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March 14th, 2014

Dysphagia and Normal Endoscopy – Should We Biopsy Everyone?

The “discovery” of eosinophilic esophagitis (EoE) has added immensely to our understanding of many patients with dysphagia, and when endoscopic signs are present (furrowing, rings, white nodules, etc.), we should always confirm the diagnosis with endoscopic biopsies. However, many patients with EoE have a normal-appearing esophageal mucosa, and EoE would remain undetected if biopsies were not obtained. This concept has led many endoscopists to now routinely obtain endoscopic esophageal biopsies in all patients with dysphagia. I admit that this has become my predominant practice as well.

What are you doing in your practices?

More specifically …

  • Do you routinely biopsy the esophagus in patients with dysphagia and an esophagus that appears normal?
  • If yes, where do you biopsy, how many biopsies do you take, and how often are findings positive in these patients?
  • If no, do you perform any other diagnostic tests in these patients with a normal-appearing esophagus (e.g., barium pill swallows, esophageal motility studies, etc.)?

January 28th, 2014

What Bowel Prep for the Sensitive Stomach?

Although it is clear that split-dose polyethylene glycol (PEG), our first-line bowel prep, provides the optimal bowel cleansing for colonoscopy, many of my patients find it difficult or even impossible to tolerate this solution (i.e., due to vomiting). Although alternatives such as Gatorade/Miralax, with or without magnesium citrate and Dulcolax, are used by many endoscopy units, these also do not work for some of my patients.

So, what approach are you taking to bowel prep for your patients with sensitive stomachs?

Specifically…

  • What do you use for bowel prep in patients intolerant of standard PEG-based preps?
  • What is your success rate in avoiding vomiting during this alternative prep?
  • Do you ever prophylactically treat with anti-emetics before starting a prep?

December 9th, 2013

Are You Removing Diminutive Colonic Polyps with a Forceps?

Small colorectal polyps are commonly encountered during colonoscopy, and their removal is important in colorectal cancer prevention. These smaller lesions (≤5 mm) are relatively easy to remove — usually done by either forceps “biopsy” or mini-snare polypectomy. The choice of removal tool is often based on operator preference, but with forceps biopsy removal, recovering the lesion is easier and seemingly quicker. However, recent data suggest that forceps biopsy is less effective than snare polypectomy at total polyp removal.

So, given that this remains a gray area in terms of best practices, what I would like to know is:

  • How do you remove small (≤5 mm) polyps detected during colonoscopy?
  • Do you use one technique exclusively?
  • Do you comment on whether the polyp appears to be totally removed?
  • After you remove a polyp, do you review the pathology report to see if there is a margin of normal tissue?
  • What evidence would make you change your preference?

Looking forward to your responses.

 

November 25th, 2013

Does Suppressing Gastric Acid Cause Community-Acquired Pneumonia?

Ever since early observational studies documented an association between acid suppression and pneumonia, many clinicians have assumed this association meant causation. This intrigues me because results of numerous prospective trials that have controlled for underlying patient comorbidities have refuted any causative effect. Moreover, acid suppression does not result in a gastric environment conducive to bacterial overgrowth — the mechanism proposed in the hypothesis.

So why are more studies being conducted despite continuing results that show the same thing (acid-suppressive drugs are NOT associated with community-acquired pneumonias)?

What are your thoughts? Specifically:

  • Do you believe that acid-suppressing drugs might cause pneumonia?
  •  If you believe this effect exists, is it the same for all agents (e.g., H2-receptor antagonists vs. PPIs)?
  •  Are there patients you believe to be at higher risk for this effect?
  •  How do you manage this issue?

Looking forward to seeing what you think.

November 6th, 2013

Iron Deficiency Anemia: When Do We Stop Scoping?

It is standard practice to perform endoscopy in patients with iron deficiency anemia who have evidence of gastrointestinal bleeding or other symptoms. Even in the absence of symptoms, in patients aged 50 years or older, who are at increased risk for colorectal cancer, age alone would indicate that at least a colonoscopy is in order.

However, I am increasingly seeing requests for colonoscopy and upper endoscopy in patients younger than age 50 and without evidence of bleeding or symptoms of GI disease. Even when silent celiac disease is raised as a possibility, a negative serology for TTG antibodies has a 99% negative predictive value and is much less invasive and expensive as a “rule-out” test than scoping.

But the requests don’t stop there. Once a colonoscopy and upper endoscopy have excluded GI disease in an asymptomatic patient free of bleeding, we are now often being asked to assess the small bowel by capsule endoscopy. Next, it will be requests for full enteroscopy.

So, how are you handling these patients? Here are a few questions:

When evaluating IDA in the absence of evidence of GI bleeding or GI symptoms …

  • What do you recommend in: (a) patients aged <40; (b) patients aged 40 to 50; (c) patients aged >50?
  • Do you ever do capsule endoscopy or enteroscopy in this situation?

Thanks for sharing your approach.

September 23rd, 2013

Making Bowel Preps Palatable

We know that split-dose, polyethylene glycol (PEG)–based bowel preparation solutions provide the best cleansing before colonoscopy. However, many patients are not compliant with the bowel prep procedure because of the poor taste of the PEG solution. Results of a recent trial suggest a practical approach to overcoming this problem: Use candy. In the trial, use of menthol-flavored candy while drinking the PEG solution improved tolerability and resulted in higher-quality colon preparation and a better patient experience.

In that same vein, I have noted that physicians use other methods of making the solution more palatable, including adding flavoring to the prep or masking the flavor of PEG with an additional agent during ingestion. (My personal favorite is to chase each gulp with a sip of black coffee!)

So what do you do to enhance your colonoscopy prep’s tolerability?

  • Add a dilutant with flavor?
  • Use an adjunctive flavor when ingesting?
  • Slow delivery down further?
  • Something else?

I (and a lot of fifty-plus-year-olds) look forward to you revealing your secrets!

 

 

 

August 8th, 2013

Probiotics: Which one, and in whom?

I continue to be intrigued by the burgeoning use of probiotics  — by both patients and practitioners, including myself — to treat patients’ symptoms of digestive diseases. The problem I run into when considering their use in patients, or when answering patients’ questions about them, is in determining which patients are good candidates for probiotics, and which of the dozens of probiotics to choose.

So, I am asking for your advice and comments on this subject. Here are my questions:

1. For what conditions do you use probiotics (e.g. IBS, IBD, functional dyspepsia, chronic diarrhea, chronic constipation, abdominal pain, etc.)?

2. Do you use one probiotic in particular, or different ones for different symptoms?

3. How long do you try them out before determining they are ineffective and stopping?

4. If one is ineffective, do you try others? If so, in what order?

I am looking forward to hearing your advice and experiences.

 

July 16th, 2013

Follow-up after Barrett esophagus ablation: How do you do it, and when do you stop (if ever)?

We have shifted the paradigm of treating neoplastic Barrett esophagus (BE) away from a choice between intensive surveillance or surgery and towards endoscopic ablation. In the last 5 years, I have done hundreds of BE ablations using radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR), and many thousands have been performed worldwide. However, on post-ablation surveillance, evidence is lacking on whether and when patients can be cut loose. Moreover, I am beginning to see patients who were believed to be cured after ablation (no signs of BE or neoplasia during years of surveillance) showing up with adenocarcinoma in the distal esophagus 4 or more years later.

Until now, I have been telling my patients that once they are BE- and dysplasia-free, I want them to undergo surveillance every 4 months for 1 year, then every 6 months for 1 year, then yearly for a couple of years, and then every other year if things remain stable.

But given the uncertainties I’ve outlined above, I am interested in discussing your practices and recommendations for surveillance after ablation for BE.

On that note, what would your approach be in the following cases?

1) If a patient with high-grade dysplasia has their BE completely ablated (no BE and no dysplasia), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

2) If a patient with low-grade dysplasia has their BE completely ablated (no BE and no dysplasia), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

3) If a patient with NO dysplasia has their BE completely ablated (no BE and no dysplasia), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

4) Do you ever tell patients that they are cured and no longer need surveillance (e.g., after 5 years, after 10 years, etc.)?

5) If a patient with dysplasia has their neoplastic BE completely ablated (no dysplasia but residual BE), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

Please join the discussion to shed some light on this issue.

June 28th, 2013

Colonoscopy Preps: Patient Marketing vs. Patient Quality

There are innumerable bowel preps on the market as well as “home brewed” ones (e.g. Miralax™ and Gatorade™). In my community, many gastroenterology practices appear to choose their colonoscopy prep based on patient acceptability and/or taste preference. I find this choice of bowel prep based on “marketing” to patients troublesome.

Although I absolutely understand the issues of patient satisfaction (I have had two colonoscopy preps), the reality is that the quality of the bowel prep directly correlates with detection of polyps and, thus, ultimately affects the ability of colonoscopy to protect against colon cancer.

In my experience, if patients are given the choice between a bowel prep that tastes good or is easier to use and the “best” one for cleaning the colon (a split-dose, PEG-based prep) and optimizing polyp detection, they will choose the latter. Frankly, I think that the use of any less optimal prep should be accompanied with documentation that the patient is aware of the “risk” associated with use of the alternate prep (missed polyps, possible increased risk for later cancer, need for another colonoscopy earlier than usual, etc.)

So, what is your approach to this issue? Specifically, I am wondering the following:

1)    How do you choose bowel preps in your practice?

2)    If you choose anything other than split-dose, PEG-based preps, do you inform patients that they may have a greater risk for missed polyps?

3)    Do you track bowel prep quality as a quality measure in your practice?

4)    In patients with a suboptimal prep, when do you reschedule them back?

I look forward to the conversation.

June 4th, 2013

Suspected Lower GI Bleeding: When do you do an Upper Scope?

Most gastroenterologists I know seem pretty confident that they can differentiate bright red blood from a lower GI (e.g., colonic) source and massive upper GI bleeding presenting as bright red blood in the lower GI tract. The location of bleeding is critical from a treatment and prognosis perspective. Lower GI bleeding usually ceases spontaneously, requires no pharmacological intervention and rarely requires an endoscopic intervention, whereas with upper GI bleeding, PPI infusion and endoscopic therapy offer improvement in outcomes.

Because the distinction is important, some authorities suggest consideration of an urgent EGD in this situation and an elective colonoscopy (if at all). My observation is that most endoscopists do not follow this management approach: They forego the EGD and do an urgent colonoscopy.

So, let’s discuss a hypothetical case.

A patient has an apparent lower GI bleed and is hemodynamically stable upon resuscitation. Which would you do?

1. An urgent colonoscopy
2. An urgent colonoscopy, followed by an EGD if nothing is found
3. An urgent EGD and elective colonoscopy
4. Another approach

Please share your approach and the thinking behind your management strategy. I look forward to a dialogue.

Gastroenterology Research: Author M. Brian Fennerty, M.D.

M. Brian Fennerty, MD

Editor-in-Chief

NEJM Journal Watch Gastroenterology

Biography | Disclosures | Summaries

Learn more about Gut Check on Gastroenterology.