- Email: [email protected]
Continuing Medical Education Exam: July 2014
GIE
TM
CME ACTIVITY
Continuing Medical Education Exam: July 2014 James Buxbaum, MD, William Ross, MD, Shou-Jiang Tang, MD, Brian Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section Glenn M. Eisen, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Siao D, Sewell J, Day L. Assessment of delivery methods used in the informed consent process at a safety-net hospital. Gastrointest Endosc 2014;80;61-8. Weilert F, Bhat YM, Binmoeller KF, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study. Gastrointest Endosc 2014;80:97-104. Shinozaki S, Yamamoto H, Yano T, et al. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by double-balloon endoscopy. Gastrointest Endosc 2014;80:112-7. Gleeson FC, Levy M, Dozois E, et al. Endoscopically identified well-differentiated rectal carcinoid tumors: impact of tumor size on the natural history and outcomes. Gastrointest Endosc 2014;80:144-51. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives Upon completion of this educational activity, participants will be able to: 1. Assess the methods of delivery of informed consent. 2. Compare EUS-FNA versus ERCP-based tissue sampling in evaluating suspected malignant biliary obstruction. 3. Demonstrate endoscopic management of GI bleeding secondary to small-intestine vascular lesions. 4. Explain how to manage rectal carcinoid tumors.
Continuing Medical Education The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditÔ. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity Start Date: July 1, 2014 Activity Expiration Date: July 31, 2016
Disclosures Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: G. S. Raju, MD, FASGE (Associate Editor for Journal CME): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus Shou-Jiang Tang, MD (CME Editor): James Buxbaum, MD (CME Editor): Disclosed no relevant financial relationships. Disclosed no relevant financial relationships. Brian Weston, MD (CME Editor): Disclosed no relevant financial relationships. All CME activities, including their associated articles are copyrighted by the ASGE. Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh) Windows 95,98,2000, NT or Mac OS Netscape 4. or Microsoft Internet Explorer 4. and above 16 MB RAM 56.6K modem
152 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: July 2014 QUESTION 1 OBJECTIVE: Assess the methods of delivery of informed consent.
How to consent patients! Question 1: A 64-year-old man with intermittent rectal bleeding is referred for colonoscopy at a safety net health center. He is a recent immigrant from China, has limited financial resources, and speaks only Cantonese. Which of the following is most accurate regarding the informed consent process for this patient?
Possible answers: (A-D) A. Given language limitations, the informed consent process should focus on the risks of colonoscopy including perforation in lieu of a detailed discussion of procedure indications and alternatives.
B. He is more likely to recall key components of the informed consent such as procedure indications, alternatives, and risks if the process is performed as part of a multilingual group education class C. He is less likely to remember specific details of the upcoming procedure if the informed consent process is performed as part of a class with 20 other patients. D. The patient is more likely to be satisfied with the informed consent discussion if it is done in the clinic with a physician as opposed to a teaching class led by a nurse practitioner.
Look-up: Siao D, Sewell J, Day L. Assessment of delivery methods used in the informed consent process at a safety-net hospital. Gastrointest Endosc 2014;80:61-8.
QUESTION 2 OBJECTIVE: Compare EUS-FNA versus ERCP-based tissue sampling in evaluating suspected malignant biliary obstruction.
EUS-FNA versus ERCP-based tissue sampling in evaluating suspected malignant biliary obstruction Question 2:
Possible answers: (A-D)
A 60-year-old woman is seen for evaluation of jaundice and weight loss. Abdominal CT shows a dilated common bile duct and main pancreatic duct with an ill-defined pancreatic head mass. No metastatic disease is appreciated. Which of the following is the best method to establish a tissue diagnosis?
A. B. C. D.
ERCP with bile duct brushing ERCP with bile duct brushing and intraductal biopsy Percutaneous biopsy EUS-FNA
Look-up: Weilert F, Bhat YM, Binmoeller KF, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study. Gastrointest Endosc 2014;80:97-104.
www.giejournal.org
Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 152.e1
CME Exam
QUESTION 3 OBJECTIVE: Demonstrate endoscopic management of GI bleeding secondary to small-intestine vascular lesions.
How to manage bleeding from small-bowel vascular lesions Question 3: A 65-year-old man with iron deficiency anemia and recurrent melena, with normal EGD and colonoscopy findings, is referred to you. Capsule endoscopy reveals multiple small jejunal angioectasias. Despite balloonassisted enteroscopy and ablation of several jejunal angioectasias with argon plasma coagulation (APC) (Fig. 1), recurrent melena persists. What is the most appropriate management option?
Possible answers: (A-D) A. B. C. D.
Repeat colonoscopy Repeat wireless capsule endoscopy Repeat balloon assisted enteroscopy Refer the patient to surgery
Look-up: Shinozaki S, Yamamoto H, Yano T, et al. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by doubleballoon endoscopy. Gastrointest Endosc 2014;80:112-7.
QUESTION 4 OBJECTIVE: Explain how to manage rectal carcinoid tumors.
Which rectal carcinoid tumors need surgery? Question 4: A 52-year-old man is seen for screening colonoscopy. He has a firm yellowish 15-mm subepithelial lesion in the rectum that may be a carcinoid. What is the appropriate management of this lesion?
B. C. D. E.
Endoscopic mucosal resection (EMR) EUS-FNA as initial step Surgical referral Endoscopic biopsy
Possible answers: (A-E) A. Endoscopic polypectomy Look-up: Gleeson FC, Levy M, Dozois E, et al. Endoscopically identified well-differentiated rectal carcinoid tumors: impact of tumor size on the natural history and outcomes. Gastrointest Endosc 2014;80:144-51.
152.e2 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: July 2014 QUESTION 1 CORRECT RESPONSE: B Rationale for correct response: Ethical, legal, and society guidelines mandate that informed consent for endoscopic procedures involves a thorough discussion of the indications and potential benefits of the procedure in addition to the risks.1 Furthermore, the alternatives of the procedure and the right to refuse must be presented to the patient.2 These principles are particularly important in the under-served population where educational and language barriers may impact patient understanding of the information that is presented.3 In this prospective study, Siao et at compared patient recall of informed consent components and satisfaction in those who underwent pre-procedure counseling in an endoscopy education class versus those who underwent teaching in the gastroenterology clinic at the same safety net health center. Those who attended multilingual endoscopy education classes led by nurse practitioners had significantly greater recall of critical elements of the informed consent process including the right to refuse as well as procedure indication, details, and alternatives compared with those counseled in the gastroenterology clinic. Although those in the teaching class had less education and English fluency than those seen in the clinic, the presentation was performed in multiple languages, used helpful cartoon images and pictures, and the class members had the opportunity to share their questions with the group. There was no difference in patient satisfaction between those counseled in the gastroenterology clinic versus those who attended the class. Take-home point: Performance of counseling as part of a multilingual pre-endoscopy education class improves patient recall of the critical elements of the informed consent process including procedure details, indication, and alternatives, as well as the right of refusal. It appears to be an effective method for thoroughly gaining the consent of patients for upcoming procedures, particularly in the underserved population. REFERENCE: 1. Zuckerman MJ, Shen B, Harrison ME, 3rd, et al. Informed consent for GI endoscopy. Gastrointest Endosc 2007;66:213-8. 2. Siao D, Sewell J, Day L. Assessment of delivery methods used in the informed consent process at a safety-net hospital. Gastrointest Endosc 2014;80: 61-8. 3. Marcus EN. The silent epidemicdthe health effects of illiteracy. N Engl J Med 2006;355:339-41.
www.giejournal.org
Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 152.e3
CME Answers
QUESTION 2 CORRECT RESPONSE: D Rationale for correct response: Establishing the diagnosis of biliary strictures can be challenging. Diagnostic options for biliary strictures: 1. ERCP-based tissue sampling 2. EUS-FNA 3. Percutaneous biopsy ERCP-based tissue sampling of malignant biliary strictures has been shown to have a diagnostic yield of 35% to 70%. Higher yields have been found when both brushing and biopsies are performed than either alone.1-5 The yield of ERCP sampling will be highest for primary biliary lesions and those that directly invade the bile duct versus those lesions that just cause extrinsic compression of the bile duct. Some studies have suggested that cholangioscopy-directed intraductal biopsies may improve diagnostic yield1, 6-7; this is not usually performed as a first-line test. EUS-FNA has a well-established sensitivity for the diagnosis of malignant biliary strictures ranging from 85% to 93%, even in the absence of identifiable mass on prior imaging and in the setting of suspected cholangiocarcoinoma (sensitivity 73%-89%).8-13 EUS-FNA has also been shown to provide a better yield than percutaneous tissue biopsy with a lower risk of tumor seeding.14-15 Weilert et al directly compared EUS-FNA to ERCP in a series of 51 unselected patients with suspected malignant biliary obstruction. The sensitivity and accuracy were 94% and 94% for EUS-FNA and 50% and 53% for ERCP sampling, respectively. EUS-FNA was shown to be superior to ERCP-based tissue sampling for patients with pancreatic masses (P ! .0001). There were no differences in the sensitivity and accuracy of EUS-FNA and ERCP based sampling for patients with biliary masses (sensitivity 79% for both) and indeterminate strictures defined as jaundice and evidence of biliary obstruction without visible mass on pre-procedure imaging (sensitivity 80% vs 67%).1 This finding was consistent with results from several published series that revealed high sensitivity (73%-89%) for EUS-FNA in suspected cholangiocarcinoma.10-13 Take-home point: EUS-FNA is superior to ERCP tissue sampling in evaluating suspected malignant biliary obstruction, particularly for pancreatic masses. REFERENCES: 1. Weilert F, Bhat YM, Binmoeller KF, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction : results of a prospective, single-blind, comparative study. Gastrointest Endosc 2014;80:97-104. 2. Ponchon T, Gagnon P, Berger F, et al. Value of endobiliary brush cytology and biopsies for the diagnosis of malignant bile duct stenosis: results of a prospective study. Gastrointest Endosc 1995;42:565-72. 3. Glasbrenner B, Ardan M, Boeck W, et al. Prospective evaluation of brush cytology of biliary strictures during endoscopic retrograde cholangiopancreatography. Endoscopy 1999;31:712-7. 4. Jailwala J, Fogel E, Sherman S, et al. Triple-tissue sampling at ERCP in malignant biliary obstruction. Gastrointest Endosc 2000;51:383-90. 5. Pugliese V, Conio M, Nicolo G, et al. Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study. Gastrointest Endosc 1995;42:520-6. 6. Siddiqui A, Mehendriatta V, Jackson W, et al. Identification of cholangiocarcinoma by using the spyglass spyscope system for peroral cholangioscopy and biopsy collection. Clin Gastroenterol Hepatol 2012;10:466-71. 7. Draganov P, Chauhan S, Wagh M, et al. Diagnostic accuracy of conventional and cholangioscopic-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term, follow-up study. Gastrointest Endosc 2012;75:347-53. 8. Hewitt M, McPhail M, Possamai L, et al. EUS-guided FNA for the diagnosis of solid pancreatic neoplasms: a meta-analysis. Gastrointest Endosc 2012;75:319-31. 9. Wang W, Shpaner A, Krishna S, et al. Use of EUS-FNA in diagnosing pancreatic neoplasm without definitive mass on CT. Gastrointest Endosc 2013;78:73-80. 10. Mohamadnejad M, DeWitt J, Sherman S, et al. Role of EUS for preoperative evaluation of cholangiocarcinoma: a large single-center experience. Gastrointest Endosc 2011;73:71-8. 11. Fritscher-Ravens A, Broering D, Knoefel W, et al. EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. Am J Gastroenterol 2004;99:45-51. 12. Eloubedi M, Chen V, Jhala N, et al. Endoscopic ultrasound-guided fine needle aspiration biopsy of suspected cholangiocarcinoma. Clin Gastroenterol Hepatol 2004;2:209-13. 13. DeWitt J, Misra V, LeBlanc J, et al. EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results. Gastrointest Endosc 2006;64:325-33. 14. Micames C, Jowell P, White R, et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs percutaneous FNA. Gastrointest Endosc 2003;58:690-5. 15. Horwhat J, Paulson E, McGrath K, et al. A randomized comparison of EUS-guided FNA versus CT or US-guided FNA for the evaluation of pancreatic mass lesion. Gastrointest Endosc 2006;63:966-75.
152.e4 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
www.giejournal.org
CME Answers
QUESTION 3 CORRECT RESPONSE: C Rationale for correct response: Deep small-bowel endoscopy with endotherapy, such as balloon-assisted enteroscopy, has revolutionized the way gastroenterologists approach small-bowel bleeding. Bleeding from enteral vascular lesions recurs despite successful initial endoscopic hemostasis. Managing such patients can be challenging. In a recent publication, Yamamoto’s group described the long-term outcomes and impact of repeat balloon-assisted enteroscopy for small-bowel vascular lesions.1 Yano-Yamamoto classification of small-bowel vascular lesions is helpful in the choice of treatment based on endoscopic findings (Fig. 2).2 When multiple vascular lesions are observed, they document the type that is considered to be the most likely cause of bleeding: Yano-Yamamoto Classification of small-intestinal vascular lesions Endoscopic classification of small intestinal vascular lesions (Yano-Yamamoto classification) Type 1a:
Punctulate erythema (less than 1 mm) with or without oozing
Type 1b:
Patchy erythema (a few mm) with or without oozing
Type 2a:
Punctulate lesions (less than 1 mm) with pulsatile bleeding
Type 2b:
Pulsatile red protrusion without surrounding venous dilatation
Type 3:
Pulsatile red protrusion with surrounding venous dilatation
Type 4:
Other lesions not classified into any of the above categories
Endoscopic management of small-intestinal vascular lesions Type 1a & b lesions: Angioectasia - Argon plasma coagulation Type 2a & b lesions: Dieulafoy lesions - Endoclip Type 3 lesions: Arterio-venous malformations - Endoclip In this retrospective cohort study, 43 patients underwent 69 sessions of double-balloon enteroscopy endotherapy of small-bowel vascular lesions, with a mean follow-up of 4.9 years. Overt rebleeding occurred 37% of patients. Risk factors for recurrent bleeding: B Multiple small-bowel vascular lesions B Type Ia lesions Recurrent bleeding decreased after endoscopic retreatment Take-home point: Repeat endoscopic treatment reduces recurrent bleeding in patients with small-bowel angioectasia. REFERENCES: 1. Shinozaki S, Yamamoto H, Yano T, et al. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by double-balloon endoscopy. Gastrointest Endosc 2014;80:112-7. 2. Yano T, Yamamoto H, Sunada K, et al. Endoscopic classification of vascular lesions of the small intestine (with videos). Gastrointest Endosc 2008;67:169-72.
www.giejournal.org
Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 152.e5
CME Answers
QUESTION 4 CORRECT RESPONSE: C Rationale for correct response: Management of bumps and lumps in the rectum can be tricky. Practical approach to rectal bumps and lumps: Step 1: Assess the origin of the lesion: Before assuming every bump as an epithelial lesion, assess whether the lesion is epithelial or subepithelial in origin by studying the surface pit pattern of the lesion. A normal round mucosal pit pattern indicates the lesion is subepithelial in origin. Step 2: Endoscopic diagnosis and treatment: Yellowish lesions are likely to be carcinoid tumors. a. Small lesions (!10 mm): Low risk of metastatic spread; endoscopic excision Although one gets tempted to biopsy them, consider the option of complete excision with tumor-free margins by endoscopic mucosal resection (EMR) for smaller lesions with a band or cap-assisted EMR technique; or endoscopic submucosal dissection (ESD). If one decides to perform biopsy upon a small lesion, consider complete excision biopsy and ensure that the resection base is free of yellow tumor. If in doubt about carcinoid tumor, place a tattoo for easy identification of the site for follow-up. b. Larger lesions (O 20 mm): High risk of metastatic spread; further imaging to stage the disease and surgical referral. c. Intermediate lesions (11-19 mm): High risk of metastatic spread based on Gleeson et al.1 In this study, Gleeson et al argue that lesions 11 to 19 mm in size can be just as invasive over time as those 20 mm or more at presentation. The lesion in the case is at the upper limit of the range at which endoscopic resection has proven to be a viable option.1 Risk factors for metastatic disease: 1. Size: Rate of metastatic disease with tumor in the range of 11to 19 mm is 10% to 15%.3 2. Histology: Involvement of the muscularis propria, lymphovascular invasion, central depression, venous invasion, high mitotic rate and high Ki-67 index are other risk factors.2-4 3. Lymph node spread: EUS can assess TN staging and help define risk of metastatic disease while FNA can establish diagnosis. Management: Endoscopic submucosal dissection (ESD) has a higher rate of complete resection compared to EMR, with comparable adverse event rates and recurrence rates.2 Transanal excision is another option, if ESD and EMR expertise is not available.5 If endoscopic removal is performed, the site should be marked to simplify follow-up.6 Take-home point: Consider the risk of lymph node spread in patients with larger rectal carcinoid tumors (O10 mm); assess with an EUS. REFERENCES: 1. Gleeson FC, Levy M, Dozois E, et al. Endoscopically identified well-differentiated rectal carcinoid tumors: impact of tumor size on the natural history and outcomes. Gastrointest Endosc 2014;80:144-51. 2. Zhou X, Xie H, Xie L et al. Endoscopic resection therapies for rectal neuroendocrine tumors: a systematic review and meta-analysis. J Gastroenterol Hepatol 2014;29:259-68. 3. Kasuga A, Chino A, Uragami N et al. Treatment strategy for rectal carcinoids: a clinicopathological analysis of 229 cases at a single cancer institution. J Gastroenterol Hepatol 2012;27:1801-7. 4. Shields, CJ, Tiret E, Winter DC, et al. Carcinoid tumors of the rectum: a multi-institutional international collaboration. Ann Surg 2010;252:750-5. 5. Kwaan MR, Goldberg JE, Bleday R. Rectal carcinoid tumors: review of results after endoscopic and surgical therapy. Arch Surg 2008;143:471-5. 6. Keller D, Jaffe J, Philip MM, et al. Should all endoscopically excised rectal polyps be tattooed? A plea for localization. Surg Endosc 2012;26:3101-5.
152.e6 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
www.giejournal.org
TM
CME ACTIVITY
Continuing Medical Education Exam: July 2014 James Buxbaum, MD, William Ross, MD, Shou-Jiang Tang, MD, Brian Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section Glenn M. Eisen, MD, MPH, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Siao D, Sewell J, Day L. Assessment of delivery methods used in the informed consent process at a safety-net hospital. Gastrointest Endosc 2014;80;61-8. Weilert F, Bhat YM, Binmoeller KF, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study. Gastrointest Endosc 2014;80:97-104. Shinozaki S, Yamamoto H, Yano T, et al. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by double-balloon endoscopy. Gastrointest Endosc 2014;80:112-7. Gleeson FC, Levy M, Dozois E, et al. Endoscopically identified well-differentiated rectal carcinoid tumors: impact of tumor size on the natural history and outcomes. Gastrointest Endosc 2014;80:144-51. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives Upon completion of this educational activity, participants will be able to: 1. Assess the methods of delivery of informed consent. 2. Compare EUS-FNA versus ERCP-based tissue sampling in evaluating suspected malignant biliary obstruction. 3. Demonstrate endoscopic management of GI bleeding secondary to small-intestine vascular lesions. 4. Explain how to manage rectal carcinoid tumors.
Continuing Medical Education The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The ASGE designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 CreditÔ. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity Start Date: July 1, 2014 Activity Expiration Date: July 31, 2016
Disclosures Disclosure information for authors of the articles can be found with the article in the abstract section. All disclosure information for GIE editors can be found online at http://www.giejournal.org/content/conflictofinterest. CME editors, and their disclosures, are as follows: G. S. Raju, MD, FASGE (Associate Editor for Journal CME): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus Shou-Jiang Tang, MD (CME Editor): James Buxbaum, MD (CME Editor): Disclosed no relevant financial relationships. Disclosed no relevant financial relationships. Brian Weston, MD (CME Editor): Disclosed no relevant financial relationships. All CME activities, including their associated articles are copyrighted by the ASGE. Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh) Windows 95,98,2000, NT or Mac OS Netscape 4. or Microsoft Internet Explorer 4. and above 16 MB RAM 56.6K modem
152 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: July 2014 QUESTION 1 OBJECTIVE: Assess the methods of delivery of informed consent.
How to consent patients! Question 1: A 64-year-old man with intermittent rectal bleeding is referred for colonoscopy at a safety net health center. He is a recent immigrant from China, has limited financial resources, and speaks only Cantonese. Which of the following is most accurate regarding the informed consent process for this patient?
Possible answers: (A-D) A. Given language limitations, the informed consent process should focus on the risks of colonoscopy including perforation in lieu of a detailed discussion of procedure indications and alternatives.
B. He is more likely to recall key components of the informed consent such as procedure indications, alternatives, and risks if the process is performed as part of a multilingual group education class C. He is less likely to remember specific details of the upcoming procedure if the informed consent process is performed as part of a class with 20 other patients. D. The patient is more likely to be satisfied with the informed consent discussion if it is done in the clinic with a physician as opposed to a teaching class led by a nurse practitioner.
Look-up: Siao D, Sewell J, Day L. Assessment of delivery methods used in the informed consent process at a safety-net hospital. Gastrointest Endosc 2014;80:61-8.
QUESTION 2 OBJECTIVE: Compare EUS-FNA versus ERCP-based tissue sampling in evaluating suspected malignant biliary obstruction.
EUS-FNA versus ERCP-based tissue sampling in evaluating suspected malignant biliary obstruction Question 2:
Possible answers: (A-D)
A 60-year-old woman is seen for evaluation of jaundice and weight loss. Abdominal CT shows a dilated common bile duct and main pancreatic duct with an ill-defined pancreatic head mass. No metastatic disease is appreciated. Which of the following is the best method to establish a tissue diagnosis?
A. B. C. D.
ERCP with bile duct brushing ERCP with bile duct brushing and intraductal biopsy Percutaneous biopsy EUS-FNA
Look-up: Weilert F, Bhat YM, Binmoeller KF, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction: results of a prospective, single-blind, comparative study. Gastrointest Endosc 2014;80:97-104.
www.giejournal.org
Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 152.e1
CME Exam
QUESTION 3 OBJECTIVE: Demonstrate endoscopic management of GI bleeding secondary to small-intestine vascular lesions.
How to manage bleeding from small-bowel vascular lesions Question 3: A 65-year-old man with iron deficiency anemia and recurrent melena, with normal EGD and colonoscopy findings, is referred to you. Capsule endoscopy reveals multiple small jejunal angioectasias. Despite balloonassisted enteroscopy and ablation of several jejunal angioectasias with argon plasma coagulation (APC) (Fig. 1), recurrent melena persists. What is the most appropriate management option?
Possible answers: (A-D) A. B. C. D.
Repeat colonoscopy Repeat wireless capsule endoscopy Repeat balloon assisted enteroscopy Refer the patient to surgery
Look-up: Shinozaki S, Yamamoto H, Yano T, et al. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by doubleballoon endoscopy. Gastrointest Endosc 2014;80:112-7.
QUESTION 4 OBJECTIVE: Explain how to manage rectal carcinoid tumors.
Which rectal carcinoid tumors need surgery? Question 4: A 52-year-old man is seen for screening colonoscopy. He has a firm yellowish 15-mm subepithelial lesion in the rectum that may be a carcinoid. What is the appropriate management of this lesion?
B. C. D. E.
Endoscopic mucosal resection (EMR) EUS-FNA as initial step Surgical referral Endoscopic biopsy
Possible answers: (A-E) A. Endoscopic polypectomy Look-up: Gleeson FC, Levy M, Dozois E, et al. Endoscopically identified well-differentiated rectal carcinoid tumors: impact of tumor size on the natural history and outcomes. Gastrointest Endosc 2014;80:144-51.
152.e2 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: July 2014 QUESTION 1 CORRECT RESPONSE: B Rationale for correct response: Ethical, legal, and society guidelines mandate that informed consent for endoscopic procedures involves a thorough discussion of the indications and potential benefits of the procedure in addition to the risks.1 Furthermore, the alternatives of the procedure and the right to refuse must be presented to the patient.2 These principles are particularly important in the under-served population where educational and language barriers may impact patient understanding of the information that is presented.3 In this prospective study, Siao et at compared patient recall of informed consent components and satisfaction in those who underwent pre-procedure counseling in an endoscopy education class versus those who underwent teaching in the gastroenterology clinic at the same safety net health center. Those who attended multilingual endoscopy education classes led by nurse practitioners had significantly greater recall of critical elements of the informed consent process including the right to refuse as well as procedure indication, details, and alternatives compared with those counseled in the gastroenterology clinic. Although those in the teaching class had less education and English fluency than those seen in the clinic, the presentation was performed in multiple languages, used helpful cartoon images and pictures, and the class members had the opportunity to share their questions with the group. There was no difference in patient satisfaction between those counseled in the gastroenterology clinic versus those who attended the class. Take-home point: Performance of counseling as part of a multilingual pre-endoscopy education class improves patient recall of the critical elements of the informed consent process including procedure details, indication, and alternatives, as well as the right of refusal. It appears to be an effective method for thoroughly gaining the consent of patients for upcoming procedures, particularly in the underserved population. REFERENCE: 1. Zuckerman MJ, Shen B, Harrison ME, 3rd, et al. Informed consent for GI endoscopy. Gastrointest Endosc 2007;66:213-8. 2. Siao D, Sewell J, Day L. Assessment of delivery methods used in the informed consent process at a safety-net hospital. Gastrointest Endosc 2014;80: 61-8. 3. Marcus EN. The silent epidemicdthe health effects of illiteracy. N Engl J Med 2006;355:339-41.
www.giejournal.org
Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 152.e3
CME Answers
QUESTION 2 CORRECT RESPONSE: D Rationale for correct response: Establishing the diagnosis of biliary strictures can be challenging. Diagnostic options for biliary strictures: 1. ERCP-based tissue sampling 2. EUS-FNA 3. Percutaneous biopsy ERCP-based tissue sampling of malignant biliary strictures has been shown to have a diagnostic yield of 35% to 70%. Higher yields have been found when both brushing and biopsies are performed than either alone.1-5 The yield of ERCP sampling will be highest for primary biliary lesions and those that directly invade the bile duct versus those lesions that just cause extrinsic compression of the bile duct. Some studies have suggested that cholangioscopy-directed intraductal biopsies may improve diagnostic yield1, 6-7; this is not usually performed as a first-line test. EUS-FNA has a well-established sensitivity for the diagnosis of malignant biliary strictures ranging from 85% to 93%, even in the absence of identifiable mass on prior imaging and in the setting of suspected cholangiocarcoinoma (sensitivity 73%-89%).8-13 EUS-FNA has also been shown to provide a better yield than percutaneous tissue biopsy with a lower risk of tumor seeding.14-15 Weilert et al directly compared EUS-FNA to ERCP in a series of 51 unselected patients with suspected malignant biliary obstruction. The sensitivity and accuracy were 94% and 94% for EUS-FNA and 50% and 53% for ERCP sampling, respectively. EUS-FNA was shown to be superior to ERCP-based tissue sampling for patients with pancreatic masses (P ! .0001). There were no differences in the sensitivity and accuracy of EUS-FNA and ERCP based sampling for patients with biliary masses (sensitivity 79% for both) and indeterminate strictures defined as jaundice and evidence of biliary obstruction without visible mass on pre-procedure imaging (sensitivity 80% vs 67%).1 This finding was consistent with results from several published series that revealed high sensitivity (73%-89%) for EUS-FNA in suspected cholangiocarcinoma.10-13 Take-home point: EUS-FNA is superior to ERCP tissue sampling in evaluating suspected malignant biliary obstruction, particularly for pancreatic masses. REFERENCES: 1. Weilert F, Bhat YM, Binmoeller KF, et al. EUS-FNA is superior to ERCP-based tissue sampling in suspected malignant biliary obstruction : results of a prospective, single-blind, comparative study. Gastrointest Endosc 2014;80:97-104. 2. Ponchon T, Gagnon P, Berger F, et al. Value of endobiliary brush cytology and biopsies for the diagnosis of malignant bile duct stenosis: results of a prospective study. Gastrointest Endosc 1995;42:565-72. 3. Glasbrenner B, Ardan M, Boeck W, et al. Prospective evaluation of brush cytology of biliary strictures during endoscopic retrograde cholangiopancreatography. Endoscopy 1999;31:712-7. 4. Jailwala J, Fogel E, Sherman S, et al. Triple-tissue sampling at ERCP in malignant biliary obstruction. Gastrointest Endosc 2000;51:383-90. 5. Pugliese V, Conio M, Nicolo G, et al. Endoscopic retrograde forceps biopsy and brush cytology of biliary strictures: a prospective study. Gastrointest Endosc 1995;42:520-6. 6. Siddiqui A, Mehendriatta V, Jackson W, et al. Identification of cholangiocarcinoma by using the spyglass spyscope system for peroral cholangioscopy and biopsy collection. Clin Gastroenterol Hepatol 2012;10:466-71. 7. Draganov P, Chauhan S, Wagh M, et al. Diagnostic accuracy of conventional and cholangioscopic-guided sampling of indeterminate biliary lesions at the time of ERCP: a prospective, long-term, follow-up study. Gastrointest Endosc 2012;75:347-53. 8. Hewitt M, McPhail M, Possamai L, et al. EUS-guided FNA for the diagnosis of solid pancreatic neoplasms: a meta-analysis. Gastrointest Endosc 2012;75:319-31. 9. Wang W, Shpaner A, Krishna S, et al. Use of EUS-FNA in diagnosing pancreatic neoplasm without definitive mass on CT. Gastrointest Endosc 2013;78:73-80. 10. Mohamadnejad M, DeWitt J, Sherman S, et al. Role of EUS for preoperative evaluation of cholangiocarcinoma: a large single-center experience. Gastrointest Endosc 2011;73:71-8. 11. Fritscher-Ravens A, Broering D, Knoefel W, et al. EUS-guided fine-needle aspiration of suspected hilar cholangiocarcinoma in potentially operable patients with negative brush cytology. Am J Gastroenterol 2004;99:45-51. 12. Eloubedi M, Chen V, Jhala N, et al. Endoscopic ultrasound-guided fine needle aspiration biopsy of suspected cholangiocarcinoma. Clin Gastroenterol Hepatol 2004;2:209-13. 13. DeWitt J, Misra V, LeBlanc J, et al. EUS-guided FNA of proximal biliary strictures after negative ERCP brush cytology results. Gastrointest Endosc 2006;64:325-33. 14. Micames C, Jowell P, White R, et al. Lower frequency of peritoneal carcinomatosis in patients with pancreatic cancer diagnosed by EUS-guided FNA vs percutaneous FNA. Gastrointest Endosc 2003;58:690-5. 15. Horwhat J, Paulson E, McGrath K, et al. A randomized comparison of EUS-guided FNA versus CT or US-guided FNA for the evaluation of pancreatic mass lesion. Gastrointest Endosc 2006;63:966-75.
152.e4 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
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CME Answers
QUESTION 3 CORRECT RESPONSE: C Rationale for correct response: Deep small-bowel endoscopy with endotherapy, such as balloon-assisted enteroscopy, has revolutionized the way gastroenterologists approach small-bowel bleeding. Bleeding from enteral vascular lesions recurs despite successful initial endoscopic hemostasis. Managing such patients can be challenging. In a recent publication, Yamamoto’s group described the long-term outcomes and impact of repeat balloon-assisted enteroscopy for small-bowel vascular lesions.1 Yano-Yamamoto classification of small-bowel vascular lesions is helpful in the choice of treatment based on endoscopic findings (Fig. 2).2 When multiple vascular lesions are observed, they document the type that is considered to be the most likely cause of bleeding: Yano-Yamamoto Classification of small-intestinal vascular lesions Endoscopic classification of small intestinal vascular lesions (Yano-Yamamoto classification) Type 1a:
Punctulate erythema (less than 1 mm) with or without oozing
Type 1b:
Patchy erythema (a few mm) with or without oozing
Type 2a:
Punctulate lesions (less than 1 mm) with pulsatile bleeding
Type 2b:
Pulsatile red protrusion without surrounding venous dilatation
Type 3:
Pulsatile red protrusion with surrounding venous dilatation
Type 4:
Other lesions not classified into any of the above categories
Endoscopic management of small-intestinal vascular lesions Type 1a & b lesions: Angioectasia - Argon plasma coagulation Type 2a & b lesions: Dieulafoy lesions - Endoclip Type 3 lesions: Arterio-venous malformations - Endoclip In this retrospective cohort study, 43 patients underwent 69 sessions of double-balloon enteroscopy endotherapy of small-bowel vascular lesions, with a mean follow-up of 4.9 years. Overt rebleeding occurred 37% of patients. Risk factors for recurrent bleeding: B Multiple small-bowel vascular lesions B Type Ia lesions Recurrent bleeding decreased after endoscopic retreatment Take-home point: Repeat endoscopic treatment reduces recurrent bleeding in patients with small-bowel angioectasia. REFERENCES: 1. Shinozaki S, Yamamoto H, Yano T, et al. Favorable long-term outcomes of repeat endotherapy for small-intestine vascular lesions by double-balloon endoscopy. Gastrointest Endosc 2014;80:112-7. 2. Yano T, Yamamoto H, Sunada K, et al. Endoscopic classification of vascular lesions of the small intestine (with videos). Gastrointest Endosc 2008;67:169-72.
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Volume 80, No. 1 : 2014 GASTROINTESTINAL ENDOSCOPY 152.e5
CME Answers
QUESTION 4 CORRECT RESPONSE: C Rationale for correct response: Management of bumps and lumps in the rectum can be tricky. Practical approach to rectal bumps and lumps: Step 1: Assess the origin of the lesion: Before assuming every bump as an epithelial lesion, assess whether the lesion is epithelial or subepithelial in origin by studying the surface pit pattern of the lesion. A normal round mucosal pit pattern indicates the lesion is subepithelial in origin. Step 2: Endoscopic diagnosis and treatment: Yellowish lesions are likely to be carcinoid tumors. a. Small lesions (!10 mm): Low risk of metastatic spread; endoscopic excision Although one gets tempted to biopsy them, consider the option of complete excision with tumor-free margins by endoscopic mucosal resection (EMR) for smaller lesions with a band or cap-assisted EMR technique; or endoscopic submucosal dissection (ESD). If one decides to perform biopsy upon a small lesion, consider complete excision biopsy and ensure that the resection base is free of yellow tumor. If in doubt about carcinoid tumor, place a tattoo for easy identification of the site for follow-up. b. Larger lesions (O 20 mm): High risk of metastatic spread; further imaging to stage the disease and surgical referral. c. Intermediate lesions (11-19 mm): High risk of metastatic spread based on Gleeson et al.1 In this study, Gleeson et al argue that lesions 11 to 19 mm in size can be just as invasive over time as those 20 mm or more at presentation. The lesion in the case is at the upper limit of the range at which endoscopic resection has proven to be a viable option.1 Risk factors for metastatic disease: 1. Size: Rate of metastatic disease with tumor in the range of 11to 19 mm is 10% to 15%.3 2. Histology: Involvement of the muscularis propria, lymphovascular invasion, central depression, venous invasion, high mitotic rate and high Ki-67 index are other risk factors.2-4 3. Lymph node spread: EUS can assess TN staging and help define risk of metastatic disease while FNA can establish diagnosis. Management: Endoscopic submucosal dissection (ESD) has a higher rate of complete resection compared to EMR, with comparable adverse event rates and recurrence rates.2 Transanal excision is another option, if ESD and EMR expertise is not available.5 If endoscopic removal is performed, the site should be marked to simplify follow-up.6 Take-home point: Consider the risk of lymph node spread in patients with larger rectal carcinoid tumors (O10 mm); assess with an EUS. REFERENCES: 1. Gleeson FC, Levy M, Dozois E, et al. Endoscopically identified well-differentiated rectal carcinoid tumors: impact of tumor size on the natural history and outcomes. Gastrointest Endosc 2014;80:144-51. 2. Zhou X, Xie H, Xie L et al. Endoscopic resection therapies for rectal neuroendocrine tumors: a systematic review and meta-analysis. J Gastroenterol Hepatol 2014;29:259-68. 3. Kasuga A, Chino A, Uragami N et al. Treatment strategy for rectal carcinoids: a clinicopathological analysis of 229 cases at a single cancer institution. J Gastroenterol Hepatol 2012;27:1801-7. 4. Shields, CJ, Tiret E, Winter DC, et al. Carcinoid tumors of the rectum: a multi-institutional international collaboration. Ann Surg 2010;252:750-5. 5. Kwaan MR, Goldberg JE, Bleday R. Rectal carcinoid tumors: review of results after endoscopic and surgical therapy. Arch Surg 2008;143:471-5. 6. Keller D, Jaffe J, Philip MM, et al. Should all endoscopically excised rectal polyps be tattooed? A plea for localization. Surg Endosc 2012;26:3101-5.
152.e6 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 1 : 2014
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