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Continuing Medical Education Exam: February 2012
GIE
CME ACTIVITY
Continuing Medical Education Exam: February 2012 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 articles in this issue carefully and complete the activity: Vahabzadeh B, Seetharam AB, Cook MB, et al. Validation of the Prague C & M criteria for the endoscopic grading of Barrett’s esophagus by gastroenterology trainees: a multicenter study. Gastrointest Endosc 2012;75:236-41. Rodriguez L, Rosen R, Manfredi M, et al. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study. Gastrointest Endosc 2012;75:302-9. Dhir V, Bhandari S, Bapat M, et al. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access. Gastrointest Endosc 2012;75:354-9. Jensen DM. The ins and outs of diverticular bleeding. Gastrointest Endosc 2012;75:388-91. 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 acessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives Upon completion of this educational activity, participants will be able to: 1. Describe the Prague classification of Barrett’s esophagus. 2. Define the best strategies for the management of gastroparesis in children. 3. Compare the techniques of EUS-guided rendezvous and precut papillotomy in gaining biliary access in difficult biliary cannulation. 4. Distinguish the different endoscopic management options of colonic diverticular bleeding.
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 enduring material for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity Start Date: February 1, 2012 Activity Expiration Date: February 28, 2014
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 copyShou-Jiang Tang, MD (CME Editor): righted by the ASGE. Consulting/Advisory/Speaking: Olympus America Other Financial: Ethicon Endo-Surgery, licensing agreement for Minimum Online System Requirements: magnetic anchoring and guidance sysytem; Patents pending 486 Pentium 1 level computer (PC or Macintosh) 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
www.giejournal.org
Volume 75, No. 2 : 2012 GASTROINTESTINAL ENDOSCOPY 399
CME ACTIVITY
Continuing Medical Education Questions: February 2012 QUESTION 1 OBJECTIVE: To describe the Prague classification of Barrett’s esophagus.
How to report Barrett’s esophagus using the Prague classification? Question 1: Your program director institutes an instructional program for identification and classification of Barrett’s mucosa using the Prague classification. Here is an endoscopy report of a patient with Barrett’s esophagus, with the following markings. The diaphragmatic hiatus was located at 40 cm; the top of the gastric folds at 35 cm; the proximal margin of circumferential Barrett’s esophagus at 33 cm; the proximal margin of the longest tongue of Barrett’s esoph-
agus at 31 cm, and the proximal margin of the erosions at 30 cm. How do you describe it using the Prague classification?
Possible answers: (A-D) A. B. C. D.
C2, C7, C7, C2,
M4 M9 M10 M5
Look-up: Vahabzadeh B, Seetharam AB, Cook MB, et al. Validation of the Prague C & M criteria for the endoscopic grading of Barrett’s esophagus by gastroenterology trainees: a multicenter study. Gastrointest Endosc 2012;75:236-41.
QUESTION 2 OBJECTIVE: To define the best strategies for the management of gastroparesis in children.
What are the best treatment options for the treatment of gastroparesis in children? Question 2: A 13-year-old boy with a history of idiopathic gastroparesis presents to you with intermittent vomiting refractory to medical therapy. He has delayed gastric emptying demonstrated on a nuclear medicine gastric emptying study performed 7 months ago. The patient has already undergone esophagogastroduodenoscopy with intrapyloric injection of botulinum toxin A, which resulted in a significant reduction of his symptoms for approximately 3 months. He now presents with worsening, frequent vomiting and weight loss.
Which of the following would be a reasonable next step in the management of the patient’s symptoms?
Possible answers: (A-D) A. B. C. D.
Antroduodenal manometry Repeat intrapyloric botox injection Percutaneous endoscopic gastrostomy tube placement Pyloromyotomy
Look-up: Rodriguez L, Rosen R, Manfredi M, et al. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study. Gastrointest Endosc 2012;75:302-9.
QUESTION 3 OBJECTIVE: To compare the techniques of EUS-guided rendezvous and precut papillotomy in gaining biliary access in difficult biliary cannulation.
How good is EUS-guided rendezvous technique for biliary access? Question 3: A 45-year-old male presents with a 2-week history of obstructive jaundice and moderate mid-epigastric pain. A CT scan shows a 3-cm mass in the head of the pancreas with a long stricture at the common bile duct with proximal biliary dilation. As an expert in endosonography and 399.e1 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 2 : 2012
ERCP, you are planning for biliary drainage. After several failed conventional ERCP techniques to access the bile duct, you are unable to see the ampulla well because of bleeding and marked edema. Which of the following should you try next to gain access to the bile duct? www.giejournal.org
CME Exam
Possible answers: (A-D) A. Pre-cut papillotomy B. EUS-guided rendezvous technique
C. Percutaneous transhepatic biliary drainage D. Choledochojejunostomy
Look-up: Dhir V, Bhandari S, Bapat M, et al. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access. Gastrointest Endosc 2012;75:354-9.
QUESTION 4 OBJECTIVE: To distinguish the different endoscopic management options of colonic diverticular bleeding.
Banding a bleeding diverticulum Question 4: A 73-year-old woman is seen with severe painless hematochezia and hypotension. After a negative EGD, you perform an urgent colonoscopy after rapid colon preparation and notice a bleeding vessel in the base of the diverticulum (Fig. 1). Which of the following is recommended for definitive therapy by the CURE Hemostasis Group?
Possible answers: (A-D) A. B. C. D.
Clip application Band ligation Cautery Epinephrine injection
Figure 1.
Look-up: Jensen DM. The ins and outs of diverticular bleeding. Gastrointest Endosc 2012;75:388-91.
www.giejournal.org
Volume 75, No. 2 : 2012
GASTROINTESTINAL ENDOSCOPY
399.e2
CME ACTIVITY
Continuing Medical Education Answers: February 2012 QUESTION 1 CORRECT RESPONSE: A Rationale for correct response: Accurate description of the esophageal findings and landmarks in the endoscopic report should encompass information on 3 important variables in patients with gastroesophageal reflux disease—Barrett’s esophagus (BE) and its extent, hiatal hernia and its type, and erosive esophagitis and its severity. A subgroup of the International Working Group for the Classification of Oesophagitis (IWGCO) with a special interest in BE developed the Prague C & M Criteria, which uses the “C” value as the “circumferential extent” and the “M” value as “maximal extent” of BE above the gastroesophageal junction (GEJ) in centimeters (Fig. 2). Measure the endoscope insertion distance at the following sites to report the C & M values in the endoscopic report: A. Diaphragmatic hiatus (in this report, it is located at 40 cm) B. Top of the gastric folds (in this report, it is located at 35 cm) C. Circmferential segment of BE (in this report, it is located at 33 cm) D. Top of the tongue of BE (in this report, it is located at 31 cm) Prague classification of the Barrett’s esophagus in the test case should be reported as C2, M4. 1. Circumferential (C) segment C2cm (B minus C ⫽ 35 - 33cm) 2. Maximum extent (M) including tongues M4cm (B minus D ⫽ 35 - 31) Like the insertion and total colonoscopy times, the C & M criteria should be part of every EGD report. The study in this issue of the journal by Vahabzadeh et al shows good agreement among trainees in identifying and describing Barrett’s esophagus from video clips.1 Unfortunately, baseline assessments before the instruction were not obtained, so it is not possible to define the impact of the instruction. How the level of agreement would be affected by live endoscopic imaging and enhancements like narrow-band imaging (NBI) is unclear. One area with poor agreement was identification of Barrett’s less than 1 cm in length. NBI with its ability to clearly define the squamocolumnar junction may help with this identification. Recommendations on technique may improve agreement further, such as consistently taking measurements on withdrawal of the endoscope and using NBI when available. Although the focus is on the length of esophagus at risk, the more biologically relevant factor is surface area covered by Barrett’s. The relation between length and cancer rate is not linear as suggested, but rather the slope declines with increasing length, consistent with the relevance of the surface area.2,3
Figure 2.
399.e3 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 2 : 2012
www.giejournal.org
CME Answers
Take-home message: Learning the Prague criteria for Barrett’s esophagus and incorporating it into clinical practice could be a useful quality improvement project for endoscopy units. REFERENCES: 1. Vahabzadeh B, Seetharam AB, Cook MB, et al. Validation of the Prague C&M Criteria for the endoscopic grading of Barrett’s esophagus among gastroenterology trainees: a multicenter study. Gastrointest Endosc 2012;75:236-41. 2. Rudolph RE, Vaughan TL, Storer BE, et al. Effect of segment length on risk for neoplastic progression in patients with Barrett’s esophagus. Ann Intern Med 2000;132:612-20. 3. Gaddam S, Young PE, Alsop BR, et al. Relationship between Barrett’s sophagus (BE) length and the risk of high grade dysplasia (HGD), and esophageal adenocarcinoma (EAC) in patients with non dysplastic Barrett’s esophagus results from a large multicenter cohort. Gastroenterology 2011;140(5,suppl 1):S-81.
QUESTION 2 CORRECT RESPONSE: B Rationale for correct response: Gastroparesis is a serious condition in children, which often is not responsive to medical management with prokinetic agents or antiemetics. Patients can present with a variety of symptoms, including nausea, vomiting, retching, abdominal distention, early satiety, abdominal pain, and feeding intolerance. Endoscopic intrapyloric botulinum A injection (IPBI) has not been well studied in the management of gastroparesis in children. In a retrospective study, 47 children with gastroparesis treated with IPBI in a single medical center from 2004 to 2010 were included.1 Follow-up data were available in 45 patients, of which 51% were female with a mean age of 9.98 ⫾ 6.5 years. Treatment response was considered mild if symptoms improved but the patient still required medical therapy, moderate if symptoms improved with discontinuation of medical therapy, and complete if the patient was asymptomatic. Of the 45 patients, 30 (67%) had at least a mild response and 15 (33%) were considered treatment failures. Of the responders, 10% had a mild response, 50% had a moderate response, and 40% were completely asymptomatic. The median duration of the response was 3 months (1.2-4.8 months). On multivariate regression analysis, older age (⬎12) and the presence of vomiting were independent predictors of response to IPBI. Of the responders, 18 patients underwent more than 1 injection for recurrence of symptoms. Follow-up data were available in 15 of these patients, and a sustained response was found in 8 patients after repeated injections. Male gender was associated with treatment response to repeat IPBI. There were no complications reported with IPBI. Take-home message: IPBI is safe and may be effective in the management of gastroparesis in children. Older age and history of vomiting appear to be associated with a response to initial IPBI, whereas male sex is associated with a response to repeat injections. REFERENCE: 1. Rodriguez L, Rosen R, Manfredi M, et al. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open label study. Gastrointest Endosc 2012;75:302-9.
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: When conventional ERCP with a sphincterotome and a guidewire fails to provide access to the bile duct, other available modalities include pre-cut papillotomy, percutaneous transhepatic biliary drainage (PTBD), surgical biliary drainage (choledochojejunostomy), and EUS-assisted techniques. ● Pre-cut papillotmy: Although the complication rate of pre-cut papillotomy is not any higher when it is performed by an experienced endoscopist than that of conventional ERCP, it still poses a significant risk of bleeding, perforation, and pancreatitis. ● PTBD is a safe and effective technique with a high success rate but requires availability of an interventional radiologist. ● Surgical biliary drainage is also effective and long-lasting but, in most patients, not practical, especially when preoperative chemoradiation is planned or patients have significant co-morbidities. ● EUS-assisted techniques appear to be effective and efficient. In EUS-guided rendezvous technique, the left hepatic duct or extrahepatic bile duct (preferably the common bile duct) is punctured with a 19-gauge needle under EUS guidance, and a guidewire is advanced down to the duodenum through the needle, stricture, and ampulla under fluoroscopic guidance. The echoendoscope is then replaced by a side-viewing scope, and the guidewire is grabbed by a snare. Once biliary access has been established, conventional ERCP can be performed. Recently, Dhir et al compared the efficacy of EUS-guided rendezvous technique and pre-cut papillotomy for biliary access in difficult cannulation.1 www.giejournal.org
Volume 75, No. 2 : 2012
GASTROINTESTINAL ENDOSCOPY
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CME Answers
EUS-guided rendezvous technique had a significant higher rate of technical success than that of precut papillotomy (57/58 [98.3%] vs. 130/144 [90.3%]; P ⫽ .03). ● Precut group had an overall success rate of 95.8% (138/144) after 8/14 patients with initial failure had a second attempt at ERCP. ● The complication rates of the two techniques were similar (pre-cut 6.9% and EUS 3.4% [P ⫽ .27]). X Pre-cut group had one severe pancreatitis, 3 moderate pancreatitis, 6 bleeding (5 mild and 1 moderate). X EUS group had 2 pericholedochal tracking of contrast with abdominal pain, which resolved with conservative management within 72 hours. Take-home message: EUS-guided rendezvous technique offers a high technical success rate in difficult ERCP where conventional ERCP attempts fail. However, this method requires an expert endosonographer and a patent duodenum. When they are not available, PTBD is a good alternative with a proven track record. ●
REFERENCES: 1. Dhir V, Bhandari S, Bapat M, et al. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access. Gastrointest Endosc 2012;75:354-9.
QUESTION 4 CORRECT RESPONSE: A Rationale for correct response: Diverticular bleeding is one of the most common causes of acute lower GI bleeding. Bleeding is arterial and can occur either in the base or in the neck of the diverticulum.1 Major stigmata of recent hemorrhage (SRH) in a diverticulum include active bleeding, non-bleeding visible vessel, and adherent clot. CURE Hemostasis Group recommendations for diverticular bleeding: A. Bleeding diverticulum easily identified: 1. Bleeding site clearly seen in the neck of diverticulum: Multipoloar electrocoagulation (MPEC) using moderate tamponade at the neck of the diverticulum is the fastest, easiest, and most effective method of hemostasis. 2. Bleeding site clearly seen in the base of the diverticulum: Hemoclip application using the clip with reopening function. 3. Active bleeding or adherent clot in the diverticulum: Preinjection of dilute epinephrine (1:20,000 in saline solution) is recommended to slow the bleeding or for the clot, before cold guillotining to shave it down to a short pedicle and before hemoclip in the base or MPEC at the neck of the diverticulum. 4. After control of bleeding: Tattoo the mucosa in 3 to 4 areas adjacent to the diverticulum with the signs of recent hemorrhage, in case of rebleeding or resection. 5. Mesenteric angiography and embolization may be used in selected patents if the patient rebleeds and is unfit for repeat colonoscopy or if the patient is unstable for urgent colonoscopy or surgery. B. Bleeding diverticulum and site not easily identified: 1. Measures to identify the bleeding diverticulum: Use glucagon to control peristalsis, target water jet irrigation and suctioning, and then injection of dilute epinephrine for initial control of active bleeding (and before cold guillotining clots), followed by either MPEC (at the neck) or hemoclip (at the base). 2. Measures to identify the bleeding site in the diverticulum (angulation of the colon, depth of the diverticulum, or narrowness of the neck): a. Tattoo the area around the diverticulum (with India ink). b. Go back with an endoscope fitted either with a short (5-6 mm) transparent cap or hood to evert the diverticulum and treat the SRH with hemoclip or a rubber band ligation as a backup technique. c. An oblique-viewing endoscope with an elevator may have a role in difficult cases. Take-home message: Use MPEC for bleeding from the neck of a diverticulum and a clip for bleeding from the base of a diverticulum. REFERENCES: 1. Jensen DM. The ins and outs of diverticular bleeding. Gastrointest Endosc 2012;75:388-91.
399.e5 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 2 : 2012
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Exam: February 2012 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 articles in this issue carefully and complete the activity: Vahabzadeh B, Seetharam AB, Cook MB, et al. Validation of the Prague C & M criteria for the endoscopic grading of Barrett’s esophagus by gastroenterology trainees: a multicenter study. Gastrointest Endosc 2012;75:236-41. Rodriguez L, Rosen R, Manfredi M, et al. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study. Gastrointest Endosc 2012;75:302-9. Dhir V, Bhandari S, Bapat M, et al. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access. Gastrointest Endosc 2012;75:354-9. Jensen DM. The ins and outs of diverticular bleeding. Gastrointest Endosc 2012;75:388-91. 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 acessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives Upon completion of this educational activity, participants will be able to: 1. Describe the Prague classification of Barrett’s esophagus. 2. Define the best strategies for the management of gastroparesis in children. 3. Compare the techniques of EUS-guided rendezvous and precut papillotomy in gaining biliary access in difficult biliary cannulation. 4. Distinguish the different endoscopic management options of colonic diverticular bleeding.
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 enduring material for a maximum of 1.0 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Activity Start Date: February 1, 2012 Activity Expiration Date: February 28, 2014
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 copyShou-Jiang Tang, MD (CME Editor): righted by the ASGE. Consulting/Advisory/Speaking: Olympus America Other Financial: Ethicon Endo-Surgery, licensing agreement for Minimum Online System Requirements: magnetic anchoring and guidance sysytem; Patents pending 486 Pentium 1 level computer (PC or Macintosh) 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
www.giejournal.org
Volume 75, No. 2 : 2012 GASTROINTESTINAL ENDOSCOPY 399
CME ACTIVITY
Continuing Medical Education Questions: February 2012 QUESTION 1 OBJECTIVE: To describe the Prague classification of Barrett’s esophagus.
How to report Barrett’s esophagus using the Prague classification? Question 1: Your program director institutes an instructional program for identification and classification of Barrett’s mucosa using the Prague classification. Here is an endoscopy report of a patient with Barrett’s esophagus, with the following markings. The diaphragmatic hiatus was located at 40 cm; the top of the gastric folds at 35 cm; the proximal margin of circumferential Barrett’s esophagus at 33 cm; the proximal margin of the longest tongue of Barrett’s esoph-
agus at 31 cm, and the proximal margin of the erosions at 30 cm. How do you describe it using the Prague classification?
Possible answers: (A-D) A. B. C. D.
C2, C7, C7, C2,
M4 M9 M10 M5
Look-up: Vahabzadeh B, Seetharam AB, Cook MB, et al. Validation of the Prague C & M criteria for the endoscopic grading of Barrett’s esophagus by gastroenterology trainees: a multicenter study. Gastrointest Endosc 2012;75:236-41.
QUESTION 2 OBJECTIVE: To define the best strategies for the management of gastroparesis in children.
What are the best treatment options for the treatment of gastroparesis in children? Question 2: A 13-year-old boy with a history of idiopathic gastroparesis presents to you with intermittent vomiting refractory to medical therapy. He has delayed gastric emptying demonstrated on a nuclear medicine gastric emptying study performed 7 months ago. The patient has already undergone esophagogastroduodenoscopy with intrapyloric injection of botulinum toxin A, which resulted in a significant reduction of his symptoms for approximately 3 months. He now presents with worsening, frequent vomiting and weight loss.
Which of the following would be a reasonable next step in the management of the patient’s symptoms?
Possible answers: (A-D) A. B. C. D.
Antroduodenal manometry Repeat intrapyloric botox injection Percutaneous endoscopic gastrostomy tube placement Pyloromyotomy
Look-up: Rodriguez L, Rosen R, Manfredi M, et al. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open-label study. Gastrointest Endosc 2012;75:302-9.
QUESTION 3 OBJECTIVE: To compare the techniques of EUS-guided rendezvous and precut papillotomy in gaining biliary access in difficult biliary cannulation.
How good is EUS-guided rendezvous technique for biliary access? Question 3: A 45-year-old male presents with a 2-week history of obstructive jaundice and moderate mid-epigastric pain. A CT scan shows a 3-cm mass in the head of the pancreas with a long stricture at the common bile duct with proximal biliary dilation. As an expert in endosonography and 399.e1 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 2 : 2012
ERCP, you are planning for biliary drainage. After several failed conventional ERCP techniques to access the bile duct, you are unable to see the ampulla well because of bleeding and marked edema. Which of the following should you try next to gain access to the bile duct? www.giejournal.org
CME Exam
Possible answers: (A-D) A. Pre-cut papillotomy B. EUS-guided rendezvous technique
C. Percutaneous transhepatic biliary drainage D. Choledochojejunostomy
Look-up: Dhir V, Bhandari S, Bapat M, et al. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access. Gastrointest Endosc 2012;75:354-9.
QUESTION 4 OBJECTIVE: To distinguish the different endoscopic management options of colonic diverticular bleeding.
Banding a bleeding diverticulum Question 4: A 73-year-old woman is seen with severe painless hematochezia and hypotension. After a negative EGD, you perform an urgent colonoscopy after rapid colon preparation and notice a bleeding vessel in the base of the diverticulum (Fig. 1). Which of the following is recommended for definitive therapy by the CURE Hemostasis Group?
Possible answers: (A-D) A. B. C. D.
Clip application Band ligation Cautery Epinephrine injection
Figure 1.
Look-up: Jensen DM. The ins and outs of diverticular bleeding. Gastrointest Endosc 2012;75:388-91.
www.giejournal.org
Volume 75, No. 2 : 2012
GASTROINTESTINAL ENDOSCOPY
399.e2
CME ACTIVITY
Continuing Medical Education Answers: February 2012 QUESTION 1 CORRECT RESPONSE: A Rationale for correct response: Accurate description of the esophageal findings and landmarks in the endoscopic report should encompass information on 3 important variables in patients with gastroesophageal reflux disease—Barrett’s esophagus (BE) and its extent, hiatal hernia and its type, and erosive esophagitis and its severity. A subgroup of the International Working Group for the Classification of Oesophagitis (IWGCO) with a special interest in BE developed the Prague C & M Criteria, which uses the “C” value as the “circumferential extent” and the “M” value as “maximal extent” of BE above the gastroesophageal junction (GEJ) in centimeters (Fig. 2). Measure the endoscope insertion distance at the following sites to report the C & M values in the endoscopic report: A. Diaphragmatic hiatus (in this report, it is located at 40 cm) B. Top of the gastric folds (in this report, it is located at 35 cm) C. Circmferential segment of BE (in this report, it is located at 33 cm) D. Top of the tongue of BE (in this report, it is located at 31 cm) Prague classification of the Barrett’s esophagus in the test case should be reported as C2, M4. 1. Circumferential (C) segment C2cm (B minus C ⫽ 35 - 33cm) 2. Maximum extent (M) including tongues M4cm (B minus D ⫽ 35 - 31) Like the insertion and total colonoscopy times, the C & M criteria should be part of every EGD report. The study in this issue of the journal by Vahabzadeh et al shows good agreement among trainees in identifying and describing Barrett’s esophagus from video clips.1 Unfortunately, baseline assessments before the instruction were not obtained, so it is not possible to define the impact of the instruction. How the level of agreement would be affected by live endoscopic imaging and enhancements like narrow-band imaging (NBI) is unclear. One area with poor agreement was identification of Barrett’s less than 1 cm in length. NBI with its ability to clearly define the squamocolumnar junction may help with this identification. Recommendations on technique may improve agreement further, such as consistently taking measurements on withdrawal of the endoscope and using NBI when available. Although the focus is on the length of esophagus at risk, the more biologically relevant factor is surface area covered by Barrett’s. The relation between length and cancer rate is not linear as suggested, but rather the slope declines with increasing length, consistent with the relevance of the surface area.2,3
Figure 2.
399.e3 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 2 : 2012
www.giejournal.org
CME Answers
Take-home message: Learning the Prague criteria for Barrett’s esophagus and incorporating it into clinical practice could be a useful quality improvement project for endoscopy units. REFERENCES: 1. Vahabzadeh B, Seetharam AB, Cook MB, et al. Validation of the Prague C&M Criteria for the endoscopic grading of Barrett’s esophagus among gastroenterology trainees: a multicenter study. Gastrointest Endosc 2012;75:236-41. 2. Rudolph RE, Vaughan TL, Storer BE, et al. Effect of segment length on risk for neoplastic progression in patients with Barrett’s esophagus. Ann Intern Med 2000;132:612-20. 3. Gaddam S, Young PE, Alsop BR, et al. Relationship between Barrett’s sophagus (BE) length and the risk of high grade dysplasia (HGD), and esophageal adenocarcinoma (EAC) in patients with non dysplastic Barrett’s esophagus results from a large multicenter cohort. Gastroenterology 2011;140(5,suppl 1):S-81.
QUESTION 2 CORRECT RESPONSE: B Rationale for correct response: Gastroparesis is a serious condition in children, which often is not responsive to medical management with prokinetic agents or antiemetics. Patients can present with a variety of symptoms, including nausea, vomiting, retching, abdominal distention, early satiety, abdominal pain, and feeding intolerance. Endoscopic intrapyloric botulinum A injection (IPBI) has not been well studied in the management of gastroparesis in children. In a retrospective study, 47 children with gastroparesis treated with IPBI in a single medical center from 2004 to 2010 were included.1 Follow-up data were available in 45 patients, of which 51% were female with a mean age of 9.98 ⫾ 6.5 years. Treatment response was considered mild if symptoms improved but the patient still required medical therapy, moderate if symptoms improved with discontinuation of medical therapy, and complete if the patient was asymptomatic. Of the 45 patients, 30 (67%) had at least a mild response and 15 (33%) were considered treatment failures. Of the responders, 10% had a mild response, 50% had a moderate response, and 40% were completely asymptomatic. The median duration of the response was 3 months (1.2-4.8 months). On multivariate regression analysis, older age (⬎12) and the presence of vomiting were independent predictors of response to IPBI. Of the responders, 18 patients underwent more than 1 injection for recurrence of symptoms. Follow-up data were available in 15 of these patients, and a sustained response was found in 8 patients after repeated injections. Male gender was associated with treatment response to repeat IPBI. There were no complications reported with IPBI. Take-home message: IPBI is safe and may be effective in the management of gastroparesis in children. Older age and history of vomiting appear to be associated with a response to initial IPBI, whereas male sex is associated with a response to repeat injections. REFERENCE: 1. Rodriguez L, Rosen R, Manfredi M, et al. Endoscopic intrapyloric injection of botulinum toxin A in the treatment of children with gastroparesis: a retrospective, open label study. Gastrointest Endosc 2012;75:302-9.
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: When conventional ERCP with a sphincterotome and a guidewire fails to provide access to the bile duct, other available modalities include pre-cut papillotomy, percutaneous transhepatic biliary drainage (PTBD), surgical biliary drainage (choledochojejunostomy), and EUS-assisted techniques. ● Pre-cut papillotmy: Although the complication rate of pre-cut papillotomy is not any higher when it is performed by an experienced endoscopist than that of conventional ERCP, it still poses a significant risk of bleeding, perforation, and pancreatitis. ● PTBD is a safe and effective technique with a high success rate but requires availability of an interventional radiologist. ● Surgical biliary drainage is also effective and long-lasting but, in most patients, not practical, especially when preoperative chemoradiation is planned or patients have significant co-morbidities. ● EUS-assisted techniques appear to be effective and efficient. In EUS-guided rendezvous technique, the left hepatic duct or extrahepatic bile duct (preferably the common bile duct) is punctured with a 19-gauge needle under EUS guidance, and a guidewire is advanced down to the duodenum through the needle, stricture, and ampulla under fluoroscopic guidance. The echoendoscope is then replaced by a side-viewing scope, and the guidewire is grabbed by a snare. Once biliary access has been established, conventional ERCP can be performed. Recently, Dhir et al compared the efficacy of EUS-guided rendezvous technique and pre-cut papillotomy for biliary access in difficult cannulation.1 www.giejournal.org
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EUS-guided rendezvous technique had a significant higher rate of technical success than that of precut papillotomy (57/58 [98.3%] vs. 130/144 [90.3%]; P ⫽ .03). ● Precut group had an overall success rate of 95.8% (138/144) after 8/14 patients with initial failure had a second attempt at ERCP. ● The complication rates of the two techniques were similar (pre-cut 6.9% and EUS 3.4% [P ⫽ .27]). X Pre-cut group had one severe pancreatitis, 3 moderate pancreatitis, 6 bleeding (5 mild and 1 moderate). X EUS group had 2 pericholedochal tracking of contrast with abdominal pain, which resolved with conservative management within 72 hours. Take-home message: EUS-guided rendezvous technique offers a high technical success rate in difficult ERCP where conventional ERCP attempts fail. However, this method requires an expert endosonographer and a patent duodenum. When they are not available, PTBD is a good alternative with a proven track record. ●
REFERENCES: 1. Dhir V, Bhandari S, Bapat M, et al. Comparison of EUS-guided rendezvous and precut papillotomy techniques for biliary access. Gastrointest Endosc 2012;75:354-9.
QUESTION 4 CORRECT RESPONSE: A Rationale for correct response: Diverticular bleeding is one of the most common causes of acute lower GI bleeding. Bleeding is arterial and can occur either in the base or in the neck of the diverticulum.1 Major stigmata of recent hemorrhage (SRH) in a diverticulum include active bleeding, non-bleeding visible vessel, and adherent clot. CURE Hemostasis Group recommendations for diverticular bleeding: A. Bleeding diverticulum easily identified: 1. Bleeding site clearly seen in the neck of diverticulum: Multipoloar electrocoagulation (MPEC) using moderate tamponade at the neck of the diverticulum is the fastest, easiest, and most effective method of hemostasis. 2. Bleeding site clearly seen in the base of the diverticulum: Hemoclip application using the clip with reopening function. 3. Active bleeding or adherent clot in the diverticulum: Preinjection of dilute epinephrine (1:20,000 in saline solution) is recommended to slow the bleeding or for the clot, before cold guillotining to shave it down to a short pedicle and before hemoclip in the base or MPEC at the neck of the diverticulum. 4. After control of bleeding: Tattoo the mucosa in 3 to 4 areas adjacent to the diverticulum with the signs of recent hemorrhage, in case of rebleeding or resection. 5. Mesenteric angiography and embolization may be used in selected patents if the patient rebleeds and is unfit for repeat colonoscopy or if the patient is unstable for urgent colonoscopy or surgery. B. Bleeding diverticulum and site not easily identified: 1. Measures to identify the bleeding diverticulum: Use glucagon to control peristalsis, target water jet irrigation and suctioning, and then injection of dilute epinephrine for initial control of active bleeding (and before cold guillotining clots), followed by either MPEC (at the neck) or hemoclip (at the base). 2. Measures to identify the bleeding site in the diverticulum (angulation of the colon, depth of the diverticulum, or narrowness of the neck): a. Tattoo the area around the diverticulum (with India ink). b. Go back with an endoscope fitted either with a short (5-6 mm) transparent cap or hood to evert the diverticulum and treat the SRH with hemoclip or a rubber band ligation as a backup technique. c. An oblique-viewing endoscope with an elevator may have a role in difficult cases. Take-home message: Use MPEC for bleeding from the neck of a diverticulum and a clip for bleeding from the base of a diverticulum. REFERENCES: 1. Jensen DM. The ins and outs of diverticular bleeding. Gastrointest Endosc 2012;75:388-91.
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