Dayna S. Early

Complications of ERCP

d ( t s f t c s n d i a s a 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 prepared this text. This document is an update of a previous ASGE publication.1 In preparing this document, a search of the medical iterature was performed using PubMed. Additional refernces were obtained from the bibliographies of the identied articles and from recommendations of expert consulants. When limited or no data exist from well-designed rospective trials, emphasis is given to results from large eries and reports from recognized experts. Position stateents are based on a critical review of the available data nd expert consensus at the time that the document was rafted. Further controlled clinical studies may be needed o clarify aspects of this document, which may be revised s necessary to account for changes in technology, new ata, or other aspects of clinical practice. This document is intended to be an educational device o provide information that may assist endoscopists in roviding care to patients. This position statement is not a ule and should not be construed as establishing a legal tandard of care or as encouraging, advocating, requirng, or discouraging any particular treatment. Clinical ecisions in any particular case involve a complex analsis of the patient’s condition and available courses of ction. Therefore, clinical considerations may lead an ndoscopist to take a course of action that varies from this osition statement. Since its introduction in 1968, ERCP has become a comonly performed endoscopic procedure.2 The diagnostic nd therapeutic utility of ERCP has been well demonstrated or a variety of disorders, including the management of choedocholithiasis, the diagnosis and management of biliary nd pancreatic neoplasms, and the postoperative manageent of biliary perioperative complications.3-5 The evolution of the role of ERCP has occurred simultaneously with that of other diagnostic and therapeutic modalities, most notably magnetic resonance imaging/MRCP, laparoscopic cholecystectomy (with or without intraoperative cholangiography), and EUS. For endoscopists to accurately assess the clinical appropriateness of ERCP, it is important to have a thorough

Complications of colonoscopy

Summary Endoscopic complications are rare but inevitable, occurring in fewer than 0.35% of procedures [B]. Knowledge of potential complications and their expected frequency can lead to an improved informed consent process [C]. Complications from the procedure include perforation, hemorrhage, postpolypectomy coagulation syndrome, infection, preparation-associated complications, and death, and are more likely to occur with therapeutic procedures rather than diagnostic procedures [B]. Risk factors for poylpectomy-associated complications include the location and size of the polyp, experience of the operator, polypectomy technique and possibly the type of electrocoagulation current used [B]. Use of saline solution injection under large sessile polyps decreases depth of thermal injury [A] and may decrease complications [B]. Early recognition of complications and prompt intervention may decrease patient morbidity [C]. Treatment of complications range from supportive for postpolypectomy coagulation syndrome, to repeat colonoscopy with injection or electrocoagulation for bleeding, to surgical repair for free perforation [B]. Consideration of the risks and benefits may improve clinical outcome by identifying potential complications and taking appropriate steps to minimize the risks [C].

The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus

i ( n d m e 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 using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited 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 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).1 The strength of individual recommendations is based on both 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 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.

Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy

BACKGROUND The prevalence of missed polyps in patients with inadequate bowel preparation on screening colonoscopy is unknown. OBJECTIVE To determine the prevalence of missed adenomas in average-risk patients presenting for screening colonoscopy who are found to have inadequate bowel preparation. DESIGN Retrospective chart review. Endoscopy and pathology reports were examined to determine the characteristics of polyps. Data from repeat colonoscopies were collected through 2010. SETTING Outpatient endoscopy center at an academic medical center. PATIENTS This study involved patients who underwent outpatient average-risk screening colonoscopy between 2004 and 2009 documented to have inadequate bowel preparation and who had colonoscopy to the cecum. MAIN OUTCOME MEASUREMENTS Initial adenoma detection rate and adenoma detection rate on follow-up examination. RESULTS Inadequate bowel preparation was reported on 373 patients, with an initial adenoma detection rate of 25.7%. Of 133 patients who underwent repeat colonoscopy, 33.8% had at least 1 adenoma detected, and 18.0% had high-risk states detected (≥ 3 adenomas, 1 adenoma ≥ 1 cm, or any adenoma with villous features or high-grade dysplasia). Per-adenoma miss rate was 47.9%. Among patients with at least 1 adenoma on repeat colonoscopy, 31.1% had no polyps on initial colonoscopy; mean time between colonoscopies was 340 days. Among patients with high-risk states, 25.0% had no polyps seen on initial colonoscopy; mean time between colonoscopies was 271 days. LIMITATIONS Retrospective design. CONCLUSION Adenomas and high-risk lesions were frequently detected on repeat colonoscopy in patients with inadequate bowel preparation on initial screening colonoscopy, suggesting that these lesions were likely missed on initial colonoscopy.

The role of endoscopy in the management of acute non-variceal upper GI bleeding

d c p B s i R 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, 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 from 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 are based on reviewed studies and are graded on the strength of the supporting evidence1 (Table 1). he strength of individual recommendations is based on oth the aggregate evidence quality and an assessment of the nticipated benefits and harms. Weaker recommendations re indicated by phrases such as “We suggest . . . ,” whereas tronger recommendations are typically stated as “We recmmend . . . .” 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.

Incidence of Sedation-Related Complications With Propofol Use During Advanced Endoscopic Procedures

BACKGROUND & AIMS Propofol is an effective sedative in advanced endoscopy. However, the incidence of sedation-related complications is unclear. We sought to define the frequency of sedation-related adverse events, particularly the rate of airway modifications (AMs), with propofol use during advanced endoscopy. We also evaluated independent predictors of AMs. METHODS Patients undergoing sedation with propofol for advanced endoscopic procedures, including endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, and small-bowel enteroscopy, were studied prospectively. Sedative dosing was determined by a certified registered nurse anesthetist with the goal of achieving deep sedation. Sedation-related complications included AMs, hypoxemia (pulse oximetry [SpO(2)] < 90%), hypotension requiring vasopressors, and early procedure termination. AMs were defined as chin lift, modified face mask ventilation, and nasal airway. We performed a regression analysis to compare characteristics of patients requiring AMs (AM+) with those who did not (AM-). RESULTS A total of 799 patients were enrolled over 7 months. Procedures included endoscopic ultrasound (423), endoscopic retrograde cholangiopancreatography (336), and small-bowel enteroscopy (40). A total of 87.2% of patients showed no response to endoscopic intubation. Hypoxemia occurred in 12.8%, hypotension in 0.5%, and premature termination in 0.6% of the patients. No patients required bag-mask ventilation or endotracheal intubation. There were 154 AMs performed in 115 (14.4%) patients, including chin lift (12.1%), modified face mask ventilation (3.6%), and nasal airway (3.5%). Body mass index, male sex, and American Society of Anesthesiologists class of 3 or higher were independent predictors of AMs. CONCLUSIONS Propofol can be used safely for advanced endoscopic procedures when administered by a trained professional. Independent predictors of AMs included male sex, American Society of Anesthesiologists class of 3 or higher, and increased body mass index.

Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States

BACKGROUND The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted. METHODS A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion. RESULTS Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported (p=0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions. CONCLUSIONS EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

The management of antithrombotic agents for patients undergoing GI endoscopy.

Ruben D. Acosta, MD, Neena S. Abraham, MD, MSCE, FASGE (invited content expert, ad-hoc member), Vinay Chandrasekhara, MD, Krishnavel V. Chathadi, MD, Dayna S. Early, MD, FASGE, Mohamad A. Eloubeidi, MD, MHS, FASGE, John A. Evans, MD, Ashley L. Faulx, MD, FASGE, Deborah A. Fisher, MD, MHS, FASGE, Lisa Fonkalsrud, BSN, RN, CGRN, Joo Ha Hwang, MD, PhD, FASGE, Mouen A. Khashab, MD, Jenifer R. Lightdale, MD, MPH, FASGE, V. Raman Muthusamy, MD, FASGE, Shabana F. Pasha, MD, John R. Saltzman, MD, FASGE, Aasma Shaukat, MD, MPH, FASGE, Amandeep K. Shergill, MD, Amy Wang, MD, Brooks D. Cash, MD, FASGE, previous Committee Chair, John M. DeWitt, MD, FASGE, Chair

Adverse events of upper GI endoscopy

c f s a a e l 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 document, 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. This document is based on a critical review of the available data and expert consensus at the time that the document was drafted. Further controlled clinical studies may be needed to clarify aspects of this document. This document may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This document is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This document 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 document.

Bowel preparation before colonoscopy

This is one of a series of documents discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this document that updates a previously issued consensus statement and a technology status evaluation report on this topic. In preparing this guideline, a search of the medical literature was performed by using PubMed between January 1975 and March 2014 by using the search terms “colonoscopy,” “bowel preparation,” “intestines,” and “preparation.” Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Recommendations for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the documents are drafted. Further controlled clinical studies may be needed to clarify aspects of recommendations contained in this document. This document 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). The strength of individual recommendations is based both on 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. It 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 recommendations and suggestions.