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CME Activity
CME ACTIVITY
Continuing Medical Education Exam: February 2005 INSTRUCTIONS: 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 educational activity for a maximum of one category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity. Test ID no.: gie002 Contact hours: 1.0 Expiration date: February 28, 2005 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.mosby.com/gie
PARTICIPANTS This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
OBJECTIVES: After evaluating specific articles published in GIE Gastrointestinal Endoscopy, participants in 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.
New light for Crohn’s disease Question 1:
Possible answers (A-E)
An 18-year old engineering college student from Israel came to see you in your office. A few weeks before coming to the U.S., she had undergone colonoscopy and enteroclysis, and a diagnosis of Crohn’s colitis was made. Currently, she is asymptomatic on 5-ASA. She is inquiring whether she should undergo any further evaluation by capsule endoscopy. Which of the following are correct?
1. A normal enteroclysis study rules out the possibility of Crohn’s disease involving the small bowel. 2. Video capsule endoscopy detects more lesions in the small bowel than push enteroscopy in patients with Crohn’s disease. 3. Video capsule endoscopy is contraindicated in patients with Crohn’s disease with suspected small bowel disease because of increased risk of capsule retention. 4. Video capsule endoscopy detects lesions in the small bowel, even if the enteroclysis looks completely normal. A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Capsule endoscopy vs. push enteroscopy and enteroclysis in suspected small-bowel Crohn’s disease Authors: Chong, Taylor, Miller, Hennessy, Connell, Desmond 2005; 61:255-61
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 281
CME Exam
Is the SBI helpful in capsule endoscopy? Question 2:
Possible answers (A-E)
An 82-year old retired endoscopy nurse was readmitted at 8 am on Thanksgiving day with a two-day history of melena. Her vitals were stable on admission. She had been discharged from the hospital during the previous week, after a diagnosis of overt gastrointestinal bleeding and had a negative EGD and colonoscopy. A video capsule endoscopy was performed immediately after her admission to the emergency room. You are eager to find out the source of bleeding quickly by using a recently installed software upgrade, the “Suspected Blood Indicator” (SBI). What is the value of SBI in the diagnosis of obscure gastrointestinal bleeding?
1. The SBI is sensitive in the detection of blood in 100% of cases. 2. The SBI is sensitive in the detection of AVMs in over 80% of cases. 3. The SBI function cuts down the time spent to review the video capsule endoscopy significantly. 4. The SBI-based does not alleviate the reading time for the clinician; complete reading of the entire recording is required. A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Does the “Suspected Blood Indicator” improve the detection of bleeding lesions by capsule endoscopy? Authors: D’Halluin, Delvaux, Lapalus, Sacher-Huvelin, Ben Soussan, Heyries, Filoche, Saurin, Gay, Heresbach 2005; 61:243-9
Risks for gallbladder cancer Question 3:
Possible answers (A-E)
A 70-year-old woman, mother of your partner, came from Chile to visit her son in the U.S. During her visit, she developed right upper quadrant pain. Ultrasound of the gallbladder demonstrated a single, sessile, gallbladder polyp and a large (4 cm) stone. A cholecystectomy is performed and the gallbladder specimen reveals cancer. What are the various risk factors associated with the development of gallbladder cancer?
1. 2. 3. 4.
Pancreatico-biliary maljunction Large gallbladder stone Pancreatico-biliary reflux Porcelain gallbladder A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Precancerous mucosal changes in the gallbladder of patients with occult pancreatobiliary reflux Authors: Sai, Suyama, Nobukawa, Kubokawa, Yokomizo, Sato 2005; 61:264-8
282 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie
CME Exam
Thermal ablation for Barrett’s esophagus Question 4:
Possible answers (A-E)
A 40-year-old gastroenterologist from Texas elects to undergo ablation of his Barrett’s esophagus (BE). He has been asymptomatic on twice-a-day PPI therapy. Endoscopy demonstrated a long segment of BE (7 cm) without any dysplasia or erosive esophagitis. He loves hunting and fishing and therefore prefers to avoid photodynamic therapy. After having done a PUBMED literature search on various options of endoscopic ablation, he came to see you to discuss whether he should undergo ablation with argon plasma coagulation (APC) or multipolar electrocoagulation (MPEC). You counsel him with the following correct statement:
1. The number of endoscopic sessions required to endoscopically fully ablate Barrett’s with either MPEC or APC is directly correlated with initial length of BE, with longer lengths requiring a greater number of ablative sessions. 2. Endoscopic ablation of BE without dysplasia should be considered experimental at this time, and should not be undertaken unless part of a formal research protocol. 3. Endoscopic findings of complete BE ablation do not correlate with histologic ablation because surveillance biopsy specimens obtained from neosquamous regrowth frequently show buried specialized epithelium as well as columnar epithelium. 4. Failure to fully ablate BE has been correlated with longer lengths of BE (especially ≥ 6 cm), size of hiatal hernia, and severity of pathologic acid reflux as determined on 24-hour ambulatory pH studies. 5. Endoscopic ablation of BE without dysplasia has been shown to prevent the development of adenocarcinoma. A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus Authors: Dulai, Jensen, Cortina, Fontana, Ippoliti 2005; 61:232-40
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 283
CME ACTIVITY
Continuing Medical Education Answers: February 2005 QUESTION 1: CORRECT RESPONSE: C Rationale for correct response: Despite the initial trepidation, capsule endoscopy has been shown to be superior to small bowel series, enteroclysis, CT scan, and push enteroscopy in the diagnosis of Crohn’s disease. Fireman et al. have reported the diagnostic superiority of capsule endoscopy in 17 patients with suspected CD, who had a normal small bowel radiograph and upper and lower gastrointestinal endoscopy—12 of the 17 (71%) patients were diagnosed as having CD of the small bowel.1 Ge et al. have reported a similar percentage (13 of 20 patients, 65%) diagnosis of small bowel Crohn’s disease on capsule endoscopy in patients who had a normal upper and lower GI endoscopy and small bowel follow-through.2 Chong et al. have reported a higher diagnostic yield for capsule endoscopy in the diagnosis of Crohn’s disease involving the small bowel compared with push enteroscopy and enteroclysis.3 Capsule endoscopy is not contraindicated in patients with suspected small-bowel Crohn’s disease. However, caution is required in the evaluation of patients with suspected smallbowel obstruction, and pros and cons of capsule endoscopic examination and risk of capsule retention in this setting should be discussed with the patient. REFERENCES: 1. Fireman Z, Mahajna E, Broide E, Shapiro M, Fich L, Sternberg A, Kopelman Y, Scapa E. Diagnosing small bowel Crohn's disease with wireless capsule endoscopy. Gut 2003;52:390-2. 2. Ge ZZ, Hu YB, Xiao SD. Capsule endoscopy in diagnosis of small bowel Crohn's disease. World J Gastroenterol 2004;10:1349-52. 3. Chong AKH, Taylor A, Miller A, Hennessy O, Connell W, Desmond P. Capsule endoscopy vs. push enteroscopy and enteroclysis in suspected small-bowel Crohn’s disease. Gastrointest Endosc 2005;61:255-61.
QUESTION 2: CORRECT RESPONSE: D Rationale for correct response: Reading of the video capsule endoscopy recordings is a tedious procedure, typically taking anywhere between a half hour to 1 hour. Suspected Blood Indicator (SBI), a new feature provided in the software for reading capsule endoscopy, is designed to detect blood and mark appropriate images for interpretation among the 50,000 frames and decrease the duration of endoscopic examination. D’Halluin et al. reported a low sensitivity (37%), specificity (59%), positive predictive value (50%), and negative predictive value (46%) to detect the presence of a bleeding lesion in front of a red tag. Based on this report, SBI is not helpful in the reducing the reading time of capsule endoscopies.1 Liangpunsakul et al. have reported the performance of SBI in 24 patients. The overall sensitivity, positive predictive value, and accuracy of SBI to detect significant small bowel lesions were 25.7%, 90%, and 34.8%, respectively. If only actively bleeding lesions in the small bowel were considered, SBI had sensitivity, positive predictive value, and accuracy of 81.2%, 81.3%, and 83.3%, respectively.2 Based on the current literature, there is no short-cut to reading of capsule endoscopy. Complete review of the study by the physician is still needed! REFERENCES: 1. D’Halluin PN, Delvaux M, Lapalus MG, Sacher-Huvelin S, Soussan EB, Heyries L, Filoche B, Saurin JC, Gay G, Heresbach D. Does the “Suspected Blood Indicator” improve the detection of bleeding lesions by capsule endoscopy? Gastrointest Endosc 2005;61:243-9. 2. Liangpunsakul S, Mays L, Rex DK. Performance of given suspected blood indicator. Am J Gastroenterol 2003;98: 2676-8.
284 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie
CME Answers
QUESTION 3: CORRECT RESPONSE: E Rationale for correct response: Gallbladder cancer is a tumor of elderly women, with an extremely high prevalence in Chile (13/100,000 inhabitants), Israel, Poland, Mexico, Bolivia, and with Native Americans. Cholelithiasis is a well-established risk factor for gallbladder cancer. The risk of cancer correlates with stone size—odds ratio for developing cancer with stones ≥ 3 cm is 10. Single, sessile, echogenic gallbladder polyps are associated with a higher risk of cancer. Pancreatico-biliary maljunction and porcelain gallbladder are additional risk factors; up to a quarter of the patients with pancreatico-biliary maljunction and porcelain gallbladders were found to have gallbladder cancer.1 Another risk factor could be occult pancreatico-biliary reflux (diagnosed by high biliary amylase concentration of more than 10,000 IU/L in the presence of a normal pancreaticobiliary junction) as reported by Sai et al.2 In this report of 13 cholecystectomy patients with occult pancreaticobiliary reflux, 5 (38%) of the 13 patients had gallbladder cancer, 4 (31) had dysplasia, and 2 (12.5% had only hyperplasia of the gallbladder. Prophylactic cholecystectomy is indicated in patients with anomalous junction of the pancreaticobiliary duct with or without choledochal cyst and patients with a porcelain gallbladder. Currently there is insufficient data to make a definite recommendation about prophylactic cholecystectomy in patients with large gallbladder stones (>3 cm) and single sessile polyp >1 cm. These patients should have close follow-up with serial ultrasound examinations of the gallbladder.1 REFERENCES: 1. Sheth S, Bedford A, Chopra S. Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy. Am J Gastroenterol 2000;95:1402-10. 2. Sai JK, Suyama M, Nobukawa B, Kubokawa Y, Yokomizo K, Sato N. Precancerous mucosal changes in the gallbladder of patients with occult pancreatobiliary reflux. Gastrointest Endosc 2005;61:264-8.
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 285
CME Answers
QUESTION 4: CORRECT RESPONSE: A Rationale for correct response: Dulai et al.1 have demonstrated that there was a positive correlation between initial length of Barrett’s segment and the number of endoscopic sessions of APC or MPEC required for ablation. Prevention of adenocarcinoma, the ultimate goal of ablation of BE, has not yet been demonstrated. In fact, in several case reports of patients undergoing complete ablation of BE on follow-up, advanced or even metastatic Barrett’s adenocarcinoma is uncovered. 2,3 Unfortunately, columnar epithelium buried underneath squamous tissue regrowth, as well as minute islands of residual Barrett’s epithelium on the mucosal surface, may be recognized endoscopically after such therapy. The incidence for this troubling finding is highly variable, ranging from 5% to 45%.1,4-6 These unsuspected residual foci of columnar epithelium harbor the potential for unrecognized progression to cancer. Dulai et al. 1 as well as Basu et al.6 and Kahaleh et al.7 have shown that failure to ablate BE is related to its length, but not the size of hiatal hernia. Severity of pathologic acid reflux has not been shown to correlate with failure to ablate BE; however, failure to take PPI has been shown to predict recurrence or regrowth of BE once ablated.6 Thermal ablation of BE with either APC or MPEC has been established as a method to eliminate BE; however, because the risk of Barrett’s progression is very small and the benefits of interventional ablative modalities are yet to be established (in conjunction with the risks involved—bleeding, perforation, death, etc), conducting ablative therapy for non-dysplastic or even low-grade dysplastic mucosa should not be carried out unless as part of a clinical research study.1 REFERENCES: 1. Dulai GS, Jensen DM, Cortina G, Fontana L, Ippoliti A. Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus. Gastrointest Endosc 2004;61:232-40. 2. Shand A, Dallal H, Palmer K, et al. Adenocarcinoma arising in columnar lined oesophagus following treatment with argon plasma coagulation. Gut 2001;48:580-1. 3. Van Laethem JL, Peny MO, Salmon I, et al. Intramucosal adenocarcinoma arising under squamous re-epithelialisation of Barrett’s oesophagus. Gut 2000;46:574-7. 4. Van Laethem J-L, Cremer M, Peny MO, et al. Eradication of Barrett’s mucosa with argon plasma coagulation and acid suppression: immediate and midterm results. Gut 1998;43:747-51. 5. Grade AJ, Shah IA, Medlin SM, et al. The efficacy and safety of argon plasma coagulation therapy in Barrett’s esophagus. Gastrointest Endosc 1999;50: 18-22. 6. Basu KK, Pick B, Bale R, West KP, de Caestecker JS. Efficacy and one-year follow-up of argon plasma coagulation therapy for ablation of Barrett's oesophagus: factors determining persistence and recurrence of Barrett's epithelium. Gut 2002;51:776-80. 7. Kahaleh M, Van Laethem JL, Nagy N, Cremer M, Deviere J. Long-term follow-up and factors predictive of recurrence in Barrett's esophagus treated by argon plasma coagulation and acid suppression. Endoscopy 2002;34:950-5.
286 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie
Continuing Medical Education Exam: February 2005 INSTRUCTIONS: 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 educational activity for a maximum of one category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity. Test ID no.: gie002 Contact hours: 1.0 Expiration date: February 28, 2005 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.mosby.com/gie
PARTICIPANTS This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
OBJECTIVES: After evaluating specific articles published in GIE Gastrointestinal Endoscopy, participants in 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.
New light for Crohn’s disease Question 1:
Possible answers (A-E)
An 18-year old engineering college student from Israel came to see you in your office. A few weeks before coming to the U.S., she had undergone colonoscopy and enteroclysis, and a diagnosis of Crohn’s colitis was made. Currently, she is asymptomatic on 5-ASA. She is inquiring whether she should undergo any further evaluation by capsule endoscopy. Which of the following are correct?
1. A normal enteroclysis study rules out the possibility of Crohn’s disease involving the small bowel. 2. Video capsule endoscopy detects more lesions in the small bowel than push enteroscopy in patients with Crohn’s disease. 3. Video capsule endoscopy is contraindicated in patients with Crohn’s disease with suspected small bowel disease because of increased risk of capsule retention. 4. Video capsule endoscopy detects lesions in the small bowel, even if the enteroclysis looks completely normal. A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Capsule endoscopy vs. push enteroscopy and enteroclysis in suspected small-bowel Crohn’s disease Authors: Chong, Taylor, Miller, Hennessy, Connell, Desmond 2005; 61:255-61
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 281
CME Exam
Is the SBI helpful in capsule endoscopy? Question 2:
Possible answers (A-E)
An 82-year old retired endoscopy nurse was readmitted at 8 am on Thanksgiving day with a two-day history of melena. Her vitals were stable on admission. She had been discharged from the hospital during the previous week, after a diagnosis of overt gastrointestinal bleeding and had a negative EGD and colonoscopy. A video capsule endoscopy was performed immediately after her admission to the emergency room. You are eager to find out the source of bleeding quickly by using a recently installed software upgrade, the “Suspected Blood Indicator” (SBI). What is the value of SBI in the diagnosis of obscure gastrointestinal bleeding?
1. The SBI is sensitive in the detection of blood in 100% of cases. 2. The SBI is sensitive in the detection of AVMs in over 80% of cases. 3. The SBI function cuts down the time spent to review the video capsule endoscopy significantly. 4. The SBI-based does not alleviate the reading time for the clinician; complete reading of the entire recording is required. A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Does the “Suspected Blood Indicator” improve the detection of bleeding lesions by capsule endoscopy? Authors: D’Halluin, Delvaux, Lapalus, Sacher-Huvelin, Ben Soussan, Heyries, Filoche, Saurin, Gay, Heresbach 2005; 61:243-9
Risks for gallbladder cancer Question 3:
Possible answers (A-E)
A 70-year-old woman, mother of your partner, came from Chile to visit her son in the U.S. During her visit, she developed right upper quadrant pain. Ultrasound of the gallbladder demonstrated a single, sessile, gallbladder polyp and a large (4 cm) stone. A cholecystectomy is performed and the gallbladder specimen reveals cancer. What are the various risk factors associated with the development of gallbladder cancer?
1. 2. 3. 4.
Pancreatico-biliary maljunction Large gallbladder stone Pancreatico-biliary reflux Porcelain gallbladder A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Precancerous mucosal changes in the gallbladder of patients with occult pancreatobiliary reflux Authors: Sai, Suyama, Nobukawa, Kubokawa, Yokomizo, Sato 2005; 61:264-8
282 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie
CME Exam
Thermal ablation for Barrett’s esophagus Question 4:
Possible answers (A-E)
A 40-year-old gastroenterologist from Texas elects to undergo ablation of his Barrett’s esophagus (BE). He has been asymptomatic on twice-a-day PPI therapy. Endoscopy demonstrated a long segment of BE (7 cm) without any dysplasia or erosive esophagitis. He loves hunting and fishing and therefore prefers to avoid photodynamic therapy. After having done a PUBMED literature search on various options of endoscopic ablation, he came to see you to discuss whether he should undergo ablation with argon plasma coagulation (APC) or multipolar electrocoagulation (MPEC). You counsel him with the following correct statement:
1. The number of endoscopic sessions required to endoscopically fully ablate Barrett’s with either MPEC or APC is directly correlated with initial length of BE, with longer lengths requiring a greater number of ablative sessions. 2. Endoscopic ablation of BE without dysplasia should be considered experimental at this time, and should not be undertaken unless part of a formal research protocol. 3. Endoscopic findings of complete BE ablation do not correlate with histologic ablation because surveillance biopsy specimens obtained from neosquamous regrowth frequently show buried specialized epithelium as well as columnar epithelium. 4. Failure to fully ablate BE has been correlated with longer lengths of BE (especially ≥ 6 cm), size of hiatal hernia, and severity of pathologic acid reflux as determined on 24-hour ambulatory pH studies. 5. Endoscopic ablation of BE without dysplasia has been shown to prevent the development of adenocarcinoma. A: 1, 2, and 3 B: 1 and 3 C: 2 and 4 D: 4 only E: All of the above
Look up: Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus Authors: Dulai, Jensen, Cortina, Fontana, Ippoliti 2005; 61:232-40
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 283
CME ACTIVITY
Continuing Medical Education Answers: February 2005 QUESTION 1: CORRECT RESPONSE: C Rationale for correct response: Despite the initial trepidation, capsule endoscopy has been shown to be superior to small bowel series, enteroclysis, CT scan, and push enteroscopy in the diagnosis of Crohn’s disease. Fireman et al. have reported the diagnostic superiority of capsule endoscopy in 17 patients with suspected CD, who had a normal small bowel radiograph and upper and lower gastrointestinal endoscopy—12 of the 17 (71%) patients were diagnosed as having CD of the small bowel.1 Ge et al. have reported a similar percentage (13 of 20 patients, 65%) diagnosis of small bowel Crohn’s disease on capsule endoscopy in patients who had a normal upper and lower GI endoscopy and small bowel follow-through.2 Chong et al. have reported a higher diagnostic yield for capsule endoscopy in the diagnosis of Crohn’s disease involving the small bowel compared with push enteroscopy and enteroclysis.3 Capsule endoscopy is not contraindicated in patients with suspected small-bowel Crohn’s disease. However, caution is required in the evaluation of patients with suspected smallbowel obstruction, and pros and cons of capsule endoscopic examination and risk of capsule retention in this setting should be discussed with the patient. REFERENCES: 1. Fireman Z, Mahajna E, Broide E, Shapiro M, Fich L, Sternberg A, Kopelman Y, Scapa E. Diagnosing small bowel Crohn's disease with wireless capsule endoscopy. Gut 2003;52:390-2. 2. Ge ZZ, Hu YB, Xiao SD. Capsule endoscopy in diagnosis of small bowel Crohn's disease. World J Gastroenterol 2004;10:1349-52. 3. Chong AKH, Taylor A, Miller A, Hennessy O, Connell W, Desmond P. Capsule endoscopy vs. push enteroscopy and enteroclysis in suspected small-bowel Crohn’s disease. Gastrointest Endosc 2005;61:255-61.
QUESTION 2: CORRECT RESPONSE: D Rationale for correct response: Reading of the video capsule endoscopy recordings is a tedious procedure, typically taking anywhere between a half hour to 1 hour. Suspected Blood Indicator (SBI), a new feature provided in the software for reading capsule endoscopy, is designed to detect blood and mark appropriate images for interpretation among the 50,000 frames and decrease the duration of endoscopic examination. D’Halluin et al. reported a low sensitivity (37%), specificity (59%), positive predictive value (50%), and negative predictive value (46%) to detect the presence of a bleeding lesion in front of a red tag. Based on this report, SBI is not helpful in the reducing the reading time of capsule endoscopies.1 Liangpunsakul et al. have reported the performance of SBI in 24 patients. The overall sensitivity, positive predictive value, and accuracy of SBI to detect significant small bowel lesions were 25.7%, 90%, and 34.8%, respectively. If only actively bleeding lesions in the small bowel were considered, SBI had sensitivity, positive predictive value, and accuracy of 81.2%, 81.3%, and 83.3%, respectively.2 Based on the current literature, there is no short-cut to reading of capsule endoscopy. Complete review of the study by the physician is still needed! REFERENCES: 1. D’Halluin PN, Delvaux M, Lapalus MG, Sacher-Huvelin S, Soussan EB, Heyries L, Filoche B, Saurin JC, Gay G, Heresbach D. Does the “Suspected Blood Indicator” improve the detection of bleeding lesions by capsule endoscopy? Gastrointest Endosc 2005;61:243-9. 2. Liangpunsakul S, Mays L, Rex DK. Performance of given suspected blood indicator. Am J Gastroenterol 2003;98: 2676-8.
284 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie
CME Answers
QUESTION 3: CORRECT RESPONSE: E Rationale for correct response: Gallbladder cancer is a tumor of elderly women, with an extremely high prevalence in Chile (13/100,000 inhabitants), Israel, Poland, Mexico, Bolivia, and with Native Americans. Cholelithiasis is a well-established risk factor for gallbladder cancer. The risk of cancer correlates with stone size—odds ratio for developing cancer with stones ≥ 3 cm is 10. Single, sessile, echogenic gallbladder polyps are associated with a higher risk of cancer. Pancreatico-biliary maljunction and porcelain gallbladder are additional risk factors; up to a quarter of the patients with pancreatico-biliary maljunction and porcelain gallbladders were found to have gallbladder cancer.1 Another risk factor could be occult pancreatico-biliary reflux (diagnosed by high biliary amylase concentration of more than 10,000 IU/L in the presence of a normal pancreaticobiliary junction) as reported by Sai et al.2 In this report of 13 cholecystectomy patients with occult pancreaticobiliary reflux, 5 (38%) of the 13 patients had gallbladder cancer, 4 (31) had dysplasia, and 2 (12.5% had only hyperplasia of the gallbladder. Prophylactic cholecystectomy is indicated in patients with anomalous junction of the pancreaticobiliary duct with or without choledochal cyst and patients with a porcelain gallbladder. Currently there is insufficient data to make a definite recommendation about prophylactic cholecystectomy in patients with large gallbladder stones (>3 cm) and single sessile polyp >1 cm. These patients should have close follow-up with serial ultrasound examinations of the gallbladder.1 REFERENCES: 1. Sheth S, Bedford A, Chopra S. Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy. Am J Gastroenterol 2000;95:1402-10. 2. Sai JK, Suyama M, Nobukawa B, Kubokawa Y, Yokomizo K, Sato N. Precancerous mucosal changes in the gallbladder of patients with occult pancreatobiliary reflux. Gastrointest Endosc 2005;61:264-8.
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 285
CME Answers
QUESTION 4: CORRECT RESPONSE: A Rationale for correct response: Dulai et al.1 have demonstrated that there was a positive correlation between initial length of Barrett’s segment and the number of endoscopic sessions of APC or MPEC required for ablation. Prevention of adenocarcinoma, the ultimate goal of ablation of BE, has not yet been demonstrated. In fact, in several case reports of patients undergoing complete ablation of BE on follow-up, advanced or even metastatic Barrett’s adenocarcinoma is uncovered. 2,3 Unfortunately, columnar epithelium buried underneath squamous tissue regrowth, as well as minute islands of residual Barrett’s epithelium on the mucosal surface, may be recognized endoscopically after such therapy. The incidence for this troubling finding is highly variable, ranging from 5% to 45%.1,4-6 These unsuspected residual foci of columnar epithelium harbor the potential for unrecognized progression to cancer. Dulai et al. 1 as well as Basu et al.6 and Kahaleh et al.7 have shown that failure to ablate BE is related to its length, but not the size of hiatal hernia. Severity of pathologic acid reflux has not been shown to correlate with failure to ablate BE; however, failure to take PPI has been shown to predict recurrence or regrowth of BE once ablated.6 Thermal ablation of BE with either APC or MPEC has been established as a method to eliminate BE; however, because the risk of Barrett’s progression is very small and the benefits of interventional ablative modalities are yet to be established (in conjunction with the risks involved—bleeding, perforation, death, etc), conducting ablative therapy for non-dysplastic or even low-grade dysplastic mucosa should not be carried out unless as part of a clinical research study.1 REFERENCES: 1. Dulai GS, Jensen DM, Cortina G, Fontana L, Ippoliti A. Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus. Gastrointest Endosc 2004;61:232-40. 2. Shand A, Dallal H, Palmer K, et al. Adenocarcinoma arising in columnar lined oesophagus following treatment with argon plasma coagulation. Gut 2001;48:580-1. 3. Van Laethem JL, Peny MO, Salmon I, et al. Intramucosal adenocarcinoma arising under squamous re-epithelialisation of Barrett’s oesophagus. Gut 2000;46:574-7. 4. Van Laethem J-L, Cremer M, Peny MO, et al. Eradication of Barrett’s mucosa with argon plasma coagulation and acid suppression: immediate and midterm results. Gut 1998;43:747-51. 5. Grade AJ, Shah IA, Medlin SM, et al. The efficacy and safety of argon plasma coagulation therapy in Barrett’s esophagus. Gastrointest Endosc 1999;50: 18-22. 6. Basu KK, Pick B, Bale R, West KP, de Caestecker JS. Efficacy and one-year follow-up of argon plasma coagulation therapy for ablation of Barrett's oesophagus: factors determining persistence and recurrence of Barrett's epithelium. Gut 2002;51:776-80. 7. Kahaleh M, Van Laethem JL, Nagy N, Cremer M, Deviere J. Long-term follow-up and factors predictive of recurrence in Barrett's esophagus treated by argon plasma coagulation and acid suppression. Endoscopy 2002;34:950-5.
286 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie