Search

Ruben D. Acosta, MD, Neena S. Abraham, MD, MSCE, FASGE (invited content expert, ad-hoc member), Vinay Chandrasekhara, MD, Krishnavel V. Chathadi, MD, Dayna S. Early, MD, FASGE, Mohamad A. Eloubeidi, MD, MHS, FASGE, John A. Evans, MD, Ashley L. Faulx, MD, FASGE, Deborah A. Fisher, MD, MHS, FASGE, Lisa Fonkalsrud, BSN, RN, CGRN, Joo Ha Hwang, MD, PhD, FASGE, Mouen A. Khashab, MD, Jenifer R. Lightdale, MD, MPH, FASGE, V. Raman Muthusamy, MD, FASGE, Shabana F. Pasha, MD, John R. Saltzman, MD, FASGE, Aasma Shaukat, MD, MPH, FASGE, Amandeep K. Shergill, MD, Amy Wang, MD, Brooks D. Cash, MD, FASGE, previous Committee Chair, John M. DeWitt, MD, FASGE, Chair

Author(s): Gupta, Samir; Lieberman, David; Anderson, Joseph C; Burke, Carol A; Dominitz, Jason A; Kaltenbach, Tonya; Robertson, Douglas J; Shaukat, Aasma; Syngal, Sapna; Rex, Douglas K | Abstract: Colonoscopy is routinely performed for colorectal cancer (CRC) screening, follow-up of other abnormal screening tests, work up of signs and symptoms of gastrointestinal disease, and surveillance after CRC and polyp removal. Post procedure, colonoscopists are expected to provide follow-up recommendations to patients and referring physicians. Recommendations for follow-up after normal colonoscopy among individuals age-eligible for screening, and post-polypectomy among all individuals with polyps are among the most common clinical scenarios requiring guidance1.Risk of metachronous advanced neoplasia is associated with findings on prior colonoscopy. After high quality colonoscopy, patients with no neoplasia detected are at the lowest risk, and those with polyps are risk stratified based on the histology, number, location, and size of polyps detected. Since release of the last US Multi-Society Task Force (Task Force) recommendations for post colonoscopy follow-up and polyp surveillance in 20122, a number of papers have been published on risk of CRC based on colonoscopy findings and patient characteristics, as well as the potential impact of screening and surveillance colonoscopy on outcomes such as incident CRC and polyps. Further, recent studies increasingly reflect the modern era of colonoscopy with more awareness of the importance of quality factors (e.g. adequate bowel preparation, cecal intubation, adequate adenoma detection, complete polyp resection), and utilization of state of the art technologies (e.g. high definition colonoscopes).n Higher quality colonoscopy could impact the importance of previously identified risk factors. Our aim was to review newly available evidence and update recommendations for follow-up after colonoscopy with or without polypectomy.Keywords:nnaftercare, colon polyps, colonoscopy, colon cancer, consensus statement, early detection of cancer, practice guideline

Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.

Background and Aims The biological environment varies across the colorectum and may therefore affect neoplastic growth differently in the proximal and distal colon. The aim of the study was to evaluate the risk for recurrent adenomas and their anatomic location based on adenoma location at baseline colonoscopy. Methods Data were extracted from 3 adenoma prevention trials (n = 2430). Participants had at least 1 adenoma at baseline colonoscopy and underwent subsequent surveillance colonoscopy, at which time metachronous adenomas could be detected. We calculated the risk ratio (RR) and the 95% confidence interval (CI) for metachronous adenomas by location of the baseline lesion and considered the impact of advanced neoplasia and multiplicity. Results At baseline, 522 patients (21.5%) had adenomas only in the proximal colon, 1266 patients (52.1%) had adenomas only in the distal colorectum, and 642 (26.4%) had adenomas in both regions. Overall, 877 patients (36.5%) had metachronous adenomas during the follow-up period. Those with only proximal adenomas at baseline had a higher risk of metachronous adenomas compared with patients with only distal adenomas (RR, 1.17; 95% CI, 1.01–1.35). A greater proximal risk was found after restricting the analysis to patients with multiple proximal adenomas versus multiple distal adenomas (RR, 1.35; 95% CI, 1.10–1.67). The risk of recurrent adenomas on the same side was 48% higher for patients with only proximal adenomas at baseline compared with those with only distal adenomas at baseline (RR, 1.48; 95% CI, 1.22–1.80). Conclusions Patients with proximal adenomas only have a modestly greater risk of adenoma recurrence than patients with adenomas limited to the distal colon, and have a greater likelihood of adenoma recurrence on the same side compared with patients with distal adenomas. This observation suggests that biological factors may differentially affect neoplasia growth across the colon.

OAE is commonly used. The majority of patients referred for OAE are considered appropriate for endoscopy according to ASGE guidelines. Most patients undergoing OAE procedures are knowledgeable about the study and are satisfied with the experience. Several potential problems have been identified, including inappropriate referrals, communication errors, and inadequately prepared or informed patients. OAE can be safely used if preprocedure assessment, informed consent, information transfer, patient safety, and satisfaction are addressed in all cases.

We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. 44BB We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. We suggest that endoscopy be considered in patients with multiple risk factors for Barrett’s esophagus. We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett’s esophagus. We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options.

presented to our ER with acute GI bleeding from Jan. 2009 to Dec. 2010 was performed using a prospectively maintained endoscopic database. Patients who presented with melena or hematochezia were included, whereas those with hematemesis were excluded to minimize bias in favor of ER physician assessment. ER physician prediction as to source of bleeding was performed prior to laboratory testing. Endoscopy was performed within 24 hours of presentation in all patients. Data were abstracted for patient demographics, laboratory studies, and definitive endoscopic findings. Inter-rater agreement and diagnostic performance of ER physician assessment vs. BUN/Cr ratio for upper GI bleeding source were compared against endoscopic findings. Strength of agreement was assessed using the Landis and Koch’s criteria for kappa statistics. Results: Ninety-eight (48 men; mean age 69.6 13.3 years) of the 400 patients evaluated met the inclusion criteria. A prior history of GI bleeding was found in 28 (29%) patients. There were 55 (56%) patients on NSAIDs and 43 (44%) patients on PPI at the time of presentation. A total of 48 (49%) patients presented with melena, whereas 50 (51%) patients had hematochezia. The mean Hgb was 10.7 2.4 g/dl, mean BUN was 26.3 16.8 mg/dl, and mean Cr was 0.98 0.39 mg/dl. A total of 48 (49%) patients had an upper GI bleeding source, whereas 50 (51%) patients had a lower source according to endoscopic findings. Inter-rater agreement between ER physician assessment and BUN/Cr ratio was fair with 0.24. The sensitivity, specificity and positive predictive value (PPV) for physician prediction of an upper GI bleeding source were 94%, 88% and 88%, respectively. The sensitivity, specificity and PPV of the BUN/Cr ratio for predicting an upper GI bleeding source were 35%, 100% and 100%, respectively. Overall accuracies of ER physician assessment and BUN/Cr ratio for predicting an upper GI bleeding source were 91% and 68%, respectively. Conclusion: There was only fair agreement between ER physician assessment and BUN/Cr ratio in predicting an upper GI bleeding source. ER physician assessment was more sensitive, less specific, and more accurate than the BUN/Cr ratio for prediction of an upper GI bleeding source.