Endoscopy Flashcards
What is the incidence of DEATH from EGD?
1 in 10,000 patients (respiratory and cardiac - SEDATION)
Is RECENT MI a relative CONTRAINDICATION to EGD?
YES
What are some of the COMPLICATIONS that can be experienced from endoscopy using UNCLEAN SCOPES?
BACTEREMIA, PHLEBITIS, ASPIRATION PNA, ENDOCARDITIS
Esophageal DILATION and SCLEROTHERAPY carry a higher risk of what COMPLICATION?
BACTEREMIA
Which EGD perocedure carries the HIGHEST RISK for ASPIRATION PNA?
HIGH-VOLUME UGIB
Does ASPIRIN increase the risk of an UGIB during EGD?
NO
How can METHEMOGLOBINEMIA occur during EGD?
ORAL TOPICAL ANESTHESIA
What complication can occur in a patient with ASCITES undergoing esophageal variceal BANDING?
INFECTION of ASCITES
Colon PREPS using MAGNESIUM, SODIUM POHOSPHATE or MANNITOL can cause what issues?
TOXICITY in patients with** RENAL FAILURE** (especially in patients on ACE-I, ARBs and NSAIDs)
MANNITOL or LACTULOSE should NEVER be used for COLON preps, why?
Can cause EXPLOSIONS with ELECTROCAUTERY
What should be CONSIDERED in all patients undergoing endoscopic procedures who have PACEMAKERS and the potential use of ELECTROCAUTERY is there?
GROUNDING PAD AWAY from the HEART and pacemaker should be tuned OFF during procedure
How LONG after a **COLONIC POLYPECTOMY **can there be a procedure-related BLEED?
A FEW WEEKS
HIGHEST RISK of PERFORATION during a COLONOSCOPY occurs after what SURGERY?
HYSTERECTOMY (mostly in rectosigmid or junction of sigmoid and descending)
Colon PERFORATIONS due to AGGRESSIVE INUFFLATION occur where?
CECUM
What is the MISS rate on COLONOSCOPY for polyps >1 cm; < 5 mm?
> 1 cm - 6%
< 5 mm - 27%
Is the RISK of STROKE, MI or PE by stopping anti-thrombotic agents > than the risk of the BLEED that one is trying to manage endoscopcially?
Usually YES
What is an EMERGENCY option for the REMOVAL of the EFFECT of DABIGATRAN (PRADAXA) in a patient with an emergent profuse bleed?
HEMODIALYSIS (or IDARUCIZUMAB, a monoclonal antibody antidote)
What is the REVERSAL AGENT that can be used with APIXABAN (eliquis) and RIVEROXABAN (xarelto)?
ADNEXANET ALFA
What is the REVERSAL AGENT used when anticoagulation is on board with INR >2.5 and endoscopy is needed?
4-FACTOR PROTHROMBIN COMPLEX CONCENTRATE + Vit K or FFP
When is PROTAMINE used as the reversal agent for HEPARIN potentiated BLEED when endoscopy is needed?
LIFE-THREATENING BLEED
In a patient with a RECENTLY-PLACED VASCULAR STENT (< 1 year) or Acute Coronary Syndrome, on ANTICOAGULATION, what is done if ENDOSCOPY is needed?
CONSULTATION with the prescribing service
How should ANTICOAGULATION be RESUMED in a patient after endoscopy with HIGH RISK of REBLEED?
UNFRACTIONATED HEPARIN (short half-life)
What is done with a patient requiring endoscopy and who are on ANTIPLATELET AGENTS (clopidogrel)?
HOLD these until HEMOSTASIS is achieved
For patients with A-FIB associated with VALVULAR DISEASE, MECHANICAL heart valve, LVAD, history of CVA or CHF, CHADSVASC score >2, age >75, prior TIA or CVA, HTN or DM, what is the recommendation for those taking anticoagulation prior to elective ENDOSCOPY?
Use HEPARIN or LMWH BRIDGE (these are HIGH-RISK patients)
For patients with history of DVT, non-valvular A-FIB, BIOPROSTHETIC VALVES, what is recommended for those taking anticoagulation prior to elective ENDOSCOPY?
HOLD meds and RESUME post procedure, NO BRIDGING (LOW-RISK)
In a patient with a DRUG-ELUTING stent, ot a patient on DVT anticoagulation, what is the recommendation for ELECTIVE ENDOSCOPY?
WAIT until anticoagulation period is completed (12 months for the stents)
Do ASPIRIN and NSAIDs need to be stopped for ENDOSCOPIC procedures?
NO
What is the RECOMMENDATION for the THIENOPYRIDINES (clopidogrel, prasugrel and ticagrelor) prior to ENDOSCOPIC procedures?
For HIGH-RISK (of bleeding)procedures, HOLD these for 5-7 DAYS and switch to ASA monotherapy. For LOW-RISK procedures, these may be continued. These may be RESTARTED once endoscopic hemostasis is achieved.
What should be done with a GP IIb/IIIa (eptifibatide, tirofiban) infusion when a patient requires an EMERGENT endoscopic procedure for ACUTE GIB?
DISCONTINUE the infusion (if needed, platelet transfusion or DDAVP may be considered)
When can WARFARIN be restarted after an ENDOSCOPIC procedure?
ON THE SAME DAY if no ongoing bleeding
For RAPIDLY-ACTING (Novel Oral Anti-Coagulants) such as DABIGRATAN, APIXABAN and RIVAROXABAN, WHEN can these agents be restarted after ENDOSCOPIC procedures?
Once ADEQUATE HEMOSTASIS is ensured (no furtheer signs of bleeding) so 12-24 HOURS after and if not use HEPARIN BRIDGE 2-6 HOURS after the procedure. These are ALL RENALLY cleared.
If ANTITHROMBOTIC therapy MUST be restarted after an EMERGENT/URGENT endoscopic procedure, what is the SAFEST WAY to go?
IV UNFRACTIONATED HEPARIN (fast half-life)
HOW do you BRIDGE a patient for an ELECTIVE ENDOSCOPIC procedure with LMWH?
HOLD the WARFARIN for 5 DAYS and CONCOMITANTLY start the LMWH and DISCONTINUE the LMWH 8 HOURS before the procedure.
In which patients can you NOT use LMWH for BRIDGING for ENDOSCOPIC procedures?
PREGNANT WOMEN with MECHANICAL HEART VALVES (thromboses)
Are PROPHYLACTIC antibiotics for ENDOCARDITIS recommended for patients undergoing ENDOSCOPIC procedures?
NO
For WHICH endoscopic procedure is the SUGGESTION of PROPHYLACTIC antibiotics against ENDOCARDITIS, REASONABLE?
ERCP when CHOLANGITIS (E. coli) is suspected and HIGH-RISK patient (prosthetic heart valve, heart transplant, history of previous infectious endocarditis, and congenital heart conditions pre/post repair)
In patients considered for ERCP in which there is the suspicion of INCOMPLETE DRAINAGE - OBSTRUCTION, PSC, HILAR STRICTURES, HEPATIC TRANSPLANT, what is RECOMMENDED?
ANTIBIOTICS to cover GM-negatives and Enterococci
What is the RECOMMENDATION for PROPHYLAXIS for EUS-FNA of CYSTIC lesions?
ANTIBIOTICS
What is the RECOMMENDATION for PROPHYLAXIS for PEG procedures?
CEFAZOLIN 30 minutes BEFORE procedure
What is the RECOMMENDATION for PROPHYLAXIS for ALL patients with CIRRHOSIS and ACUTE GIB?
IV CEFTRIAXONE or ORAL NORFLOXACIN
Is ANTIBIOTIC PROPHYLAXIS recommended for synthetic vascular and non-valvular grafts or ORTHOPEDIC JOINT procedures prior to ENDOSCOPIC procedures?
NO
What is the RECOMMENDATION for ANTIBIOTIC PROPHYLAXIS prior to COLONOSCOPY procedures for patients on CONTINUOUS PERITONEAL DIALYSIS?
1 g AMPICILLIN + one dose of an AMONOGLYCOSIDE with or without METRONIDAZOLE with EMPTYING of the ABDOMEN
What is the RECOMMENDED CECAL intubation RATE for ENDOSCOPISTS?
>90% in ALL cases and > 95%in SCREENING in a HEALTHY adult - photo documentation should be obtained
What is the RECOMMENDED ADENOMA DETECTION RATE (ADR) in colonoscopy for MEN and WOMEN?
MEN >30% & WOMEN >20% (>25% together)
What is the RECOMMENDED SURVEILLANCE COLONOSCOPY FREQUENCY for a patient with a FIRST DEGREE RELATIVE who developed COLON CANCER BEFORE 60 YO and for one that developed it AFTER 60 YO?
BEFORE 60 YO - every 5 years
AFTER 60 YO- every 10 years
What is the RECOMMENDED NEXT SURVEILLANCE COLONOSCOPY for a patient found to have a colonic ADENOMATOUS POLYP >2 cm which was removed in PIECEMEAL FASHION?
NEXT in 3-6 MONTHS then in 1 YEAR
In a patient who has undergone CURATIVE SURGICAL RESECTION of a CANCER in the COLON or RECTUM, when is the RECOMMENDED NEXT COLONOSCOPY?
1 YEAR (then in 3 years, then every 5 years) or 3-6 months if obstructive colorectal cancer
What is the ANTIDOTE for DABIGATRAN?
IDARUCIZUMAB
What is the ANTIDOTE for BOTH APIXABAN and RIVAROXABAN?
ANDEXANET ALFA
When are ANTIBIOTICS RECOMMENDED PRIOR to ERCP
ONLY if INCOMPLETE DRAINAGE is ANTICIPATED in spite of the ERCP (hilar stricture, PSC)
For WHICH TWO EGD procedures is BACTEREMIA an 8% RISK?
BALLOON DILATION (perforation) and VARICEAL THERAPY (peritonitis and aspiration)
What kind of CONSTRAST is used when SUSPECTING an ENDOSCOPIC PERFORATION?
WATER-SOLUBLE CONTRAST ONLY
What is the 30-DAY MORTALITY RISK for PEG placement?
15%
Sodium Phosphate and Mag Citrate colon preps can cause what?
EXACERBATE or INDUCE IRREVERSIBLE RENAL FAILURE
Why are MANNITOL and LACTULOSE NOT used as COLON PREPS?
Cause EXPLOSIONS with CAUTERY
What is the KEY to a good outcome POST ENDOSCOPIC PERFORATION?
EARLY RECOGNITION
Patient becomes BLUE and CYANOTIC appearing but ALERT TALKING just after given MIDAZOLAM, SpO2 LOW but PaO2 is NORMAL?
METHEMOGLOBINEMIA - treat with METHYLENE BLUE IV (altered Hb Iron)
After CAUTERY POLYPECTOMY, pt develops abdominal pain, mild FEVER, mild LEUKOCYTOSIS, NO FREE AIR, what happened?
TRANSMURAL BURN (no surgery, observe only)
For what INR does a patient require anticoagulation REVERSAL prior to EGD with HEMOSTASIS?
INR >2.5
What should be done with ANTICOAGULANTS (warfarin, heparin, factor Xa inhibitors, direct thrombin inhibitors) when treating a patient ENDOSCOPICALLY for HEMOSTASIS?
HOLD them to FACILITATE HEMOSTASIS
For a patient on WARFARIN with SEVERE, LIFE-THREATENING BLEEDING, what MUST be done PRIOR to ENDOSCOPY?
4-FACTOR CRYOPRECIPITATE + Vit K or FFP
What should be done PRIOR to DISCONTINUING ANTI-PLATELET therapy for ENDOSCOPIC procedures?
CONSULT PRESCRIBING PHYSICIAN BEFORE HOLDING (drug-eluting stent < 1 YEAR; bare metal stent < 30 DAYS; ACS < 90 DAYS
How LONG should WARFARIN be HELD for prior to ELECTIVE ENDOSCOPY?
5 DAYS
How LONG should DABIGATRAN (Pradaxa) be HELD for prior to ELECTIVE ENDOSCOPY?
1-3 DAYS (longer for decreased GFR - 4-6 days) - SAME with other NOACs
VALVULAR A-FIB, MECHANICAL VALVE, H/O CVA, CHF, ChADsVAsc >2, LVAD, post-ACS, what is recommended for ANTICOAGULATION MANAGEMENT prior to ENDOSCOPY?
BRIDGING
Pt has a POOR BOWEL PREP, when do you repeat colonoscopy?
WITHIN 1 YEAR
Pt has a FAIR BOWEL PREP, when do you repeat colonoscopy?
5 YEARS
Can a DIAGNOSIS of EOE be ENDOSCOPIC?
NO (histology only) - 15 eosinophils/hpf
How is EOE treated?
Budesonide/Fluticasone and 2 MONTHS of PPI followed by repeat EGD with biopsies
What is the RISK of BLEEDING of a NON-BLEEDING VISIBLE VESSEL (in an ulcer, etc.) WITHOUT medical INTERVENTION?
50%
HIV patient with CANDIDA esophagus with an exophytic growth?
SQUAMOUS PAPILLOMA
This is associated with an ABNORMAL PANCREATICO-BILIARY JUNCTION, abdominal PAIN and abnormal ERCP with long COMMON CHANNEL?
TYPE-I choledochocele (high-risk for CHOLANGIOCARCINOMA) - SURGERY
ODYNOPHAGIA, ESOPHAGEAL LESIONS, MULTINUCLEATED GIANT CELLS (histology), WHERE DO YOU BIOPSY?
BORDER BIOPSY - HSV (NOT CENTER - CMV)
ODYNOPHAGIA, ESOPHAGEAL LESIONS, OWL EYES (histology), WHERE DO YOU BIOPSY?
CENTER of ULCER (CMV) - not border as in HSV
Incidental finding in ESOPHAGUS with ASYMPTOMATIC enlarged WHITISH plaques noted also in COWDEN’s SYNDROME, biopsies show ENLARGED SQUAMOUS CELLS with ABUNDANT CYTOPLASM, what is the TREATMENT?
GLYCOGENIC ACANTHOSIS - no treatment needed
When the PANCREATIC DUCT is of what SIZE is SURGICAL EXCISION of an IPMN RECOMMENDED?
> 10 mm
A patient with UC and PSC has an INCREASED RISK of what CANCERS?
COLON CANCER and CHOLANGIOCARCINOMA
SPINDLE CELLS, CD117 POSITIVE?
GIST
EUS: SUBMUCOSAL HYPERECHOIC GASTRIC LESION?
LIPOMA
EUS: SUBMUCOSAL HYPOECHOIC GASTRIC LESION arising from MUSCULARIS PROPRIA, SPINDLE CELLS and CD177?
GIST
SERRATED POLYPOSIS SYNDROME, what is recommended SURVEILLANCE?
EVERY 1 YEAR
SESSILE SERRATED POLYPS < 1 cm WITHOUT DYSPLASIA, what is the recommended SURVEILLANCE?
EVERY 5 YEARS
For SESSILE SERRATED POLYPS > 1 cm OR ANY SIZE with DYSPLASIA or TRADITIONAL SERRATED ADENOMA, what is the recommended SURVEILLANCE?
EVERY 3 YEARS
What can cause HEMOSUCCUS PANCREATICUS (hemorrhage from the pancreatic duct)?
Contrast-enhanced CT or Angiography - PANCREATITIS with SPLENIC ARTERY PSEUDOANEURYSM
**Is PSEUDOMALANOSIS DUODENI caused by laxative use as in melanosis coli? How is it treated?
NO, it is caused by macrophage uptake of blood, NO TREATMENT NEEDED
How do you treat ENTEROBIASIS (pinworms in colon)?
MEBENDAZOLE or ALBENDAZOLE
A patient with ISOLATED GASRTIC VARICES (fundus) are liekly due to SPLENIC VEIN THROMBOSIS caused by what condition?
PANCREATITIS - Do ABD CT (not TIPS)
Like esophageal varices, these VARICES are also caused by PORTAL HTN, they can cause MASSIVE BLEEDING and are TREATED how?
RECTAL VARICES (beta-blockers + TIPS)
Raised **WHITE VERRUCOUS LESIONS **in RECTUM on RETROLFEXION?
CONDYLOMA ACCUMINATA - HPV
Small MUCOSAL BUMPS in DISTAL ILEUM?
LYMPHOID HYPERPLASIA - BENIGN
