July 10th, 2011
Pancreatic cancer pain: Better treated in the endoscopy unit or pain clinic?
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!
June 13th, 2011
Foreign-body retrieval from the stomach: how do you do it?
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.
May 17th, 2011
How good a colonoscopist are you?
I have noticed that we all think we are the best endoscopist around (in my case, that is indeed true!). However, we really never measured colonoscopy skill as a “patient-centered” metric and instead often use speed, efficiency, sedation needs, etc. when judging our colleagues. What is more important than these measures, however, is whether we find and remove adenomas, thereby preventing colon cancer downstream in our patients.
A number of surrogate markers for quality colonoscopy and polyp detection have been used in the past, including scope-withdrawal time from the cecum. But the one measure that has been the best predictor of quality is an endoscopist’s ADR (adenoma detection rate). In fact, this is the most reliable quality measure yet determined, and it may become the basis for being paid for these procedures in the not so distant future.
So I need to ask you:
1) Do you know your ADR?
2) Do you or does your group compare your ADR to other endoscopists within your endoscopy unit or practice?
3) Is there a program to increase ADR in low performers in your endoscopy unit?
4) Do you use your ADR as a marketing tool?
5) What is your take on the ADR as a quality measure?
I look forward to hearing from you on this topic!
April 29th, 2011
Treating chronic hepatitis C: Do we finally have the answer?
Although the treatment of chronic hepatitis C virus infection has come a long way, I have been frustrated that less than half of patients are cured with current interferon/ribavirin based therapy. That is why I have been closely watching the data related to the use of protease inhibitors such as telaprevir and boceprevir.
Now that the data demonstrate the remarkable effectiveness of these agents, gastroenterologists will have to consider how and when they will be used, what changes in monitoring will be necessary, and whether infectious disease doctors will take over this treatment (
So I am asking you:
Will you use these agents as soon as they become available?
Are you comfortable using a protease inhibitor along with IF/ribavirin?
How will this alter your monitoring?
What are your thoughts about ID specialists managing these patients?
March 25th, 2011
H. pylori: Is it time to change our first-line treatment?
H. pylori dominated the GI news in the 1990s, and despite it disappearing from the front pages, it remains a common and important clinical problem. The dominant recommended initial treatment strategy has been a clarithromycin-based PPI triple therapy, with either amoxicillin or metronidazole as the third drug. This approach was based on clinical studies, ease of use, and tolerability factors. Bismuth-based quadruple therapy (a bismuth agent, metronidazole, tetracycline, and a PPI), despite demonstrating excellent activity, was usually relegated to second-line therapy because of the complexity of the dosing as well as compliance and tolerability issues.
However, duringthe last decade, the widespread use of macrolides in the general population has led to rising resistance to clarithromycin (by 30% or more of H. pylori strains in some areas), and when clarithromycin resistance is present, the efficacy of clarithromycin-containing triple therapy falls from about 80% to 50% or even lower. However, clarithromycin resistance does not affect the efficacy of bismuth-based quadruple therapy, and that efficacy of those regimens remains at about 90% when patients are compliant with the treatment.
So the questions for you to consider are:
1) Do you know what the clarithromycin resistance rate in H. pylori is in your community?
2) What first-line H. pylori treatment regimen do you use?
3) Are you planning to change your H. pylori treatment strategy now that clarithromycin resistance rates are rising?
Let us know what you think.
March 7th, 2011
Lower gastrointestinal bleeding: Rush in now to scope or wait till morning?
It used to be dogma that the earlier we “scoped” patients with gastrointestinal bleeding the better off they would be in terms of outcomes such as fewer transfusions, less need for surgery, and shorter hospital stays. However, we now have good data that demonstrate for most patients with upper GI bleeding that this is not the case. Instead, patients with upper GI bleeding scoped electively, but within 24 hours, fare as well as those scoped urgently, although there are exceptions one should keep in mind.
Is the same true of lower GI hemorrhage? Well, the lesions are different, as diverticular bleeding, AVMs, hemorrhoids, and neoplasia predominate as causes of lower GI bleeding. Nonetheless, urgent endoscopy after rapid bowel prep was how I was taught to manage these folks, and most of my colleagues seemed to treat them the same way. More recently, though, the benefits of urgent colonoscopy in patients presenting with suspected lower GI bleeding have been called into question.
So I am asking you:
1) When do you think we should scope patients with lower GI bleeding who are otherwise stable: within a few hours, 12 hours, 24 hours, or more?
2) Should we begin the prep right away or wait and do it later?
3) Do you use the prep to get ready for the procedure, to monitor bleeding, or both?
4) What do you do if patients have had a high-quality colonoscopy in the last 3 years with a finding of tics only? Do you still scope them?
5) What other issues do you consider or think are important in managing these patients?
February 14th, 2011
Can colonoscopy cause diverticulitis?
Many of you out there have done many tens of thousands of colonoscopy like I have and are well aware of the complications most known to be associated with this procedure, like bleeding or perforation. And most of us are aware of very unusual complications that have been reported, such as splenic lacerations or barotraumas.
However, I recently had a patient develop acute diverticulitis within 24 hours of colonoscopy, and I have consulted in the last year on another patient who developed diverticulitis shortly after the procedure.
Although diverticulitis precipitated by colonoscopy prep or the procedure itself (microperforation from the bowel prep, pressure from the shaft of the instrument or air infused during the procedure, etc.) is plausible, there seems to be little in the literature on this subject.
One reason for the lack of data might be that there is not really an association, that these are two unrelated events. Another might be that because diverticulitis is not immediately evident (like bleeding or perforation), the causal link has been missed, given that delayed complications are not often reported in large series of procedures.
So I am asking you endoscopists out there:
1) Have you observed diverticulitis in a patient shortly after a colonoscopy?
2) Do you think the procedure can cause diverticulitis?
3) If so, what do you think the mechanism is for this complication?
I look forward to hearing from you.
January 24th, 2011
A new way to treat IBS?
The more we look into the normal gut bacteria flora the more complex it becomes. We know these bugs that reside in our small and large intestines affect immunology, motor, sensory and a myriad of other gut functions. The ability to modulate this diverse population of bugs does seem to help some patients with IBS and inflammatory bowel disease. Most of the recent attempts at influencing the types of bugs in a patient’s GI tract have been through probiotics. More recently using antibiotics has garnered increased attention.
What I would like to know is:
-Who out there has been using antibiotics in patients with IBS?
-What types of IBS patients seem to respond and how often do you see a response?
-What antibiotics are you using?
-Have you seen any side effects?
Let us know what you think and what you are doing.
October 15th, 2010
Plavix (Clopidogrel) and endoscopy: the great dilemma!
Plavix and other platelet inhibitors have saved countless lives by preventing cardiovascular events. But those same inhibitory effects on platelets theoretically could increase bleeding risks after GI procedures that include biopsy or tissue removal (polypectomy).
Unfortunately there are little data regarding whether bleeding risk is increased when patients on Plavix undergo endoscopy procedures. The clinical choices are either to stop the Plavix and maybe decrease the risk of bleeding post procedure but also maybe increase the patient’s risk for a cardiovascular complication or continue the Plavix and possibly increase the risk of GI bleeding but protect their heart and brain!
What a dilemma and little of no data to guide us. So what do you do: stop Plavix or perform the procedure on the drug? Let us know how you are dealing with this difficult dilemma.
October 1st, 2010
Esophageal food impaction: Are you a secret pusher?
I, like most endoscopists, remember being told that you should never push an esophageal food impaction into the stomach but instead all food should be removed first, then the cause of the impaction determined and treated.
Well I suspect that most endoscopists do what I do and that is try and safely push the impaction into the stomach, as removal of the bolus is difficult and frankly more dangerous in my opinion, than a careful attempt at a “push”. In order to remove the impaction we have to basket it, snare it, grasp it, put an overtube in or combine and or perform other potentially harmful maneuvers. On the other hand, gently sliding by the impaction keeping the esophageal wall in view usually results in the impaction being pushed or dragged into the stomach without the risk of the maneuvers mentioned above.
So I confess-I am a pusher. How many of you out there are pushers and what has been your experience of going against endoscopic dogma and pushing gently or sliding by to remove impactions?
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
Biography | Disclosures | Summaries
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