M. Brian Fennerty, MD, is the editor of Journal Watch Gastroenterology and Professor of Medicine and Section Chief of Gastroenterology in the Department of Internal Medicine at Oregon Health & Science University.
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(4 votes, average: 3.75 out of 5)We all are seeing this disease more often than in the past. Whereas the diagnostic criteria now seem firmly entrenched, the optimal treatment strategy remains to be determined. Treatments have included food avoidance, anti-secretory drugs, topical steroids, immunomodulators, and combinations of these approaches.
So I am interested in how you treat eosinophilic esophagitis.
What is your first line therapy?
Do you put every patient on a PPI?
Do you use food avoidance, and, if so, is it directed empirically or by allergy testing?
Which topical steroid do you use?
Do you treat before dilating?
How long do you treat, or do you maintain patients on therapy?
Let’s get the conversation rolling!
(5 votes, average: 4.40 out of 5)Most gastroenterologists are aware of the increasing incidence of hepatocellular cancer (HCC) in patients with cirrhosis. Most are also aware of the updated 2011 guidelines from the American Association for Study of Liver Diseases that recommend screening many patients with cirrhosis for HCC with every 6-month ultrasound examinations. These guidelines are based largely on a cost-effectiveness analysis showing that, at a certain threshold, incidence of HCC screening would be cost-effective in various cirrhotic states. However, there is a lack of data from prospective trials showing that screening is effective in preventing death from HCC and almost no data on the efficacy of such an intervention in the U.S.
1. Do you think we should screen patients with cirrhosis for HCC?
2. How effective do you think such screening is?
3. How would you screen (ultrasound, CT, MRI, alpha fetoprotein)?
4. What frequency intervals should be used?
5. If you do not screen, what data would compel you to begin screening?
I look forward to the discussion.
(3 votes, average: 4.00 out of 5)The importance of our normal gut flora becomes apparent when antibiotics wipe out a portion of it and give Clostridium difficile a niche to reside in, which can lead to severe colitis. Relapse of the colitis is the rule until the normal gut flora is reestablished, and treatment of relapsing C. difficile colitis has usually involved trials of antibiotics and toxin binding agents.
More recently, fecal transplants have been reported as both first-line and relapse treatment for C. diff. The effect seems to be far superior to that from traditional approaches and is being touted as a treatment for other GI and nonGI diseases as well.
Have you used fecal transplants?
If not, what would it take for you to start using them?
If yes, how do you a) prepare them and b) deliver them (e.g., through the scope or by oral capsule delivery)?
What diseases do you screen the donor for?
What success rate have you observed?
How much does the treatment cost?
I look forward to hearing what your experiences have been.
(2 votes, average: 5.00 out of 5)The American Society for Gastrointestinal Endoscopy has stated: “In order for colorectal polyps <5 mm in size to be resected and discarded without pathologic assessment, endoscopic technology (when used with high confidence) used to determine histology of polyps <5 mm in size, when combined with the histopathologic assessment of polyps >5 mm in size, should provide a >90% agreement in assignment of post-polypectomy surveillance intervals when compared to decisions based on pathology assessment of all identified polyps.”*
How many of us heed this guidance? We do have technologies that in some of our hands exceed the threshold established here for identifying polyp histology >90% of the time (narrow band imaging, confocal microscopy, etc.). But are we teaching, learning, and implementing these technologies to save the patient and payer the substantial pathology charges arising from resecting the many thousands of these diminutive lesions?
So my questions to you are:
1. Do you ever use real-time histology technology to assess colon polyps?
2. Which one do you use and in what circumstance (small vs. large polyps, all polyps, etc.)?
3. Do you make clinical decisions based on that assessment?
4. If you do not use the technology to make clinical decisions, what accuracy will it take to allow you to “resect and discard” these small polyps?
* Rex, et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps (Gastrointest Endosc 2011; 73:419).
(2 votes, average: 4.50 out of 5)What I am interested in hearing about from you is:
1) Do you routinely use water infusion during colonoscopy?
2) If yes, what temperature do you use?
3) If you use warm water, in what manner do you think it further improves colonoscopy versus room-temperature water, and what specific temperature do you warm it to?
I look forward to hearing from you.
(3 votes, average: 5.00 out of 5)One area of gastroenterology that is guided more by dogma than evidence regards surveillance of nondysplastic Barrett esophagus (BE). Surveillance of BE lesions is widely practiced, despite a large body of evidence that the practice is not cost-effective, the cancer risk from BE is very low, and the life expectancy of BE patients is normal. Even guidelines of professional societies (the AGA, ASGE, and ACG) do not endorse such surveillance, but instead view it as an optional strategy.
Now, a new study shows that cancer risk from BE is much lower than the already low rate we had been estimating (see summary in Journal Watch Gastroenterology).
Based on these emerging facts, I’d like to generate a discussion regarding these questions:
1. Should we be screening for BE, and, if so, in whom?
2. In patients discovered to have nondysplastic BE, should we be doing surveillance?
3. If we do surveillance, how often should it be done?
4. If we recommend no surveillance, what should we be telling these patients?
I look forward to your discussion.
(1 votes, average: 5.00 out of 5)The right side of the colon seems to be the Achilles heel of colonoscopy because polyps there tend to be flat and harder to find, and we confer the least protection from later colon cancer in that zone.
A recent article summary in Journal Watch Gastroenterology concludes that when we see a right-sided colon polyp, we may have missed another, so we should go back and look again.
This provocative recommendation represents a major change in the way we normally perform colonoscopy. But the issue is, and always has been, how to identify and remove all polyps from the colon.
So the questions I have for you are:
1) Should we routinely reexamine the right colon in everyone, only those with a polyp, or no one?
2) Have you already changed the way you inspect the right colon, or will you now?
3) If you do inspect the right colon differently, do you use retroflexion, repeat examination, narrow-band imaging?
I look forward to your response.
(3 votes, average: 4.67 out of 5)The first cases of Barrett esophagus (BE) ablation in the late 1980s used YAG and Argon laser. Since then, a myriad of ablation techniques have been described, including multipolar electrocautery (MPEC), argon plasma coagulation (APC), cryotherapy, radiofrequency ablation (RFA), and endoscopic mucosal resection (EMR). Each technique has had its advocates, and some of the techniques appear to have certain advantages in certain types of BE: e.g., long segment, nodular, etc.
Most cases of BE are short segment, and most neoplastic cases do not have nodules or erosions. So the question I would like to see discussed is: In a patient with 1–2 cm of otherwise featureless flat but neoplastic BE:
What ablation technique would you use, and what do you feel makes this technique advantageous?
What would be your second option, and when would you employ it?
Do you use more than one technique, and, if so, which ones do you use and why?
What are the most common complications you see with BE ablation?
What is your overall success at complete BE elimination?
We look forward to your comments.
(1 votes, average: 5.00 out of 5)I had always assumed EUS-directed celiac plexus blocks, if they worked, were the best therapy for pancreatic cancer pain. However, when speaking recently with one of my pain clinic colleagues, he indicated that splanchnic nerve blocks also work pretty well in these patients.
The literature supports both approaches, but I was somewhat surprised that the evidence for splanchnic blocks possibly was superior.
So here is what I would like to ask you:
1) When you refer a patient (or have a patient) with pancreatic cancer pain, do you:
a) do an EUS guided celiac block or refer to the pain clinic for a splanchnic block?
b) discuss the options of celiac versus splanchnic nerve blocks?
2) What do you think is the best way to treat pancreatic cancer pain?
3) Were you even aware that splanchnic blocks for pancreatic pain were available?
I look forward to hearing from you on this subject!
(1 votes, average: 1.00 out of 5)I have observed extreme variation in how my colleagues manage GI foreign-body retrieval from the stomach. Some always use general anesthesia and endotracheal intubation; others (myself included) use conscious sedation. Some use an overtube to withdraw the object into if possible; others simply pull it up to the endoscope and use the endoscope to guide it through the esophagogastric junction and upper esophageal sphincter. The reasons for this variation are clearly related to the perceived risk of airway compromise or gastrointestinal wall injury during withdrawal of the object from the stomach.
So my questions to you are:
1) When do you ask for endotracheal intubation during foreign-body retrieval?
2) Do you use an overtube when removing foreign bodies from the stomach, and, if so, always or in what situations?
3) If you don’t use an overtube, what technique do you use during withdrawal of the object?
4) What is your favorite “tool” or endoscopic accessory to grab objects from the stomach?
I look forward to hearing your thoughts on this issue.
