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““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
The New England TeamAlain Ades, MD
Steven Brandwein, MD
Pamela Connors, MD
Mark Lena, MD
Jeffry Potash, MD
Gary Shapiro, MD
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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 theapyPhysical exam is normal, FOBT (-)
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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.
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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 diaphoreticInitial hgb=6.5, INR 3.9EKG without ischemia
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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.
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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!”
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
67 yo male referred due to a 10 pound weight loss and progressive dysphagia to solids
Smoked for 35 years quitting 2 years agoHeavy alcohol in his thirtiesWhat is the next test?
““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy
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