TOPICS IN ENDOSCOPY
| IMPROVING THE PATIENT’S EXPERIENCE —Lawrence J. Brandt, MD, Professor of Medicine and Surgery, Albert
Einstein College of Medicine, New York, NY, and Chief of Gastroenterology, Montefiore Medical Center, Bronx, NY
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| Preprocedure concerns (study): 800 patients about to have endoscopy asked to quantify concerns on 5-point scale;
44 concerns grouped into 4 major categories; 1) sensory or discomfort—pain, gagging, fear of needles; 2) adverse
outcome—fear of finding cancer; need for surgery; 3) incompetence and inconvenience—need for another procedure
4) miscellaneous—fear of doctors, concern about others watching procedure; after procedure, patients given
findings by physician and asked their impression of procedure and whether it went as they expected
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 | Results: 60% of patients had at least one concern; 9% had >1 concern; 2 most common concerns finding out what was
wrong and pain from procedure; women more likely to express concerns before procedure and more concerned about
pain than men; younger patients had more concerns than older patients, and more frequently concerned about pain;
concern about finding something wrong more frequent in older patients; patients undergoing endoscopy for first time
expressed more concerns than those who had previous procedures; few patients concerned about complications arising
during procedure; after procedure, youngest patients reported most difficulty with procedure and twice as likely to report
procedure worse than expected; in general, preprocedure concerns predicted greater difficulty with procedure
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| Concerns by procedure (study): before procedure—patients about to undergo flexible sigmoidoscopy had fewer and
less severe concerns than those about to undergo colonoscopy, esophagogastroduodenoscopy (EGD), or combined EGD and
colonoscopy; after procedure—patients who underwent flexible sigmoidoscopy rated their procedure more difficult than
expected, while those who had colonoscopy, EGD, or combined procedure described procedure as less difficult than expected
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| Analysis of patient concerns: in all categories of concern, female sex, younger age, nonwhite race, and fewer years of
education associated with higher rates of concern; higher levels of dissatisfaction after procedure associated with female
sex, longer duration of procedure, and higher level of anticipated difficulty; greater satisfaction with procedure associated
with higher levels of education and lower levels of anticipated difficulty; sex, level of education, and preprocedure level
of concern affected patients’ perceived difficulty with procedure and satisfaction with procedure and may also affect patient
compliance with postprocedure recommendations
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| Colon cancer screening: <10% of Americans eligible for screening get tested; study data—fear of pain main obstacle
to screening in primary care population; 25% of unselected group of patients willing to surrender 1 yr of life to avoid
screening procedure; greater compliance with screening recommendations associated with 1) having family member who
had test, 2) association of test with perceived benefit, and 3) advice from physician (however, physician advice irrelevant
if patients thought procedure would hurt)
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| Flexible sigmoidoscopy: generally considered quick easy examination by physician; medications to achieve conscious
sedation (CS) usually not given; study—patients who underwent flexible sigmoidoscopy without CS describe experience
as unpleasant and painful; CS preferred by 75% of patients, yet only 28% of endoscopists thought CS indicated;
women more likely than men to experience significant pain during procedure, and depth of examined colon less than in
men
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| Reducing patient’s anxiety and concerns: medications—most complications associated with endoscopy due to
medications rather than procedure; consider colonoscopy without CS in men and in women who have not had pelvic surgery,
with medication on request (10%-15% of speaker’s colonoscopies); success rate of colonoscopy without CS for selected
groups of patients >90%; study—patients to undergo colonoscopy randomized to routine CS or CS on request;
examination to cecum successful in ≈90%; male sex, older age, no history of abdominal pain, college degree, and low
anxiety level associated with willingness to forego CS; patient satisfaction similar in patients given CS routinely or on
demand; patients receiving CS on demand had longer procedure and recovery time, slightly more pain, and more hypoxemia
and hypotension during procedure; another study—found no correlation between preprocedure anxiety and dose
of medication given, or between dose of medication required and postprocedure satisfaction and assessment of difficulty;
other methods (study data)—patients shown informational 10-min video 1 wk prior to procedure experienced less anxiety
and had more knowledge about procedure than patients who only spoke to office personnel and read information
leaflet; cognitive and behavioral techniques can reduce anxiety during stressful events and increase self-confidence;
when information given not congruent with patient’s coping style (ie, detailed explanation to information seeker and simple
explanation to information avoider) anxiety not reduced; types of information—procedural (describes what patient
will experience); sensory (what patient will see, hear, feel, or smell during procedure); anxiety reduced when information
given on sensations to be experienced, but not by information on technical details
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| MANAGEMENT OF ANTICOAGULANTS AND ANTIPLATELET FACTORS AT THE TIME OF ENDOSCOPY —
David A. Greenwald, MD, Associate Professor of Medicine, Albert Einstein College of Medicine, New York, NY
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| Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs): aspirin—irreversibly acetylates and inactivates
platelet cyclooxygenase, resulting in suppression of thromboxane A2 -dependent platelet aggregation; affects
bleeding time for 7 to 8 days; NSAIDs—cyclooxygenase effect reversible; typically lasts as long as half-life of drug;
Shiffman et al (1994)—retrospectively looked at gastrointestinal (GI) bleeding after endoscopic procedures (biopsy
and polypectomy) in ≈700 patients; postprocedure bleeding occurred in ≈5% of patients; minor bleeding (self-limited)
occurred more often in patients who had taken NSAIDs in previous week; major bleeding occurred with same frequency
in patients who took NSAIDs as in those who did not; conclusions—aspirin and NSAIDs not associated with
increased risk for significant bleeding after endoscopy
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| Warfarin and heparin: warfarin inhibits vitamin K–dependent clotting factors II, VII, IX and X, as well as action of
proteins C and S; low molecular weight heparin (LMWH) activates antithrombin III
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| American Society of Gastrointestinal Endoscopy (ASGE): divides procedures into low- and high-risk and categorizes
conditions for which patient taking anticoagulation into high- and low-risk; low-risk procedures—standard endoscopic
procedures without therapeutic component; include diagnostic endoscopy with biopsy but not polypectomy, diagnostic
endoscopic retrograde cholangiopancreatography (ERCP) and other biliary procedures without
sphincterotomy, endoscopic ultrasonography (EUS) without fine needle aspiration (FNA), and enteroscopy; no change
in anticoagulation indicated for low-risk procedure; check patient’s international normalized ratio (INR) before procedure,
and consider delaying elective procedure in patient with supratherapeutic INR; high-risk procedures—low-risk
procedures plus therapeutic component; include colonoscopy with polypectomy, ERCP with sphincterotomy, dilation,
sclerotherapy, laser therapy, argon plasma coagulation (APC), and percutaneous endoscopic gastrostomy (PEG); risk
stratification—strategy based on indication for anticoagulation; low-risk conditions include deep venous thrombosis
(DVT), uncomplicated atrial fibrillation, and mechanical aortic valve; high-risk conditions include atrial fibrillation in
patient with vascular disease or prior thromboembolic event, mechanical mitral valve, and mechanical valve in patient
with prior thromboembolic event
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| Management: high-risk procedure with low-risk condition—discontinue anticoagulant or LMWH 5 days before procedure;
check INR day of or day before procedure and consider delay if INR supratherapeutic; high-risk procedure with
high-risk condition—keep patient on anticoagulation up to and through procedure; consider using LMWH until immediately
before procedure; study—colonoscopy showed polyps in patients on anticoagulation; patients continued on anticoagulation
if polyps <1 cm, and standard snare technique used with placement of 1 or 2 clips; no postpolypectomy
bleeding
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| Thienopyridines: include clopidogrel (Plavix) and ticlopidine (Ticlid); antagonists of platelet cell surface adenosine
diphosphate (ADP) receptor binding; inhibit 40% to 60% of ADP-induced platelet aggregation after 3 to 5 days; maintain
some antiplatelet activity for 7 to 10 days; consider discontinuing in patient who develops acute GI bleeding (balance risk
of discontinuing with reason patient placed on drug, eg, stent); consider platelet transfusion if rapid therapy required;
ASGE guidelines suggest applying low-risk/high-risk algorithm; low-risk procedures do not require change in anticoagulation;
consider discontinuing thienopyridine 7 days before procedure and restarting immediately after procedure; evidence
that increased hemorrhagic complications associated with aspirin and clopidogrel combined vs aspirin alone; if
patient on combined regimen, discontinue clopidogrel before procedure, maintain aspirin therapy during procedure, then
reintroduce clopidogrel after procedure
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| Glycoprotein IIb/IIIa receptor inhibitors: commonly used in acute coronary syndrome and after stent placement;
include monoclonal antibody to receptor (eg, abciximab [Reopro]) and competitive inhibitors of receptor (eptifibatide
[Integrelin] and tirofiban [Aggrastat]); differ in duration of action, with abciximab having longest effect; patients taking
these agents should not have elective endoscopy; for emergent endoscopy, consider discontinuing infusion before procedure,
with careful attention to timing and duration of effect of specific inhibitor; consider transfusion or desmopressin
(DDAVP) if rapid reversal needed
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| ENDOSCOPIC ULTRASONOGRAPHY BEFORE AND AFTER DIAGNOSIS —Tyler Stevens, MD, Department of
Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH
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| EUS in pancreatic cancer: diagnosis and staging—good test in experienced hands for local staging (presence or absence
of vascular invasion) and distant staging (shows celiac axis and portions of left and right hepatic lobes); can perform
appropriate sampling using FNA if lesions found; EUS invasive, not readily available, and operator-dependent;
study data—EUS better than computed tomography (CT) at detecting lesions <3 cm; EUS recommended in patients
with negative or equivocal CT or if clinical suspicion high for pancreatic cancer; however, studies suggest no major difference
between EUS and CT for staging and overall determination of resectability; CT remains mainstay of staging because
of better availability; tissue biopsy—EUS permits sampling of pancreatic tissue; consider biopsy in patients with
unresectable mass to get tissue diagnosis and allow patients to undergo chemotherapy or radiotherapy; consider biopsy in
patients with resectable mass to obtain diagnosis before surgery or detect medically treatable condition, eg, lymphoma;
consider patient preference and presence or absence of atypical features when deciding about biopsy in patient with resectable
tumor; screening tool—pancreatic tumors highly aggressive, and patients usually present with symptoms at advanced
stage; high-risk patients include those with cancer syndromes or strong family history of pancreatic cancer; study
found high rate of abnormal EUS findings, including changes suggestive of chronic pancreatitis and cystic changes in
pancreas, in some high-risk patients; ERCP performed in patients with abnormal EUS; majority of patients with abnormal
EUS had abnormal ERCP; pancreatectomy revealed widespread dysplasia, including intraductal papillary-mucinous
neoplasia (IPMN) and pancreatic intraepithelial neoplasia (PanIN); EUS detected early changes of dysplasia before development
of cancer
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| Therapeutic indications: pain relief—pain major factor affecting quality of life (QOL) in patients with advanced GI
malignancies; consider EUS-guided anesthetic blockade in patients with benign disease; consider EUS-guided celiac
plexus neurolysis (CPN) to improve pain in patients with cancer; studies looking at percutaneous technique for CPN
suggest benefit for pain relief, reduction in pain scores, reduction in narcotic consumption and side effects, and improvement
in QOL; EUS may improve delivery of CPN because of proximity to celiac trunk and elimination of need to
pass needle across spine; EUS-guided CPN offered as ancillary treatment for pain in patients with unresectable pancreatic
cancer and other GI malignancies
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| Treating cancer: techniques include fine needle injection, radiofrequency ablation, injection of allogenic mixed lymphocyte
cultures, implantation of radioactive seeds, metal implant-focused gamma knife technology, and gene therapy;
TNFerade—replication-deficient adenovirus containing human tumor necrosis factor alpha (TNF-α) gene joined to
radiation-inducible promoter gene; TNFerade thought to act synergistically with radiation and chemotherapy to cause
tumor necrosis; alcohol cyst lavage—study of 26 patients who had 2- to 6-cm pancreatic cysts treated with alcohol
cyst lavage during EUS; no complications; subset of patients had complete regression at 1 yr
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| WHY NOT TO DO ERCP—Franklin E. Kasmin, MD, Co-Director, Advanced Endoscopy Training Program, Beth Israel
Medical Center, New York, NY
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| Common bile duct (CBD) stones: liver function test (LFT) patterns help predict likelihood of CBD stones; hyperbilirubinemia
important predictor; CBD diameter another factor; ultrasonography (US) or CT showing stone present in
CBD most specific test; patients who present with acute biliary colic with rapid increase in LFTs may have passed CBD
stone; consider intraoperative cholangiography at time of laparoscopic cholecystectomy to make sure stone passed; consider
ERCP in patient who may have persistent CBD stone; consider observing patient for 1 to 2 days to allow LFTs to
return to normal if cholangitis, pain, or increased bilirubin levels not present; avoid hydroxyiminodiacetic acid (HIDA)
scan in absence of other compelling factors (high false-positive rate because of biliary edema from passing stone); consider
EUS in medium-risk patients; magnetic resonance cholangiopancreatography (MRCP)—consider in low-risk
patients; MRCP not accurate enough in case of single stone because stone can lodge at bottom of duct; MRCP shows area
of duct that contains fluid; avoid MRCP in patient where stones suspected because it may miss small stone
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| Idiopathic abdominal pain: not indication for ERCP; consider other causes, eg, porphyria, sprue; sphincter of Oddi
dysfunction—form of idiopathic abdominal pain, but patient has more biliary or pancreatic-type pain; type 3 cases involve
no objective findings, eg, duct dilation or abnormal LFTs, and no delay in drainage; ERCP has low yield and high risk for
pancreatitis in these patients; diffuse GI dysmotility present in many patients; these patients may not respond to tegaserod
(Zelnorm) or metoclopramide (eg, Reglan); send patient with type 3 dysfunction for manometry to document objective findings
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| Pancreatic masses and cysts: EUS more helpful than ERCP in absence of jaundice or stent; prefer EUS with FNA to
diagnose pancreatic adenocarcinoma and for diagnostic and prognostic information in cystic disease
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| Proximal biliary malignancy: ERCP appropriate in nonsurgical patients; surgical resection important alternative in
patients with Klatskin tumors; proximal stenting requires careful planning; recognize which duct dilated and plan to stent
appropriate duct; plastic stents common cause of cholangitis immediately after procedure; prefer Wall stents, although
they limit ability to get good margin; consider Wall stent in patient with hilar disease without resection; Wall stent can
occlude over time and may require percutaneous drain
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Suggested Readings
Brugge WR: Advances in the endoscopic management of patients with pancreatic and biliary malignancies. JOP 8:85,
2007; De Angelis C et al: Pancreatic cancer imaging: the new role of endoscopic ultrasound. South Med J 99:1358,
2006; Denberg TD et al: Predictors of nonadherence to screening colonoscopy. J Gen Intern Med 0:989, 2005;
Drossman DA et al: A preliminary study of patients' concerns related to GI endoscopy. Am J Gastroenterol 91:287,
1996; Goel A et al: National survey of anticoagulation policy in endoscopy. Eur J Gastroenterol Hepatol 19:51, 2007;
Frakes JT: The ERCP-related lawsuit: "Best avoid it!".Gastrointest Endosc 63:385, 2006; Frank CD et al: Post-
ERCP pancreatitis and its prevention. Nat Clin Pract Gastroenterol Hepatol 23:680, 2006; Harewood GC: Recommendations
for endoscopy in the patient on chronic anticoagulation: apply with care! Gastrointest Endosc 64:79, 2006;
Makar GA et al: Therapy insight: approaching endoscopy in anticoagulated patients. Nat Clin Pract Gastroenterol
Hepatol 3:43, 2006; Nicholson FB et al: Acceptance of flexible sigmoidoscopy and colonoscopy for screening and surveillance
in colorectal cancer prevention. J Med Screen 12:89, 2005; Ringel Y et al: Flexible sigmoidoscopy: the patients'
perception. Gastrointest Endosc 55:315, 2002; Zubarik R et al: Procedure-related abdominal discomfort in
patients undergoing colorectal cancer screening: a comparison of colonoscopy and flexible sigmoidoscopy. Am J Gastroenterol
97:3056, 2002; Tran QN et al: Endoscopic ultrasound-guided celiac plexus neurolysis for pancreatic cancer
pain: a single-institution experience and review of the literature. J Support Oncol 4:460, 2006.
Educational Objectives
| The goal of this program is to improve the patient’s experience with endoscopic procedures, the management of anticoagulation
during endoscopy, the application of endoscopic ultrasonography (EUS), and decision making when considering endoscopic
retrograde cholangiopancreatography (ERCP). After hearing and assimilating this program, the clinician will be
better able to:
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| 1. Describe the concerns of patients undergoing endoscopic procedures.
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| 2. Utilize methods to reduce anxiety in patients undergoing endoscopic procedures.
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| 3. Discuss the management of patients on anticoagulants at time of endoscopy.
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| 4. Describe the advantages of EUS in patients with pancreatic cancer.
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| 5. Discuss the disease characteristics that determine when to avoid ERCP.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts
were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial
interest. For this program, the following has been disclosed: Dr. Brandt reports receiving honoraria for lectures from Novartis,
AstraZeneca, and TAP Pharmaceuticals.
Acknowledgements
Dr. Brandt was recorded at Disorders of the Upper Alimentary Tract, held November 30 to December 2, 2006, in Lake
Buena Vista, FL, and sponsored by the University of South Florida. Drs. Greenwald and Kasmin were recorded at Frontiers
in Endoscopy, held December 13-16, 2006, in New York, NY, and sponsored by the New York Society for Gastrointestinal
Endoscopy. Dr. Stevens was recorded at the 42nd Annual Gastroenterology Update, held November 16-17,
2006, in Cleveland, OH, and sponsored by the Cleveland Clinic, Department of Gastroenterology and Hepatology. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
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