- Email: [email protected]
Continuing Medical Education Exam: August 2011
GIE
CME ACTIVITY
Continuing Medical Education Exam: August 2011 Raquel E. Davila, MD, Jeffrey H. Lee, MD, William Ross, MD, Shou-Jiang Tang, 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 on-line. To complete do the following: 1. Read the CME article in this issue carefully and complete the activity: Saleem A, Leggett CL, Murad MH, et al. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011;74:321-7. Sakamoto H, Yamamoto H, Hayashi Y, et al. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011;74:328-33. Fernandez-Esparrah G, Ayuso-Colella JR, Sendino O, et al. EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study. Gastrointest Endosc 2011;74:347-54. Almadi MA, Almussabi A, Wong P, et al. Ectopic varices. Gastrointest Endosc 2011;74:380-8. 2. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College and have provided a welcome opportunity for the ACC to cultivate leadership and engage members. Visit the journals Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College. 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 As a result of completing this activity, participating physicians will be able to: 1. To review the performance of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. 2. To recognize the role of double-balloon endoscopy in Peutz-Jeghers Syndrome. 3. To determine the best strategies in the staging of rectal cancer. 4. To indicate the diagnosis and management of ectopic varices.
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 educational activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: August 1, 2011 Activity Expiration Date: August 31, 2013
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): Jeffrey H. Lee, MD (CME Editor): Consulting/Advisory/Speaking: Wyeth, Olympus Disclosed no relevant financial relationships. Research Support: ConMed Raquel E. Davila, MD (CME Editor): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus All CME activities, including their associated articles are copyrighted by the ASGE.
Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh)
Shou-Jiang Tang, MD (CME Editor): Consulting/Advisory/Speaking: Olympus America Other Financial: Ethicon Endo-Surgery, licensing agreement for magnetic anchoring and guidance sysytem; Patents pending for magnetic anchoring and guidance system
Windows 95,98,2000, NT or Mac OS Netscape 4. ⫻ or Microsoft Internet Explorer 4. ⫻ and above 16 MB RAM 56.6K modem 374 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 2 : 2011
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: August 2011 QUESTION 1 OBJECTIVE: To review the performance of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction.
Is there a difference between covered versus uncovered metal stents for palliation of bile duct obstruction? Question 1: A 73-year-old male with a tissue-confirmed pancreatic adenocarcinoma is seen with obstructive jaundice and severe pruritus. His CT scan of the abdomen shows a 4-cm mass in the head of the pancreas encircling the superior mesenteric artery and vein. You decide to perform an ERCP to place a self-expanding metal stent (SEMS) to decompress the bile duct, and you counsel about the differences between covered and uncovered SEMS.
Which of the following statements would be true regarding uncovered SEMS?
Possible answers: (A-D) A. B. C. D.
Uncovered Uncovered Uncovered Uncovered
SEMS SEMS SEMS SEMS
has has has has
a a a a
longer higher higher higher
patency rate migration rate rate of cholecystitis rate of tumor ingrowth
Look-up: Saleem A, Leggett CL, Murad MH, et al. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011;74:321-7.
QUESTION 2 OBJECTIVE: To recognize the role of double-balloon endoscopy in Peutz-Jeghers Syndrome.
Benefits of double-balloon endoscopy in Peutz-Jeghers Syndrome Question 2:
Possible answers: (A-D)
A 28-year-old attorney with newly diagnosed PeutzJeghers Syndrome (PJS) is referred to you for double-balloon endoscopy (DBE) for evaluation of small bowel polyps. During the interview, he expresses frustration on finding little useful information on the internet on the role of DBE in PJS. Which of the following is an accurate counseling statement about surveillance DBE?
A. Reduces risk of small cancer B. Reduces GI blood loss C. Reduces need for surgical correction of intussusception D. Reduces polyp burden
Look-up: Sakamoto H, Yamamoto H, Hayashi Y, et al. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011;74:328-33.
QUESTION 3 OBJECTIVE: To determine the best strategies in the staging of rectal cancer.
What are the best modalities for the evaluation and staging of rectal cancer? Question 3: A 68-year-old woman with a history of adenomatous polyps is referred for surveillance colonoscopy. The patient is found to have a 20-mm sessile polypoid lesion in the mid rectum. Biopsies of the lesion show invasive, welldifferentiated adenocarcinoma and fragments of tubulovillous adenoma.
www.giejournal.org
Which of the following is the best study for determining the T stage of the cancer?
Possible answers: (A-D) A. B. C. D.
EUS Narrow-band imaging CT Magnetic resonance imaging
Volume 74, No. 2 : 2011
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CME Exam
Look-up: Fernandez-Esparrah G, Ayuso-Colella JR, Sendino O, et al. EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study. Gastrointest Endosc 2011;74:347-54.
QUESTION 4 OBJECTIVE: To indicate the diagnosis and management of ectopic varices.
Ectopic varices in the gastrointestinal tract Question 4:
Possible answers: (A-D)
A 65-year-old man with history of pancreatitis and portal vein thrombosis is seen with painless hematochezia. His upper endoscopy is normal. Colonoscopy is unremarkable except for the following findings in the rectum (Fig. 1 & Video, available online at www.giejournal.org). Which of the following is the most appropriate management of this patient?
A. B. C. D.
Infrared radiation Rubber band ligation Hemorrhoidectomy Transjugular intrahepatic portosystemic shunt
Look-up: Almadi MA, Almussabi A, Wong P, et al. Ectopic varices. Gastrointest Endosc 2011;74:380-8.
374.e2 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 2 : 2011
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: August 2011 QUESTION 1 CORRECT RESPONSE: D Rationale for correct response: Self-expanding metal stents have certainly revolutionized endoscopic palliation of malignant biliary obstruction. Covered SEMS were introduced in the 1990s to improve the stent patency by preventing tissue ingrowth. Several studies compared covered SEMS with uncovered SEMS in the management of malignant biliary obstruction, but the results have not been conclusive. A number of different issues need to be considered in the palliation of malignant biliary obstruction. 1. Covered versus uncovered SEMS Findings of a meta-analysis (5 multicenter randomized controlled trials; n ⫽ 781 patients) comparing the covered with the uncovered SEMS for palliation of distal malignant bile duct obstruction are summarized here:1 Stent patency: Longer with covered SEMS. Stent survival: Longer with covered SEMS. Stent migration: Higher with covered SEMS. Tumor overgrowth: Higher with covered SEMS. Sludge formation: Higher with covered SEMS. Although stent dysfunction occurs at a similar rate, there is a trend toward later obstruction with covered SEMS. There is no difference in the rate of cholecystitis or pancreatitis between the covered and uncovered SEMS. 2. Type of stent material: nitinol versus stainless steel Both stent patency and complications were similar in patients with malignant distal biliary obstruction treated with stainless steel and nitinol SEMS (n ⫽ 96 and 81, respectively).2 3. Biliary sphincterotomy before insertion of SEMS There are no prospective studies on the outcomes of endoscopic sphincterotomy prior to the insertion of SEMS. Although endoscopic sphincterotomy may reduce pancreatitis by separating the pancreatic and biliary sphincters and preventing the SEMS from occluding the pancreatic duct orifice, it is associated with a complication rate of approximately 10% (bleeding, pancreatitis, and perforation) and an overall mortality rate of 1%. 4. Management of occluded uncovered SEMS from tissue ingrowth Placement of a covered SEMS within the occluded uncovered SEMS provides better patency than insertion of a second uncovered SEMS or a plastic stent.3 Take-home message: Covered SEMSs have a higher patency rate than uncovered SEMSs, but with a higher migration rate than uncovered SEMSs. When an uncovered SEMS is occluded by tissue ingrowth, insertion of a covered SEMS is recommended. REFERENCES: 1. Saleem A, Leggett CL, Murad MH, et al. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011;74:321-7. 2. Weston BR, Ross WA, Liu J, et al. Clinical outcomes of nitinol and stainless steel uncovered metal stents for malignant biliary strictures: is there a difference. Gastrointest Endosc 2010;72:1195-2000. 3. Togawa O, Kawabe T, Isayama H, et al. Management of occluded uncovered metallic stents in patients with malignant distal biliary obstructions using covered metallic stents. J Clin Gastroenterol 2008;42:546-9.
QUESTION 2 CORRECT RESPONSE: D Rationale for correct response: Peutz–Jeghers syndrome (PJS) is an autosomal dominant disorder, characterized by multiple hamartomatous polyps throughout the GI tract, as well as mucocutaneous pigmentation. The most frequent complications of PJS are intussusception and bleeding from small-bowel polyps, and patients often undergo multiple laparotomies with intestinal resection, which can ultimately result in short-bowel syndrome and/or severe adhesions. www.giejournal.org
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CME Answers
During the last decade, we have seen the introduction of several deep enteroscopic techniques, with therapeutic potential, that enable us to understand the natural history of small-bowel polyps in patients with PJS. In a retrospective study (2000-2009) of 15 patients with PJS undergoing double-balloon endoscopy, the polyp burden decreased at each session1: ● Reduction in the number of resected polyps ⬎20 mm. ● Reduction in the size of resected polyps. ● Complications: perforation (n ⫽ 1), pancreatitis (n ⫽ 2) and bleeding (n ⫽ 2). Only one patient underwent surgery for intussusception during the study period. The current report focuses on intussusception risk, and there is no mention of the impact of DBE examination on GI blood loss. The natural history of PJS in terms of risk of small-bowel cancer and small-bowel intussusception have yet to be fully defined. Recent data on natural history of intussusception puts the lifetime risk at 69% and need for surgery at 64%.2 The median age was 16 years and risk by age 20 was 50%. So, an intervention to impact the intussusception risk would have to start at an earlier age and push the limits of therapeutic DBE use in the pediatric population.3 A different approach using small-bowel capsule endoscopy every 2 to 3 years starting at age 10 has been proposed in recent cancer surveillance guidelines for PJS.4 Clearly, if large polyps were identified, then therapeutic DBE could be used. The capsule endoscopy retention rates in pediatric polyposis patients is low relative to other pediatric groups and comparable to adult polyposis patients.5 Such a capsule endoscopy– based program would mitigate the procedural risk but allow surveillance to begin without undue risk at an earlier age. The report by Sakamoto et al suggests great promise for DBE in PJS.1 However, future prospective studies will be needed to demonstrate the potential for DBE to reduce not only intussusception rates, but small-bowel cancer risk and GI blood loss. Take-home message: Deep enteroscopy and resection of large polyps reduces polyp burden in patients with PJS; with time, it may translate into reduced need for surgery. REFERENCES: 1. Sakamoto H, Yamamoto H, Hayashi Y, et al. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011;74:328-33. 2. Van Lier MGF, Mathus-Vliegen EM, Wagner A, et al. High cumulative risk of intussusception I patients with Peutz-Jeghers syndrome: time to update surveillance guidelines? Am J Gastroenterol. Epub 2010 Dec 14. 3. Nishimura N, Yamamoto J, Yano T, et al. Safety and efficacy of double-balloon enteroscopy in pediatric patients. Gastrointest Endosc 2010;71:287-94. 4. Van Lier MGF, Wagner A, Mathus-Vliegen EMH, et al. High cancer risk in Peutz-Jeghers syndrome: a systematic review and surveillance recommendations. Am J Gastroenterol 2010;105:1258-64. 5. Cohen SA, Klevens AI. Use of capsule endoscopy in diagnosis and management of pediatric patients, based on meta-analysis. Clin Gastroenterol Hepatol. Epub 2011 Mar 28.
QUESTION 3 CORRECT RESPONSE: A Rationale for correct response: The accurate staging of rectal cancer is important because it determines patient management. Currently, neoadjuvant chemoradiation is recommended for advanced locoregional cancers (T3, N0; T4, N0; TX, N1; TX, N2) because it reduces postoperative local recurrence. Superficial tumors (T1, N0; T2, N0) are directly managed by surgical resection. CT has an important role in the detection of distant metastases but has poor accuracy in determining the T stage of tumors. Both magnetic resonance imaging (MRI) and EUS are currently used to determine depth of tumor invasion (T stage) and are used for the detection of locoregional lymph nodes with similar accuracy. In a study from Barcelona, 90 patients with untreated rectal cancer were prospectively evaluated with EUS and MRI from 2007 to 2009.1 The examinations were performed by different operators that were blinded to the results of the other procedure. The majority of tumors (85%) were stage T2 or T3. Polypoid tumors were reported in 27% of cases, whereas a malignant stenosis was found in 22% of cases. The accuracies of EUS and MRI for the staging of T2 and T3 tumors were similar and there was no statistical significant difference. MRI was not able to visualize any of the T1 tumors. On univariate analysis, polypoid morphology of the tumor inversely correlated with the T stage accuracy of MRI. EUS missed all T4 tumors. Although MRI appeared to be better than EUS for nodal staging with accuracy of 79% versus 65% respectively, this difference was not statistically significant. Take-home message: Both EUS and MRI are useful in the staging of rectal cancer with similar accuracy. EUS appears to have an advantage in the evaluation of early cancers as T1 tumors may be missed by MRI. REFERENCE: 1. Fernandez-Esparrah G, Ayuso-Colella JR, Sendino O, et al. EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study. Gastrointest Endosc 2011;74:347-54.
374.e4 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 2 : 2011
www.giejournal.org
CME Answers
QUESTION 4 CORRECT RESPONSE: B Rationale for correct response: This patient has rectal varices without noticeable internal hemorrhoids. Although uncommon, ectopic varices can involve any part of the GI tract and are challenging for clinicians to identify, diagnose, and manage (Fig 1). Definitions:
Extent Color Proctoscopy
Rectal varices
Hemorrhoids
Varicose veins that extend ⬎4 cm above the dentate line Blue Do not prolapse into proctoscope
Vascular cushions that do not extend above the dentate line Purple Prolapse into the proctoscope
Failure to differentiate between rectal varices and hemorrhoids could delay appropriate management and result in preventable mortality. Management of ectopic varices: ● Bleeding rectal varices: rubber band ligation and clipping can be applied. Surgical stapling has been used successfully in rectal varices. ● Bleeding small-bowel and peristomal varices: Injection sclerotherapy has been used successfully in controlling. This modality has the potential for causing systemic bacteremia. Although TIPS could be used, it carries the risk of hepatic decompensation and may not be suitable in patients with ectopic varices due to focal venous obstruction. Take-home message: Although uncommon, ectopic varices can involve any other part of the GI tract and are challenging for clinicians to identify, diagnose, and manage. REFERENCE: 1. Almadi M, Almussabi A, Wong P, et al. Ectopic varices. Gastrointest Endosc 2011;74:380-8.
www.giejournal.org
Volume 74, No. 2 : 2011
GASTROINTESTINAL ENDOSCOPY
374.e5
CME ACTIVITY
Continuing Medical Education Exam: August 2011 Raquel E. Davila, MD, Jeffrey H. Lee, MD, William Ross, MD, Shou-Jiang Tang, 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 on-line. To complete do the following: 1. Read the CME article in this issue carefully and complete the activity: Saleem A, Leggett CL, Murad MH, et al. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011;74:321-7. Sakamoto H, Yamamoto H, Hayashi Y, et al. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011;74:328-33. Fernandez-Esparrah G, Ayuso-Colella JR, Sendino O, et al. EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study. Gastrointest Endosc 2011;74:347-54. Almadi MA, Almussabi A, Wong P, et al. Ectopic varices. Gastrointest Endosc 2011;74:380-8. 2. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College and have provided a welcome opportunity for the ACC to cultivate leadership and engage members. Visit the journals Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. To date, ACC Sections and their Councils have been a valuable resource for the decision-making bodies of the College. 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 As a result of completing this activity, participating physicians will be able to: 1. To review the performance of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. 2. To recognize the role of double-balloon endoscopy in Peutz-Jeghers Syndrome. 3. To determine the best strategies in the staging of rectal cancer. 4. To indicate the diagnosis and management of ectopic varices.
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 educational activity for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: August 1, 2011 Activity Expiration Date: August 31, 2013
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): Jeffrey H. Lee, MD (CME Editor): Consulting/Advisory/Speaking: Wyeth, Olympus Disclosed no relevant financial relationships. Research Support: ConMed Raquel E. Davila, MD (CME Editor): William Ross, MD (CME Editor): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Boston Scientific, Olympus All CME activities, including their associated articles are copyrighted by the ASGE.
Minimum Online System Requirements: 486 Pentium 1 level computer (PC or Macintosh)
Shou-Jiang Tang, MD (CME Editor): Consulting/Advisory/Speaking: Olympus America Other Financial: Ethicon Endo-Surgery, licensing agreement for magnetic anchoring and guidance sysytem; Patents pending for magnetic anchoring and guidance system
Windows 95,98,2000, NT or Mac OS Netscape 4. ⫻ or Microsoft Internet Explorer 4. ⫻ and above 16 MB RAM 56.6K modem 374 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 2 : 2011
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: August 2011 QUESTION 1 OBJECTIVE: To review the performance of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction.
Is there a difference between covered versus uncovered metal stents for palliation of bile duct obstruction? Question 1: A 73-year-old male with a tissue-confirmed pancreatic adenocarcinoma is seen with obstructive jaundice and severe pruritus. His CT scan of the abdomen shows a 4-cm mass in the head of the pancreas encircling the superior mesenteric artery and vein. You decide to perform an ERCP to place a self-expanding metal stent (SEMS) to decompress the bile duct, and you counsel about the differences between covered and uncovered SEMS.
Which of the following statements would be true regarding uncovered SEMS?
Possible answers: (A-D) A. B. C. D.
Uncovered Uncovered Uncovered Uncovered
SEMS SEMS SEMS SEMS
has has has has
a a a a
longer higher higher higher
patency rate migration rate rate of cholecystitis rate of tumor ingrowth
Look-up: Saleem A, Leggett CL, Murad MH, et al. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011;74:321-7.
QUESTION 2 OBJECTIVE: To recognize the role of double-balloon endoscopy in Peutz-Jeghers Syndrome.
Benefits of double-balloon endoscopy in Peutz-Jeghers Syndrome Question 2:
Possible answers: (A-D)
A 28-year-old attorney with newly diagnosed PeutzJeghers Syndrome (PJS) is referred to you for double-balloon endoscopy (DBE) for evaluation of small bowel polyps. During the interview, he expresses frustration on finding little useful information on the internet on the role of DBE in PJS. Which of the following is an accurate counseling statement about surveillance DBE?
A. Reduces risk of small cancer B. Reduces GI blood loss C. Reduces need for surgical correction of intussusception D. Reduces polyp burden
Look-up: Sakamoto H, Yamamoto H, Hayashi Y, et al. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011;74:328-33.
QUESTION 3 OBJECTIVE: To determine the best strategies in the staging of rectal cancer.
What are the best modalities for the evaluation and staging of rectal cancer? Question 3: A 68-year-old woman with a history of adenomatous polyps is referred for surveillance colonoscopy. The patient is found to have a 20-mm sessile polypoid lesion in the mid rectum. Biopsies of the lesion show invasive, welldifferentiated adenocarcinoma and fragments of tubulovillous adenoma.
www.giejournal.org
Which of the following is the best study for determining the T stage of the cancer?
Possible answers: (A-D) A. B. C. D.
EUS Narrow-band imaging CT Magnetic resonance imaging
Volume 74, No. 2 : 2011
GASTROINTESTINAL ENDOSCOPY
374.e1
CME Exam
Look-up: Fernandez-Esparrah G, Ayuso-Colella JR, Sendino O, et al. EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study. Gastrointest Endosc 2011;74:347-54.
QUESTION 4 OBJECTIVE: To indicate the diagnosis and management of ectopic varices.
Ectopic varices in the gastrointestinal tract Question 4:
Possible answers: (A-D)
A 65-year-old man with history of pancreatitis and portal vein thrombosis is seen with painless hematochezia. His upper endoscopy is normal. Colonoscopy is unremarkable except for the following findings in the rectum (Fig. 1 & Video, available online at www.giejournal.org). Which of the following is the most appropriate management of this patient?
A. B. C. D.
Infrared radiation Rubber band ligation Hemorrhoidectomy Transjugular intrahepatic portosystemic shunt
Look-up: Almadi MA, Almussabi A, Wong P, et al. Ectopic varices. Gastrointest Endosc 2011;74:380-8.
374.e2 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 2 : 2011
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: August 2011 QUESTION 1 CORRECT RESPONSE: D Rationale for correct response: Self-expanding metal stents have certainly revolutionized endoscopic palliation of malignant biliary obstruction. Covered SEMS were introduced in the 1990s to improve the stent patency by preventing tissue ingrowth. Several studies compared covered SEMS with uncovered SEMS in the management of malignant biliary obstruction, but the results have not been conclusive. A number of different issues need to be considered in the palliation of malignant biliary obstruction. 1. Covered versus uncovered SEMS Findings of a meta-analysis (5 multicenter randomized controlled trials; n ⫽ 781 patients) comparing the covered with the uncovered SEMS for palliation of distal malignant bile duct obstruction are summarized here:1 Stent patency: Longer with covered SEMS. Stent survival: Longer with covered SEMS. Stent migration: Higher with covered SEMS. Tumor overgrowth: Higher with covered SEMS. Sludge formation: Higher with covered SEMS. Although stent dysfunction occurs at a similar rate, there is a trend toward later obstruction with covered SEMS. There is no difference in the rate of cholecystitis or pancreatitis between the covered and uncovered SEMS. 2. Type of stent material: nitinol versus stainless steel Both stent patency and complications were similar in patients with malignant distal biliary obstruction treated with stainless steel and nitinol SEMS (n ⫽ 96 and 81, respectively).2 3. Biliary sphincterotomy before insertion of SEMS There are no prospective studies on the outcomes of endoscopic sphincterotomy prior to the insertion of SEMS. Although endoscopic sphincterotomy may reduce pancreatitis by separating the pancreatic and biliary sphincters and preventing the SEMS from occluding the pancreatic duct orifice, it is associated with a complication rate of approximately 10% (bleeding, pancreatitis, and perforation) and an overall mortality rate of 1%. 4. Management of occluded uncovered SEMS from tissue ingrowth Placement of a covered SEMS within the occluded uncovered SEMS provides better patency than insertion of a second uncovered SEMS or a plastic stent.3 Take-home message: Covered SEMSs have a higher patency rate than uncovered SEMSs, but with a higher migration rate than uncovered SEMSs. When an uncovered SEMS is occluded by tissue ingrowth, insertion of a covered SEMS is recommended. REFERENCES: 1. Saleem A, Leggett CL, Murad MH, et al. Meta-analysis of randomized trials comparing the patency of covered and uncovered self-expandable metal stents for palliation of distal malignant bile duct obstruction. Gastrointest Endosc 2011;74:321-7. 2. Weston BR, Ross WA, Liu J, et al. Clinical outcomes of nitinol and stainless steel uncovered metal stents for malignant biliary strictures: is there a difference. Gastrointest Endosc 2010;72:1195-2000. 3. Togawa O, Kawabe T, Isayama H, et al. Management of occluded uncovered metallic stents in patients with malignant distal biliary obstructions using covered metallic stents. J Clin Gastroenterol 2008;42:546-9.
QUESTION 2 CORRECT RESPONSE: D Rationale for correct response: Peutz–Jeghers syndrome (PJS) is an autosomal dominant disorder, characterized by multiple hamartomatous polyps throughout the GI tract, as well as mucocutaneous pigmentation. The most frequent complications of PJS are intussusception and bleeding from small-bowel polyps, and patients often undergo multiple laparotomies with intestinal resection, which can ultimately result in short-bowel syndrome and/or severe adhesions. www.giejournal.org
Volume 74, No. 2 : 2011
GASTROINTESTINAL ENDOSCOPY
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CME Answers
During the last decade, we have seen the introduction of several deep enteroscopic techniques, with therapeutic potential, that enable us to understand the natural history of small-bowel polyps in patients with PJS. In a retrospective study (2000-2009) of 15 patients with PJS undergoing double-balloon endoscopy, the polyp burden decreased at each session1: ● Reduction in the number of resected polyps ⬎20 mm. ● Reduction in the size of resected polyps. ● Complications: perforation (n ⫽ 1), pancreatitis (n ⫽ 2) and bleeding (n ⫽ 2). Only one patient underwent surgery for intussusception during the study period. The current report focuses on intussusception risk, and there is no mention of the impact of DBE examination on GI blood loss. The natural history of PJS in terms of risk of small-bowel cancer and small-bowel intussusception have yet to be fully defined. Recent data on natural history of intussusception puts the lifetime risk at 69% and need for surgery at 64%.2 The median age was 16 years and risk by age 20 was 50%. So, an intervention to impact the intussusception risk would have to start at an earlier age and push the limits of therapeutic DBE use in the pediatric population.3 A different approach using small-bowel capsule endoscopy every 2 to 3 years starting at age 10 has been proposed in recent cancer surveillance guidelines for PJS.4 Clearly, if large polyps were identified, then therapeutic DBE could be used. The capsule endoscopy retention rates in pediatric polyposis patients is low relative to other pediatric groups and comparable to adult polyposis patients.5 Such a capsule endoscopy– based program would mitigate the procedural risk but allow surveillance to begin without undue risk at an earlier age. The report by Sakamoto et al suggests great promise for DBE in PJS.1 However, future prospective studies will be needed to demonstrate the potential for DBE to reduce not only intussusception rates, but small-bowel cancer risk and GI blood loss. Take-home message: Deep enteroscopy and resection of large polyps reduces polyp burden in patients with PJS; with time, it may translate into reduced need for surgery. REFERENCES: 1. Sakamoto H, Yamamoto H, Hayashi Y, et al. Nonsurgical management of small-bowel polyps in Peutz-Jeghers syndrome with extensive polypectomy by using double-balloon endoscopy. Gastrointest Endosc 2011;74:328-33. 2. Van Lier MGF, Mathus-Vliegen EM, Wagner A, et al. High cumulative risk of intussusception I patients with Peutz-Jeghers syndrome: time to update surveillance guidelines? Am J Gastroenterol. Epub 2010 Dec 14. 3. Nishimura N, Yamamoto J, Yano T, et al. Safety and efficacy of double-balloon enteroscopy in pediatric patients. Gastrointest Endosc 2010;71:287-94. 4. Van Lier MGF, Wagner A, Mathus-Vliegen EMH, et al. High cancer risk in Peutz-Jeghers syndrome: a systematic review and surveillance recommendations. Am J Gastroenterol 2010;105:1258-64. 5. Cohen SA, Klevens AI. Use of capsule endoscopy in diagnosis and management of pediatric patients, based on meta-analysis. Clin Gastroenterol Hepatol. Epub 2011 Mar 28.
QUESTION 3 CORRECT RESPONSE: A Rationale for correct response: The accurate staging of rectal cancer is important because it determines patient management. Currently, neoadjuvant chemoradiation is recommended for advanced locoregional cancers (T3, N0; T4, N0; TX, N1; TX, N2) because it reduces postoperative local recurrence. Superficial tumors (T1, N0; T2, N0) are directly managed by surgical resection. CT has an important role in the detection of distant metastases but has poor accuracy in determining the T stage of tumors. Both magnetic resonance imaging (MRI) and EUS are currently used to determine depth of tumor invasion (T stage) and are used for the detection of locoregional lymph nodes with similar accuracy. In a study from Barcelona, 90 patients with untreated rectal cancer were prospectively evaluated with EUS and MRI from 2007 to 2009.1 The examinations were performed by different operators that were blinded to the results of the other procedure. The majority of tumors (85%) were stage T2 or T3. Polypoid tumors were reported in 27% of cases, whereas a malignant stenosis was found in 22% of cases. The accuracies of EUS and MRI for the staging of T2 and T3 tumors were similar and there was no statistical significant difference. MRI was not able to visualize any of the T1 tumors. On univariate analysis, polypoid morphology of the tumor inversely correlated with the T stage accuracy of MRI. EUS missed all T4 tumors. Although MRI appeared to be better than EUS for nodal staging with accuracy of 79% versus 65% respectively, this difference was not statistically significant. Take-home message: Both EUS and MRI are useful in the staging of rectal cancer with similar accuracy. EUS appears to have an advantage in the evaluation of early cancers as T1 tumors may be missed by MRI. REFERENCE: 1. Fernandez-Esparrah G, Ayuso-Colella JR, Sendino O, et al. EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study. Gastrointest Endosc 2011;74:347-54.
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CME Answers
QUESTION 4 CORRECT RESPONSE: B Rationale for correct response: This patient has rectal varices without noticeable internal hemorrhoids. Although uncommon, ectopic varices can involve any part of the GI tract and are challenging for clinicians to identify, diagnose, and manage (Fig 1). Definitions:
Extent Color Proctoscopy
Rectal varices
Hemorrhoids
Varicose veins that extend ⬎4 cm above the dentate line Blue Do not prolapse into proctoscope
Vascular cushions that do not extend above the dentate line Purple Prolapse into the proctoscope
Failure to differentiate between rectal varices and hemorrhoids could delay appropriate management and result in preventable mortality. Management of ectopic varices: ● Bleeding rectal varices: rubber band ligation and clipping can be applied. Surgical stapling has been used successfully in rectal varices. ● Bleeding small-bowel and peristomal varices: Injection sclerotherapy has been used successfully in controlling. This modality has the potential for causing systemic bacteremia. Although TIPS could be used, it carries the risk of hepatic decompensation and may not be suitable in patients with ectopic varices due to focal venous obstruction. Take-home message: Although uncommon, ectopic varices can involve any other part of the GI tract and are challenging for clinicians to identify, diagnose, and manage. REFERENCE: 1. Almadi M, Almussabi A, Wong P, et al. Ectopic varices. Gastrointest Endosc 2011;74:380-8.
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