- Email: [email protected]
Continuing Medical Education Exam: May 2010
GIE
CME ACTIVITY
Continuing Medical Education Exam: May 2010 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: Gastrointestinal Endoscopy CME Activity can now be completed entirely on-line. To complete this CME activity, you will need to do the following: 1. Read the following articles that have been designated for CME in this issue: Hatta W, Uno K, Koike T, et al. Optical coherence tomography for the staging of tumor infiltration in superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2010;71:899-906. Mekky MA, Yamao K, Sawaki A, et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010;71:913-9. Gersin KS, Rothstein RI, Rosenthal RJ, et al. Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates. Gastrointest Endosc 2010;71:976-82. Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010;71:998-1005. 2. Log-in on-line to complete a single exam with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the exam and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives As a result of completing this activity, participating physicians will be able to: 1. To review the outcomes and limitations of optical coherence tomography in superficial esophageal squamous cell carcinoma staging. 2. To assess the factors that influence the adequacy and diagnostic yield of EUS-guided FNA of gastric subepithelial lesions. 3. To analyze the effects of endoscopic duodenaljejunal bypass liner on weight loss before bariatric surgery. 4. To review the outcomes of continuation of antiplatelet therapy in patients undergoing colonoscopy.
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 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: May 1, 2010 Activity Expiration Date: May 31, 2012
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): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Wyeth, Olympus Research Support: ConMed Raquel E. Davila, MD (CME Editor): Disclosed no relevant financial relationships. William Ross, MD (CME Editor): 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) Windows 95, 98, 2000, NT or Mac OS Netscape 4.x or Microsoft Internet Explorer 4.x and above 16 MB RAM 56.6K modem
1028 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 6 : 2010
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
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: May 2010 QUESTION 1 OBJECTIVE: To review the outcomes and limitations of optical coherence tomography in superficial esophageal squamous cell carcinoma staging.
How good is optical coherence tomography in the staging cancer? Question 1:
Possible answers: (A-D)
A 49-year-old Asian male presents with recurrent epigastric pain. Upper endoscopic biopsy of a 1-cm nodular lesion in the midesophagus reveal squamous cell carcinoma. CT scan of the chest and abdomen are normal. Before endoscopic resection of the lesion, you perform EUS and optical coherence tomography (OCT) to assess the depth of tumor penetration. Which of the following is an advantage of the OCT over the EUS in staging esophageal cancer?
A. Deeper-penetration than EUS B. Better delineation of cancer versus inflammatory cell infiltration than EUS C. Better delineation of the normal esophageal tissue and cancer of the epithelial layer D. Higher-resolution images than EUS
Look-up: Hatta W, Uno K, Koike T, et al. Optical coherence tomography for the staging of tumor infiltration in superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2010;71:899-906.
QUESTION 2 OBJECTIVE: To assess the factors that influence the adequacy and diagnostic yield of EUS-guided FNA of gastric subepithelial lesions.
What factors determine the adequacy and diagnostic yield of EUS-guided FNA of gastric subepithelial lesions? Question 2:
Possible answers: (A-D)
A 57-year-old woman with long-standing gastroesophageal reflux disease undergoes esophagogastroduodenoscopy for Barrett’s esophagus screening. Incidentally, she is found to have a 3-cm subepithelial lesion in the fundus of the stomach along the lesser curve. The patient is referred for an EUS for further evaluation. Which of the following factors impacts the adequacy and diagnostic yield of EUS-guided FNA?
A. B. C. D.
Number of needle passes Heterogeneous echopattern Origin of the lesion within the muscularis propria Presence of mucosal ulceration
Look-up: Mekky MA, Yamao K, Sawaki A, et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010;71:913-9.
www.giejournal.org
Volume 71, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY 1028.e1
CME Exam
QUESTION 3 OBJECTIVE: To analyze the effects of endoscopic duodenaljejunal bypass liner on weight loss before bariatric surgery.
Will your bariatric patients benefit from a duodenaljejunal bypass liner? Question 3: A 45-year-old woman with a body mass index (BMI) of 45 (kg/m2), diabetes mellitus, and hypertension consults you for insertion of an endoscopic duodenaljejunal bypass liner to reduce weight before bariatric surgery. She denies any GI problems. You discuss the procedure, risks, benefits, and outcome of the procedure and also explain the mechanism of action.
What surgical procedure does the endoscopic duodenaljejunal bypass liner simulate?
Possible answers: (A-D) A. B. C. D.
Roux-en-Y gastric bypass Roux-en-Y gastric bypass without gastric restriction Biliopancreatic diversion Biliopancreatic diversion without gastric restriction
Look-up: Gersin KS, Rothstein RI, Rosenthal RJ, et al. Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates. Gastrointest Endosc 2010;71:976-82.
QUESTION 4 OBJECTIVE: To review the outcomes of continuation of antiplatelet therapy in patients undergoing colonoscopy.
What is the risk of postpolypectomy bleeding in patients on antiplatelet therapy? Question 4:
Possible answers: (A-D)
A 55-year-old man, who had a drug-eluting coronary stent inserted 14 months ago, is referred to you for colonoscopy with intermittent rectal bleeding. His hemoglobin is 12 g/dL. His medications include atenolol, clopidogrel, and aspirin. Which of the following would be the most appropriate management option?
A. Defer colonoscopy for 10 months B. Stop both clopidogrel and aspirin for 1 week and proceed with colonoscopy C. Stop aspirin for 1 week and proceed with colonoscopy D. Continue both aspirin and clopidogrel and proceed with colonoscopy
Look-up: Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010;71:998-1005.
1028.e2 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 6 : 2010
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: May 2010 QUESTION 1 CORRECT RESPONSE: D Rationale for correct response: Accurate staging is critical before endoscopic mucosal resection (EMR) of early stage cancers of the GI tract. Catheter probe EUS (CPEUS) is used for T-staging of early GI cancers. Another local tumor staging modality is optical coherence tomography (OCT), which has been evaluated in the GI tract and pancreatic ductal system.1,2 Here is a summary of the EUS and OCT imaging characteristics:1,2 ● OCT uses infrared light instead of sound waves used in EUS. Images are generated by measuring the echo time delay and the intensity of back-scattered light. ● OCT yields higher spatial resolution compared with EUS (10 m vs 100 m with EUS). ● OCT’s depth of penetration is limited to the mucosa and submucosa, compared with CPEUS capacity to image the full thickness of the gut wall. ● OCT requires less need for acoustic coupling compared with the EUS. In a study involving 62 patients with superficial esophageal squamous cell carcinoma, OCT showed esophageal wall components that corresponded to the histological findings.3 The study demonstrated a staging accuracy of 94.9% for tumors confined to the epithelium or invading lamina propria mucosa, 85.0% for tumors invading the muscularis mucosa, and 90.9% for tumors invading the submucosa, with an overall accuracy rate of 92.7 %.3 In an ex-vivo pilot study, OCT was able to distinguish the presence or absence of neoplasia within the wall of the main pancreatic duct without distinguishing inflammatory changes and low-grade dysplasia.2 Take-home message: OCT and CPEUS are complementary techniques. OCT is useful for assessing the extent of precancerous disorders such as Barrett’s esophagus and early cancers, while EUS would be more appropriate for lesions that extend beyond the submucosa. REFERENCES: 1. Das A, Sivak MV Jr, Chak A, et al. High-resolution endoscopic imaging of the GI tract: a comparative study of optical coherence tomography versus high-frequency catheter probe EUS. Gastrointest Endosc 2001;54:219-24. 2. Testoni PA, Mangiavillano B, Albarello L, et al. Optical coherence tomography to detect epithelial lesions of the main pancreatic duct: An ex vivo study, Am J Gastro 2005;100:2777-83. 3. Hatta W, Uno K, Koike T, et al. Optical coherence tomography for the staging of tumor infiltration in superficial esophageal squamous cell carcinoma Gastrointest Endosc 2010;71:899-906.
QUESTION 2 CORRECT RESPONSE: B Rationale for correct response: Gastric subepithelial lesions can often be found on routine endoscopy. GI stromal tumors (GIST) represent the majority of subepithelial lesions in the stomach and are considered to be malignant or have malignant potential.1 The accurate diagnosis of subepithelial lesions is, therefore, important in differentiating benign from malignant or premalignant tumors. Unfortunately, EUS features alone are not sufficient for determining the diagnosis. EUS-guided FNA has become a useful modality for tissue acquisition, but its yield has not been well established. In a retrospective study of 141 patients with gastric subepithelial lesions, EUS-FNA was diagnostic in 43.3%, suspicious in 39%, and nondiagnostic in 17.7% of cases.2 Heterogeneous echopattern was found to be the only independent predictor of FNA adequacy and diagnostic yield on logistic regression analysis. Number of needle passes, EUS layer of origin, location within the stomach, and lesion size (⬍ 20 mm vs ⱖ 20 mm) were not predictive of FNA adequacy. Take-home message: EUS-guided FNA is useful in the diagnosis of gastric subepithelial lesions. The presence of a heterogenous echopattern on EUS may be associated with a higher EUS-FNA diagnostic yield. REFERENCES: 1. Davila RE, Faigel DO. GI stromal tumors. Gastrointest Endosc 2003;58: 80-8. 2. Mekky MA, Yamao K, Sawaki A, et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010;71:913-9.
www.giejournal.org
Volume 71, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY 1028.e3
CME Answers
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: Duodenojejunal bypass liner simulates the effects of Roux-en-Y gastric bypass without gastric restriction. The 1998 National Institutes of Health obesity consensus panel called for aggressive treatment of obese individuals including use of diet, exercise, behavioral modification, pharmacotherapy, and bariatric surgery.1 In addition, the panel proposed that obese patients should attempt to lose 10% of their body weight over 6 months before bariatric surgery based on the documented benefits of such an intervention. Several endoscopic options are currently being explored to help patients lose weight before bariatric surgery. In a 12-week, open-label, sham-controlled randomized trial in obese patients (Body Mass Index [BMI] of ⱖ40 kg/m2 and ⱕ60 kg/m2 or ⱖ35 kg/m2 with comorbid conditions), duodenojejunal bypass liner (DJBL) implantation was successful in 21 of 25 patients. Eight patients discontinued trial participation before 12 weeks. At week 12 (DJBL n ⫽ 13, sham n ⫽ 24), excess weight loss was 11.9 ⫾ 1.4% in the DJBL arm compared with the 2.7 ⫾ 2.0% in the sham arm (P ⬍ .001). Total body weight change was 8.2 ⫾ 1.3 kg in the DJBL arm compared with –2.0 ⫾ 1.1 kg in the sham arm (P ⫽ .002). The majority of adverse events were mild or moderate. There were no signs or symptoms of biliary obstruction, pancreatic duct obstruction, or obstructions or migrations of the device in any subject. Three patients with DJBL developed clinically significant GI bleeding. Seven subjects had the DJBL explanted early due to device-related adverse events, including abdominal pain, nausea ,and/or vomiting.2 Take-home message: Endoscopic DJBL can achieve significant short-term preoperative weight loss. However, these patients can develop device-related abdominal pain, nausea and/or vomiting, and GI bleeding. REFERENCES: 1. National Institutes of Health clinical guideline on the identification, evaluation and treatment of overweight and obesity in adults. NIH Publication 98-4083, Sept 1998. 2. Gersin KS, Rothstein RI, Rosenthal RJ, et al. Open-label, sham-controlled trial of an endoscopic duodenaljejunal bypass liner for preoperative weight loss in bariatric surgery candidates. Gastrointest Endosc 2010;71:976-82.
QUESTION 4 CORRECT RESPONSE: C Rationale for correct response: The traditional approach of stopping all anti-platelet medications in patients with drug eluting coronary stents is no longer recommended because of significant risk of coronary stent thrombosis. Although informed consent involves weighing the risks versus benefits in deciding about the procedure, this may be complicated when weighing one risk (coronary stent thrombosis in patients undergoing colonoscopy after withdrawal of antiplatelet therapy) against another (postpolypectomy bleeding in patients with coronary stents who continue antiplatelet therapy). Interruption of antiplatelet therapy could result in fatal myocardial infarction in 15% to 75% and nonfatal myocardial infarction in 25% to 65% in patients with coronary drug– eluting stents. This is an important fact worth quoting during the consent process.1 ● In patients with coronary stents on antiplatelet therapy the following actions could be undertaken: ● Colonoscopy with biopsy: This could be undertaken without discontinuation of antiplatelet therapy. ● Colonoscopic polypectomy: The decision should be individualized based on stent type, number, date of insertion, and procedure planned. If a decision is made to stop clopidogrel, aspirin should be continued.2,3 However, there are few data to stop clopidogrel versus aspirin with regards to the risk that either action presents to the patients in terms of cardiac or bleeding event. Singh et al4 reported a retrospective data analysis on the risk of colonoscopic postpolypectomy bleeding in patients on uninterrupted clopidogrel therapy. A total of 375 polypectomies were performed in patients on clopidogrel, and the risk of bleeding was compared with 3226 polypectomies in patients who were not on clopidogrel therapy.4 The risk of immediate bleeding was similar in both groups. The risk of delayed bleeding in the clopidogrel group was increased compared with those who were not taking clopidogrel (3.5% vs. 1%; P ⫽ .02). Yet in all of the cases of delayed bleeding in the clopidogrel group, the patients were also on aspirin therapy. Patients who were not on concomitant aspirin therapy had no increased risk of immediate or delayed bleeding when continuing clopidogrel. Importantly, patients who experienced postpolypectomy bleeding had minimal negative outcomes. Hospitalization, transfusion, and additional interventions were seen in 60% of the patients taking clopidogrel and 40% of those not taking clopidogrel, and there was no mortality in either group. Thus, bleeding was increased, but the actual damage to the patient was minimal. In the best interest of the patient, the patient’s cardiologist should be involved in the decision process. 1028.e4 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 6 : 2010
www.giejournal.org
CME Answers
Take-home message: Colonoscopic polypectomy in patients taking clopidogrel does not increase the risk of postpolypectomy bleeding, unless aspirin is also continued, in which case the risk of bleeding continues to be low. REFERENCES: 1. Petrini JL. Primum non nocere. Gastrointest Endosc 2010:71:1006-8. 2. Zuckerman MJ, Hirota WK, Adler DG, et al. ASGE. The management of low molecular weight heparin and non-aspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc 2005;61:189-94. 3. Becker RC, Sheiman J, Dauerman HL, et al. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. Am J Gastroenterol 2009;104:2903-17. 4. Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010:71:998-1005.
www.giejournal.org
Volume 71, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY 1028.e5
CME Answers
EVALUATION PAGE, GIE Please complete the following questions in order to complete the process for earning your CME. Assessment of change in knowledge, skills and/or practice In general, this activity (check all that apply): □ Yes □ Yes □ Yes
Reinforced by existing knowledge and/or skills. Increased by knowledge. Will positively impact my practice.
□ No □ No □ No
Please specify any changes you plan to implement in your practice as a result of this activity:
Overall Evaluation of Activity
Strongly agree
Agree
Disagree
□ □ □
□ □ □
□ □ □
1. The overall educational value of this activity is excellent. 2. I would recommend this activity to a colleague. 3. I am interested in participating in future journal CME activities. Did you perceive commercial bias in this activity?
1028.e6 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 6 : 2010
□
Yes
□
No
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Exam: May 2010 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: Gastrointestinal Endoscopy CME Activity can now be completed entirely on-line. To complete this CME activity, you will need to do the following: 1. Read the following articles that have been designated for CME in this issue: Hatta W, Uno K, Koike T, et al. Optical coherence tomography for the staging of tumor infiltration in superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2010;71:899-906. Mekky MA, Yamao K, Sawaki A, et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010;71:913-9. Gersin KS, Rothstein RI, Rosenthal RJ, et al. Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates. Gastrointest Endosc 2010;71:976-82. Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010;71:998-1005. 2. Log-in on-line to complete a single exam with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the exam and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.
Target Audience This activity is designed for physicians who are involved with providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning Objectives As a result of completing this activity, participating physicians will be able to: 1. To review the outcomes and limitations of optical coherence tomography in superficial esophageal squamous cell carcinoma staging. 2. To assess the factors that influence the adequacy and diagnostic yield of EUS-guided FNA of gastric subepithelial lesions. 3. To analyze the effects of endoscopic duodenaljejunal bypass liner on weight loss before bariatric surgery. 4. To review the outcomes of continuation of antiplatelet therapy in patients undergoing colonoscopy.
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 Credit ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Activity Start Date: May 1, 2010 Activity Expiration Date: May 31, 2012
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): Disclosed no relevant financial relationships. Consulting/Advisory/Speaking: Wyeth, Olympus Research Support: ConMed Raquel E. Davila, MD (CME Editor): Disclosed no relevant financial relationships. William Ross, MD (CME Editor): 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) Windows 95, 98, 2000, NT or Mac OS Netscape 4.x or Microsoft Internet Explorer 4.x and above 16 MB RAM 56.6K modem
1028 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 6 : 2010
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
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Questions: May 2010 QUESTION 1 OBJECTIVE: To review the outcomes and limitations of optical coherence tomography in superficial esophageal squamous cell carcinoma staging.
How good is optical coherence tomography in the staging cancer? Question 1:
Possible answers: (A-D)
A 49-year-old Asian male presents with recurrent epigastric pain. Upper endoscopic biopsy of a 1-cm nodular lesion in the midesophagus reveal squamous cell carcinoma. CT scan of the chest and abdomen are normal. Before endoscopic resection of the lesion, you perform EUS and optical coherence tomography (OCT) to assess the depth of tumor penetration. Which of the following is an advantage of the OCT over the EUS in staging esophageal cancer?
A. Deeper-penetration than EUS B. Better delineation of cancer versus inflammatory cell infiltration than EUS C. Better delineation of the normal esophageal tissue and cancer of the epithelial layer D. Higher-resolution images than EUS
Look-up: Hatta W, Uno K, Koike T, et al. Optical coherence tomography for the staging of tumor infiltration in superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2010;71:899-906.
QUESTION 2 OBJECTIVE: To assess the factors that influence the adequacy and diagnostic yield of EUS-guided FNA of gastric subepithelial lesions.
What factors determine the adequacy and diagnostic yield of EUS-guided FNA of gastric subepithelial lesions? Question 2:
Possible answers: (A-D)
A 57-year-old woman with long-standing gastroesophageal reflux disease undergoes esophagogastroduodenoscopy for Barrett’s esophagus screening. Incidentally, she is found to have a 3-cm subepithelial lesion in the fundus of the stomach along the lesser curve. The patient is referred for an EUS for further evaluation. Which of the following factors impacts the adequacy and diagnostic yield of EUS-guided FNA?
A. B. C. D.
Number of needle passes Heterogeneous echopattern Origin of the lesion within the muscularis propria Presence of mucosal ulceration
Look-up: Mekky MA, Yamao K, Sawaki A, et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010;71:913-9.
www.giejournal.org
Volume 71, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY 1028.e1
CME Exam
QUESTION 3 OBJECTIVE: To analyze the effects of endoscopic duodenaljejunal bypass liner on weight loss before bariatric surgery.
Will your bariatric patients benefit from a duodenaljejunal bypass liner? Question 3: A 45-year-old woman with a body mass index (BMI) of 45 (kg/m2), diabetes mellitus, and hypertension consults you for insertion of an endoscopic duodenaljejunal bypass liner to reduce weight before bariatric surgery. She denies any GI problems. You discuss the procedure, risks, benefits, and outcome of the procedure and also explain the mechanism of action.
What surgical procedure does the endoscopic duodenaljejunal bypass liner simulate?
Possible answers: (A-D) A. B. C. D.
Roux-en-Y gastric bypass Roux-en-Y gastric bypass without gastric restriction Biliopancreatic diversion Biliopancreatic diversion without gastric restriction
Look-up: Gersin KS, Rothstein RI, Rosenthal RJ, et al. Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates. Gastrointest Endosc 2010;71:976-82.
QUESTION 4 OBJECTIVE: To review the outcomes of continuation of antiplatelet therapy in patients undergoing colonoscopy.
What is the risk of postpolypectomy bleeding in patients on antiplatelet therapy? Question 4:
Possible answers: (A-D)
A 55-year-old man, who had a drug-eluting coronary stent inserted 14 months ago, is referred to you for colonoscopy with intermittent rectal bleeding. His hemoglobin is 12 g/dL. His medications include atenolol, clopidogrel, and aspirin. Which of the following would be the most appropriate management option?
A. Defer colonoscopy for 10 months B. Stop both clopidogrel and aspirin for 1 week and proceed with colonoscopy C. Stop aspirin for 1 week and proceed with colonoscopy D. Continue both aspirin and clopidogrel and proceed with colonoscopy
Look-up: Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010;71:998-1005.
1028.e2 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 6 : 2010
www.giejournal.org
CME ACTIVITY
Continuing Medical Education Answers: May 2010 QUESTION 1 CORRECT RESPONSE: D Rationale for correct response: Accurate staging is critical before endoscopic mucosal resection (EMR) of early stage cancers of the GI tract. Catheter probe EUS (CPEUS) is used for T-staging of early GI cancers. Another local tumor staging modality is optical coherence tomography (OCT), which has been evaluated in the GI tract and pancreatic ductal system.1,2 Here is a summary of the EUS and OCT imaging characteristics:1,2 ● OCT uses infrared light instead of sound waves used in EUS. Images are generated by measuring the echo time delay and the intensity of back-scattered light. ● OCT yields higher spatial resolution compared with EUS (10 m vs 100 m with EUS). ● OCT’s depth of penetration is limited to the mucosa and submucosa, compared with CPEUS capacity to image the full thickness of the gut wall. ● OCT requires less need for acoustic coupling compared with the EUS. In a study involving 62 patients with superficial esophageal squamous cell carcinoma, OCT showed esophageal wall components that corresponded to the histological findings.3 The study demonstrated a staging accuracy of 94.9% for tumors confined to the epithelium or invading lamina propria mucosa, 85.0% for tumors invading the muscularis mucosa, and 90.9% for tumors invading the submucosa, with an overall accuracy rate of 92.7 %.3 In an ex-vivo pilot study, OCT was able to distinguish the presence or absence of neoplasia within the wall of the main pancreatic duct without distinguishing inflammatory changes and low-grade dysplasia.2 Take-home message: OCT and CPEUS are complementary techniques. OCT is useful for assessing the extent of precancerous disorders such as Barrett’s esophagus and early cancers, while EUS would be more appropriate for lesions that extend beyond the submucosa. REFERENCES: 1. Das A, Sivak MV Jr, Chak A, et al. High-resolution endoscopic imaging of the GI tract: a comparative study of optical coherence tomography versus high-frequency catheter probe EUS. Gastrointest Endosc 2001;54:219-24. 2. Testoni PA, Mangiavillano B, Albarello L, et al. Optical coherence tomography to detect epithelial lesions of the main pancreatic duct: An ex vivo study, Am J Gastro 2005;100:2777-83. 3. Hatta W, Uno K, Koike T, et al. Optical coherence tomography for the staging of tumor infiltration in superficial esophageal squamous cell carcinoma Gastrointest Endosc 2010;71:899-906.
QUESTION 2 CORRECT RESPONSE: B Rationale for correct response: Gastric subepithelial lesions can often be found on routine endoscopy. GI stromal tumors (GIST) represent the majority of subepithelial lesions in the stomach and are considered to be malignant or have malignant potential.1 The accurate diagnosis of subepithelial lesions is, therefore, important in differentiating benign from malignant or premalignant tumors. Unfortunately, EUS features alone are not sufficient for determining the diagnosis. EUS-guided FNA has become a useful modality for tissue acquisition, but its yield has not been well established. In a retrospective study of 141 patients with gastric subepithelial lesions, EUS-FNA was diagnostic in 43.3%, suspicious in 39%, and nondiagnostic in 17.7% of cases.2 Heterogeneous echopattern was found to be the only independent predictor of FNA adequacy and diagnostic yield on logistic regression analysis. Number of needle passes, EUS layer of origin, location within the stomach, and lesion size (⬍ 20 mm vs ⱖ 20 mm) were not predictive of FNA adequacy. Take-home message: EUS-guided FNA is useful in the diagnosis of gastric subepithelial lesions. The presence of a heterogenous echopattern on EUS may be associated with a higher EUS-FNA diagnostic yield. REFERENCES: 1. Davila RE, Faigel DO. GI stromal tumors. Gastrointest Endosc 2003;58: 80-8. 2. Mekky MA, Yamao K, Sawaki A, et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010;71:913-9.
www.giejournal.org
Volume 71, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY 1028.e3
CME Answers
QUESTION 3 CORRECT RESPONSE: B Rationale for correct response: Duodenojejunal bypass liner simulates the effects of Roux-en-Y gastric bypass without gastric restriction. The 1998 National Institutes of Health obesity consensus panel called for aggressive treatment of obese individuals including use of diet, exercise, behavioral modification, pharmacotherapy, and bariatric surgery.1 In addition, the panel proposed that obese patients should attempt to lose 10% of their body weight over 6 months before bariatric surgery based on the documented benefits of such an intervention. Several endoscopic options are currently being explored to help patients lose weight before bariatric surgery. In a 12-week, open-label, sham-controlled randomized trial in obese patients (Body Mass Index [BMI] of ⱖ40 kg/m2 and ⱕ60 kg/m2 or ⱖ35 kg/m2 with comorbid conditions), duodenojejunal bypass liner (DJBL) implantation was successful in 21 of 25 patients. Eight patients discontinued trial participation before 12 weeks. At week 12 (DJBL n ⫽ 13, sham n ⫽ 24), excess weight loss was 11.9 ⫾ 1.4% in the DJBL arm compared with the 2.7 ⫾ 2.0% in the sham arm (P ⬍ .001). Total body weight change was 8.2 ⫾ 1.3 kg in the DJBL arm compared with –2.0 ⫾ 1.1 kg in the sham arm (P ⫽ .002). The majority of adverse events were mild or moderate. There were no signs or symptoms of biliary obstruction, pancreatic duct obstruction, or obstructions or migrations of the device in any subject. Three patients with DJBL developed clinically significant GI bleeding. Seven subjects had the DJBL explanted early due to device-related adverse events, including abdominal pain, nausea ,and/or vomiting.2 Take-home message: Endoscopic DJBL can achieve significant short-term preoperative weight loss. However, these patients can develop device-related abdominal pain, nausea and/or vomiting, and GI bleeding. REFERENCES: 1. National Institutes of Health clinical guideline on the identification, evaluation and treatment of overweight and obesity in adults. NIH Publication 98-4083, Sept 1998. 2. Gersin KS, Rothstein RI, Rosenthal RJ, et al. Open-label, sham-controlled trial of an endoscopic duodenaljejunal bypass liner for preoperative weight loss in bariatric surgery candidates. Gastrointest Endosc 2010;71:976-82.
QUESTION 4 CORRECT RESPONSE: C Rationale for correct response: The traditional approach of stopping all anti-platelet medications in patients with drug eluting coronary stents is no longer recommended because of significant risk of coronary stent thrombosis. Although informed consent involves weighing the risks versus benefits in deciding about the procedure, this may be complicated when weighing one risk (coronary stent thrombosis in patients undergoing colonoscopy after withdrawal of antiplatelet therapy) against another (postpolypectomy bleeding in patients with coronary stents who continue antiplatelet therapy). Interruption of antiplatelet therapy could result in fatal myocardial infarction in 15% to 75% and nonfatal myocardial infarction in 25% to 65% in patients with coronary drug– eluting stents. This is an important fact worth quoting during the consent process.1 ● In patients with coronary stents on antiplatelet therapy the following actions could be undertaken: ● Colonoscopy with biopsy: This could be undertaken without discontinuation of antiplatelet therapy. ● Colonoscopic polypectomy: The decision should be individualized based on stent type, number, date of insertion, and procedure planned. If a decision is made to stop clopidogrel, aspirin should be continued.2,3 However, there are few data to stop clopidogrel versus aspirin with regards to the risk that either action presents to the patients in terms of cardiac or bleeding event. Singh et al4 reported a retrospective data analysis on the risk of colonoscopic postpolypectomy bleeding in patients on uninterrupted clopidogrel therapy. A total of 375 polypectomies were performed in patients on clopidogrel, and the risk of bleeding was compared with 3226 polypectomies in patients who were not on clopidogrel therapy.4 The risk of immediate bleeding was similar in both groups. The risk of delayed bleeding in the clopidogrel group was increased compared with those who were not taking clopidogrel (3.5% vs. 1%; P ⫽ .02). Yet in all of the cases of delayed bleeding in the clopidogrel group, the patients were also on aspirin therapy. Patients who were not on concomitant aspirin therapy had no increased risk of immediate or delayed bleeding when continuing clopidogrel. Importantly, patients who experienced postpolypectomy bleeding had minimal negative outcomes. Hospitalization, transfusion, and additional interventions were seen in 60% of the patients taking clopidogrel and 40% of those not taking clopidogrel, and there was no mortality in either group. Thus, bleeding was increased, but the actual damage to the patient was minimal. In the best interest of the patient, the patient’s cardiologist should be involved in the decision process. 1028.e4 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 6 : 2010
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CME Answers
Take-home message: Colonoscopic polypectomy in patients taking clopidogrel does not increase the risk of postpolypectomy bleeding, unless aspirin is also continued, in which case the risk of bleeding continues to be low. REFERENCES: 1. Petrini JL. Primum non nocere. Gastrointest Endosc 2010:71:1006-8. 2. Zuckerman MJ, Hirota WK, Adler DG, et al. ASGE. The management of low molecular weight heparin and non-aspirin antiplatelet agents for endoscopic procedures. Gastrointest Endosc 2005;61:189-94. 3. Becker RC, Sheiman J, Dauerman HL, et al. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. Am J Gastroenterol 2009;104:2903-17. 4. Singh M, Mehta N, Murthy UK, et al. Postpolypectomy bleeding in patients undergoing colonoscopy on uninterrupted clopidogrel therapy. Gastrointest Endosc 2010:71:998-1005.
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Volume 71, No. 6 : 2010 GASTROINTESTINAL ENDOSCOPY 1028.e5
CME Answers
EVALUATION PAGE, GIE Please complete the following questions in order to complete the process for earning your CME. Assessment of change in knowledge, skills and/or practice In general, this activity (check all that apply): □ Yes □ Yes □ Yes
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