All right. Good morning, everybody. I hope you're excited for this weekend. I think we have a lot of things planned, and I think it's going to be a lot of fun. So again, I'm Sarah Shanahan from Beth Israel and from Boston. And so we'll be going over today an introduction to endoscopy. I have no disclosures. So just to go through an outline of what I'll be talking about today briefly, because really all of these different topics could probably be a separate lecture, but we'll be going over informed consent, how we prepare our patients for procedures, antibiotic use in endoscopy, anticoagulation, sedation, and some complications that can happen from endoscopy. So first to go over informed consent. So this is not just a form. Sometimes it feels like this is the form before the procedure, but really this is a disclosure to the patient. This is going to be a conversation that you want to have with each of your patients before the procedure so they really know what's involved with the procedure. And it really has several different aspects, including first being the nature of the procedure. And this literally comes down to what will you be doing during their examination. And so this is when I will literally say to a patient, we have a long, thin tube with a camera. We'll be inserting it into your mouth. We'll be going down and taking a look into your stomach, and so on. You want to really describe what the benefits, why are you actually doing the procedure and what can the patient expect. Sometimes the patient actually expects a lot more than we are really even capable of doing during these procedures. So that's really important to go through. And then there's the risks. Now all of our procedures have some risk, and it's important to really spend some time here because this is often where you'll have that urge to just quickly go through it, so make it sound less scary. But really this is where you want to elaborate on for the patient, make sure that they really know what they're getting themselves involved in, go through, and do they have any questions about the procedure. You want to discuss alternatives to the procedure. Is there anything else you might be able to do, including not doing a procedure and what those risks might be? And then limitations often comes down to colonoscopy, PrEP, mispolyps, that kind of thing. And so to go through informed consent a little bit more, it's important to really use layman's terms as much as possible and to really listen to yourself when you're giving a consent. You want to make sure that you're also speaking to the patient in their language, their form of communication. So using hospital interpreters is really, really important. And encourage patient involvement, family involvement. It's always good to have another set of ears there. I know during COVID we might not so much have that lately. But if a family member is there, ask if they have any questions about the procedure too. You want to make sure that this is really a conversation. And by the end of that informed consent, you want to really make sure that the patient understands the procedure and that all questions are really answered before going in so that everyone feels comfortable moving forward. Now risks. Now risks can be a little bit tricky, in my experience, to talk about. And it's because a lot of the data that we have, looking at, I mean, look for the endoscopy, you'll see some numbers of, oh, risk of complications can be anywhere from 1 in 200 to 1 in 10,000. And how useful is that to really talk about? And this is really what's going to be quoted in the literature. And what this really reflects is the fact that the data really come from some that capture really minor things, mild bleeding after a biopsy versus need for hospitalization in other studies, which is why there's this wide range. And so what's important for you to really learn is, what is the risk at your home institution? That might be something that's more useful to quote to a patient if they say, what is the risk of this procedure? And then eventually, as your career goes on, you'll end up wanting to develop your own report card to some degree so that you can actually give a more real number to your patients. But again, just to go through this, so endoscopy, colonoscopy, 2.8 out of about 1,000. Endoscopy with dilation, about 1 in 1,000. And colonoscopy for 1 in 1,000. And again, these are some minor things, some major things, too, including need for transfusions, need for hospitalizations. PEG placements a little bit higher because you're making an incision into the skin. And ERCP for a risk of pancreatitis. So you also really want to discuss what potentially could happen from some of these complications. So you could quote, there's a small risk for perforation, which potentially could result in hospitalization, ICU admission, need for surgery, and even discussing a remote possibility of death. I remember when I first started as a first year, listing these things and feeling like I probably came off as super scary to patients, listing all of the risks. You'll naturally develop this conversation so that you feel more comfortable doing it as well, which will make the patient more comfortable having this conversation. It's important to discuss the risk for missed lesions. Sometimes when patients come in for a screening colonoscopy, they're expecting that you will absolutely see everything. And that's just not realistic. You want to make sure that the patient's prep is adequate and you're taking a really good look and taking your time. But there's always a possibility of a missed lesion. Use witnesses if possible. If there's other staff nearby, just to document some of this conversation, especially if there's questions that arise. If there's any sort of issue with the consent, you want to make sure that you have enough witnesses there too so that you can help confirm that conversation and document it. We have the form that we'll have people fill out. Most places do have a written form. But again, if there's any questions or any sort of issue that came up, it's always better to protect yourself by putting it into the medical record and having that conversation. Any questions at all so far? And just so you know, if you do have a question, everyone, there should be a microphone at your desk table. You can just sort of hit that on and it allows it to be recorded and also so everybody can hear. So then going on to patient preparation. So what do we tell people about what they can take in? So for the most part, we discuss continuing essential medications. We want to make sure most medications are really fine to take before a procedure. We'll talk about sort of anticoagulation a little bit later on. But in general, we have people remain NPO for about six hours for solids before any sort of endoscopic procedure. Given concern for aspiration, we want to make sure their stomach is also emptied out. And clear liquids about two hours. But keep in mind who your patient is. You might actually alter this a little bit if they have a known history of delayed gastric emptying or if they've had past failed procedures because of food retention in the stomach or failed colon preps. You might want to alter this to make it more patient specific. And then getting to cleansing. So I'm sure a lot of you have probably already had this experience so far in even just the first month of fellowship. But colon prep, it makes a big, big difference in terms of what you're able to see. And so it's important to even include this as part of the conversation, especially if a patient brings up that they're not sure if their prep was adequate before a procedure. Because having this conversation before rather than after, if you tell them, oh, we could have missed something because the prep wasn't great. It's just a better conversation to have before. Depending on how things look for the prep, you might potentially miss a lesion. You might need to repeat the procedure. And that it probably will also increase your procedure time, which also increases risk of insufflation, potential barotrauma, those kinds of things. OK. And now we're switching over to antibiotics. So in the past, actually, for patients who had risk factors for endocarditis, valve replacements, or valve disease, we used to actually give antibiotic prophylaxis before routine GI procedures. And this, in about 2007, 2008, was changed. And so this comes up, I think, in my sort of short experience less. I've seen this come up a couple times where a patient may ask, oh, by the way, I have valve disease. I need antibiotics before my colonoscopy. So we no longer give any sort of antibiotic prophylaxis for endocarditis risk. OK. And this really comes from the fact that the risk for transient bacteremia from our endoscopic procedures is really quite low, especially when we compare it to just routine daily activities like brushing our teeth. So in this study, we have quoted that endoscopy is anywhere from 0% to 8%, stigmoidoscopy up to 1%. And this is all in comparison to brushing and flossing, which can shockingly, in some studies, apparently lead to 68% of transient bacteremia. So based on some of this data, really the risk of potential adverse reactions to the antibiotics outweighs any sort of protection when it comes to infective endocarditis. However, that's different from procedures where we routinely give everybody antibiotics. And so this has nothing to do with endocarditis per se. But due to risk of either a local infection, bloodstream infection, or any complications, we do routinely give antibiotics before these procedures. So this is PEG placements, ERCP, where there may be incomplete drainage of the biliary ERCP in the presence of a pancreatic pseudocyst due to concern of seeding of that pseudocyst. Endoscopic cyst enteroscopy and an EUS with FNA for cyst aspiration. So those procedures, we would more routinely give antibiotics to everybody. And now we're shifting to antiplatelet anticoagulation, which can be a tricky topic. And I think just to sort of before we jump into this a little bit more, really there's two questions you want to ask yourself before deciding on anybody's antiplatelet and anticoagulation. And that really comes down to what is the risk of the procedure that you're doing? Is there a high risk of bleeding or low risk of bleeding? And then the other question being, what is the risk of stopping the antiplatelet or anticoagulation? So is it a high risk? Is this somebody who has AFib, relatively low chance of ASC, and you're going to want to say, OK, the risk of stopping it is probably low, versus is this someone with a mechanical valve? So those are all going to be really important questions you want to ask before just deciding to stop someone's anticoagulation. So getting into the antiplatelet medication, so there's really no data on stopping NSAIDs or aspirin really prior to any endoscopic procedure. So for the most part, you can generally leave those ones alone. Clopidogrel, however, you might consider discontinuing about seven days prior to any high risk procedures, which we'll go through a little bit too. And it's, again, always trying to weigh the risks and benefits of stopping these therapies before proceeding with any endoscopic procedure. And so for anticoagulation, so just in general, so low risk procedures in general. So this is more of our routine diagnostic endoscopy, colonoscopy with biopsies are OK to do on anticoagulation, ERCP without sphincterotomy, EUSs without FNA, and enteroscopy. So for the most part, you can feel generally pretty comfortable knowing that you always have to take into account your individual patient factors. But those are generally low risk procedures, and you wouldn't want to change their anticoagulation. All right. You know, although you may consider delaying, and you probably should delay if they have a super therapeutic INR. So if this is someone who's just coming in for a routine endoscopy, no urgency to the procedure, and they have an INR of, you know, 3.2, you know, you might consider waiting until the INR is under 2.5 before proceeding. And now high risk procedures. So high risk procedures in general, we fall under polypectomy, although you'll see some practice variation on sort of size of polyps, you know, being a factor, where you might, you know, if somebody is on, you know, warfarin, and you're doing a colonoscopy, if they have a big, big polyp, you might want to bring them back to do the polypectomy off of anticoagulation, you know, versus if it's a smaller polyp, you know, oftentimes you can be OK. But sphincterotomy, balloon dilatation, sclerotherapy, PEG placements in EOS with FNA, again, you are more considered high risk procedures. And then you're really going to want to be adjusting the anticoagulation, balancing that need for anticoagulation. So this is not necessarily a OK high risk procedure must stop. This needs to be, you know, in some cases you really, you know, would consider bridging or doing something like that really to help reduce the risk of adverse events from clotting. And the ACGE actually has these really nice tables that can help guide you, because this is, you know, it can be a really nuanced question for the individual patient. And so just to sort of orient you to the slide, so on the very top, you have the endoscopy induced bleeding risk. So this is either low risk or high risk. And on the side here, you have the cardiovascular risk, either being low or high. AC is anticoagulation, APA is the antiplatelet agent. You know, so again, if you're in the category of a low induced bleeding risk, you know, low risk for cardiovascular, you're going to likely just continue the warfarin, NOAC. You know, whereas if you get into more high risk procedures, if it's a low cardiovascular risk, you'll consider discontinuing therapy and so on. So this table is, you know, at your – is published through the ACGE, and you're able to access this to, again, sort of help determine where your patient might fit. Okay, so again, to go through this, the ASGE recommendations for low risk procedures, no adjustment for warfarin, low molecular weight heparin, or antiplatelet medications, although you may delay the procedure if they're above the therapeutic range. And then for high risk procedures with a low risk cardiovascular condition, you're going to want to stop the anticoagulation. Generally it's about three to five days, depending on the agent, before the procedure. Low molecular weight heparin for about eight hours before. And then the antiplatelet medications, again, separating aspirin and NSAIDs for about five to seven days before the procedure. And then high risk procedures with a high risk condition, this is when it can be tricky, but you're going to want to think about bridging the patient with heparin or low molecular weight heparin, and then ideally hold the antiplatelet medication, again, for about five to seven days beforehand. You know, and this can be a joint task. Oftentimes you can discuss with the patient's cardiologist and come up with a more individual plan so that you're not also always making these decisions by yourself. Okay. And then this is basically a statement from the cardiologist chapters, but, you know, dual antiplatelet therapy with aspirin and thionibiridines has shown to reduce cardiac events after coronary stenting. And they've basically found that providers often prematurely stop this dual antiplatelet therapy, which does increase the risk of stent thrombosis. And you know, the stent thrombosis itself really carries a really high risk. So it's not nothing to just say, okay, for me it would be really convenient to just stop everything. You really need to take into account that, you know, a stent thrombosis can have an up to 25 to 40 percent mortality rate, and that we can deal with bleeding. You know, as you go on, become more comfortable treating bleeding, you can treat bleeding. And so you can carry that risk, you know, knowing that at least their heart is protected. So now a little bit about sedation and procedural monitoring. So going through, you know, a typical routine endoscopy, every procedure has a timeout. You want to make sure you have the right patient, right procedure. You have all the equipment that you need. You want to make sure that you're monitoring the patient with a pulse ox, monitoring their blood pressure, heart rates. You know, it's important. As much as, you know, anesthesia might be there, you'll have your nurse there, you want to make sure that you yourself know where the resuscitation equipment is so that you can have access to it and any reversal agents. And you know, it's also really important to assess the patient before you do any procedure. You know, is this patient, you know, elderly? Do they have a lot of comorbidities? You know, if you yourself are providing the moderate sedation, you want to make sure you start low, go slow to make the procedure as safe as possible. And assess their airway. You know, again, knowing where location is of equipment is important. And as you become more familiar with your endoscopy center, you know, that's going to be, you know, important to know where the suctioning devices are, if you need any airway access, ambu bag, and again, the reversal agents. You know, and what are the complications? You know, most complications, we went through sort of the endoscopy complications, colonoscopy complications. Most are really, you know, cardiopulmonary complications from sedation or from intubating the esophagus. But people can also have reactions to the medications that you give. You know, propofol can burn a lot as it goes in, and so people can get some irritation there. And then, you know, desaturation is really the most commonly observed event during endoscopic procedures. So how do we manage complications? First off, you want to prevent them from happening the first case. You know, really knowing your patient. You know, if you need anesthesia, don't feel like you need to handle this all on your own and, you know, be the hero. So, you know, ask for help when you need it. And you know, maintain a sort of high level of suspicion, especially if you have a more complicated patient that you're undergoing a procedure. You know, take pain seriously. You know, nobody wants to have a complication, but what you really don't want is to have a complication and to miss that and to have bad consequences for the patient as a result. You know, if somebody's having a lot of pain, get the imaging, you know, get the information so that you know how to properly triage. A lot of complications, the earlier you can detect them and get them on antibiotics, have them seen by surgery, you know, the better. And then treatment. So again, you always want to assess your patient. You know, if you're concerned about, you know, a bleeding or perforation, you want to make them MPO, make sure that they have antibiotics on board early. And again, get the right people involved, get surgery involved, explain the situation. You know, don't try to just say, oh, I hope nothing bad happened, and I'll just send them home and cross my fingers. And talk with the patient and the family. You know, when a complication happens, it can be, you know, it can feel horrible. But what you really want to do is make sure that you're talking to the patient about what happened, talking to their family members, because you can imagine how scary it can be on the other end of that as well. So that's basically what I have. So just to, I'll stop there before I just go through some, you know, summary slides. Any questions about any of that? I know there's like several different topics, but. I have a question. For example. Am I just using the microphone just so I can, thank you. Yeah. So my question is about like solid foods, liquids, you mentioned, what about gastrographin? How many hours after that can we do? How many hours after gastrographin? Yeah. So a lot of times with a lot of like the barium, gastrographin, you know, it can end up coding like the esophagus, the stomach, and can limit visualization. You know, depending on what procedure you're doing and how urgent it is, that's probably going to determine more about that timing. You know, so I think if you're worried, like if you're worried the contrast might exclude visibility, then, you know, I probably would even put it off another day if you can. It sort of depends on, I guess, the urgency of the procedure as well. Okay. All right. All right. So just some conclusion. Inform consent. Educate your patient and their family members. You know, make it a dynamic process. Make sure answers, you know, you answer their questions. And anything that's not documented never happens. So if there's any sort of different, you know, part of that procedure, make sure it goes into the record. Prepare your patient. Antibiotics. There's really no more cardiac prophylaxis, however, there are procedures that need them. Anticoagulation. You know, don't just stop it because it makes your part easier. You know, make sure that you really assess the risk of stopping those medications. And then sedation. There is this website that you can look at, the www.sedationfacts.org. That can be a good reference for you. And then complications, anticipate them before they happen. You know, know your patient before you do a procedure. And you know, be open, honest, and really vigilant if there is any sort of abnormalities after. That's it. All right. Thank you.

endoscopy

informed consent

patient preparation

anticoagulation

sedation

complications