All righty, so how many of you guys have been on call so far? There's a lot, all right. So I have no disclosures. So have you guys asked yourself this so far? All right. So nobody has had the best sleep yet, all right. Okay, so I'm gonna go case-based scenario. So call started at 6 p.m., and at 6.05 there's a page. You're like, oh my God, it's a bleeder, infection, what do I gotta do? But the best question, I have a colonoscopy tomorrow, so what's the, so this guy lost his instructions. What do I do? This gonna happen all the time, and these are one of the questions you're gonna get time and again and again and again. And so anytime you get these questions, you generally have to follow these principles because if you get a page or a phone call, you delay too long, there's all this anxiety amongst the patient, and he's gonna keep calling you. So sooner the later, as soon as you can get back to them, they'll be more relaxed, and you'll be also able to do other things. So, and this is a graph demonstrating that. And accuracy is important because if you try to make up stories and eventually he's gonna tell your attending tomorrow, this is what I was told, and that won't go very well. So if you're not sure about it, talk to your senior fellows, talk to your attendings, and it's better to say, hey, I'll call you back with the right answer. And then colonoscopy practices are pretty, what prep your institution is based on, insurance and attending preference. So I would get well versed with what your institution uses so that you can answer these questions better when the patient calls you. All right, typically at this point, it has been as well established, split prep is better than one time four liter, go lightly, what used to be done. And it has been shown to have better adenoma detection rate and also better patient satisfaction. Now, over-the-counter bisacryl to give it or not, I don't usually prescribe it unless some patient has had a poor prep history or I know he's diabetic and I anticipate any of those factors that would increase risk of poor prep, then I would give a five or 10 milligram pill. But I definitely have them on a low residue diet for two to three days prior to their procedure. And obviously everybody's on a clear liquid diet for 24 hours prior to the procedure. And I don't think this is clear liquid, but you would be asked, can I have my sandwich? And answer is no. And any clear, by all means clear, something that you can see through. So coffee or tea without milk is fine, milk is not clear either. So anything that is clear and is not red, patients can have, and you wanna avoid red or purple or violet kind of stuff because it may confuse with your colonoscopy images. I have never had a patient who drank a lot of red stuff before the procedure, so I really can't comment on that, but that's what I was all the time in my fellowship. And then another common question would be what all medications are okay for the procedure? And so say if a patient is on these medication, so what should patient generally take on the AM of their exam? So there's a poll for that. Fish oil is popular a little bit, I see that. All right, so most of you got it right, lisinopril, and that's the right answer. So all essential medications, your antihypertensive, antiarrhythmics, anti-seizure meds should be continued. On the morning of your exam, hold your oral anti-hypoglycemics. Your regular insulin or any short-acting insulin should not be taken that day. Half of your long-acting insulin is what you take that morning. Also, if some patients are on insulin pumps and they have a really complicated diabetic story, I would encourage them to see their endocrinologist prior to exam because you don't want them to get too hypoglycemic before their procedure. Antithrombotics, there's a whole lecture on that and you have already heard that. Aspirin should be continued. 81 milligrams should not be stopped. Rest depends on the risk of the procedure and the patient's risk profile. And then you decide based on those. So I'm not gonna go into those. There's a whole guidelines for that and you can review that. Now this guy, now you gave him what you're gonna do and but he vomited. So now he calls you back. Should I cancel my procedure? And this is also a pretty common scenario where patients call you and about this situation and in this typically, I have seen if you ask your patient to really keep the PrEP chilled, it prevents these vomiting episodes and you can tell them to use a straw because sometimes it's not the vomiting, it's the taste that's making them puke. So if they use a straw, then they can bypass the tongue and that prevents sometimes this flavoring where the crystallite would be would be fine and you don't want to tell them to just take small sips over an entire day because these medicate, these PrEPs work in a in a fashion where you have at least 200-250 cc's at one time rather than one sip. Then you wait for an hour, another sip. So you want to tell them to take a certain amount in a short period. But I think keeping them cold using a straw definitely would help and some kind of flavoring agent. So finally the guy's happy and but so but other thing I want to say, anytime you have a patient who asks you these questions, you're not unsure, you're not sure about this, call your attending, call your senior fellow because you want to give them the right advice, especially earlier on in your first few, five, six months, we're not sure about all scenarios. So this guy was done, you were like, all right, things are good, I'm gonna eat, but you get another page now and ICU resident is July, he wants you to come and scope right now and patient is having some GI bleed, so so I want you to understand emergent and urgent scenarios. Emergent is gonna be that patient who you get called that night and you want to settle that patient and do the endoscopic procedure that night because it could potentially lead to bad scenario if you do not scope that night. Urgent would be a patient you got 12 to 24 hours, so basically you stabilize or and you have time enough to do it in morning rather than that night. He's not that unstable yet. So out of these scenarios which does not require emergent endoscopy. Dr. Kowalski, this is a first-year's course, I mean. All right, so everybody got this right. And because the first one would be a guy with complete food impaction. Second, ascites, vomiting blood, I'm expecting a very slow bleed here. And the last one, coffee bean, is typical scenario, would be a volvulus. So these guys need to be taken care of that night. On coumarin, red blood, protorectum, stable, you can sit on it. If he was unstable, then you got to go in. Okay, so we already talked about it. Do not wait if there's overt major bleeding leading to patient being unstable. If you suspect a very slow bleed. And post high-risk intervention, that is a case-by-case scenario. If a patient, you did a sphincterotomy or had a polyp removed, patient comes with a bleed, I would prep that patient. But unless he's unstable, I'm not doing that night. But I'll probably do that in the morning, I'll have him prepped. Most of these bleeds stop themselves, actually. But I would rather have him prepped so that in the morning, if I need to go in, I don't, I want to be able to do the procedure. Food impaction definitely has to be done that night. And colonic volvulus. Okay, so again, like, you guys have been on the other side as well, now you're fellows. So you want to guide the residents in a way that they have, they understand and you want to help them with their appropriate decision making. So because they might call you with small amount of blood and an overt major bleed, they might still be not super, you know, thinking that this needs to be emergently handled. So you need to understand where they're coming from, guide them appropriately, and help them understand the process of decision making. And that goes with your history and physical exam. Like, if somebody's on NSAID, you're going to expect a peptic ulcer bleed. If somebody has signs of cirrhosis in your brain, you're already thinking this could be a variceal bleed, so you're going to guide them appropriately and give them directions so that they understand your process of thinking. Ask them specific questions, such as, call me back if a patient vomits blood. If I give them a unit, call me back with a post-transfusion CBC. Do not leave it open-ended for them to decide, because you may leave a patient eating solid food and never hear a call back, and things may go bad. So you want to give specific directions and specific recommendations. When in doubt, I again would say, assess the patient yourself, specifically in your first few months. If you are worried, go to the hospital, see the patient, talk to your attending, and if you're worried enough, I would call the attending when you have evaluated the patient, because you don't want to just sit on those patients and make a bad judgment call. So this patient we discussed was cirrhotic and bleeding hypotensive, so you plan on doing the endoscopy, and at that point you're thinking, this is a cirrhotic, where is he? Is he on a floor? Is he in an ICU? Are they appropriately monitored, and does the patient need to be intubated? So these things are already going on in your head while you are listening to the resident or the ER calling you about it. And obviously, if you see a perforation or any major surgical emergency, you're going to call the surgery. And I also would recommend see imaging yourself, because this is how you would learn it. We all understand we're not awesome right now at reading all CTs and MRIs, but you read it every day, give it one year, you'll be really good at it. And then you can find things even radiologists would have missed, because you have the clinical context there. And these things we discussed about patients should be dissociated properly, and their airways should be protected. So obviously, this patient got too large for IVs, octeotide, TPI, antibiotic management has been done, and you go there, save the day, put the bands, and you feel great about it. But you're on call, so there's more calls coming. All right, so this guy, while he was feeling proud of himself, yes, I did it, but there's four more calls, and one of those guys had an ERCP, so which needs an ERCP. So which one of this would be emergent or an urgent indication for ERCP? All right. So bile leak after transplant would be a more of an urgent indication unless patient has a drain and he's already draining the bile. A cholangitis who's nonseptic, you can cholangitis without overt sepsis, you can wait on it till morning. Malignability obstruction, you can wait. It took weeks for that to happen or months. Gallstone panic, also there's different indication for that, but generally that is not emergent. And so again, as we talk about cholangitis with sepsis, there's specific guidelines for that. As you do your interventional calls, you'll learn more about it. And bile leak post-surgery in an undrained without a JP drain would be a more urgent indication for ERCP. And this guy just, I mean, I think I would classify him as black cloud. He's, I mean, yeah. And this, he gets another call now about a patient who had a colonoscopy having a lot of belly pain. And these are pretty common scenarios. And I still remember my first call, I was, I had a patient who had these symptoms and I'll tell you what happened to him. But so anytime you get this call, you have to look into the procedure note what was done. Was it just a regular screening colonoscopy or was there polypectomy attempted or were there clipping done because of some bleed? Because that leads into what could have happened and why is he calling you? So if a patient is having severe worsening pain, fevers, hematochezia, or it's just you're worried he's not doing well, send him to emergency room, call your attending who was involved in that procedure. They would always thank you for letting them know rather than I just took care of it and next thing patient's already in OR, surgery is taking care of it. And that would not be appreciated by the attending who did the procedure. So significant discomfort is not expected after which intervention. So, biliary sphincterotomy, PEG placement, you're going to have some abdominal discomfort. And variceal banding is generally, they have some discomfort, but it's not that bad. Esophageal stent, they're going to have some discomfort. Sphincterotomy typically does not lead to major abdominal discomfort unless you end up having post ERCP pancreatitis or something, so, yeah. And that same patient who called you with pain, you looked up into his colonoscopy report. He had a polyp that was removed with a heart snare. And so, in your brain, you're already thinking, hey, is this a PERF, is this a post polypectomy syndrome? And so, these are the things that are going on in your head. So, post colonoscopy abdominal discomfort, gas pain is common. Perforation, in a regular screening, colonoscopy perforation is very rare. I mean, the numbers from these retrospective studies are 1 in 1,000 to 1 in 10,000. Numbers obviously go up if you're doing a large EMR, ESD, but again, that's why this patient had a small, one side was small poly, but he had a heart EMR. So, in my brain, I'm thinking, could this be a post polypectomy syndrome or a PERF? And then, other rare things could be mesenteric tear or splenic rupture. I haven't seen yet, but I've had stories heard from other patients or from other hospitals that patients have been through this. So, patient went to ER because you were worried and cascading was done, no free air, and this was diagnosed as post polypectomy syndrome and managed with clear liquidated antibodies. My patient also had post polypectomy syndrome and it's actually, you may even see some very small specks of air right there, but they just improve suddenly within the next 48 hours, they get better with liquidated antibiotics. So, again, this guy just can't get any sleep. So, you get, he gets another call and of a patient who had an ERCP done earlier. So, which of these are correct for rates of post ERCP complications? I think most of you got this right. Pancreatitis rate we quote is around 5%. Numbers obviously go higher in younger females. Perforation, 3% is a very high rate. Chances are much, much lower, typically less than even 1%. Post-sphinctotomy bleeding is around 1%. Bileak is more of a laparoscopic cholecystectomy complication. Post-USTP bileak is like pretty, pretty rare. I mean, we have the treatment for bileak. So, pancreatitis, again, less than 7% number coded here. Post-sphinctotomy bleeding around 1%. Perforation is very, very low. And again, overall, a much less incidence of perforation. So, now, general on-call principle I want to share. If patient calls you with something concerning, take that seriously because there could be a real complication that could have happened. So, if in doubt, go and evaluate that patient. When you're worried about something, call your attending, discuss with him. No, no time is too late. Even if it is 2 a.m. and you're worried, I would like to know what has happened to my patient so that I can guide the fellow on-call appropriately because you're just very new in this. It's very beginning yet. And documentation is critical because once you document and you give appropriate recommendations, that's the best you can do. And complications are gonna happen, but if you do everything right on your part, that's the best you can do. And if, again, the involving other specialty like surgery and IR, I won't make that call alone yet. I would involve the attending physician on-call, discuss with them before you call surgery or IR, and yeah. Alrighty, I mean, he's happy now, I guess. Yeah. All right. Any questions? Yes. For abdominal pain after polypectomy, I guess, if there are signs where their pain is really severe, are you going to direct them to the ED? Are there any other symptoms that we should specifically look out for and that would suggest more serious complications other than just distention? So, if it's gas pain, that's your other differential. Post-polypectomy syndrome is another differential. Gas pain typically gradually gets better. Post-polypectomy, if you had a perforation, it would get worse. Second, people may start having fevers. Third, overall, they'll be just like, I'm just continuously getting worse. So, if your patient is, like, calling you with a lot of discomfort, pain, fever, at that patient, you want to assume the worst, hope for the best, but assume worse. And at that point, you want to sit on that patient. You want to tell him to come to ER. Because post-polypectomy syndrome could initially present very similar to a perforation, but the only way to diagnose that would be on imaging. So, for that, he needs to come to ER. Yeah, all right. Thank you.

on call

gastroenterology complications

patient calls

colonoscopy preparation

post-procedure complications