ENDOSCOPY AND THE ESOPHAGUS
| PROPOFOL vs STANDARD SEDATION —Lawrence Cohen, MD, Associate Clinical Professor, Mount Sinai School of
Medicine, New York City
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| Does propofol improve patient satisfaction during endoscopy, compared with conventional sedation? of 4 small
randomized trials performed, 2 showed propofol superior to conventional sedation for patient satisfaction, 2 showed
methods comparable
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 | Patient preferences: 62 patients (some of whom were endoscopists) sedated with propofol who had undergone previous examinations
with conventional sedation; 60% favored propofol
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| Physician preferences: study—surveyed 5000 physicians performing endoscopy and found ≈75% of respondents using benzodiazepines
and opioids exclusively for sedation, and 25% using propofol for some endoscopic examinations; physicians using
conventional sedation rated overall satisfaction level 8.1 on 10-point scale (10 being highest); mean satisfaction score for
those using propofol 9.3 (significant difference); of 1300 respondents, 48% of endoscopists said they would prefer propofol
if they were being examined, 40% would choose conventional sedation, 2% would choose some other form of sedation, and
10% to 12% wanted no sedation; more younger physicians preferred propofol than physicians >65 yr of age
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| Conclusion: compared to conventional drugs, propofol appears to improve patient satisfaction during endoscopy
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| Methods of administration: only 2 models proposed in literature for nonanesthesiologists, ie, propofol monotherapy and
combination of propofol with opioid and benzodiazepine
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| Propofol alone: has no analgesic properties, so patients must be deeply sedated to achieve satisfactory outcome
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| Combination: propofol with small dose of fentanyl and midazolam (0.5-1.0 mg) achieves fast induction and quick recovery;
study—propofol, remifentanyl, or both combined given by computer-controlled infusion to humans given noxious painful
stimulus; synergistic effect of combination 5 to 33 times that achieved with either drug alone; conclusion—can
achieve comparable results and levels of satisfaction with smaller doses of propofol and reduced levels of sedation by using
combination, while retaining benefits of propofol alone; study of patients undergoing colonoscopy—showed 98%
of patients rated satisfaction level good or excellent
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| Anesthesiology societies’ argument: sedation on continuum; propofol results in deep sedation, and since deep sedation
one step away from general anesthesia, physicians need to be prepared to rescue patients from general anesthesia; since
anesthesiologists only physicians prepared to do so, they alone should use propofol; rebuttal—combination of propofol
with opioid and benzodiazepine produces moderate levels of sedation; patients may be less deeply sedated than
with conventional agents
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| Safety of combination propofol: of 4200 cases, 2 patients required pharmacologic intervention (1 required naloxone, 1 required
naloxone and flumazenil for prolonged drowsiness); no patient required ventilatory support or had any other
complications
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| Conclusion: combination propofol provides benefits of propofol alone but with reduced level of sedation and greater safety
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| Food and Drug Administration (FDA): labeling of propofol states that it should be administered only by persons trained
in administration of general anesthesia and not involved in conduct of procedure; FDA dictates what drug and device
manufacturers can and cannot state about their product but does not mandate medical practice
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| Gastrointestinal (GI) societies’ position on endoscopy-administered propofol: 3 GI societies published series of recommendations
on administration of sedation supporting use of propofol by adequately trained nonanesthesiologists;
American Society for Gastrointestinal Endoscopy (ASGE) training committee published guidelines for training in use of
propofol for GI endoscopy; programs now being developed that will allow physician endoscopists to learn how to use
propofol and incorporate it into practice
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| Conclusion: GI societies support use of propofol by endoscopists trained in how to use it
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| Summary of propofol sedation: speaker has 15-yr experience using conventional sedation and started using propofol ≈4 yr
ago with positive results; use of propofol may improve efficiency; requires less recovery room space; may improve patient
flow through endoscopy suite; makes endoscopy more fun and pleasant; patients happier because they are not losing day of
their life recovering from sedation every time endoscopic procedure required; propofol use may increase referrals and patient
volume; expected to make endoscopy more acceptable to patients required to return for second or multiple procedures; no
data, but speaker suspects propofol improves safety because of ability to titrate dose; institutional, state, and local barriers may
not permit its use; medicolegal concerns; training required; question of additional costs not adequately addressed in literature
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| SCREENING FOR BARRETT’S ESOPHAGUS —Hans Gerdes, MD, Associate Attending Physician, Memorial Sloan-
Kettering Cancer Center, New York City
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| Definitions: screening—endoscopic evaluation of patients with gastroesophageal reflux disease (GERD) to identify presence
of intestinal metaplasia in distal esophagus; surveillance—periodic endoscopic and biopsy assessment of patients
previously diagnosed with Barrett’s esophagus for detection of neoplasia; neoplasia—dysplasia or cancer
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| Goals of screening for neoplasia: reduce mortality and morbidity and, if possible, prevent development of cancer by
treatment of premalignant conditions
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| Requirements for effective cancer screening: disease should have high prevalence; treatment should be more successful
when applied to early stages; test inexpensive, easy to administer, has high specificity and sensitivity, and acceptable and safe to
patients
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| Esophageal cancer: least common of GI malignancies; almost uniformly fatal; pattern of incidence changed over past 30
yr, ie, formerly predominant squamous cell carcinoma decreased and adenocarcinomas of esophagus and esophagogastric
(EG) junction increased; cause—not known; postulated to be caused by repeated reflux and healing in presence of ongoing
reflux, with genetic events contributing to process, resulting in neoplasia (Barrett’s dysplasia), invasive cancer, and
metastatic disease
|
| Prevalence and surveillance: Barrett’s esophagus—estimated to affect >700,000 Americans (may be significantly
higher, since many patients asymptomatic); demonstrated in ≥10% of patients with GERD; autopsy studies suggest prevalence
in general population may be as high as 25%; rate of adenocarcinoma 30 to 125 times higher in patients with Barrett’s
esophagus than in age-matched population
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| Surveillance endoscopy: meta-analysis—data from 7 studies show incidence of development of adenocarcinoma in patients
with Barrett’s who undergo surveillance endoscopy 1 in 175 to 1 in 48 patient years of follow-up; suggests
yearly incidence 1.3%; other data—show cancers detected during surveillance at earlier stage than cancers detected
when patients not under surveillance present with symptoms; after resection, long-term survival better in patients
whose cancers detected during surveillance; possible bias—Shaheen et al suggest that studies that find lower risk for
cancer and have smaller numbers of patients may not be published; actual risk for cancer in Barrett’s patients undergoing
surveillance may be 5 per 1000 patient years of follow-up (0.5%); cost-utility ratio—based on revised risk estimate;
$98,000 per quality-adjusted life years gained for surveillance every 5 yr, $590,000 for surveillance every 2 yr
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| American College of Gastroenterology (ACG) revised guidelines: patients with chronic GERD should undergo screening
endoscopy; biopsies should be taken every 2 cm in 4 quadrants to confirm presence of intestinal metaplasia and detect
dysplasia; subsequent surveillance should be every 3 yr if no dysplasia found on 2 consecutive endoscopies; if low-grade
dysplasia found, surveillance every year until no dysplasia found; repeat endoscopy in 3 mo if focal low-grade dysplasia
present; intervention (surgery, endoscopic ablation or resection, or close surveillance with endoscopic biopsies) should
be considered if multifocal high-grade dysplasia found
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| GERD and esophageal cancer: risk of developing adenocarcinoma of esophagus or EG junction significantly associated
with presence of GERD, based on frequency >3 times/mo, severity (reflux score), and duration (>20 yr); need to follow
1400 GERD patients for 1 yr to detect 1 cancer; in men, morbid obesity increases risk for cancer; traditional endoscopy
unreasonably expensive to use as screening tool; other methods may be more cost effective
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| Problems with screening guidelines: GERD and Barrett’s common problems, but only 6000 to 10,000 new cases of adenocarcinoma
seen each year; 40% of patients with adenocarcinoma do not have history of chronic GERD; 38% of adenocarcinomas
not associated with microscopic evidence of Barrett’s esophagus; only 5% of adenocarcinoma patients have
history of Barrett’s esophagus; endoscopic surveillance has not been shown to decrease incidence of adenocarcinoma or
to increase life expectancy (studies not done); need to screen 1400 GERD patients to detect one adenocarcinoma
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| Conclusion: no randomized studies support screening, but screening high-risk population (eg, obese men >50 yr of age who
have chronic GERD) may be effective; alternative methods of screening being investigated; prospective randomized studies
needed
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| EFFICIENCY IN ENDOSCOPY —Grace Elta, MD, Professor of Medicine, and Associate Chief for Clinical Programs,
University of Michigan Medical School, Ann Arbor
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| Why efficiency matters in practice: increased productivity only way gastroenterologists can maintain or increase their
income in face of decreasing reimbursement; gastroenterologist shortage in United States; Medicare increased payment
for patient consultations and decreased payment for procedures; increases have not offset decreases in procedural fees
(one physician found reimbursement in his practice decreased 17%)
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| Why efficiency matters in nation: 2.5 million colonoscopies per year must be performed by ≈14,000 gastroenterologists;
wide variations in number of colonoscopies per physician and in how rapidly colonoscopy performed (efficiency); average
178 colonoscopies per endoscopist per year; gastroenterologist shortage (significant drop in GI fellowships from
1991 to 1999); gastroenterologists now spend >60% of clinical practice performing endoscopy
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| Components of efficiency: physician speed—must not impair quality of examination (must have high cecal intubation
rates); must pay attention to withdrawal times (6-8 min probably mandatory for complete colon examination) and to patient
satisfaction; assistive personnel—help increase productivity; difficult to reward their productivity in unionized
centers; procedure room turnover—may be most important factor in efficiency, particularly if only one endoscopy
room available; preparation and recovery bays—at least 3 for every procedure room; other factors—adequate medical
records or information technology (IT) support; preparation quality (poorly prepared colons take longer); minimizing
nonprocedural time—have nurses obtain consents and administer sedation; dictated notes faster than typed template;
postprocedure—give copy of report to patient, and have nurses provide patient education about nonserious findings
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| Problems with greater efficiency: increased physician fatigue (no data on this); increased musculoskeletal injuries in endoscopists
(hand, wrist, arm, neck, and back)
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| ESOPHAGEAL FOREIGN BODIES —Marsha Kay, MD, Department of Pediatric Gastroenterology and Nutrition, Cleveland
Clinic, Cleveland
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| Prevalence: ≈80% of all foreign body cases occur in children; majority witnessed; >107,000 cases in children and adolescents
in year 2000; almost all cases in children unintentional; most common are coins (number one ingestion in United
States), toys, toy parts, batteries, chicken or fish bones, food impactions; meat impaction most common in adults
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| Symptoms: vary depending on object ingested, where it is, and size of patient; almost all patients with foreign body stuck
in oropharynx symptomatic; abscess can develop as result of impaction; can be nonspecific in children (may choke,
drool, wheeze, or alter diet [eg, prefer liquids]); older children and teenagers often report difficulty swallowing or pain
(location may not correlate); respiratory symptoms may be only sign in small children (trachea small and compressable);
coins in stomach or small intestine typically asymptomatic and may not require removal unless causing obstruction
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| Triage cases: 5 cases of foreign body ingestion present simultaneously; 1) AA size battery in 1-yr-old, 2) 1999 penny, 3)
button battery in mid esophagus of asymptomatic 2-yr-old, 4) toothbrush in asymptomatic 16-yr-old anorexic or bulimic
who swallowed it an hour ago, and 5) quarter in esophagus of 14-mo-old who is taking solids less frequently,
wheezing for 10 days, and has been tried on asthma medications and oral antibiotics
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| Button battery in esophagus: number one priority because battery contains caustic material; serious injury can develop
quickly, eg, perforation, stricture, fistula, death; symptoms do not correlate with severity; immediate x-ray and endoscopy
indicated; risk for injury outweighs risk of anesthesia
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| Quarter in esophagus: second priority because child symptomatic; this quarter lodged for long time, so have time to have
patient npo for 3 to 4 hr; may be too difficult to remove with flexible instrument; may want ear, nose, and throat (ENT)
colleague with rigid instrument ready
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| Gastric battery: third priority; this size battery unlikely to pass in this size child; for adults, object >10 cm in length or
>15 mm in diameter or 2 cm x 5 cm in oval shape will not pass; battery likely to be harmless but too big to pass; complications
for gastric batteries include ulceration and, theoretically, mercury poisoning
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| Toothbrush: fourth priority; too big to pass and must be removed; can wait until patient fasted
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| Penny: last priority; if patient asymptomatic can wait several weeks for it to pass; if penny present on repeat x-ray, remove it
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Educational Objectives
| The goal of this program is to educate the listener about endoscopy and esophageal diseases and procedures. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. List the evidence in favor of using propofol over standard sedation for endoscopic procedures.
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| 2. Describe the intentions of the Food and Drug Administration’s labeling requirements.
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| 3. Explain the problems associated with screening for Barrett’s esophagus.
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| 4. Discuss several things gastroenterologists can do to increase their efficiency in the endoscopy suite.
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| 5. Describe several case scenarios of foreign body ingestion and list them in order of priority.
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Discussed on This Program
Fentanyl [Sublimaze]
Flumazenil [Romazicon]
Midazolam HCl [Versed]
Naloxone HCl [Narcan]
Propofol [Diprivan]
Programs of Related Interest
Dumot JA et al: Esophageal procedures. Audio-Digest Gastroenterology 17:01(Jan), 2003; Hoffman B et al: Endoscopy
update. Audio-Digest Gastroenterology 18:05(May), 2004; Hunt RH et al: Reflux disease. Audio-Digest Gastroenterology
17:11(Nov), 2003.
To Order, Contact Subscriber Service (1-800-423-2308)
Suggested Reading
Abuksis G et al: A patient education program is cost-effective for preventing failure of endoscopic procedures in a gastroenterology
department. Am J Gastroenterol 96:1786, 2001; Akazawa Y et al: The management of possible fishbone ingestion.
Auris Nasus Larynx 31:413, 2004; Chaves DM et al: Removal of a foreign body from the upper gastrointestinal
tract with a flexible endoscope: a prospective study. Endoscopy 36:887, 2004; Clarke AC et al: Sedation for endoscopy:
the safe use of propofol by general practitioner sedationists. Med J Aust 176:158, 2002; Cohen LB et al: Moderate level
sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest
Endosc 59:795, 2004; Khan MA et al: Management of foreign bodies in the esophagus. J Coll Physicians Surg
Pak 14:218, 2004; Lagergren J et al: Utility of endoscopic screening for upper gastrointestinal adenocarcinoma. JAMA
284:961, 2000; Pera M et al: Increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction.
Gastroenterology 104:510, 1993; Roseveare C et al: Patient-controlled sedation and analgesia, using propofol and alfentanil,
during colonoscopy: a prospective randomized controlled trial. Endoscopy 30:768, 1998; Sampliner RE: Practice
guidelines on the diagnosis, surveillance, and therapy of Barrett’s esophagus. The Practice Parameters Committee of the
American College of Gastroenterology. Am J Gastroenterol 93:1028, 1998; Shaheen NJ et al: Is there publication bias in
the reporting of cancer risk in Barrett’s esophagus? Gastroenterology 119:333, 2000; Sivak MV Jr: Endoscopic technology:
is this as good as it gets? Gastrointest Endosc 50:718, 1999; Uyemura MC: Foreign body ingestion in children. Am
Fam Physician 72:287, 2005; Yardeni D et al: Severe esophageal damage due to button battery ingestion: can it be prevented?
Pediatr Surg Int 20:496, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Cohen, Gerdes, and Elta were recorded December 16, 2004, in New York City at the 28th Annual New York Course: A
Critical Appraisal of Endoscopic Trends and Practices, jointly sponsored by the Albert Einstein College of Medicine and
the New York Society of Gastrointestinal Endoscopy; Dr. Kay, on September 9, 2004, in Cleveland, at the 40th Annual
Gastroenterology Update, sponsored by the Cleveland Clinic Department of Gastroenterology and Hepatology in joint
sponsorship with the American College of Gastroenterology. The Audio-Digest Foundation thanks the speakers and the
sponsors for their cooperation in the production of this program.
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