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CME Activity: Continuing Medical Education Exam: July 2008
CME ACTIVITY
Continuing Medical Education Exam: July 2008 Todd H. Baron, MD, Brenna C. Bounds, MD, Robert Sedlack, MD, Allan P. Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Test ID no.: gie043
Expiration date: December 31, 2008
Category 1 credit can be earned by reading the text material and taking this CME examination online. For complete instructions, visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (non-members).
Target Audience: This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning: After evaluating specific articles published in GIE: Gastrointestinal Endoscopy, participants in the journal’s CME activity should be able to demonstrate an increase in, or affirmation of, their knowledge of clinical endoscopic medicine. Participants should be able to evaluate the appropriateness of the clinical information as it applies to patient care.
What should we expect after radiofrequency ablation of Barrett’s esophagus? Question 1: A 65-year-old man is referred to you for ablation of a 5-cm Barrett’s esophagus (BE) containing high-grade dysplasia (HGD). After explaining the procedure, risks, benefits, and alternatives, endoscopic radiofrequency ablation is undertaken. Figure 1 shows the ablated Barrett’s mucosa at the end of the procedure. The patient is instructed to undergo follow-up endoscopy in 3 months. What is the most likely outcome at 1 year after BE ablation?
Possible answers (A-D) A. Complete elimination of HGD in 100% of cases B. Complete elimination of intestinal metaplasia in 100% of cases C. Complete elimination of HGD in 90% of cases D. Complete elimination of intestinal metaplasia in 90% of cases
Figure 1.
Look-up: Ganz RA, Overholt BF, Sharma VK, et al. Circumferential ablation of Barrett’s esophagus that contains high-grade dysplasia: a U.S. multicenter registry. Gastrointest Endosc 2008;68:35-40.
www.giejournal.org
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 111
CME Exam
How to evaluate patients with postcholecystectomy pain Question 2:
Possible answers (A-D)
You are asked to evaluate a 34-year-old woman with postcholecystectomy right upper quadrant abdominal pain. The surgical specimen reveals chronic cholecystitis, without gallbladder stones. Abdominal US, liver and pancreatic enzymes, and an endoscopy show normal results both before and after her surgery. What do you recommend next to the patient?
A. ERCP B. ERCP with empiric biliary sphincterotomy C. ERCP with bile crystal analysis D. ERCP with SOD manometry
Look-up: Okoro N, Patel A, Goldstein M, et al. Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis. Gastrointest Endosc 2008;68:69-74.
How good is outpatient ERCP? Question 3:
Possible answers (A-D)
You have just initiated a program of same-day discharge of patients after ERCP. A 35-year-old woman undergoes biliary sphincterotomy with removal of common bile duct (CBD) stones. Thirty minutes after the procedure, she is awake and feels fine. The recovery room nurse calls you regarding the timing of her discharge to home. What is the best time to discharge this patient home?
A. Immediately B. After 2 hours C. After 4 hours D. After 8 hours
Look-up: Jeurnink SM, Poley JW, Steyerberg EW, et al. ERCP as an outpatient treatment: a review. Gastrointest Endosc 2008;68:118-23.
Unexpected video capsule retention Question 4: You perform video capsule endoscopy (VCE) on a 75-year-old retired nurse presenting with obscure GI bleeding. She has had no symptoms suggestive of partial small-bowel obstruction, and she is not using nonsteroidal anti-inflammatory drugs (NSAIDs). The capsule enters the small intestine at 1 hour, is delayed, and captures the image shown in Figure 2 at 6 hours. The capsule fails to enter the colon. What is the diagnosis?
Possible answers (A-D) A. Lipoma B. NSAID-induced ulcer with diaphragm disease C. Ischemic stricture D. Carcinoid tumor Figure 2. Look-up: Li F, Gurudu SR, De Petris G, et al. Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures. Gastrointest Endosc 2008;68:174-180.
112 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: July 2008 QUESTION 1: CORRECT RESPONSE: C Rationale for correct response: BE and HGD can be ablated by using either photodynamic therapy (PDT) or radiofrequency ablation. The latter approach is attractive because it avoids deep injury that is frequently seen with PDT. Either circumferential or focal radiofrequency ablation can be achieved by using the recently introduced HALO360 system or the HALO90 ablation catheters, respectively. In a U.S. multicenter registry study, 142 patients with BE and HGD were treated with radiofrequency ablation. Twentyfour of those patients (17%) had an EMR performed before the radiofrequency ablation. There were no serious adverse events reported during 229 total ablation sessions, with the exception of 1 patient who developed an asymptomatic esophageal stricture.1 During a median follow-up period of 12 months, the postablation endoscopy esophageal biopsy sepciments for 92 patients revealed the following findings: 1. 10% of patients had HGD. 2. 10% of patients had LGD. 3. 46% of patients had residual nondysplastic intestinal metaplasia. Take-home point: Radiofrequency ablation has an excellent safety profile and a very promising 1- year efficacy in eliminating BE and HGD. REFERENCE: 1. Ganz RA, Overholt BF, Sharma VK, et al. Circumferential ablation of Barrett’s esophagus that contains high-grade dysplasia: a U.S. multicenter registry. Gastrointest Endosc 2008;68:35-40.
QUESTION 2: CORRECT RESPONSE: D Rational for correct response: Postcholecystectomy pain occurs in 25% of patients undergoing cholecystectomy for cholelithiasis and in 50% of patients with no obvious stone disease.1,2 Sources for such pain include chronic pancreatitis, peptic ulcer disease, retained common bile duct stone, sphincter of Oddi dysfunction (SOD), and the often overlooked myofascial abdominal wall pain. In this patient, liver and pancreatic enzymes, abdominal US, and endoscopy showed normal results before and after surgery, excluding the possibilities of gallstones, ulcers, pancreatitis, and SOD type I and II. SOD type III is still a possibility in this patient, but guidelines strongly suggest against ERCP in these patients because the procedure risks far outweigh potential benefits. However, if undertaken, SOD manometry should be included in such an evaluation.3 In a prospective randomized trial of 12 patients with postcholecystectomy pain and bile crystals, pain significantly improved or resolved after ursodeoxycholic acid treatment, 300 mg by mouth twice each day for about 6 months.4 Whether this medical management could be included in clinical practice is not clear because the data are limited and preliminary. Myofascial pain should be kept in mind when managing these patients, and a detailed abdominal reexamination with trigger point injection therapy or the use of neuromodulating agents (including low-dose tricyclic antidepressants, duloxetine, or gabapentin) should be considered. REFERENCES: 1. Ahmed F, Sherman S. Should patients with biliary-type pain after cholecystectomy be evaluated for microlithiasis? Gastrointest Endosc 2008;68:75-7. 2. Fenster F, Longborg R, Thirlby R, et al. What symptoms does cholecystectomy cure? Insights from an outcomes measurement and review of the literature. Am J Surg 1995;169:533-8. 3. Cohen S, Bacon BR, Berlin JA, et al. National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy, January 1416, 2002. Gastrointest Endosc 2002;56:803-9. 4. Okoro N, Patel A, Goldstein M, et al. Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis. Gastrointest Endosc 2008;68:69-74.
www.giejournal.org
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 113
CME Answers
QUESTION 3: CORRECT RESPONSE: C Rationale for correct response: Patients undergoing outpatient ERCP need at least 4 hours of observation before their discharge home, in contrast to the shorter observation of patients undergoing screening endoscopy or colonoscopy. Outpatient ERCP has been performed for about 20 years and appears to be safe and cost effective, even in those patients undergoing uncomplicated pseudocyst drainage.1-2 In a recent review of 2483 patients undergoing ERCP as an outpatient procedure, complications occurred in 7% of patients, of which 72% presented within 2 to 6 hours, 10% within 6 to 24 hours, and 18% more than 24 hours after ERCP.3 Hence, most complications will be identified and managed during the 4-hour observation period. Based on this data, one could consider developing a discharge protocol for patients undergoing ERCP as an outpatient procedure. Patients who are in relatively good health (ASA class I or II) who have corrected coagulopathy, who are not at increased risk for post-ERCP complications (ie, previous history of pancreatitis, SOD, or difficult cannulation), who stay within a 30-minute driving distance from the hospital, and who are escorted by a driver could be discharged after 4 hours of observation. It is critical that the endoscopist see these patients and confirm that they are pain-free before discharge. Take-home point: Outpatient ERCP is safe and cost effective in selected patients. REFERENCES: 1. Pfau PR. Outpatient ERCP—everybody is doing it: does this make it right? Gastrointest Endosc 2008;68:124-6. 2. Gibbs CM, Baron TH. Outcome following endoscopic transmural drainage of pancreatic fluid collections in outpatients. J Clin Gastroenterol 2005;39: 634-7. 3. Jeurnink SM, Poley JW, Steyerberg EW, et al. ERCP as an outpatient treatment: a review. Gastrointest Endosc 2008;68:118-23.
QUESTION 4: CORRECT RESPONSE: B Rationale for correct response: Counseling about capsule retention should be part of the consent process. Appropriate steps to address the issue should be discussed with every patient before capsule endoscopy. The postprocedure protocol setup at the Mayo Clinic Scottsdale for patients undergoing capsule endoscopy serves as a useful guide for others to incorporate into their practice (Table 1). TABLE 1. Postprocedure protocol setup at the Mayo Clinic Scottsdale for patients undergoing capsule endoscopy Based on the capsule endoscopy video findings, the following steps could be undertaken: 1. Capsule enters the colon: no further action is needed. 2. Capsule does not enter the colon: call the patient and question about capsule expulsion. a. Capsule expulsion not witnessed: Get an abdominal radiograph on day 14 after the study. 1. Capsule retained: Get serial radiographs to confirm capsule expulsion. Once the capsule retention is confirmed, get a surgical consult for further management. In a retrospective study of 1000 patients, capsule retention occurred in 1.4% of patients. The most common cause was NSAID enteropathy (diaphragm disease, 11 patients), as shown in Figure 2. Some of the patients with NSAID enteropathy may have had exposure to NSAIDs in the remote past. Carcinoid tumor and metastatic ovarian cancer accounted for the remaining cases. All patients remained asymptomatic from the retained capsules. Thirteen patients underwent elective, partial small–bowel resection and capsule removal, with prompt recovery in 11 patients and mild postoperative ileus in 2 patients. There was no mortality associated with surgery.1 Take-home point: NSAID enteropathy is an important cause of capsule retention. A clear-cut protocol helps management. REFERENCE: 1. Li F, Gurudu SR, De Petris G, et al. Retention of the capsule endoscope: a single center experience of 1000 capsule endoscopy procedures. Gastrointest Endosc 2008;68:174-80.
114 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
www.giejournal.org
Continuing Medical Education Exam: July 2008 Todd H. Baron, MD, Brenna C. Bounds, MD, Robert Sedlack, MD, Allan P. Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Test ID no.: gie043
Expiration date: December 31, 2008
Category 1 credit can be earned by reading the text material and taking this CME examination online. For complete instructions, visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (non-members).
Target Audience: This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning: After evaluating specific articles published in GIE: Gastrointestinal Endoscopy, participants in the journal’s CME activity should be able to demonstrate an increase in, or affirmation of, their knowledge of clinical endoscopic medicine. Participants should be able to evaluate the appropriateness of the clinical information as it applies to patient care.
What should we expect after radiofrequency ablation of Barrett’s esophagus? Question 1: A 65-year-old man is referred to you for ablation of a 5-cm Barrett’s esophagus (BE) containing high-grade dysplasia (HGD). After explaining the procedure, risks, benefits, and alternatives, endoscopic radiofrequency ablation is undertaken. Figure 1 shows the ablated Barrett’s mucosa at the end of the procedure. The patient is instructed to undergo follow-up endoscopy in 3 months. What is the most likely outcome at 1 year after BE ablation?
Possible answers (A-D) A. Complete elimination of HGD in 100% of cases B. Complete elimination of intestinal metaplasia in 100% of cases C. Complete elimination of HGD in 90% of cases D. Complete elimination of intestinal metaplasia in 90% of cases
Figure 1.
Look-up: Ganz RA, Overholt BF, Sharma VK, et al. Circumferential ablation of Barrett’s esophagus that contains high-grade dysplasia: a U.S. multicenter registry. Gastrointest Endosc 2008;68:35-40.
www.giejournal.org
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 111
CME Exam
How to evaluate patients with postcholecystectomy pain Question 2:
Possible answers (A-D)
You are asked to evaluate a 34-year-old woman with postcholecystectomy right upper quadrant abdominal pain. The surgical specimen reveals chronic cholecystitis, without gallbladder stones. Abdominal US, liver and pancreatic enzymes, and an endoscopy show normal results both before and after her surgery. What do you recommend next to the patient?
A. ERCP B. ERCP with empiric biliary sphincterotomy C. ERCP with bile crystal analysis D. ERCP with SOD manometry
Look-up: Okoro N, Patel A, Goldstein M, et al. Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis. Gastrointest Endosc 2008;68:69-74.
How good is outpatient ERCP? Question 3:
Possible answers (A-D)
You have just initiated a program of same-day discharge of patients after ERCP. A 35-year-old woman undergoes biliary sphincterotomy with removal of common bile duct (CBD) stones. Thirty minutes after the procedure, she is awake and feels fine. The recovery room nurse calls you regarding the timing of her discharge to home. What is the best time to discharge this patient home?
A. Immediately B. After 2 hours C. After 4 hours D. After 8 hours
Look-up: Jeurnink SM, Poley JW, Steyerberg EW, et al. ERCP as an outpatient treatment: a review. Gastrointest Endosc 2008;68:118-23.
Unexpected video capsule retention Question 4: You perform video capsule endoscopy (VCE) on a 75-year-old retired nurse presenting with obscure GI bleeding. She has had no symptoms suggestive of partial small-bowel obstruction, and she is not using nonsteroidal anti-inflammatory drugs (NSAIDs). The capsule enters the small intestine at 1 hour, is delayed, and captures the image shown in Figure 2 at 6 hours. The capsule fails to enter the colon. What is the diagnosis?
Possible answers (A-D) A. Lipoma B. NSAID-induced ulcer with diaphragm disease C. Ischemic stricture D. Carcinoid tumor Figure 2. Look-up: Li F, Gurudu SR, De Petris G, et al. Retention of the capsule endoscope: a single-center experience of 1000 capsule endoscopy procedures. Gastrointest Endosc 2008;68:174-180.
112 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: July 2008 QUESTION 1: CORRECT RESPONSE: C Rationale for correct response: BE and HGD can be ablated by using either photodynamic therapy (PDT) or radiofrequency ablation. The latter approach is attractive because it avoids deep injury that is frequently seen with PDT. Either circumferential or focal radiofrequency ablation can be achieved by using the recently introduced HALO360 system or the HALO90 ablation catheters, respectively. In a U.S. multicenter registry study, 142 patients with BE and HGD were treated with radiofrequency ablation. Twentyfour of those patients (17%) had an EMR performed before the radiofrequency ablation. There were no serious adverse events reported during 229 total ablation sessions, with the exception of 1 patient who developed an asymptomatic esophageal stricture.1 During a median follow-up period of 12 months, the postablation endoscopy esophageal biopsy sepciments for 92 patients revealed the following findings: 1. 10% of patients had HGD. 2. 10% of patients had LGD. 3. 46% of patients had residual nondysplastic intestinal metaplasia. Take-home point: Radiofrequency ablation has an excellent safety profile and a very promising 1- year efficacy in eliminating BE and HGD. REFERENCE: 1. Ganz RA, Overholt BF, Sharma VK, et al. Circumferential ablation of Barrett’s esophagus that contains high-grade dysplasia: a U.S. multicenter registry. Gastrointest Endosc 2008;68:35-40.
QUESTION 2: CORRECT RESPONSE: D Rational for correct response: Postcholecystectomy pain occurs in 25% of patients undergoing cholecystectomy for cholelithiasis and in 50% of patients with no obvious stone disease.1,2 Sources for such pain include chronic pancreatitis, peptic ulcer disease, retained common bile duct stone, sphincter of Oddi dysfunction (SOD), and the often overlooked myofascial abdominal wall pain. In this patient, liver and pancreatic enzymes, abdominal US, and endoscopy showed normal results before and after surgery, excluding the possibilities of gallstones, ulcers, pancreatitis, and SOD type I and II. SOD type III is still a possibility in this patient, but guidelines strongly suggest against ERCP in these patients because the procedure risks far outweigh potential benefits. However, if undertaken, SOD manometry should be included in such an evaluation.3 In a prospective randomized trial of 12 patients with postcholecystectomy pain and bile crystals, pain significantly improved or resolved after ursodeoxycholic acid treatment, 300 mg by mouth twice each day for about 6 months.4 Whether this medical management could be included in clinical practice is not clear because the data are limited and preliminary. Myofascial pain should be kept in mind when managing these patients, and a detailed abdominal reexamination with trigger point injection therapy or the use of neuromodulating agents (including low-dose tricyclic antidepressants, duloxetine, or gabapentin) should be considered. REFERENCES: 1. Ahmed F, Sherman S. Should patients with biliary-type pain after cholecystectomy be evaluated for microlithiasis? Gastrointest Endosc 2008;68:75-7. 2. Fenster F, Longborg R, Thirlby R, et al. What symptoms does cholecystectomy cure? Insights from an outcomes measurement and review of the literature. Am J Surg 1995;169:533-8. 3. Cohen S, Bacon BR, Berlin JA, et al. National Institutes of Health State-of-the-Science Conference Statement: ERCP for diagnosis and therapy, January 1416, 2002. Gastrointest Endosc 2002;56:803-9. 4. Okoro N, Patel A, Goldstein M, et al. Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis. Gastrointest Endosc 2008;68:69-74.
www.giejournal.org
Volume 68, No. 1 : 2008 GASTROINTESTINAL ENDOSCOPY 113
CME Answers
QUESTION 3: CORRECT RESPONSE: C Rationale for correct response: Patients undergoing outpatient ERCP need at least 4 hours of observation before their discharge home, in contrast to the shorter observation of patients undergoing screening endoscopy or colonoscopy. Outpatient ERCP has been performed for about 20 years and appears to be safe and cost effective, even in those patients undergoing uncomplicated pseudocyst drainage.1-2 In a recent review of 2483 patients undergoing ERCP as an outpatient procedure, complications occurred in 7% of patients, of which 72% presented within 2 to 6 hours, 10% within 6 to 24 hours, and 18% more than 24 hours after ERCP.3 Hence, most complications will be identified and managed during the 4-hour observation period. Based on this data, one could consider developing a discharge protocol for patients undergoing ERCP as an outpatient procedure. Patients who are in relatively good health (ASA class I or II) who have corrected coagulopathy, who are not at increased risk for post-ERCP complications (ie, previous history of pancreatitis, SOD, or difficult cannulation), who stay within a 30-minute driving distance from the hospital, and who are escorted by a driver could be discharged after 4 hours of observation. It is critical that the endoscopist see these patients and confirm that they are pain-free before discharge. Take-home point: Outpatient ERCP is safe and cost effective in selected patients. REFERENCES: 1. Pfau PR. Outpatient ERCP—everybody is doing it: does this make it right? Gastrointest Endosc 2008;68:124-6. 2. Gibbs CM, Baron TH. Outcome following endoscopic transmural drainage of pancreatic fluid collections in outpatients. J Clin Gastroenterol 2005;39: 634-7. 3. Jeurnink SM, Poley JW, Steyerberg EW, et al. ERCP as an outpatient treatment: a review. Gastrointest Endosc 2008;68:118-23.
QUESTION 4: CORRECT RESPONSE: B Rationale for correct response: Counseling about capsule retention should be part of the consent process. Appropriate steps to address the issue should be discussed with every patient before capsule endoscopy. The postprocedure protocol setup at the Mayo Clinic Scottsdale for patients undergoing capsule endoscopy serves as a useful guide for others to incorporate into their practice (Table 1). TABLE 1. Postprocedure protocol setup at the Mayo Clinic Scottsdale for patients undergoing capsule endoscopy Based on the capsule endoscopy video findings, the following steps could be undertaken: 1. Capsule enters the colon: no further action is needed. 2. Capsule does not enter the colon: call the patient and question about capsule expulsion. a. Capsule expulsion not witnessed: Get an abdominal radiograph on day 14 after the study. 1. Capsule retained: Get serial radiographs to confirm capsule expulsion. Once the capsule retention is confirmed, get a surgical consult for further management. In a retrospective study of 1000 patients, capsule retention occurred in 1.4% of patients. The most common cause was NSAID enteropathy (diaphragm disease, 11 patients), as shown in Figure 2. Some of the patients with NSAID enteropathy may have had exposure to NSAIDs in the remote past. Carcinoid tumor and metastatic ovarian cancer accounted for the remaining cases. All patients remained asymptomatic from the retained capsules. Thirteen patients underwent elective, partial small–bowel resection and capsule removal, with prompt recovery in 11 patients and mild postoperative ileus in 2 patients. There was no mortality associated with surgery.1 Take-home point: NSAID enteropathy is an important cause of capsule retention. A clear-cut protocol helps management. REFERENCE: 1. Li F, Gurudu SR, De Petris G, et al. Retention of the capsule endoscope: a single center experience of 1000 capsule endoscopy procedures. Gastrointest Endosc 2008;68:174-80.
114 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 1 : 2008
www.giejournal.org