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CME Activity
CME ACTIVITY
Continuing Medical Education Exam: November 2005 Manoop S. Bhutani, MD, Todd Baron, MD, John Vargo, MD, Allan 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 (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.: gie011
Contact hours: 1.0
Expiration date: November 30, 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.asge.org (members) or www.giejournal.org (non-members).
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 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.
Management of a complication of chronic pancreatitis Question 1: A 61-year-old man with alcoholic chronic pancreatitis (CP) is referred for evaluation of obstructive jaundice, worsening abdominal pain, and recent 15-lb weight loss. Abdominal ultrasound reveals dilation of intrahepatic and extrahepatic bile ducts, poor visualization of the pancreatic head, and an 8 mm pancreatic duct. The patient undergoes endoscopic ultrasonography of the head of pancreas (Figure 1). What is your diagnosis and management?
Possible answers (A-E) A. CP with biliary obstruction: ERCP & plastic stent insertion. B. CP with biliary obstruction: ERCP & covered metal stent. C. CP with biliary obstruction: Choledochojejunostomy and pancreaticojejunostomy. D. CP with pancreatic cancer: EUS fine needle aspiration cytology (FNAC) (one needle pass establishes diagnosis in this setting).
Figure 1.
E. CP with pancreatic cancer: EUS FNAC (multiple needle passes are required to establish diagnosis).
Look up: Varadarajulu S, Tamhane A, Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc 2005;62:728-36.
www.giejournal.org
Volume 62 No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY 751
CME Exam
“Weeping” PEG site Question 2: A 58-year-old man comes to your emergency room with weeping and bleeding from a PEG site, 5 months after PEG insertion for palliative nutritional therapy of head and neck cancer. Based on the findings on abdominal examination (Fig. 2), what would you do next?
Possible answers (A-E)
Figure 2.
A. Wound infection: treat with antibiotics. B. Excessive granulation tissue: treat with silver nitrate. C. Skin reaction to a tight bumper: loosen the bumper. D. Early stages of necrotizing fasciitis: surgical consult. E. Metastatic cancer: biopsy.
Look up: Cruz I, Mamel JJ, Brady PG, et al. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head & neck cancer. Gastrointest Endosc 2005;62:708-11.
Can endoscopy diagnose NERD? Question 3: A 45-year-old man undergoes EGD for evaluation of persistent heartburn despite antireflux precautions and 40 mg of omeprazole daily. Endoscopy of the distal esophagus is normal (Figure 3). What will you do next to confirm the diagnosis of GERD?
Possible answers (A-D) A. Random biopsies from the distal esophagus. B. Chromoendoscopy-directed biopsies after Lugol’s staining. C. Chromoendoscopy-directed biopsies after indigo carmine spray. D. Chromoendoscopy-directed biopsies after methylene blue spray.
Figure 3.
Look up: Yoshikawa I,Yamasaki M,Yamasaki T, et al. Lugol chromoendoscopy as a diagnostic tool in so-called endoscopy-negative GERD. Gastrointest Endosc 2005;62:698-703.
Limitations of capsule endoscopy Question 4:
Possible answers (A-D)
A patient is referred for a repeat capsule endoscopy in a course of one week. He is curious to find out about the limitations of capsule endoscopic examination in the evaluation of obscure GI bleeding. Which is the most common reason for incomplete capsule endoscopic examination of the small intestine?
A. Gaps in transmission. B. Short battery life. C. Retention of capsule in the stomach. D. Capsule retention in the small intestine.
Look up: Rondonotti E, Herrerias JM, Pennazio M, et al. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 2005;62:712-6.
752 GASTROINTESTINAL ENDOSCOPY Volume 62 No. 5 : 2005
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: November 2005 QUESTION 1: CORRECT RESPONSE: E Rationale for correct response: A hypoechoic mass is seen in the pancreatic head with associated calcification. FNA of the mass is negative in the first 5 needle passes, and the sixth needle pass cytology confirms diagnosis of cancer. Unlike patients with pancreatic cancer that develops de novo, patients with chronic pancreatitis complicated by the development of pancreatic cancer have severe desmoplastic reaction and require a higher number of needle passes to establish the diagnosis (median number of needle passes during EUS-guided FNAC: 5 versus 2; p < 0.001).1 EUS diagnosis of an occult pancreatic neoplasm in patients with chronic pancreatitis is quite challenging. It can miss a cancer in absence of an obvious focal mass. In the presence of a mass lesion, EUS-guided FNAC helps in the differentiation of cancer from pseudotumorous chronic pancreatitis, but its sensitivity in the diagnosis of cancer in patients with chronic pancreatitis is lower than in those without chronic pancreatitis.1-3 REFERENCES: 1. Varadarajulu S, Tamhane A, Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc 2005;62:728-36. 2. Bhutani MS, Gress FG, Giovannini M, et al.The No Endosonographic Detection of Tumor (NEST) study: a case series of pancreatic cancers missed on endoscopic ultrasonography. Gastrointest Endosc 2004;36:385-9. 3. Fritscher-Ravens A, Brand L, Knofel T, et al. Comparison of endoscopic ultrasound-guided fine needle aspiration of focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis. Am J Gastroenterol 2002;97:2768-75.
QUESTION 2: CORRECT RESPONSE: E Rationale for correct response: Metastatic cancer should be considered in patients with head and neck cancer who have unexplained skin changes at the gastrostomy site. Although extremely rare, abdominal wall metastasis is associated with a very poor outcome. In a retrospective study of 304 patients with head and neck cancer, of the two-thirds who had active disease when undergoing pull-type PEG placement, PEG site metastasis developed in 2 patients (0.65%).1 Although nearly all cases of PEG-related abdominal wall metastasis have occurred in the setting of pull technique,2 there are no data suggesting that modifying the endoscopic technique will alter the risk, as long as the PEG traverses the tumor. Although percutaneous tube placement may decrease the already low risk to virtually zero,3 the possibility of hematogenous metastasis cannot be totally eliminated. Discussion regarding this potential complication should be included as part of the informed consent prior to PEG placement in patients with head and neck cancer. REFERENCES: 1. Cruz I, Mamel JJ, Brady PG, et al. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head & neck cancer. Gastrointest Endosc 2005;62:708-11. 2. Lin HS, Ibrahim HZ, Kheng JW, et al. Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications. Laryngoscope 2001;111:1847-52. 3. Pickhardt PJ, Rohrmann CA Jr, Cossentino MJ. Stomal metastases complicating percutaneous endoscopic gastrostomy: CT findings and the argument for radiologic tube placement. AJR Am J Roentgenol 2002;179:735-9.
www.giejournal.org
Volume 62, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY 753
CME Answers
QUESTION 3: CORRECT RESPONSE: B Rationale for correct response: Heartburn in patients with normal endoscopy could be due to nonerosive reflux disease (NERD) or functional heartburn from a supersensitive esophagus. Differentiating these two conditions can be challenging.1 Symptomatic response to empiric proton pump inhibitor (PPI) therapy is highly variable (15%-60%), and there are no tests to predict a favorable response to empiric PPI.1,2 Random biopsy sampling of squamous epithelium in NERD patients has not proven to be useful.3 A positive 24-hour esophageal pH recording using a catheter probe is helpful in only half of the patients with NERD. Chromoendoscopy after spraying Lugol’s iodine onto a normal-appearing distal esophagus, followed by targeted biopsies of the unstained areas to look for histological changes of reflux esophagitis, may be useful in establishing the diagnosis of NERD that has been missed on standard endoscopy.4 REFERENCES: 1. Fass R, Fennerty B, Vakil N. Nonerosive reflux disease-current concepts and dilemmas (review). Am J Gastroenterol 2001;96:303-14. 2. Lind T, Havelund T, Carlsson R, et al. Heartburn without esophagitis: efficacy of omeprazole therapy and features determining therapeutic response. Scand J Gastroenterol 1997;32:974-9. 3. Nandurkar S,Talley NJ, Martin CJ, et al. Esophageal histology does not provide additional useful information over clinical assessment in identifying reflux patients presenting for esophagogastroduodenoscopy. Dig Dis Sci 2000;45:217-24. 4. Yoshikawa I, Yamasaki M, Yamasaki T, et al. Lugol chromoendoscopy as a diagnostic tool in so-called endoscopy-negative GERD. Gastrointest Endosc 2005;62:698-703.
QUESTION 4: CORRECT RESPONSE: C Rationale for correct response It is critical to counsel patients about the limitations of capsule endoscopy, leading to incomplete studies. Gaps in the recordings, short duration of capsule batteries, malfunction of the battery pack, failure to activate the capsule, failure of the localization software, and failure of downloading technically limit the capsule endoscopic examination of the entire small intestine. Patients need to be reassured that these problems are infrequent now. Difficulty in swallowing the capsule, prolonged retention of capsule in the stomach, and retention of the capsule in the small intestine may also account for incomplete examinations.1 Use of a prokinetic and simethicone before capsule ingestion and endoscopic delivery of the capsule into the duodenum can be used to overcome these limitations.2-4 In order to avoid misdiagnosis in such patients, it is critical to repeat the study. Capsule retention is relatively rare and invariably highlights the existence of a clinical problem. Retention of the capsule in the stomach is the most common reason for incomplete examination. REFERENCES: 1. Rondonotti E, Herrerias JM, Pennazio M, et al. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 2005;62:712-6. 2. Albert J, Gobel C-M, Lesske J, et al. Simethicone for small bowel preparation for capsule endoscopy: a systematic, single-blinded, controlled study. Gastrointest Endosc 2004;59:487-91. 3. Selby W. Complete small-bowel transit in patients undergoing capsule endoscopy: determining factors and improvement with metoclopramide. Gastrointest Endosc 2005;61:80-5. 4. Carey EJ, Heigh RI, Fleischer DE. Endoscopic capsule endoscope delivery for patients with dysphagia, anatomical abnormalities, or gastroparesis. Gastrointest Endosc 2004;59:423-6.
754 GASTROINTESTINAL ENDOSCOPY Volume 62, No. 5 : 2005
www.giejournal.org
Continuing Medical Education Exam: November 2005 Manoop S. Bhutani, MD, Todd Baron, MD, John Vargo, MD, Allan 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 (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.: gie011
Contact hours: 1.0
Expiration date: November 30, 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.asge.org (members) or www.giejournal.org (non-members).
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 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.
Management of a complication of chronic pancreatitis Question 1: A 61-year-old man with alcoholic chronic pancreatitis (CP) is referred for evaluation of obstructive jaundice, worsening abdominal pain, and recent 15-lb weight loss. Abdominal ultrasound reveals dilation of intrahepatic and extrahepatic bile ducts, poor visualization of the pancreatic head, and an 8 mm pancreatic duct. The patient undergoes endoscopic ultrasonography of the head of pancreas (Figure 1). What is your diagnosis and management?
Possible answers (A-E) A. CP with biliary obstruction: ERCP & plastic stent insertion. B. CP with biliary obstruction: ERCP & covered metal stent. C. CP with biliary obstruction: Choledochojejunostomy and pancreaticojejunostomy. D. CP with pancreatic cancer: EUS fine needle aspiration cytology (FNAC) (one needle pass establishes diagnosis in this setting).
Figure 1.
E. CP with pancreatic cancer: EUS FNAC (multiple needle passes are required to establish diagnosis).
Look up: Varadarajulu S, Tamhane A, Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc 2005;62:728-36.
www.giejournal.org
Volume 62 No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY 751
CME Exam
“Weeping” PEG site Question 2: A 58-year-old man comes to your emergency room with weeping and bleeding from a PEG site, 5 months after PEG insertion for palliative nutritional therapy of head and neck cancer. Based on the findings on abdominal examination (Fig. 2), what would you do next?
Possible answers (A-E)
Figure 2.
A. Wound infection: treat with antibiotics. B. Excessive granulation tissue: treat with silver nitrate. C. Skin reaction to a tight bumper: loosen the bumper. D. Early stages of necrotizing fasciitis: surgical consult. E. Metastatic cancer: biopsy.
Look up: Cruz I, Mamel JJ, Brady PG, et al. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head & neck cancer. Gastrointest Endosc 2005;62:708-11.
Can endoscopy diagnose NERD? Question 3: A 45-year-old man undergoes EGD for evaluation of persistent heartburn despite antireflux precautions and 40 mg of omeprazole daily. Endoscopy of the distal esophagus is normal (Figure 3). What will you do next to confirm the diagnosis of GERD?
Possible answers (A-D) A. Random biopsies from the distal esophagus. B. Chromoendoscopy-directed biopsies after Lugol’s staining. C. Chromoendoscopy-directed biopsies after indigo carmine spray. D. Chromoendoscopy-directed biopsies after methylene blue spray.
Figure 3.
Look up: Yoshikawa I,Yamasaki M,Yamasaki T, et al. Lugol chromoendoscopy as a diagnostic tool in so-called endoscopy-negative GERD. Gastrointest Endosc 2005;62:698-703.
Limitations of capsule endoscopy Question 4:
Possible answers (A-D)
A patient is referred for a repeat capsule endoscopy in a course of one week. He is curious to find out about the limitations of capsule endoscopic examination in the evaluation of obscure GI bleeding. Which is the most common reason for incomplete capsule endoscopic examination of the small intestine?
A. Gaps in transmission. B. Short battery life. C. Retention of capsule in the stomach. D. Capsule retention in the small intestine.
Look up: Rondonotti E, Herrerias JM, Pennazio M, et al. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 2005;62:712-6.
752 GASTROINTESTINAL ENDOSCOPY Volume 62 No. 5 : 2005
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: November 2005 QUESTION 1: CORRECT RESPONSE: E Rationale for correct response: A hypoechoic mass is seen in the pancreatic head with associated calcification. FNA of the mass is negative in the first 5 needle passes, and the sixth needle pass cytology confirms diagnosis of cancer. Unlike patients with pancreatic cancer that develops de novo, patients with chronic pancreatitis complicated by the development of pancreatic cancer have severe desmoplastic reaction and require a higher number of needle passes to establish the diagnosis (median number of needle passes during EUS-guided FNAC: 5 versus 2; p < 0.001).1 EUS diagnosis of an occult pancreatic neoplasm in patients with chronic pancreatitis is quite challenging. It can miss a cancer in absence of an obvious focal mass. In the presence of a mass lesion, EUS-guided FNAC helps in the differentiation of cancer from pseudotumorous chronic pancreatitis, but its sensitivity in the diagnosis of cancer in patients with chronic pancreatitis is lower than in those without chronic pancreatitis.1-3 REFERENCES: 1. Varadarajulu S, Tamhane A, Eloubeidi MA. Yield of EUS-guided FNA of pancreatic masses in the presence or the absence of chronic pancreatitis. Gastrointest Endosc 2005;62:728-36. 2. Bhutani MS, Gress FG, Giovannini M, et al.The No Endosonographic Detection of Tumor (NEST) study: a case series of pancreatic cancers missed on endoscopic ultrasonography. Gastrointest Endosc 2004;36:385-9. 3. Fritscher-Ravens A, Brand L, Knofel T, et al. Comparison of endoscopic ultrasound-guided fine needle aspiration of focal pancreatic lesions in patients with normal parenchyma and chronic pancreatitis. Am J Gastroenterol 2002;97:2768-75.
QUESTION 2: CORRECT RESPONSE: E Rationale for correct response: Metastatic cancer should be considered in patients with head and neck cancer who have unexplained skin changes at the gastrostomy site. Although extremely rare, abdominal wall metastasis is associated with a very poor outcome. In a retrospective study of 304 patients with head and neck cancer, of the two-thirds who had active disease when undergoing pull-type PEG placement, PEG site metastasis developed in 2 patients (0.65%).1 Although nearly all cases of PEG-related abdominal wall metastasis have occurred in the setting of pull technique,2 there are no data suggesting that modifying the endoscopic technique will alter the risk, as long as the PEG traverses the tumor. Although percutaneous tube placement may decrease the already low risk to virtually zero,3 the possibility of hematogenous metastasis cannot be totally eliminated. Discussion regarding this potential complication should be included as part of the informed consent prior to PEG placement in patients with head and neck cancer. REFERENCES: 1. Cruz I, Mamel JJ, Brady PG, et al. Incidence of abdominal wall metastasis complicating PEG tube placement in untreated head & neck cancer. Gastrointest Endosc 2005;62:708-11. 2. Lin HS, Ibrahim HZ, Kheng JW, et al. Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications. Laryngoscope 2001;111:1847-52. 3. Pickhardt PJ, Rohrmann CA Jr, Cossentino MJ. Stomal metastases complicating percutaneous endoscopic gastrostomy: CT findings and the argument for radiologic tube placement. AJR Am J Roentgenol 2002;179:735-9.
www.giejournal.org
Volume 62, No. 5 : 2005 GASTROINTESTINAL ENDOSCOPY 753
CME Answers
QUESTION 3: CORRECT RESPONSE: B Rationale for correct response: Heartburn in patients with normal endoscopy could be due to nonerosive reflux disease (NERD) or functional heartburn from a supersensitive esophagus. Differentiating these two conditions can be challenging.1 Symptomatic response to empiric proton pump inhibitor (PPI) therapy is highly variable (15%-60%), and there are no tests to predict a favorable response to empiric PPI.1,2 Random biopsy sampling of squamous epithelium in NERD patients has not proven to be useful.3 A positive 24-hour esophageal pH recording using a catheter probe is helpful in only half of the patients with NERD. Chromoendoscopy after spraying Lugol’s iodine onto a normal-appearing distal esophagus, followed by targeted biopsies of the unstained areas to look for histological changes of reflux esophagitis, may be useful in establishing the diagnosis of NERD that has been missed on standard endoscopy.4 REFERENCES: 1. Fass R, Fennerty B, Vakil N. Nonerosive reflux disease-current concepts and dilemmas (review). Am J Gastroenterol 2001;96:303-14. 2. Lind T, Havelund T, Carlsson R, et al. Heartburn without esophagitis: efficacy of omeprazole therapy and features determining therapeutic response. Scand J Gastroenterol 1997;32:974-9. 3. Nandurkar S,Talley NJ, Martin CJ, et al. Esophageal histology does not provide additional useful information over clinical assessment in identifying reflux patients presenting for esophagogastroduodenoscopy. Dig Dis Sci 2000;45:217-24. 4. Yoshikawa I, Yamasaki M, Yamasaki T, et al. Lugol chromoendoscopy as a diagnostic tool in so-called endoscopy-negative GERD. Gastrointest Endosc 2005;62:698-703.
QUESTION 4: CORRECT RESPONSE: C Rationale for correct response It is critical to counsel patients about the limitations of capsule endoscopy, leading to incomplete studies. Gaps in the recordings, short duration of capsule batteries, malfunction of the battery pack, failure to activate the capsule, failure of the localization software, and failure of downloading technically limit the capsule endoscopic examination of the entire small intestine. Patients need to be reassured that these problems are infrequent now. Difficulty in swallowing the capsule, prolonged retention of capsule in the stomach, and retention of the capsule in the small intestine may also account for incomplete examinations.1 Use of a prokinetic and simethicone before capsule ingestion and endoscopic delivery of the capsule into the duodenum can be used to overcome these limitations.2-4 In order to avoid misdiagnosis in such patients, it is critical to repeat the study. Capsule retention is relatively rare and invariably highlights the existence of a clinical problem. Retention of the capsule in the stomach is the most common reason for incomplete examination. REFERENCES: 1. Rondonotti E, Herrerias JM, Pennazio M, et al. Complications, limitations, and failures of capsule endoscopy: a review of 733 cases. Gastrointest Endosc 2005;62:712-6. 2. Albert J, Gobel C-M, Lesske J, et al. Simethicone for small bowel preparation for capsule endoscopy: a systematic, single-blinded, controlled study. Gastrointest Endosc 2004;59:487-91. 3. Selby W. Complete small-bowel transit in patients undergoing capsule endoscopy: determining factors and improvement with metoclopramide. Gastrointest Endosc 2005;61:80-5. 4. Carey EJ, Heigh RI, Fleischer DE. Endoscopic capsule endoscope delivery for patients with dysphagia, anatomical abnormalities, or gastroparesis. Gastrointest Endosc 2004;59:423-6.
754 GASTROINTESTINAL ENDOSCOPY Volume 62, No. 5 : 2005
www.giejournal.org