Endoscopy Flashcards
78 Chinese EGD for for dyspepsia- 1.5-cm nonulcerated depressed lesion with slightly elevated component (Paris 0-IIc+IIa) at the incisura angularis of the stomach [figure: the lesion on white light (WL) and narrow band imaging (NBI)]. Biopsy of this lesion revealed intramucosal adenocarcinoma with minute focus of poorly differentiated malignant neoplasm arising in a background of gastric mucosa with high-grade dysplasia and intestinal metaplasia (incomplete and complete types). Gastric mapping biopsy for immunohistochemical staining for H. pylori is negative. CT scan abdomen and pelvis with contrast shows no evidence of lymph nodes or distal metastasis. What is the most appropriate next step in management?
A. Cap-assisted EMR
B. Band-assisted EMR
C. Endoscopic submucosal dissection
D. Referral for surgical resection with lymph node dissection
E. Endoscopic full thickness resection
lesion is early gastric cancer (EGC)
- fulfills absolute criteria (clinical T1a intramucosal cancer, undifferentiated, nonulcerated, mucosal lesions that are ≤2 cm in size) for endoscopic submucosal dissection (ESD) (Table).
- Endoscopic resection is recommended with EGCs w negligible risk of lymph node metastasis.
- Lesions are considered absolute indications for endoscopic therapy if they are presupposed to have a <1% risk of lymph node metastasis and long-term outcomes similar to those with surgical gastrectomy.
- Endoscopic submucosal dissection TOC for EGCs
- EMR is an acceptable option for lesions smaller than 10-15mm with a very low probability of advanced histology (Paris 0-IIa).
- No RCTs with EMR vs ESD in stomach
- meta-analyses-ESD is associated with higher
- en bloc resection rates and
- histologically complete resection rates, and
- lower recurrence frequency.
- Endoscopic full thickness resection has a variable en bloc resection rate and is not a standard treatment for EGCs
An 83-year-old woman presents to the emergency department with recurrent rectal bleeding. Past medical history is significant for scleroderma, iron deficiency anemia, and pulmonary hypertension. CT of the abdomen and pelvis with IV and oral contrast shows a nodular liver, splenomegaly, reversed flow in the portal vein, and prominent collateral vessels. Blood work is notable for hemoglobin 10 g/dL (normal: 12-16 g/dL), prothrombin time 15 seconds (normal: 11-13 seconds), and platelet count 100,000/µL (normal: 150,000-350,000/µL). AST, ALT, and ALP are within normal limits. She has never undergone EGD or colonoscopy. Colonoscopy is arranged and the rectal findings are as seen in the figure. What is the best next step for the patient?
A. EUS-guided cyanoacrylate glue injection
B. Epinephrine injection and bipolar cautery
C. Bipolar cautery and endoscopic clipping
D. Surgical resection
rectal varix with an overlying blood clot/plug- tx w/ endoscopic cyanoacrylate glue injection, transintrahepatic portosystemic shunt (TIPS), and endoscopic variceal ligation. While epinephrine injection, bipolar cautery, and endoscopic clipping can all be used to manage gastrointestinal bleeding, they are not treatments targeted to the specific management of ectopic varices. Surgery is reserved for patients who fail TIPS or have a contraindication to TIPS.
An 84-year-old woman with a remote history of possible ulcer disease presented to the emergency department with 5 days of melena following a week’s intake of an NSAID for low back pain. She reported no other significant past medical history, and no cardio-respiratory complaints; the physical exam is normal. Initial hemoglobin is 7.5 g/dL (normal: 12-16 g/dL), with platelets of 375,000/µL (normal: 150,000-350,000/µL), and an INR of 1.03 (normal: <1.4). After stabilization and transfusion of 1 unit of packed RBCs, an EGD was performed. A 2-cm duodenal ulcer with a very firm fibrotic base was noted and was treated with epinephrine injection and endoclips. The next day, the patient has a bout of red blood hematemesis and after stabilization, an EGD is repeated. Epinephrine injection, thermal coagulation, and further clips application are attempted but there is persistent bleeding (endoscopic appearance shown in the figure). Over-the-scope clip expertise is not available at your institution. What would you do now?
A. Endoscopic application of hemostatic powder followed by trans-arterial embolization by interventional radiology
B. Endoscopic application of hemostatic powder and no further intervention
C. Monitor closely on continuous intravenous infusion of high-dose proton-pump inhibitor.
D. Send to surgery for oversewing of the duodenal ulcer.
- Hemostatic powder
- excellent in achieving immediate hemostasis cannot be sole tx, 12-24hrs, 72req following endoscopic therapy for a bleeding ulcer lesion to become a low-risk lesion.
- Options: IR emob or OTSC
A 48-year-old man with early gastric adenocarcinoma diagnosed on endoscopic biopsy with T1a (M) depth of invasion on pathology [figure] is requesting referral for gastric endoscopic submucosal dissection (ESD). What can you confidently tell the patient about why he should consider gastric ESD over surgical gastrectomy?
A. Higher rates of en bloc and curative resection than surgical gastrectomy
B. Better disease-free survival rate compared to surgical gastrectomy
C. Lower risk of overall complications and procedure-related death compared with surgical gastrectomy
D. Higher rates of lymph node metastasis for T1a (M) invasion
Gastric ESD
- significantly lower complication rates
- lower proc related death
- lower rates of en bloc resection and disease-free survival for gastric ESD
- no improvement in overall survival compared to surgery
A 68-year-old man with paroxysmal atrial fibrillation reports 3 days of dark black stool. He has been on aspirin 81 mg daily and warfarin for the last 2 years for a significant thromboembolic history. He has experienced 2 DVTs and 1 stroke within the last 4 years, with the most recent embolic event occurring 18 months ago. Over the last week, he reports using regularly scheduled ibuprofen 600 mg 3 times a day for the treatment of tennis elbow. His hemoglobin has declined from 13.5 g/dL to 8.4 g/dL and his INR is 4.5, and a 4-factor prothrombin complex is provided to normalize his INR. You proceed to EGD and find an adherent clot that is dislodged using water irrigation revealing a bleeding visible vessel. You place 2 mechanical clips but note some residual oozing at the site which you inject with epinephrine [figures A and B]. What is the optimal recommendation for warfarin in this patient?
A. Resume 10-14 days following the endoscopy.
B. Resume within 4-7 days following discontinuation of the warfarin.
C. Resume immediately.
D. Discontinue.
In general, resumption of anticoagulation should be initiated as soon as immediate hemostasis is achieved. However in this patient, hemostasis was not immediately achieved and so it is reasonable to withhold warfarin for up to 2 days after the endoscopy to let the eschar establish (i.e., within the first 4 days of temporary interruption of the anticoagulant) while maintaining the patient on ASA monotherapy. It is important to note that the warfarin is still being re-initiated within 4 days of drug interruption; this is particularly important given the patient’s history of thromboembolism, which is moderately elevated. It has been demonstrated that for a patient with warfarin-associated GI bleeding and indications for long-term antithrombotic therapy, anticoagulation should be resumed within the first week (4-7 days) following hemorrhage/drug cessation to minimize the risk of 90-day thrombosis, without incurring an increase in 90-day recurrent GI bleeding. The ASA need not be discontinued in the peri-endoscopic period; all therapeutic and diagnostic procedures can be safely performed with ASA on board.
A 33-year-old man with a past medical history of bipolar disorder was admitted to the emergency department after swallowing a piece of a small metallic bead. He denies any dysphagia or abdominal pain. His vital signs and physical examination are unremarkable. Abdominal x-ray revealed a 1.5-cm metallic foreign body in the distal stomach. What is the best next step in the management of this patient?
A. Abdominal computed tomography (CT) scan without oral contrast
B. Emergent esophagogastroduodenoscopy within 6 hours
C. Elective esophagogastroduodenoscopy within 24 hours
D. Radiographic monitoring in 1 week
- Asymptomatic patients with small (<2.5 cm in diameter and <5 cm in length), blunt objects can be managed expectantly.
- Patients should undergo radiographic monitoring weekly.
- resume a normal diet and monitor their stools
- AXR 1-2 days after the patient notes the object in the stool can help confirm
A 56-year-old woman presents to the clinic with history of progressive dysphagia for the last 6 months. Endoscopic evaluation reveals an upper esophageal stricture which is successfully dilated with a balloon dilator and biopsies are obtained. Biopsies are negative for dysplasia or malignancy. She reports a remote history of lye ingestion approximately 20 years ago. What is the most appropriate interval for surveillance endoscopy?
A. Repeat EGD as needed.
B. Repeat EGD in 3 months.
C. Repeat EGD in 3 years.
D. Repeat EGD in 5 years.
Alkaline caustic ingestion, in particular, is associated with an increased risk for squamous cell cancer of the esophagus. Patients with a history of lye ingestion have a 1,000-fold increased risk of developing esophageal cancer, with a lag time from injury of approximately 40 years. Periodic endoscopic surveillance is advocated every 1-3 years, beginning 20 years after the caustic ingestion.
20-1-3
A 77-year-old man with nonvalvular atrial fibrillation, hypertension, hyperlipidemia, and a history of transient ischemic attack (TIA) 1 year ago is admitted with congestive heart failure thought to be precipitated by a GI bleed. At presentation, he reports 24 hours of melena and was hemodynamically unstable initially but has been resuscitated appropriately. Now the hospitalist wishes to use a reversal agent before sending the patient down to the GI lab for an EGD. You recommend it would be desirable to measure the anticoagulant effect of rivaroxaban before using a reversal agent. Your lab does not have a drug-specific toxicity assay for rivaroxaban, so what other serum assay can be used to exclude a toxic level (i.e., excessive anticoagulant effect) of rivaroxaban?
A. Prothrombin time (PT) - rivaroxaban, edoxaban
B. Activated partial thromboplastin time (aPTT) - dabigatran
C. Dilute thrombin time (DTT) - dabigatran
D. Ecarin clotting time (ECT) - dabigatran
PRO RIVA + EDO
Although a normal drug-specific assay is optimal for assessing residual anticoagulant effect (i.e., a drug-specific anti-Factor Xa assay), a normal PT excludes excess levels of rivaroxaban and edoxaban, but does not exclude an excessively high level of apixaban. A dilute thrombin time, aPTT, or ecarin clotting time can be used to assess excess levels of dabigatran before use of a reversal agent.
59-year-old man, NSAID use, HDS in ICU. The ICU attending calls and tells you the patient seems to have stabilized hemodynamically. He asks you to perform an endoscopy as soon as possible. Which of the following do you recommend?
A. Start IV proton pump inhibitors (PPI) with an IV bolus followed by a continuous infusion of a PPI.
B. Perform endoscopy within 12 hours.
C. Perform endoscopy within 24 hours.
D. Obtain CT angiography and consult interventional radiology.
- In terms of timing of endoscopy, all guidelines recommend endoscopy be performed within 24 hours.
- large study - endoscopy done too early may be associated with worse outcomes. A recent randomized, prospective trial of emergent (within 6 hours) vs. urgent endoscopy performed within 24 hours showed no patient level benefits with emergent endoscopy.
Reference(s)
- Barkun AN. Management of nonvariceal upper gastrointestinal bleeding: Guideline recommendations from the International Consensus Group. Ann Intern Med. 2019;171(11):805-22.
- Laine L, Jensen D. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012;107:345-60.
- Lau JYW. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med. 2020;382:1299-308.
- Lau JW. Omeprazole before endoscopy in patients with gastrointestinal bleeding. N Engl J Med. 2007;356:1631-40.
- Laursen SB. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: A nationwide cohort study. Gastrointest Endosc. 2017;85(5):936-44.
A 55-year-old man with a history of chronic pancreatitis presents to his primary care physician for evaluation of new onset jaundice. He developed dark urine 2 weeks prior to presentation. On evaluation, he is icteric and chronically ill-appearing. Laboratory tests demonstrated a total bilirubin of 10.1 mg/dL (normal: 0.3-1.2 mg/dL), AST 346 U/L (normal: 0-35 U/L), ALT 395 U/L (normal: 0-35 U/L), alkaline phosphatase 716 U/L (normal: 36-92 U/L). A CT scan demonstrated an atrophic pancreas with multiple calcifications within the parenchyma. The bile duct measured 1.1 cm. No masses were identified. ERCP was performed, but the bile duct could not be successfully cannulated with a sphincterotome and wire-guided cannulation, double wire technique, and a precut needle knife sphincterotomy. What would be the next step to drain the biliary tree?
A. Percutaneous biliary dilatio
B. Repeat ERCP at another time
C. EUS-guided biliary drainage with rendezvous
D. Surgical biliary drainage
Choudari et al. evaluated a cohort of 542 patients that had a previously unsuccessful ERCP. The overall success rate in visualizing the desired duct was 96.4% (542 of 562 patients). The complication rate in this second attempt ERCP was 10.1%. The post-ERCP pancreatitis rate in this difficult patient population was 8.7%. A majority of the post-ERCP pancreatitis cases were mild (71.5%). The overall complication rate in this difficult patient population is comparable to the usual complication rate from this center. Percutaneous transhepatic biliary drainage (PTBD) has been widely used as an alternative procedure for patients with failed ERCP. However, PTBD involves an external fistula drainage system that drastically decreases a patient’s quality of life. EUS-guided biliary drainage is an exciting new tool that has recently been introduced into our armamentarium of biliary drainage techniques. As compared to percutaneous drainage, EUS-guided biliary drainage provides an internal conduit to drain the biliary tree. The advantages of EUS-BD is that the endoscopist can convert to this procedure immediately after a failed cannulation. Clinical success for EUS-BD is 84% (a lower success rate than first attempting a repeat ERCP, which is why this is not the best answer to the question). There is a low complication and re-intervention rate. Surgical drainage is an appropriate step in those patients in whom endoscopic or percutaneous treatment either cannot be done or are not available.
A 37-year-old woman presents to the emergency department with a 3-day history of right upper quadrant pain. She describes these symptoms occurring every month for the past 6 months. This episode is the most severe. She has 7/10 pain that is colicky in nature. Her family noted icteric sclera. In the ED, she is having pain. Temperature 100.0 degrees, BP 120/74, pulse 100. Examination noted a tender abdomen in the right upper quadrant. No Murphy’s sign. Laboratory tests demonstate total bilirubin of 5.7 mg/dL (normal: 0.3-1.2 mg/dL), AST 390 U/L (normal: 0-35 U/L), ALT 456 U/L (normal: 0-35 U/L), alkaline phosphatase 345 U/L (normal: 36-92 U/L), and lipase 45 U/L (normal: <95 U/L). Ultrasound demonstrated a dilated CBD to 1.0 cm. The gallbladder was surgically absent. The patient’s history is notable for a prior laparoscopic cholecystectomy and a Roux-en-Y gastric bypass 3 years ago. What is the most appropriate approach to treatment?
A. Use a duodenoscope to perform ERCP.
B. Perform an endoscopic ultrasound-guided transgastric ERCP (EDGE).
C. Deep enteroscopy-assisted ERCP
D. Colonoscopy-assisted ERCP
ERCP in patients that have prior Roux-en-Y gastric bypass, deep enteroscopy-assisted ERCP is the most appropriate technique.
Attempting to perform ERCP with standard duodenoscope and colonoscopes are generally not successful
A 54-year-old man presents to the emergency department with a 2-day history of right upper quadrant abdominal pain, fever, chills, and a change in the color of his urine. The evaluation of the patient in the ED demonstrates an acutely ill, icteric, middle-aged male. Temperature is 101.5°F, pulse is 110/minute, blood pressure is 90/60, and respiratory rate is 22/min.
Laboratory tests demonstrate:
WBC 15,600/µL (normal: 4,000-10,000/µL)
Hemoglobin 14 gm/dL (normal: 14-17 g/dL)
Total bilirubin 5.0 mg/dL (normal: 0.3-1.2 mg/dL)
Lipase 31 U/L (normal: <95 U/L)
AST 137 U/L (normal: 0-35 U/L)
ALT 209 U/L (normal: 0-35 U/L)
Alkaline phosphatase 341 U/L (normal: 36-92 U/L)
A CT scan demonstrates a 1.2-cm common bile duct with intrahepatic duct dilation. The gallbladder has multiple stones. There is a 1.0-cm filling defect in the distal bile duct. An ERCP is performed. The biliary orifice is displaced into a caudad location. What is the most appropriate technique to treat this patient?
A. Cannulation with standard tapered catheter
B. Cannulation with a stent introducer with subsequent stent placement
C. Needle knife sphincterotomy over bulging ampulla
D. Cannulation with a sphincterotome and a wire
The stone will protect the pancreatic duct and bile duct. The stone bulging into the lumen of the duodenum provides the appropriate cutting axis to ensure biliary access. Cannulation with a standard catheter, stent introducer, and sphincterotome are good techniques but may be much more difficult given the caudal location of the biliary orifice.
A 54-year-old man presents after swallowing a foreign body. The patient is a prisoner and has a history of multiple foreign body ingestions. As the patient refused to say what he swallowed, this is unknown and whether he swallowed multiple objects. He does not have any acute complaints and said he just wanted to get out of the prison. Examination of his abdomen is unremarkable. A plain x-ray of the abdomen shows 3 foreign bodies within the stomach. There is a coin about the size of a quarter, a spoon, and a probable razor blade. Which of the following is the best recommendation?
A. Give glucagon intravenously.
B. Obtain a contrast CT to exclude perforation.- avoid contrast, no perf concern here
C. Perform emergent endoscopy within 6 hours.
D. Perform urgent endoscopy within 24 hours.
- Recent guidelines have suggested that patients with
- blunt objects within the stomach >2.5 cm in diameter 24 hours
- blunt objects <2.5 cm in the stomach 72 hours
- Sharp objects within the esophagus warrant an emergent endoscopy within 2-6 hours. However, patients with sharp objects in the stomach, as this case, are recommended to undergo endoscopy within 24 hours.
A 61-year-old woman presents with obstructive jaundice, pancreatic head mass, and a sigmoid mass. She underwent an oral endoscopic ultrasound with biopsy of the pancreatic head mass which showed adenocarcinoma, an ERCP with biliary stent placement, and a colonoscopy with biopsy of the sigmoid mass. The pathology was read as invasive moderate to poorly differentiated adenocarcinoma with an immunophenotype and morphology consistent with metastasis from the pancreas. She continued to complain of moderate to severe diffuse abdominal pain that is dull and constant, despite being on a fentanyl patch 75 mcg/hr q 72 hours. With regard to EUS-guided celiac plexus neurolysis (CPN), which of the following is correct?
A. Following EUS-guided CPN, the patient can be discharged home within 30 minutes if they meet standard discharge criteria.
B. EUS-guided CPN is superior to a percutaneous approach based on large, randomized controlled trials.
C. Pain relief is more likely among patients with direct tumor invasion of the celiac plexus compared with those who lack direct invasion.
D. When compared to conventional pain management, patients with inoperable pancreatic adenocarcinoma treated with CPN have significantly greater pain relief.
- CPN had significantly greater pain relief in inoperable adenoCA with a trend toward lower morphine consumption at the 3 month follow-up.
- After EUS-guided CPN, the vital signs are monitored for 2 hours.
- In addition, prior to discharge, the blood pressure is checked in both a supine and standing position to assess for orthostasis.
- EUS-guided CPN to a percutaneous CPN - no trials
- direct tumor invasion of the celiac plexus (73% vs 28%) and in whom ethanol was only distributed to the left side of the celiac plexus (47% vs. 6%) - insufficient pain control likely
Indications for endoscopic submucosal dissection in the colorectum include which of the following?
A. Laterally spreading tumors (LST) non-granular type
B. 0-Ip morphology according to the Paris classification
C. Laterally spreading tumors (LST) granular type with uniform granules
D. 0-III morphology according to the Paris classification
LST non-granular type have a high propensity to invade the submucosa and en bloc resection is recommended. Therefore, answer A is correct. Pedunculated lesions (Paris 0-Ip) are best handled by snare polypectomy and excavated lesions (Paris 0-III) typically contain deeply invasive cancer and are treated by surgery. LST granular type with uniform granules have a low risk for submucosal invasion; therefore, EMR techniques are considered adequate for removal.
