Endoscopy Best Practices

Question 1

Do esophagel gastric inlet patches require biopsy?

Answer 1

NO

Question 2

What is the RISK of REBLEEDING without EGD intervention of a FORREST Class IIa ULCER (non-bleeding visible vessel)?

Answer 2

50%

Question 3

HIV patient with pill dysphagia was noted to have this lesion on EGD?

Answer 3

Candida with SQUAMOUS PAPILLOMATA

Question 4

What is this finding and what is recommended?

Answer 4

TYPE I CHOLEDOCHOCELE - HIGH RISK for CHOLANGIOCARCINOMA - SURGERY

Question 5

What is this caused by and how do you treat it?

Answer 5

HSV ulcer - multinucleated GIANT cells - PERIPHERAL biopsy and treat with ACYCLOVIR

Question 6

Spindle Cells, CD117 positive stain?

Answer 6

GIST - muscularis propria

Question 7

Patients >65 yo, MI within 30 days, Obesity, HTN, DM, CAD are all at an increased RISK of what?

Answer 7

CARDIOPULMONARY complications on EGD

Question 8

Do patients with EOE have an increased risk for perforation when performing an EGD with BALLOON DILATION?

Answer 8

NO!

Question 9

Should PEG patients get PROPHYLACTIC antibiotics?

Answer 9

YES!

Question 10

ASPIRATION and BACTERIAL PERITONITIS are increased RISK factors when performing this EGD procedure?

Answer 10

Variceal Banding

Question 11

Patient gets TOPICAL anesthetic spray and turns CYANOTIC with LOW SpO2, but behaves normally, what happened?

Answer 11

METHEMOGLOBIN from ANESTHETIC SPRAY (arterial PaO2 is normal) - altered form of HEME IRON from ferrous (Fe2+) to ferric (Fe3+) carrying less oxygen - MEASURE with CO-OXIMETER

Question 12

How is METHEMOGLOBINEMIA treated as when a patient turns CYANOTIC when given TOPICAL ANESTHETIC SPRAY?

Answer 12

METHYLENE BLUE

Question 13

Post SNARE CAUTERY POLYPECTOMY, pt presents with perforation-like symptoms of abdominal PAIN, FEVER, LEUKOCYTOSIS, but NO FREE AIR is seen on imaging, what happened?

Answer 13

TRANSMURAL BURN (POST POLYPECTOMY COAGULATION Syndrome)

Question 14

When a patient has an ACUTE GIB and is on WARFARIN, and ONLY if needed, what is recommended for REVERSAL?

Answer 14

PCC (Prothrombin Complex Concentrate) - 4 factors
NOT FFP (because it takes a large volume), NOT Vit K (takes 24-48 hrs)

Question 15

ACUTE GIB should get EGD in what time frame?

Answer 15

24 HOURS

Question 16

When a patient has an ACUTE GIB and is on DIRECT-ACTING ORAL ANTICOAGULANTS, what is recommended for REVERSAL?

Answer 16

DO NOT give Prothrombin Complex Concentrate (PCC); DO NOT give the idarucizumab for dabigratan nor the adnexanet alfa for apixaban or rivaroxaban

Question 17

When a patient has an ACUTE GIB and is on ANTIPLATELET AGENTS, what is recommended for REVERSAL?

Answer 17

DO NOT give PLATELT TRANSFUSION if PLATELETS are >100,000
DO NOT stop ASA for SECONDARY cardiac prevention
If ASA is stopped, RESUME right after hemostasis

Question 18

For ELECTIVE PROCEDURES, what is recommended for patients on WARFARIN?

Answer 18

If NOT HIGH-RISK procedure, CONTINUE WARFARIN

Question 19

For ELECTIVE PROCEDURES, if WARFARIN is stopped, is BRIDGING recommended?

Answer 19

NO! EXCEPT:
1. MECHANICAL VALVE
2. A-FIB with CHADSVASC2 >5
3. PRIOR CLOT when warfarin was stopped

Question 20

For ELECTIVE PROCEDURES, what is recommended for patients on DIRECT-ACTING ORAL ANTICOAGULANTS?

Answer 20

TEMPORARY INTERRUPTION

Question 21

For ELECTIVE PROCEDURES, what is recommended for patients on DUAL ANTIPLATELET THERAPY for SECONDARY CARDIOVASCULAR PREVENTION where one of the agents is ASA?

Answer 21

STOP the NON-ASA drug and KEEP the ASA

Question 22

WHEN should WARFARIN, ANTIPLATELET AGENTS and DIRECT-ACTING ORAL ANTICOAGULANTS be RESTARTED after ELECTIVE procedures?

Answer 22

WARFARIN and ANTIPLATELET agents: SAME DAY
DIRECT-ACTING ANTICOAGULANTS: NEXT DAY

Question 23

What should be DONE with ANTICOAGULANTS and ANTIPLATELET AGENTS when performing HIGH-RISK e**ndoscopic procedures (EUS/FNA, EMR, ESD, POEM, ERCP sphincterotomy, etc.)?

Answer 23

HOLD THEM

Question 24

How LONG is WARFARIN HELD prior to a HIGH-RISK endoscopic procedure?

Answer 24

5 DAYS

Question 25

Are **ANTIBIOTICS** needed to prevent **ENDOCARDITIS** for **ANY** endoscopic procedures?

Answer 25

**NO!**

Question 26

For a patient with **BILIARY OBSTRUCTION** who is undergoing **ERCP**, when would they require **ANTIBIOTIC** prophylaxis?

Answer 26

**ERCP** with **INCOMPLETE DRAINAGE** (PSC, HILAR stricture) and those who have had a **LIVER TRANSPLANT**

Question 27

For what **EUS** procedure is **ANTIBIOTIC PROPHYLAXIS** suggested?

Answer 27

**EUS** with **CYST** BIOPSY

Question 28

For **ALL** patients with **CIRRHOSIS** and **GI BLEED**, what is **REQUIRED**?

Answer 28

**ANTIBIOTIC PROPHYLAXIS**

Question 29

Do patients with **VASCULAR GRAFTS**, **PROSTHETIC JOINTS** or **PERITONEAL DIALYSIS** require antibiotic prophylaxis for endoscopic procedures?

Answer 29

**NO!** (only **suggested** for colonoscopy and peritoneal dialysis)

Question 30

What occurs with ingestion of **DETERGENT PODS** and **BUTTON BATTERIES**?

Answer 30

**SEVERE MUCOSAL INJURY**

Question 31

**LIQUIFACTIVE NECROSIS** of **ESOPHAGUS** is seen with ingestion of what?

Answer 31

**ALKALI**

Question 32

**COAGULATION NECROSIS** of **STOMACH** is seen with the ingestion of what?

Answer 32

**ACID**

Question 33

Why should **ENDOSCOPY** be performed within **24 HOURS** of ingestion of **CAUSTIC** materials?

Answer 33

**GRADE SEVERITY** of injury and predict **PROGNOSIS**

Question 34

What is the **MOST IMPORTANT TREATMENT** in **CAUSTIC INGESTION** injury?

Answer 34

**NPO** and **SUPPORTIVE** (nothing else)

Question 35

When should **ESOPHAGEAL CANCER** be screend for in a patient that ingested **CAUSTIC** meterial?

Answer 35

**AFTER** **10-20** YEARS, **every 2-3 YEARS**

Question 36

What is the **RECOMMENDED** performance target for reaching the **CECUM** for **ALL** colonoscopies vs **SCREENING** colonoscopies?

Answer 36

**ALL**: ≥**90%** **SCREENING**: ≥**95%**

Question 37

What is the **MINIMUM TARGET ADR** (**A**denoma **D**etection **R**ate) for **MEN** & **WOMEN** in screening colonoscopies?

Answer 37

**≥30% MEN** **≥20% WOMEN** **≥25% COMBINED**

Question 38

When should the **FIRST COLONOSCOPY** be performed after **SURGERY** for **COLON CANCER**?

Answer 38

**1 YEAR**

Question 39

What is the HIGHEST **ENDOSCOPE - to - PATIENT** infection transmission risk?

Answer 39

**ERCP** (scopes with **ELEVATORS**)

Question 40

What should be done post **colonoscopy** if this is seen?

Answer 40

Early **SURGICAL** consult (perforation with air under diaphragm)

Question 41

What is the **ROLE** of **EGD** after **CAUSTIC** ingestion, which should be performed **WITHOUT DELAY**?

Answer 41

To **GRADE** the findings using a **STANDARDIZED CLASSIFICATION** system

Question 42

On **colonoscopy**, you see these in the **CECUM**, how do you treat?

Answer 42

**Mebendazole** or **Albendazole** (pinworm in cecum)

Question 43

**Alcoholic** with **BLEED** from these, what is the recommended **NEXT** step?

Answer 43

**CT ABDOMEN** (look for evidence of **PANCREATITIS**) - because this is caused by **SPLENIC VEIN THROMBOSIS**

Question 44

**RECTAL VARICES** such as these are caused by **PORTAL HTN** and can cause **MASSIVE BLEED**, are treated how?

Answer 44

**𝞫-blockers**, **TIPS**

Question 45

This finding in the **TERMINAL ILEUM** represents what?

Answer 45

**NORMAL** **Lymphoid Hyperplasia**

Question 46

What **DEPTH** of **COLON INVASION** is considered colon **CANCER**?

Answer 46

**SUBMOCOSAL INVOLVEMENT**

Question 47

**Stage 0 COLON CANCER** means what **DEPTH of INVASION**?

Answer 47

**MUCOSA**

Question 48

**Stage I COLON CANCER** means what **DEPTH of INVASION**?

Answer 48

**SUBMUCOSA** (Superficial Ia < 1000 microns; Deep Ib >1000 microns)

Question 49

**Stage II COLON CANCER** means what **DEPTH of INVASION**?

Answer 49

**MUSCULARIS PROPRIA**

Question 50

**Stage III COLON CANCER** means what **DEPTH of INVASION**?

Answer 50

**LN INVOLVEMENT**

Question 51

**Stage IV COLON CANCER** means what **DEPTH of INVASION**?

Answer 51

**ADJACENT** or **DISTANT ORGANS**

Question 52

**Depth** of invasion **>1000 microns** (1 mm) for SESSILE (flat) polyps, **< 1-2 mm** from resection **margin**, **LN** invasion, **POOR DIFFERENTIATION**, **HIGH-GRADE BUDDING**, **PIECEMEAL** RESECTION

Answer 52

**UNFAVORABLE HISTOLOGIC** criteria of a **MALIGNANT POLYP** (send patient for **ADJUVANT SURGICAL RESECTION**)

Question 53

How **MANY** unfavorable histologic criteria make a malignant polyp a **HIGH-RISK** for recurrence?

Answer 53

JUST **ONE** (depth >1000 microns, < 1 mm resection margin, LN invasion, poor differentiation, piecemeal)

Question 54

If a patient is **NOT** a good **SURGICAL CANDIDATE** and has a resected colon polyp with **UNFAVORABLE HISTOLOGY**, what is the recommendation?

Answer 54

Do **NOT RECOMMEND SURGERY** as most high-risk cases will have no residual cancer in the surgical specimen

Question 55

What is **REQUIRED** to be able to measure **DEPTH** of **INVASION** for a **MALIGNANT POLYP**?

Answer 55

**EN-BLOCK RESECTION** not piecemeal and retrieved directly not suctioned through the scope channel

Question 56

What do the terms **CONVENTIONAL ADENOMA** and **TRADITIONAL SERRATED ADENOMA** mean?

Answer 56

**DYSPLASIA** (low or high grade, tubular, tubulovillous, villous)

Question 57

Which is higher-risk, or **ADVANCED** lesion, **TUBULAR** or **VILLOUS**?

Answer 57

**VILLOUS** (any villous components)

Question 58

Which POLYP **MORPHOLOGY** have the HIGHEST **RISK** for **DYSPLASIA** and **INVASION**?

Answer 58

**DEPRESSED**

Question 60

Of the **LATERAL SPREADING COLON POLYPS** (>1 cm LATERAL SPREAD), what **SURFACE** feature makes some a **HIGHER RISK** for **CANCER** and for **SUBMUCOSAL FIBROSIS**?

Answer 60

A **SMOOTH**, **HARD** surface, especially if **BULKY** or there is a **DEPRESSION** present (the GRANULAR lumpy bumpy surface polyps are LOWER RISK)

Question 61

Adenoma Detection Rates (**ADR**) are meant only for **CONVENTIONAL ADENOMAS** (not serrated) and in which colonoscopies?

Answer 61

**FIRST-TIME SCREENING** COLONOSCOPIES ADR **PREDICTS** interval cancer (**interval between colonoscopies**)

Question 62

What is the **MINIMUM** **A**denoma **D**etection **R**ate (**COMBINED**) and what should we be **ASPIRING** for?

Answer 62

**Minimum**: **25%** (30% men, 20% women) **Aspiring** for: **50%** **FIT positive ADR**: (45% men, 35% women for **40%** combined)

Question 63

What is RECOMMENDED **CECAL WITHDRAWAL** time?

Answer 63

**6 MIN** (preferred 8-9)

Question 64

What** SCOPE LIGHT** is best for better Adenoma Detection Rate (**ADR**)?

Answer 64

**NBI** (chromoendoscopy) better than white light

Question 65

What is the **CECAL INTUBATION RATE** recommended for **SCREENING** colonoscopies? For **OVERALL** colonoscopies?

Answer 65

**Screening**: **95%** **Overall**: **90%**

Question 66

Should pts with **BENIGN** polyps be sent to **SURGERY**?

Answer 66

**NO!** (have these reviewed by advanced endoscopist)

Question 67

ALL **COLON** lesions **≤10 mm** should be resected **HOW**?

Answer 67

**COLD SNARE** polypectomy

Question 68

If in resecting a flat polyp, a piece of the polyp **REISTS SNARING**, what is the **BEST** way to **REMOVE** it?

Answer 68

**AVULSION** (hot or cold) - not APC or cautery

Question 69

On **COLONOSCOPY** you find **ONE < 10 mm TUBULAR ADENOMA** in a patient with no family histroy of coolon cancer, whats the **NEXT** colonoscopy screening **INTERVAL**?

Answer 69

**7-10 YEARS**

Question 70

On **COLONOSCOPY** you find **ONE < 10 mm SESSILE SERRATED ADENOMA** in a patient with no family histroy of coolon cancer, whats the **NEXT** colonoscopy screening **INTERVAL**?

Answer 70

**5-10 YEARS**

Question 71

On **COLONOSCOPY** you find **ONE < 10 mm TUBULAR ADENOMA and ONE < 10 mm SESSILE SERRATED ADENOMA** in a patient with no family histroy of coolon cancer, whats the **NEXT** colonoscopy screening **INTERVAL**?

Answer 71

**5-10 YEARS** (the more high-risk lesion dictates the interval - sessile serrated adenoma)