“Bread & Butter” Issues in Endoscopy The New England Team Alain Ades, MD Steven Brandwein, MD...

““Bread & Butter” Issues in Bread & Butter” Issues in EndoscopyEndoscopy

The New England TeamAlain Ades, MD

Steven Brandwein, MD

Pamela Connors, MD

Mark Lena, MD

Jeffry Potash, MD

Gary Shapiro, MD


Your favorite internist refers a 70 yo male who winters in Florida with iron deficiency anemia (HCT 25, MCV 71, Fe 9, TIBC 500 and 4.5% Fe saturation)

Recent evaluation in Florida included a normal EGD and Colon.

He initially responded to Iron theapyPhysical exam is normal, FOBT (-)


What is the next step in the evaluation?When do you consider repeating either the

EGD or the Colon?What is the miss rate of for EGD or

Colonoscopy?What about missed AVM’s that could be

treated?What if you find a missed colon cancer?


52yo WF referred for screening colonoscopy with longstanding chronic constipation and FOBT (-).

She has had two prior pelvic surgeries including a TAH/BSO and bladder suspension

No family history of colon cancer, breast, or pancreatic cancer

She asks about the alternatives having heard about virtual colonoscopy and the risks and benefits of colonoscopy.


Virtual colonoscopy: where, who, when, what about the radiation exposure

Colonoscopy risk? Does her constipation have you choose an

alternative preparation? You pass the scope through the tortuous colon

fixed by adhesions only to the level of the ICV with 50 % of the cecum seen. What now?


62 yo male with a hx of two less than 1 cm adenomatous polyps removed 3yrs ago in Arizona. Pathology report confirms the polyps were adenomas. The patient has a significant family history of colon cancer with a father who died of metastatic colon cancer at age 75. He is otherwise well when does he need his next colonoscopy?


How do we determine the recall time?How hard do we try to find them and get

them back?Is 10 years safe for EVERYBODY? Have we been doing screening colonoscopy

long enough to determine appropriate subsets?


42 yo female with newly diagnosed crohn’s disease with small bowel fistula disease without abscess. Compliant with Pentasa 4 QID and on her second steroid taper with a flare of pain and diarrhea.

Did you have her sign an informed consent for steroids?

Did she glucose monitoring? Did she have an eye exam given risk of cataract?


Does she need a bone density study?Do you start calcium with vitamin D and/or

biphosphonates?What about budesonide?When to begin immunosuppressants?How about UP-FRONT remicade?


85 yo male presents to ER at 9pm with melena for two days and new hematemesis

Hx of aortic stenosis and atrial fibrillation on coumadin for history of CVA.

BP 70/p, HR120, pale and diaphoreticInitial hgb=6.5, INR 3.9EKG without ischemia


Fluid resuscitation, IV vitamin K, PRBC ?FFP IV PPI: IV Protonix 80mg bolus with 8mg/h drip only

one really approved for certain acute upper GI bleeding; MGH using Prevacid 60mg bolus with 6mg/h drip but not approved yet.

IV H2RA: cost vs science Prophylactic antibiotics Timing of endoscopy What methods do are being used to stop the bleed?


52 yo male with longstanding history alcohol abuse present to ER with hematemesis and hypotension.

BP80/p, HR125 Newly jaundiced according to his PMD, spiders

and palmer erythema, no HSM, no ascites and no asterixis.

AST>ALT, TB 9.5, Hgb 10, MCV102 and INR 1.9


Transferred to the ICU and stabilized. Does anyone intubate? EGD reveals varices with stigmata of recent bleeding. Band ligation Injection sclerotherapy Refractory bleeding: IV infusions Blakemore tube Beta-blockers When do they come back for repeat treatment?


50 yo female preparing for colonoscopy in the morning. Her friend called her today and said she had stopped her aspirin one week before her procedure.

Do we stop aspirin or NSAIDs prior to colonoscopy?


77 yo male with history of mechanical mitral valve is scheduled for routine colonoscopy for history colon cancer.

How do we approach his anticoagulation pre and post procedure?

Who manages the medications: us, the PMD, or the Cardiologist.


32 yo female with 12 year history of ulcerative colitis transfers her care to you. She is due for her screening colonoscopy.

She has mitral valve prolapse and you do not hear a murmur.

“My other gastroenterologist always gave me antibiotic treatment!”


?CELIAC CASE


ENDOSCOPY QUALITIY ISSUES


67 yo male referred due to a 10 pound weight loss and progressive dysphagia to solids

Smoked for 35 years quitting 2 years agoHeavy alcohol in his thirtiesWhat is the next test?


Directly to EGD? Tight malignant appearing stricture in mid

esophagus Scope will not pass, but you can see the lumen STAGING EUS STENTS PEG tubes


Enteryx case

“Bread & Butter” Issues in Endoscopy The New England Team Alain Ades, MD Steven Brandwein, MD...

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