October 1st, 2010
The New Epidemic: Narcotic Bowel and Abdominal Pain
I remember clearly when “pain” became a vital sign. As I suspect most medical professionals felt, chronic pain was a serious and disabling symptom that was poorly treated for the most part. The last decade of expanding research into mechanisms and treatments of chronic pain has brought enormous relief to the millions that suffer from this symptom.
However, it has also resulted in a growing and devastating new problem and that is visceral hyperalgesia (abdominal pain) from chronic narcotics used to treat pain. Whereas most health care professionals know that narcotics can cause alteration in bowel function (constipation from slowed colonic transit, nausea and vomiting from delayed gastric emptying, etc.), I suspect most are not aware that narcotic bowel from chronic narcotic use also includes abdominal pain arising from narcotic induced visceral hypersensitivity.
It has been said that the most common reason for consultation to a GI doctor is for IBS, but in my practice, the most common consult is now for abdominal pain that is secondary to chronic narcotic use. This is the new GI epidemic in the U.S. in my opinion.
Have you been seeing these patients as well? What are you telling them and the referring provider? Let us know what you think.
August 31st, 2010
Drown out that pain! Warm water infusions lead to better colonoscopy tolerance.
Well it seems you can teach an old dog a new trick after all! About 18 months ago I was exposed to the concept of infusing warm water into the colon during the initial part of the colonoscopy exam (100-150ml injected through the biopsy port when at the recto-sigmoid junction up through the sigmoid colon) and I have become a firm believer it helps navigate these difficult turns in the sigmoid, leads to less “looping” in the colon and as a result is more comfortable for the patient and the endoscopist.
My nurses note the difference as well and now most of my colleagues and fellows we train use this technique and all universally praise the results.
So, my question to you is:
1) Do you infuse water?
2) If so, where, how (syringe, foot pedal), how much?
3) What do you think of it?
4) If no, why not?
Look forward to hearing from you!
July 19th, 2010
Esophageal manometry: Time to teach old dogs new tricks!
I have been doing manometry for a long time and felt there really wasn’t much more to learn or see related to this field. That is until we got a high-resolution system. Now I realize I wasn’t seeing as much as I thought I was with the old perfusion systems and the physiology is incredible and much better demonstrated with the solid state high resolution systems.
I do not know how many of you are doing manometry or have had exposure to high-resolution systems but I would like to hear of your experiences.
Do you do manometry?
What systems have you used?
What is your experience with high-Resolution manometry?
Let us know what you think; I look forward to hearing how you are faring in this “brave new world” of physiology!
July 12th, 2010
I’m back! So how do you treat eosinophilic esophagitis?
Eosinophilic esophagitis has been around for a long time but we only recently have recognized it and begun to try and treat it. My dilemma has been how and for how long should I treat this patient. Part of the decision difficulty lies in the extreme variation of clinical presentation that I see in this disease and part is related tot he lack of good quality treatment information.
For example, do we treat all patients with topical steroids (inhaled steroids that are swallowed) and if so for how long (intermittent courses, maintenance long-term therapy, once)? Or are some better treated with other anti-inflammatory products? Treat first, dilate after or dilate then treat? What is the role for dietary modification in adult patients?
So I am asking you to weigh in one these issues:
Do you treat all adult patients with newly diagnosed eosinophilic esophagitis with oral inhaled then swallowed steroids (fluticasone)?
If so how long?
In those with a stricture or narrowed esophagus do you dilate first then treat or treat then dilate?
If you do not use steroids or they fail, what do you use to treat eosinophilic esophagitis?
Let me know what you do, I look forward to hearing from you.
March 1st, 2010
When Should We Stop Surveillance of Barrett’s Patients?
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!
February 25th, 2010
Who Is Better Qualified to Perform Colonoscopy?
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?
January 11th, 2010
How Do You Spell Relief for Irritable Bowel Syndrome?
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?
January 4th, 2010
Endoscopic Weight-Loss Procedures: What’s the Optimal Target?
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.
December 17th, 2009
Ulcer Bleeding: Tricks of the Trade!
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?
December 11th, 2009
Should Propofol Be Used for Routine Endoscopy?
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.
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
Biography | Disclosures | Summaries
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