did you have her sign an informed consent for steroids? • Did she glucose monitoring? • Did she have an eye exam given risk of cataract?

9. “Bread & Butter” Issues in Endoscopy • Does she need a bone density study? • Do you start calcium with vitamin D and/or biphosphonates? • What about budesonide? • When to begin immunosuppressants? • How about UP-FRONT remicade?

10. “Bread & Butter” Issues in Endoscopy • 85 yo male presents to ER at 9pm with melena for two days and new hematemesis • Hx of aortic stenosis and atrial fibrillation on coumadin for history of CVA. • BP 70/p, HR120, pale and diaphoretic • Initial hgb=6.5, INR 3.9 • EKG without ischemia

11. “Bread & Butter” Issues in Endoscopy • Fluid resuscitation, IV vitamin K, PRBC • ?FFP • IV PPI: IV Protonix 80mg bolus with 8mg/h drip only one really approved for certain acute upper GI bleeding; MGH using Prevacid 60mg bolus with 6mg/h drip but not approved yet. • IV H2RA: cost vs science • Prophylactic antibiotics • Timing of endoscopy • What methods do are being used to stop the bleed?

12. “Bread & Butter” Issues in Endoscopy • 52 yo male with longstanding history alcohol abuse present to ER with hematemesis and hypotension. • BP80/p, HR125 • Newly jaundiced according to his PMD, spiders and palmer erythema, no HSM, no ascites and no asterixis. • AST>ALT, TB 9.5, Hgb 10, MCV102 and INR 1.9

13. “Bread & Butter” Issues in Endoscopy • Transferred to the ICU and stabilized. • Does anyone intubate? • EGD reveals varices with stigmata of recent bleeding. • Band ligation • Injection sclerotherapy • Refractory bleeding: IV infusions • Blakemore tube • Beta-blockers • When do they come back for repeat treatment?

14. “Bread & Butter” Issues in Endoscopy • 50 yo female preparing for colonoscopy in the morning. Her friend called her today and said she had stopped her aspirin one week before her procedure. • Do we stop aspirin or NSAIDs prior to colonoscopy?

15. “Bread & Butter” Issues in Endoscopy • 77 yo male with history of mechanical mitral valve is scheduled for routine colonoscopy for history colon cancer. • How do we approach his anticoagulation pre and post procedure? • Who manages the medications: us, the PMD, or the Cardiologist.

16. “Bread & Butter” Issues in Endoscopy • 32 yo female with 12 year history of ulcerative colitis transfers her care to you. She is due for her screening colonoscopy. • She has mitral valve prolapse and you do not hear a murmur. • “My other gastroenterologist always gave me antibiotic treatment!”

17. “Bread & Butter” Issues in Endoscopy • ?CELIAC CASE

18. “Bread & Butter” Issues in Endoscopy • ENDOSCOPY QUALITIY ISSUES

19. “Bread & Butter” Issues in Endoscopy • 67 yo male referred due to a 10 pound weight loss and progressive dysphagia to solids • Smoked for 35 years quitting 2 years ago • Heavy alcohol in his thirties • What is the next test?

20. “Bread & Butter” Issues in Endoscopy • Directly to EGD? • Tight malignant appearing stricture in mid esophagus • Scope will not pass, but you can see the lumen • STAGING • EUS • STENTS • PEG tubes

22. “Bread & Butter” Issues in Endoscopy • Enteryx case