Brooks D. Cash

The role of endoscopy in the evaluation of suspected choledocholithiasis

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results of large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines. Gallstone disease affects more than 20 million American adults at an annual cost of

The role of endoscopy in the management of obscure GI bleeding

6.2 billion. A subset of these patients will also have choledocholithiasis, including 5% to 10% of those undergoing laparoscopic cholecystectomy for symptomatic cholelithiasis and 18% to 33% of patients with acute biliary pancreatitis. The approach to patients with suspected choledocholithiasis requires careful consideration because missed common bile duct (CBD) stones pose a risk of recurrent symptoms, pancreatitis, and cholangitis. However, the morbidity and cost

ACR appropriateness Criteria® right lower quadrant painsuspected appendicitis

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, we performed a search of the medical literature by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines were drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence (Table 1).(1) The strength of individual recommendations is based both upon the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as we suggest, whereas stronger recommendations are typically stated as we recommend. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patients condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

The Yield of Colonoscopy in Patients With Non-Constipated Irritable Bowel Syndrome: Results From a Prospective, Controlled US Trial

The diagnostic imaging of patients presenting with right lower quadrant pain and suspected appendicitis may be organized according to age and gender and to the presence or absence of classic signs and symptoms of acute appendicitis. Among adult patients presenting with clinical signs of acute appendicitis, the sensitivity and specificity of CT are greater than those of ultrasound, with improved performance when CT is performed with intravenous contrast. The use of rectal contrast has been associated with decreased time in the emergency department. Computed tomography has also been shown to reduce cost and negative appendectomy rates. Both CT and ultrasound are also effective in the identification of causes of right lower quadrant pain unrelated to appendicitis. Among pediatric patients, the sensitivity and specificity of graded-compression ultrasound can approach those of CT, without the use of ionizing radiation. Performing MRI after inconclusive ultrasound in pregnant patients has been associated with sensitivity and specificity of 80% to 86% and 97% to 99%, respectively. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Modifications in endoscopic practice for pediatric patients

OBJECTIVES:There are limited data on the yield of colonoscopy in patients with irritable bowel syndrome (IBS). This study compared the prevalence of structural colonic lesions in patients with suspected non-constipation-predominant IBS and healthy volunteers. We also determined the yield of rectosigmoid biopsies in patients with suspected IBS.METHODS:This was a prospective, case–control study conducted at three US sites. Patients with suspected non-constipation-predominant IBS (Rome II) underwent colonoscopy with rectosigmoid biopsies. Healthy persons undergoing colonoscopy for colorectal cancer screening or polyp surveillance comprised the control group. Abnormalities identified at colonoscopy were compared between suspected IBS and control groups.RESULTS:In all, 466 suspected IBS patients and 451 controls were enrolled. Suspected IBS patients were significantly younger (P<0.0001) and more frequently female (P<0.0001) than controls. The most common lesions in suspected IBS patients were hemorrhoids (18.2%), polyps (14.6%), and diverticulosis (8.8%). Suspected IBS patients had a lower prevalence of adenomas (7.7% vs. 26.1%, P<0.0001) and diverticulosis (8.8% vs. 21.3%, P<0.0001) and higher prevalence of mucosal erythema or ulceration (4.9% vs. 1.8%, P<0.01) compared with controls. Logistic regression found the between-group differences in adenoma prevalence to be robust after correction for demographic factors. The overall prevalence of microscopic colitis in suspected IBS patients was 1.5% (7/466) and 2.3% (4/171) in those ≥45 years of age.CONCLUSIONS:The prevalence of structural abnormalities of the colon is no higher in suspected non-constipation IBS patients than in healthy controls. Microscopic colitis can be identified in a small proportion of persons with IBS symptoms.

Effectiveness and patient satisfaction with screening flexible sigmoidoscopy performed by registered nurses

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, the MEDLINE and PubMed databases were used to search publications through the last 15 years related to pediatric endoscopy by using the keyword ‘‘pediatric’’ and each of the following: ‘‘gastrointestinal,’’ ‘‘endoscopy,’’ ‘‘colonoscopy,’’ ‘‘inflammatory bowel disease,’’ ‘‘sedation,’’ and ‘‘anesthesia.’’ The search was supplemented by accessing the ‘‘related articles’’ feature of PubMed with articles identified in MEDLINE and PubMed as the references. Pertinent studies published in English were reviewed. Studies or reports that described fewer than 10 patients were excluded from analysis if multiple series with more than 10 patients addressing the same issue were available. The resultant quality indicators were adequate for analysis. The reported evidence and recommendations based on reviewed studies were graded on the strength of the supporting evidence (Table 1). Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies may be needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. Pediatric endoscopy is largely in the domain of the pediatric gastroenterologist. Occasionally, pediatric surgeons may be trained in endoscopy. Because children are not simply young adults, optimal performance of endoscopy in these patients requires an adequate knowledge and understanding of pediatrics and a thorough understanding of the child’s medical background. In many practice settings, however, adult endoscopists are called upon to provide advanced therapeutic endoscopic services, such as ERCP and EUS, or basic endoscopic services when pediatric gastroenterologists are unavailable. To provide appropriate care for the child in such circumstances, a team approach is required with the pediatrician or the pediatric gastroenterologist and the adult endoscopist.

Appropriate use of GI endoscopy

BACKGROUNDnOur aim was to compare the effectiveness and patient satisfaction with flexible sigmoidoscopy performed by a registered nurse, general surgeons, and gastroenterology fellows.nnnMETHODSnConsecutive outpatients referred for sigmoidoscopy were assigned to have the procedure performed by the first available provider. Depth of insertion of the sigmoidoscope, complications, duration of the procedure, and percentage of patients with adenomas were recorded. After the procedure, patients completed a validated patient satisfaction questionnaire.nnnRESULTSnMean depth of insertion was less for general surgeons compared with the nurse and gastroenterology fellows (50 vs 53 vs 54 cm, respectively; p = 0.01). Mean duration of procedure was longer for the nurse compared with general surgeons and gastroenterology fellows (8.3 vs 7.6 vs 6.8 min, respectively; p = 0.0001). Percentage of patients with adenomas was similar among patients who underwent sigmoidoscopy by the endoscopists (7% vs 8% vs 9%; p = 0.81). No differences were detected between endoscopists for overall satisfaction (p = 0.60), technical skills of the endoscopist (p = 0.58), communication skills of the endoscopist (p = 0.61), or interpersonal skills of the endoscopist (p = 0.59).nnnCONCLUSIONnNo clinically significant differences in effectiveness or patient satisfaction were detected with flexible sigmoidoscopy performed by a registered nurse, general surgeons, or gastroenterology fellows.

ACR appropriateness Criteria® right lower quadrant pain - Suspected appendicitis

o s t This is one of a series of position statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. Position statements are based on a critical review of the available data and expert consensus at the time the document was drafted. Further controlled clinical studies may be needed to clarify aspects of this document, which may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This position statement is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from this position statement.

Persistence of Nondysplastic Barrett's Esophagus Identifies Patients at Lower Risk for Esophageal Adenocarcinoma: Results From a Large Multicenter Cohort

The most common cause of acute right lower quadrant (RLQ) pain requiring surgery is acute appendicitis (AA). This narratives focus is on imaging procedures in the diagnosis of AA, with consideration of other diseases causing RLQ pain. In general, Computed Tomography (CT) is the most accurate imaging study for evaluating suspected AA and alternative etiologies of RLQ pain. Data favor intravenous contrast use for CT, but the need for enteric contrast when intravenous contrast is used is not strongly favored. Radiation exposure concerns from CT have led to increased investigation in minimizing CT radiation dose while maintaining diagnostic accuracy and in using algorithms with ultrasound as a first imaging examination followed by CT in inconclusive cases. In children, ultrasound is the preferred initial examination, as it is nearly as accurate as CT for the diagnosis of AA in this population and without ionizing radiation exposure. In pregnant women, ultrasound is preferred initially with MRI as a second imaging examination in inconclusive cases, which is the majority.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Repeat Treatment With Rifaximin Is Safe and Effective in Patients With Diarrhea-Predominant Irritable Bowel Syndrome

BACKGROUND & AIMSnRecent population-based studies have shown a low risk of esophageal adenocarcinoma (EAC) in patients with nondysplastic Barretts esophagus (NDBE). We evaluated whether persistence of NDBE over multiple consecutive surveillance endoscopic examinations could be used in risk stratification of patients with Barretts esophagus (BE).nnnMETHODSnWe performed a multicenter outcomes study of a large cohort of patients with BE. Based on the number of consecutive surveillance endoscopies showing NDBE, we identified 5 groups of patients. Patients in group 1 were found to have NDBE at their first esophagogastroduodenoscopy (EGD). Patients in group 2 were found to have NDBE on their first 2 consecutive EGDs. Similarly, patients in groups 3, 4, and 5 were found to have NDBE on 3, 4, and 5 consecutive surveillance EGDs. A logistic regression model was built to determine whether persistence of NDBE independently protected against development of cancer.nnnRESULTSnOf axa0total of 3515 patients with BE, 1401 patients met the inclusion criteria (93.3% white; 87.5% men; median age, 60 ±17 years). The median follow-up period was 5 ± 3.9 years (7846 patient-years). The annual risk of EAC in groups 1 to 5 was 0.32%, 0.27%, 0.16%, 0.2%, and 0.11%, respectively (P for trendxa0= .03). After adjusting for age, sex, and length of BE, persistence of NDBE, based on multiple surveillance endoscopies, was associated with a gradually lower likelihood of progression to EAC.nnnCONCLUSIONSnPersistence of NDBE over several endoscopic examinations identifies patients who are at low risk for development of EAC. These findings support lengthening surveillance intervals or discontinuing surveillance of patients with persistent NDBE.