- Email: [email protected]
Continuing Medical Examination Exam: August 2008
CME ACTIVITY
Continuing Medical Examination Exam: August 2008 Todd H. Baron, MD, Brenna C. Bounds, MD, Robert Sedlack, MD, Allan P. Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Test ID no.: gie044
Expiration date: January 31, 2009
Category 1 credit can be earned by reading the text material and taking this CME examination online. For complete instructions, visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (non-members).
Target Audience: This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning: After evaluating specific articles published in GIE: Gastrointestinal Endoscopy, participants in the journal’s CME activity should be able to demonstrate an increase in, or affirmation of, their knowledge of clinical endoscopic medicine. Participants should be able to evaluate the appropriateness of the clinical information as it applies to patient care.
PEG consultation in a patient with dementia and poor oral intake Question 1:
Possible answers (A-D)
You are consulted about a 75-year-old inpatient aphasic and minimally ambulating demented man with dysphagia, poor oral intake and progressive cachexia, and weight loss for evaluation and management of nutritional deficiencies. What is the best recommendation for this patient?
A. Avoid PEG tube feedings because of limited lifespan of 30 days. B. Place a nasogastric feeding tube because of its associated lower risk of aspiration. C. First try a nasogastric feeding tube for 30 days before considering PEG. D. Place a PEG feeding tube.
Look-up: McClave SA, Delegge MH. Predicting life expectancy before percutaneous endoscopic gastrostomy placement: a lesson in futility or an exercise of injustice? Gastrointest Endosc 2008;68:228-30.
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 333
CME Exam
What to do with a CT report showing an enlarged head of pancreas? Question 2:
Possible answers (A-D)
A 60-year-old man with upper abdominal discomfort and 10-pound weight loss is found to have an enlarged head of the pancreas on CT scan. There is no dilation of the common bile duct (CBD) or the pancreatic duct (PD). His bilirubin is normal. You perform an EUS. What is the most frequent pathology encountered with this presentation?
A. Normal pancreas B. Chronic pancreatitis C. Benign cysts D. Adenocarcinoma
Look-up: Agarwal B, Krishna NB, Labundy JL, et al. EUS and/or EUS-guided FNA in patients with CT and/or magnetic resonance imaging findings of enlarged pancreatic head or dilated pancreatic duct with or without a dilated common bile duct. Gastrointest Endosc 2008;68:237-42.
What is an “adequate” colonic biopsy specimen? Question 3:
Possible answers (A-D)
While reviewing colonic biopsy specimens with an expert GI pathologist, you notice the frequency of poor quality of colonic biopsy specimens submitted from patients undergoing surveillance for dysplasia and cancer in inflammatory bowel disease. Which is the most accurate description of an adequate colonic biopsy specimen?
A. Length >3 mm; penetration <20% crush artifact. B. Length >2 mm; penetration <10% crush artifact. C. Length >1 mm; penetration <5% crush artifact. D. Length >4 mm; penetration <20% crush artifact.
into muscularis mucosa; into muscularis mucosa; into muscularis mucosa; into muscularis propria;
Look-up: Elmunzer BJ, Higgins PDR, Kwon YM, et al. Jumbo forceps are superior to standard large-capacity forceps in obtaining diagnostically adequate inflammatory bowel disease surveillance biopsy specimens. Gastrointest Endosc 2008;68:273-8.
What is the best colon preparation? Question 4:
Possible answers (A-D)
A 50-year-old female executive presents for screening colonoscopy. Which of the following regimens provides superior satisfactory colon cleansing?
A. 4-L PEG the evening before the procedure. B. 4-L PEG the evening before the procedure, plus the prokinetic tegaserod. C. 2-L PEG the evening before the procedure and 2 hours before the procedure. D. 2-L PEG the evening before the procedure and 2 hours before the procedure, plus tegaserod.
Look-up: Abdul-Baki H, Hashash JG, ElHajj II, et al. A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation. Gastrointest Endosc 2008;68:294-300.
334 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
www.giejournal.org
CME ACTIVITY
Continuing Medical Examination Answers: August 2008 QUESTION 1: CORRECT RESPONSE: D Rationale for correct response: Among the various gastroenterology consults, a PEG consult in a patient with dementia provides us an opportunity to showcase our talents in communicating with our peers and patients and their families, and in careful planning and safe execution of the procedure. The editorial by McClave and Delegge1 serves as an excellent resource that addresses the issue of PEG in a patient with dementia. A few take-home messages from this editorial are summarized below. 1. Feeding: If the patient and the family decide to continue with feeding irrespective of the stage of dementia, honor that wish. This is the first step that needs to be addressed in deciding about PEG tube placement. 2. Palliation and patient placement: If the patient cannot swallow medications, provide an enteral access for them. A 24F PEG offers a better route than a smaller-bore nasogastric tube for this purpose. In the United States, nursing homes require placement of a PEG in patients who cannot swallow because they may not have the means to manage blocked or displaced nasogastric tubes. 3. Aspiration risk: The risk is higher in patients with a nasogastric feeding tube compared to PEG feeding because of a siphoning effect along the tube up the gastroesophageal junction. This is not a good argument for recommending a nasogastric tube. 4. Lifespan: In a patient with dementia and poor speech and ambulation, lifespan is longer than we expect, typically several months instead of days or weeks! 5. Prophylactic antibiotics: Antibiotics reduce the risk of periprocedural infection. Set up a protocol to make it mandatory for every patient undergoing PEG placement. 6. Anesthesia support: Support should be provided because these patients tend to have several comorbid conditions that put them at risk for cardiopulmonary events during the procedure. REFERENCE: 1. McClave SA, Delegge MH. Predicting life expectancy before percutaneous endoscopic gastrostomy placement: a lesson in futility or an exercise of injustice? Gastrointest. Endosc 2008;68:228-30.
QUESTION 2: CORRECT RESPONSE: A Rational for correct response: Radiologists frequently report subtle findings on CT scan and recommend clinical correlation. One such finding is the enlarged head of the pancreas, or dilated PD with or without a dilated CBD. Although patients with an enlarged head of the pancreas are investigated for suspicion of pancreatic neoplasm, the outcome of such incidental findings is unclear. In a retrospective analysis of a prospectively collected database at a tertiary care center, 67 patients with an enlarged head of the pancreas and 43 patients with a dilated PD with or without a dilated CBD underwent EUS and FNA, if necessary.1 The final diagnosis was based on definitive cytology, surgical pathology, and close follow-up. In 110 study patients, the final diagnosis included adenocarcinoma (n = 7), pancreatic intraepithelial neoplasia (n = 1), neuroendocrine tumor (n = 1), tumor metastasis (n = 1), and benign cyst (n = 3). Thirty-two patients had EUS evidence of chronic pancreatitis, and in the remaining 65 patients, the pancreas was normal. The accuracy of EUS and/or EUS-FNA for diagnosing pancreatic neoplasm in these patients was 99.1%, with 88.8% sensitivity, 100% specificity, 99% negative predictive value, and 100% positive predictive value. REFERENCE: 1. Agarwal B, Krishna NB, Labundy JL, et al. EUS and/or EUS-guided FNA in patients with CT and/or magnetic resonance imaging findings of enlarged pancreatic head or dilated pancreatic duct with or without a dilated common bile duct. Gastrointest Endosc 2008;68:237-42.
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 335
CME Answers
QUESTION 3: CORRECT RESPONSE: A Rationale for correct response: Surveillance of patients with inflammatory bowel disease (IBD) for dysplasia and colon cancer involves taking 30 to 50 random biopsy specimens from different sections of the colon. It is not only the number of specimens but also the quality of biopsy specimens that is important for interpreting the underlying pathology. Expert GI pathologists at the University of Michigan consider a biopsy specimen to be adequate if it fulfills 3 characteristics. 1. Length of the specimen should be more than 3 mm. 2. Depth of the specimen should include the muscularis mucosa. 3. The specimen should have less than 20% crush artifact. The Radial Jaw 4-jumbo forceps (Boston Scientific, Natick, Mass) is a disposable, Food and Drug Administration–approved enlarged cup forceps, which can pass through the accessory channel of a standard, nontherapeutic colonoscope and procure larger mucosal specimens with minimal artifact. In a prospective comparison in 24 patients with IBD, the proportion of “adequate” biopsy specimens obtained with jumbo forceps was significantly higher than that obtained by standard large-capacity forceps (67% vs 48%, P < .0001).1 REFERENCE: 1. Elmunzer BJ, Higgins PDR, Kwon YM, et al. Jumbo forceps are superior to standard large-capacity forceps in obtaining diagnostically adequate inflammatory bowel disease surveillance biopsy specimens. Gastrointest Endosc 2008;68:273-8.
QUESTION 4: CORRECT RESPONSE: C Rationale for correct response: Despite great advances in endoscopic imaging technology that can visualize at the cellular level, there is much room to improve the quality of colon preparation. Bowel preparation is inadequate for up to 25% of patients undergoing colonoscopy, and the impact of poor preparation on procedure duration, difficulty, completion, and cost is substantial. A simple change in the strategy, such as split the dose, may make a substantial improvement in the colon preparation. The American University of Beirut Medical Center has made substantial contributions to our understanding of pharmacotherapy of colon preparations. 1. A split dose of PEG-electrolyte solution in combination with low-dose bisacodyl and minimally restricted diet improves the quality of the preparation when compared with full-dose PEG-electrolyte solution and conventional dietary restriction.1 2. A split-dose PEG-electrolyte solution and no dietary restriction provides better quality colon cleansing than wholedose preparation, but without significant impact on patient tolerability and side effects.2 3. A split-dose PEG-electrolyte solution in combination with tegaserod has a marginal effect on the quality of colon preparation compared to split-dose PEG-electrolyte solution without the use of tegaserod. The split dose was superior to whole-dose PEG-electrolyte solution, resulting in better cleansing, adherence, and tolerance.3 Take-home message: Split the PEG-electrolyte solution dose. REFERENCES: 1. El Sayed AM, Kanafani ZA, Mourad FH, et al. A randomized single-blind trial of whole versus split-dose polyethylene glycol-electrolyte solution for colonoscopy preparation. Gastrointest Endosc 2003;58:36-40. 2. Aoun E, Abdul-Baki H, Azar C, et al. A randomized single-blind trial of split-dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation. Gastrointest Endosc 2005;62:213-8. 3. Abdul-Baki H, Hashash JG, ElHajj II, et al. A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation. Gastrointest Endosc 2008;68:294-300.
336 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
www.giejournal.org
Continuing Medical Examination Exam: August 2008 Todd H. Baron, MD, Brenna C. Bounds, MD, Robert Sedlack, MD, Allan P. Weston, MD, Co-Editors, CME Section G. S. Raju, MD, Editor, CME Section George Triadafilopoulos, MD, Editor-in-Chief, Gastrointestinal Endoscopy
Instructions: The American Society for Gastrointestinal Endoscopy (ASGE) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. ASGE designates this educational activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Test ID no.: gie044
Expiration date: January 31, 2009
Category 1 credit can be earned by reading the text material and taking this CME examination online. For complete instructions, visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (non-members).
Target Audience: This program is designed for physicians who are involved in providing patient care and who wish to advance their current knowledge of clinical medicine.
Learning: After evaluating specific articles published in GIE: Gastrointestinal Endoscopy, participants in the journal’s CME activity should be able to demonstrate an increase in, or affirmation of, their knowledge of clinical endoscopic medicine. Participants should be able to evaluate the appropriateness of the clinical information as it applies to patient care.
PEG consultation in a patient with dementia and poor oral intake Question 1:
Possible answers (A-D)
You are consulted about a 75-year-old inpatient aphasic and minimally ambulating demented man with dysphagia, poor oral intake and progressive cachexia, and weight loss for evaluation and management of nutritional deficiencies. What is the best recommendation for this patient?
A. Avoid PEG tube feedings because of limited lifespan of 30 days. B. Place a nasogastric feeding tube because of its associated lower risk of aspiration. C. First try a nasogastric feeding tube for 30 days before considering PEG. D. Place a PEG feeding tube.
Look-up: McClave SA, Delegge MH. Predicting life expectancy before percutaneous endoscopic gastrostomy placement: a lesson in futility or an exercise of injustice? Gastrointest Endosc 2008;68:228-30.
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 333
CME Exam
What to do with a CT report showing an enlarged head of pancreas? Question 2:
Possible answers (A-D)
A 60-year-old man with upper abdominal discomfort and 10-pound weight loss is found to have an enlarged head of the pancreas on CT scan. There is no dilation of the common bile duct (CBD) or the pancreatic duct (PD). His bilirubin is normal. You perform an EUS. What is the most frequent pathology encountered with this presentation?
A. Normal pancreas B. Chronic pancreatitis C. Benign cysts D. Adenocarcinoma
Look-up: Agarwal B, Krishna NB, Labundy JL, et al. EUS and/or EUS-guided FNA in patients with CT and/or magnetic resonance imaging findings of enlarged pancreatic head or dilated pancreatic duct with or without a dilated common bile duct. Gastrointest Endosc 2008;68:237-42.
What is an “adequate” colonic biopsy specimen? Question 3:
Possible answers (A-D)
While reviewing colonic biopsy specimens with an expert GI pathologist, you notice the frequency of poor quality of colonic biopsy specimens submitted from patients undergoing surveillance for dysplasia and cancer in inflammatory bowel disease. Which is the most accurate description of an adequate colonic biopsy specimen?
A. Length >3 mm; penetration <20% crush artifact. B. Length >2 mm; penetration <10% crush artifact. C. Length >1 mm; penetration <5% crush artifact. D. Length >4 mm; penetration <20% crush artifact.
into muscularis mucosa; into muscularis mucosa; into muscularis mucosa; into muscularis propria;
Look-up: Elmunzer BJ, Higgins PDR, Kwon YM, et al. Jumbo forceps are superior to standard large-capacity forceps in obtaining diagnostically adequate inflammatory bowel disease surveillance biopsy specimens. Gastrointest Endosc 2008;68:273-8.
What is the best colon preparation? Question 4:
Possible answers (A-D)
A 50-year-old female executive presents for screening colonoscopy. Which of the following regimens provides superior satisfactory colon cleansing?
A. 4-L PEG the evening before the procedure. B. 4-L PEG the evening before the procedure, plus the prokinetic tegaserod. C. 2-L PEG the evening before the procedure and 2 hours before the procedure. D. 2-L PEG the evening before the procedure and 2 hours before the procedure, plus tegaserod.
Look-up: Abdul-Baki H, Hashash JG, ElHajj II, et al. A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation. Gastrointest Endosc 2008;68:294-300.
334 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
www.giejournal.org
CME ACTIVITY
Continuing Medical Examination Answers: August 2008 QUESTION 1: CORRECT RESPONSE: D Rationale for correct response: Among the various gastroenterology consults, a PEG consult in a patient with dementia provides us an opportunity to showcase our talents in communicating with our peers and patients and their families, and in careful planning and safe execution of the procedure. The editorial by McClave and Delegge1 serves as an excellent resource that addresses the issue of PEG in a patient with dementia. A few take-home messages from this editorial are summarized below. 1. Feeding: If the patient and the family decide to continue with feeding irrespective of the stage of dementia, honor that wish. This is the first step that needs to be addressed in deciding about PEG tube placement. 2. Palliation and patient placement: If the patient cannot swallow medications, provide an enteral access for them. A 24F PEG offers a better route than a smaller-bore nasogastric tube for this purpose. In the United States, nursing homes require placement of a PEG in patients who cannot swallow because they may not have the means to manage blocked or displaced nasogastric tubes. 3. Aspiration risk: The risk is higher in patients with a nasogastric feeding tube compared to PEG feeding because of a siphoning effect along the tube up the gastroesophageal junction. This is not a good argument for recommending a nasogastric tube. 4. Lifespan: In a patient with dementia and poor speech and ambulation, lifespan is longer than we expect, typically several months instead of days or weeks! 5. Prophylactic antibiotics: Antibiotics reduce the risk of periprocedural infection. Set up a protocol to make it mandatory for every patient undergoing PEG placement. 6. Anesthesia support: Support should be provided because these patients tend to have several comorbid conditions that put them at risk for cardiopulmonary events during the procedure. REFERENCE: 1. McClave SA, Delegge MH. Predicting life expectancy before percutaneous endoscopic gastrostomy placement: a lesson in futility or an exercise of injustice? Gastrointest. Endosc 2008;68:228-30.
QUESTION 2: CORRECT RESPONSE: A Rational for correct response: Radiologists frequently report subtle findings on CT scan and recommend clinical correlation. One such finding is the enlarged head of the pancreas, or dilated PD with or without a dilated CBD. Although patients with an enlarged head of the pancreas are investigated for suspicion of pancreatic neoplasm, the outcome of such incidental findings is unclear. In a retrospective analysis of a prospectively collected database at a tertiary care center, 67 patients with an enlarged head of the pancreas and 43 patients with a dilated PD with or without a dilated CBD underwent EUS and FNA, if necessary.1 The final diagnosis was based on definitive cytology, surgical pathology, and close follow-up. In 110 study patients, the final diagnosis included adenocarcinoma (n = 7), pancreatic intraepithelial neoplasia (n = 1), neuroendocrine tumor (n = 1), tumor metastasis (n = 1), and benign cyst (n = 3). Thirty-two patients had EUS evidence of chronic pancreatitis, and in the remaining 65 patients, the pancreas was normal. The accuracy of EUS and/or EUS-FNA for diagnosing pancreatic neoplasm in these patients was 99.1%, with 88.8% sensitivity, 100% specificity, 99% negative predictive value, and 100% positive predictive value. REFERENCE: 1. Agarwal B, Krishna NB, Labundy JL, et al. EUS and/or EUS-guided FNA in patients with CT and/or magnetic resonance imaging findings of enlarged pancreatic head or dilated pancreatic duct with or without a dilated common bile duct. Gastrointest Endosc 2008;68:237-42.
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 335
CME Answers
QUESTION 3: CORRECT RESPONSE: A Rationale for correct response: Surveillance of patients with inflammatory bowel disease (IBD) for dysplasia and colon cancer involves taking 30 to 50 random biopsy specimens from different sections of the colon. It is not only the number of specimens but also the quality of biopsy specimens that is important for interpreting the underlying pathology. Expert GI pathologists at the University of Michigan consider a biopsy specimen to be adequate if it fulfills 3 characteristics. 1. Length of the specimen should be more than 3 mm. 2. Depth of the specimen should include the muscularis mucosa. 3. The specimen should have less than 20% crush artifact. The Radial Jaw 4-jumbo forceps (Boston Scientific, Natick, Mass) is a disposable, Food and Drug Administration–approved enlarged cup forceps, which can pass through the accessory channel of a standard, nontherapeutic colonoscope and procure larger mucosal specimens with minimal artifact. In a prospective comparison in 24 patients with IBD, the proportion of “adequate” biopsy specimens obtained with jumbo forceps was significantly higher than that obtained by standard large-capacity forceps (67% vs 48%, P < .0001).1 REFERENCE: 1. Elmunzer BJ, Higgins PDR, Kwon YM, et al. Jumbo forceps are superior to standard large-capacity forceps in obtaining diagnostically adequate inflammatory bowel disease surveillance biopsy specimens. Gastrointest Endosc 2008;68:273-8.
QUESTION 4: CORRECT RESPONSE: C Rationale for correct response: Despite great advances in endoscopic imaging technology that can visualize at the cellular level, there is much room to improve the quality of colon preparation. Bowel preparation is inadequate for up to 25% of patients undergoing colonoscopy, and the impact of poor preparation on procedure duration, difficulty, completion, and cost is substantial. A simple change in the strategy, such as split the dose, may make a substantial improvement in the colon preparation. The American University of Beirut Medical Center has made substantial contributions to our understanding of pharmacotherapy of colon preparations. 1. A split dose of PEG-electrolyte solution in combination with low-dose bisacodyl and minimally restricted diet improves the quality of the preparation when compared with full-dose PEG-electrolyte solution and conventional dietary restriction.1 2. A split-dose PEG-electrolyte solution and no dietary restriction provides better quality colon cleansing than wholedose preparation, but without significant impact on patient tolerability and side effects.2 3. A split-dose PEG-electrolyte solution in combination with tegaserod has a marginal effect on the quality of colon preparation compared to split-dose PEG-electrolyte solution without the use of tegaserod. The split dose was superior to whole-dose PEG-electrolyte solution, resulting in better cleansing, adherence, and tolerance.3 Take-home message: Split the PEG-electrolyte solution dose. REFERENCES: 1. El Sayed AM, Kanafani ZA, Mourad FH, et al. A randomized single-blind trial of whole versus split-dose polyethylene glycol-electrolyte solution for colonoscopy preparation. Gastrointest Endosc 2003;58:36-40. 2. Aoun E, Abdul-Baki H, Azar C, et al. A randomized single-blind trial of split-dose PEG-electrolyte solution without dietary restriction compared with whole dose PEG-electrolyte solution with dietary restriction for colonoscopy preparation. Gastrointest Endosc 2005;62:213-8. 3. Abdul-Baki H, Hashash JG, ElHajj II, et al. A randomized, controlled, double-blind trial of the adjunct use of tegaserod in whole-dose or split-dose polyethylene glycol electrolyte solution for colonoscopy preparation. Gastrointest Endosc 2008;68:294-300.
336 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
www.giejournal.org