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.
When Should We Stop Surveillance of Barrett’s Patients?
M. Brian Fennerty • March 1st, 2010
Categories: Endoscopy, Patient care
(1 votes, average: 5.00 out of 5)Some of my patients who have undergone successful ablation therapy for Barrett’s esophagus ask a really good question: If I haven’t had Barrett’s for years, why do I need to keep having endoscopies?”
I admit, I do not have a uniform answer for that, nor do GI society guidelines. I would say that for patients who have never had dysplasia, surveillance is difficult to justify anyway, so we should “cut them loose” once we are sure their Barrett’s is gone. But I’ve heard many experts say that patients who have had dysplasia can never be let out of surveillance.
Why should we approach patients who had dysplasia any differently than those who had adenomatous polyps? After all, adenomas are dysplastic and, as with dysplastic Barrett’s (especially low-grade Barrett’s), are associated with only modest cancer risk. Moreover, when we remove an adenoma, we no longer worry about that site; rather, we worry about the rest of the colon because that is where recurrence takes place. After ablation, Barrett’s is gone, so why the continued intensive surveillance?
I don’t buy the argument that Barrett’s is left behind; missed buried glands are rare in patients whose biopsies are all negative after ablation. Furthermore, even oncologists consider cancer patients cured after 5 years of disease-free survival and no longer put them through surveillance imaging and blood tests.
So why are gastroenterologists resistant to the concept of “cutting loose” our Barrett’s patients, even after 5 or more years of negative endoscopies and biopsies? Let me know what you think. I have thick skin, so pile it on!
Who Is Better Qualified to Perform Colonoscopy?
M. Brian Fennerty • February 25th, 2010
Categories: Endoscopy
(1 votes, average: 5.00 out of 5)Consider this: The American Society for Gastrointestinal Endoscopy requires physicians to perform at least 200 colonoscopies before it will assess their competency (much less grant them privileges), and most fellows complete at least 500 during their 3-year training programs.
However, the American Board of Surgery now “mandates” that surgical residents need to perform only 50 colonoscopies during their 5-year surgical residency programs, and some surgeons continue to perform these procedures after completing their training.
Granted, we do not know the minimum number of colonoscopies that should be performed during training to ensure competency, but when two different specialty groups vary by a factor of 4 to 10 (50 vs. 200 to 500), something is clearly wrong.
Let me put this in another way. Who do you want to do your exam: the physician who did 50 colonoscopies during training and now does 50 a year, or the one who did 500 during training and now does 500 a year?
How Do You Spell Relief for Irritable Bowel Syndrome?
M. Brian Fennerty • January 11th, 2010
Categories: Uncategorized
(2 votes, average: 4.50 out of 5)I admit it. I’m frustrated. I do not know how to manage a substantial portion of my IBS patients because so few of them get relief from traditional therapies (bulking agents, antidiarrheals, tricyclic antidepressants, etc.).
Recently, I noticed that many of my colleagues are using Align probiotics, Iberogast herbal supplements, and other alternative/complementary therapies for their IBS patients. So, I diligently re-reviewed the literature on these treatments but came away more confused than ever; the studies are varied and usually small, the endpoints are unclear, and the follow-ups are short. Yet, my colleagues and their patients seem a whole lot more satisfied with the outcomes than I am.
Do you use alternative treatments for IBS? If so, what do you use, and what responses are you seeing?
Endoscopic Weight-Loss Procedures: What’s the Optimal Target?
M. Brian Fennerty • January 4th, 2010
Categories: Uncategorized
(2 votes, average: 5.00 out of 5)As I contemplate the last few weeks of holiday parties and notice that the gym seems more crowded and the gym rats more focused, I realize I am not the only one who fears the added weight gain from too much food and libation! The world remains in search of a cure for obesity, and the holiday season seems to refocus our attention on this issue.
What is also interesting to me is the incredible success and growing popularity of surgical weight-loss procedures as well as how many people are aware of the availability and benefits of these surgeries. However, many doctors are unaware of the enormous effort being put into the development of endoscopic weight-loss procedures. To date, no consensus guidelines have been issued for outcomes of these less-invasive techniques, and I am intrigued by what we should be looking for as these procedures enter clinical trials.
The literature on surgical weight-loss procedures suggests profound medical benefits are achieved even with modest weight reduction (a loss of 15–25 pounds improves glycemic control, lipid profiles, etc.). Yet, these procedures provide the further dividend of 25% weight loss or more. So, I am curious to know what you think an endoscopic weight-loss procedure should deliver when it comes to percent weight loss. Is it 5%, 10%, 15%, 25%, or more? Let me know what you think is the optimal and achievable target for these procedures.
Ulcer Bleeding: Tricks of the Trade!
M. Brian Fennerty • December 17th, 2009
Categories: Uncategorized
(1 votes, average: 4.00 out of 5)One of the difficulties we face when performing urgent endoscopy on a patient with upper GI bleeding is to visualize the mucosa and the lesion when blood is still present in the stomach. IV erythromycin can help by evacuating blood from the stomach, but it has become increasingly scarce; we haven’t had any available at my hospital in 6 months. In any case, when we find an ulcer, it is often obscured by an adherent clot, so we don’t know whether a vessel requiring therapy is present within that ulcer.
Now, we have new evidence that another weapon in our bag of tricks can help improve endoscopic visualization of bleeding ulcers, even those hidden by adherent clots. As described recently in Journal Watch Gastroenterology, researchers found that spraying dilute hydrogen peroxide onto blood or clots hydrolyzes hemoglobin and renders it translucent, allowing for improved visualization of underlying lesions.
So I have a couple of questions for you: First, do you have IV erythromycin in stock and, if so, do you administer it to patients with upper GI bleeding before endoscopy? Second, do you plan on keeping hydrogen peroxide on your emergency endoscopy cart and using it to improve visualization of ulcer bases beneath adherent clots?
Should Propofol Be Used for Routine Endoscopy?
M. Brian Fennerty • December 11th, 2009
Categories: Uncategorized
(2 votes, average: 3.00 out of 5)Propofol is a remarkable drug that has revolutionized sedation for patients undergoing endoscopic procedures. It can produce rapid and, when necessary, deep sedation, and its effects can be reversed within seconds to minutes. Because it has proven to be more effective than hypnotics (such as versed) and narcotics (such as fentanyl), an estimated 40% of all endoscopic sedation in the U.S. is now being performed with propofol.
Unfortunately, because propofol is labeled an anesthetic, GI docs in most hospital endoscopy units are blocked from using the drug by the hospitals’ anesthesia departments, which set sedation policies. Such policies persist, largely because of ongoing turf wars, despite documentation of more than 500,000 cases of safe propofol administration by nurses under GI-doc supervision.
Given the restrictions on propofol use, many endoscopists have resorted to calling in anesthesiologists or anesthetists to administer the drug in routine cases. But does this response meet the highest standards of professionalism? In my opinion, the turf war is wrong, but it does not justify introducing the cost of an anesthesia provider into routine endoscopic procedures.
I suspect many of you have strong opinions about this one way or the other, so please weigh in on the subject.
Gatorade and Miralax: A Better Bowel Prep?
M. Brian Fennerty • December 7th, 2009
Categories: Uncategorized
(4 votes, average: 4.50 out of 5)Only about half of U.S. adults have undergone colonoscopy screening for colorectal neoplasia. To reach our goal of screening 100% of the adult population, we must find ways not only to make the procedure more accessible and affordable for patients, but also more tolerable, especially in terms of bowel preparation.
Intolerance of the gold-standard bowel prep, which is now 4 liters of a PEG-based electrolyte solution (since Fleet’s Phospho Soda was removed from the market), has been blamed on both the unpleasant taste of the solution and the large volume that must be swallowed. Since split dosing has come into vogue, volume seems to be less of a problem, but the taste issue remains.
To help make the taste of the solution more bearable, one of my colleagues began giving patients the option of drinking split doses of a Miralax/Gatorade combination. I was surprised by how well-tolerated and effective he said the prep has been. Now, we routinely offer patients split doses of either a PEG-based or Miralax/Gatorade bowel prep. As a result, patients do not seem to complain as much about the prep when they come in for their exams. More important, a greater portion of patients complete the whole prep, and almost all of the prep results are excellent or good.
What preps do you offer patients who undergo colonoscopy, and what is your experience with Miralax/Gatorade?
The real issue in PPI-induced acid rebound: Why are PPIs used in the first place?
M. Brian Fennerty • July 6th, 2009
Categories: Uncategorized
(1 votes, average: 4.00 out of 5)A great deal of alarm has been voiced over a recent report that some patients with no previous acid-related dyspepsia or GERD developed acid symptoms after stopping PPI therapy in a month-long trial.
Should we really be surprised by this finding? Not really. PPI use is known to cause acid rebound, and the effect is thought to be related to PPI-induced gastrin secretion (secondary to an increase in gastric pH) and to gastrin’s effect on parietal cell mass expansion, which leads to increased acid secretion.
Should we be concerned that these drugs are being given to patients who have no acid-related symptoms? Absolutely. In my opinion, a PPI is warranted only if patient history indicates that gastrointestinal symptoms are likely acid related. These drugs should not be used for every abdominal discomfort or complaint.
The real take-home message from this study is not to stop taking PPIs, but rather to take a history and not to use PPIs (or for that matter any drug) unless we have a clear understanding of what we are trying to diagnose or treat.
What do you think?
Fennerty’s Top 10: Endoscopy News from DDW 2009
M. Brian Fennerty • June 9th, 2009
Categories: Uncategorized
(1 votes, average: 3.00 out of 5)Here are ten key findings about endoscopy that were reported at Digestive Disease Week 2009, held May 30 – June 4, 2009 in Chicago:
#10. We need to drop Bisacodyl from the new Gatorade prep.
#9. Wire-guided cannulation during ERCP results in less pancreatitis.
#8. Looking carefully during endoscopy finds lesions, enhanced imaging is not what does it.
#7. Balloon enteroscopy is an important tool in managing small bowel disease and needs to become more widely available.
#6. You do not need to stop aspirin, NSAIDs, or Plavix prior to endoscopic procedures.
#5. Neoplastic Barrett’s belongs to the endoscopist not the surgeon.
#4. Under-represented ethnic populations have special digestive health issues that are not being addressed adequately.
#3. If the virtual colonoscopy is positive and the colonoscopy is negative, we cannot tell the patient to come back in 10 years; we need to repeat testing in the next year or two.
#2. We miss colon cancers during colonoscopy.
#1. Gosh things change fast, and DDW is the place to learn that!
Can We Justify Performing Upper and Lower Endoscopies on Consecutive Days?
M. Brian Fennerty • June 9th, 2009
Categories: Uncategorized
(1 votes, average: 5.00 out of 5)I recently saw a patient who was referred after upper and lower endoscopies had not revealed the cause of his abdominal discomfort. What struck me was that the patient had these two exams on consecutive days. That meant two days lost from work, two days with altered diet, two trips to the endoscopy center, two days with a driver commitment, two anesthetic administrations, etc. I am not naïve to the fact that most insurers discount heavily for endoscopy procedures performed on the same day. But how do we justify the additional risk, costs, inconvenience, and impact on a patient’s quality of life by not performing needed procedures at the same time?
Perhaps I am missing something here, so I would really like to better understand the rationale for this practice. Please weigh in on the practice of same-day versus consecutive-day endoscopies.
