I'm going to go ahead and just introduce our first speaker then. So our first speaker is Dr. Alex Ulitsky from Wisconsin GI Associates, and he is going to talk on Introduction to Endoscopy. Okay. Welcome, Alex. DR. ALEX ULITSKY. Hello, everybody. So I was tasked to discuss basically the stuff that happens before you touch the scope or touch the patient. There's no disclosure. So the objectives of this is to go over things like informed consent, patient preparation, antibiotics, anticoagulation, sedation, and complications of procedures that we do. So the informed consent is a process, the main element of which is disclosure. So basically informing the patient as much as possible about what's going to happen. So it includes description of the procedure, the benefits of the procedure, the potential risks and any adverse events that could be associated with the procedure that we're doing, and alternatives, including the options of not doing the procedure to begin with. Potential harms of not proceeding with the procedure should be discussed as well. And then there's a discussion regarding potential needs for intubation, resuscitation, hospitalization, blood transfusion. The purpose of this is to, you know, not only to inform the patient, but to also strengthen the relationship, physician-patient relationship as well. We do discuss the worst possible outcomes. And it's not to scare the patient, but to, again, we emphasize that these are all fortunately quite rare, but just to make sure that they are informed about everything that could potentially go wrong. So this includes ICU care, potentially needing blood transfusion, surgery, and very remote but real possibility of dying. We also discuss things like mis-lesions, mis-polyps, tumors, et cetera, which can occur. If possible, we use a witness for this process. It could be somebody in the GI lab, like your nurses or techs. And obviously, we want to document the process as well. When you're talking to the patients, we try to use layman's language and try not to use any complicated medical terms that they may not understand. We try to encourage the participation of the patient and whoever is accompanying them, such as significant others or family. And at the end, we want to make sure that they've understood what you've told them. So you ask, you know, do you understand what we're about to do, and do you have any questions that have not been answered? So you know, we do explain possible risks of the procedures with, again, frameworks for reference, so complications of things such as a routine EGD, and that can vary depending on what you're trying to do with the EGD, or anywhere from 1 in 200 to 1 in 10,000, so quite rare. Colonoscopy complications are also quite rare, about 3 in 1,000. If you're doing an EGD with dilation of something like a stricture, for example, the complication rate is slightly higher, and you should mention that. Stag placement, again, has a slightly higher rate of complication, and ERCPs, the main complication there is potential pancreatitis, so the risk of which is anywhere from 5 to 7% of these procedures. So for patient preparation prior to the procedure, it's important to emphasize that they continue essential medications, such as, for example, blood pressure medications and so forth, because oftentimes patients think that they can't take anything, and they skip their blood pressure medications. They come in, and their blood pressure is sky high, and then you have to deal with that, so it's important for them to continue those. It's also important to emphasize the NPO guidelines, and actually, a lot of patients don't quite understand why they have to not eat, and it's often not stated in their consent form. It's important to tell them it's because they're going to be sedated, and if they are sedated, then there are contents in their stomachs that can lead to aspiration and other badness, so that they may understand why they're not allowed to eat. So for solid foods or liquids that are unclear, such as milk, it's a minimum of six hours before sedation. Two hours for clear liquids, just like water, because oftentimes patients will come into the procedure, and they just drink water before they came, so that's not as big of a deal. Some of these are longer in patients with gastroparesis or known gastroparesis, or people on drugs such as GLP-1 agonist, which is an active area of discussion in GI right now. When you're talking to them about preparing for their procedures, adequate cleansing for colonoscopies, again, should be emphasized, because the consequences of not having an adequate prep would be potentially missing polyps. You may have to cancel the procedure altogether, or it has to be repeated much earlier than you would otherwise do it. It might increase procedure time, and that potentially increase the risk of severity of complications. So this is the first question embedded, because it brings us to our next topic, and this is which of the following patients should have an antibiotic prophylaxis prior to their GI procedures? So you're welcome to pick one of these, and then we'll see what the poll shows. So go for it. Am I supposed to advance it now? You guys all had a – Oh, I see. Yeah, so they're – Oh, okay. Yeah. So you're getting a lot of responses. Cool. Yeah. So what you give is the time, then I can give you some answer, and you should show the answer. All right. Oh, well, this is the correct answer, so we'll see, I guess, what the poll showed afterwards. But basically, the correct answer here is patient presenting for a PEG placement. The other ones – I mean, we're not going to get into details why that's incorrect, but these are fairly low-risk procedures as far as infections are concerned. But PEG, because you're puncturing through the abdominal wall, does have a risk of infection, so that this is one of the procedures where antibiotic prophylaxis is required. So antibiotic prophylaxis is basically – means administration of antibiotics solely to prevent complications such as endocarditis, and this is not something that's recommended for patients undergoing pretty much most GI procedures. Oftentimes, you will have patients who receive antibiotics prior to dental procedures, and they will ask you, you know, I'm having this GI procedure, do I need to get antibiotics prior to that? The answer is pretty much always no. And why is this so? Because the rate of, you know, basically what you worry about is bacteremia, and the rate of bacteremia for routine GI procedures is actually quite low, as you can see here, as opposed to bacteremia that you can have with just routine daily activities such as brushing your teeth or just eating, which is actually quite a bit higher, and you can explain it to the patients in that way. There are some procedures where antibiotic prophylaxis is actually recommended, so these include PEG-2 placements, as we just saw in the questions, ERCP, where you're anticipating incomplete drainage of the biliary tree as a possibility for some – for example, if there's a tight stricture or a large stone. If you're doing EUS and aspirating cysts of any kind, either mediastinal cysts or pancreatic cysts, because those tend to be sterile, and then you're introducing a non-sterile needle into a sterile fluid collection, and, you know, anyone with cirrhosis who comes in with bleeding is a higher risk for bacterial complications. The next topic is antiplatelet medications. So again, a lot of our patients are on aspirin or Plavix or some other antiplatelet medications, and oftentimes they will, you know, they will wonder if they need to stop those prior to the procedures. There's basically no data to support the discontinuation of aspirin or NSAIDs prior to basically all endoscopic procedures. In fact, there's data supporting the fact that if you do that, the patients may be at high risk for cardiac events if you do that. Plavix or Clopidogrel is something that does increase the risk of bleeding if you're doing any GI interventions, and you should consider stopping at five to seven days prior to any procedures where the risk of bleeding is, you know, is higher than usual. Of course, when you do that, we have to weigh the risk of clotting of things such as stents versus bleeding from your procedure. Another question, which of the following is a procedure that's considered high risk of or bleeding? So, again, you guys can respond. We'll get to 80 or so, and then we'll see. Maybe 90. 90 is pretty good. All right. So everybody, most people picked US with FNA, which is the correct response. The other ones basically don't involve any interventions that are high risk for bleeding. So biopsies are generally fairly low risk. And ERCP without sphincterotomy is also lower risk. But with EOS, you're sticking a needle through something where there's potential blood vessels in the way. So that's obviously a higher risk. So basically, this is a slide showing different GI procedures and their risk of bleeding. So generally, again, I'm not going to go through all of these. But procedures involving cautery generally tend to be higher risk for bleeding. Procedures where you anticipate polyp removal, such as screening colonoscopies. If polyps are over a centimeter in size, the risk of bleeding will be higher than if they're smaller. ERCPs, if you're anticipating a sphincterotomy procedure, obviously is higher risk than the procedure where that's not anticipated. This slide basically talks about the management of antithrombotic agents in the elective endoscopy setting. So it's kind of a busy slide, but it kind of divides into four quadrants. So endoscopy-induced bleeding risk being high or low versus cardiovascular risk being high or low. The left side of this is the simpler one. Basically, this involves lower risk endoscopic procedures, procedures lower risk for bleeding, and the underlying cardiovascular risk being low. You basically don't really need to do much. So if you're anticipating a very low risk of endoscopic-related bleeding and the patient is at low risk for cardiovascular complications, you can basically continue their anticoagulation, such as warfarin or direct antithrombin agents. You pretty much always continue aspirin and NSAIDs. As we discussed before, there's no data showing that stopping them actually decreases the bleeding risk. If the patient is at high risk for cardiovascular complications, again, you just continue their anticoagulation as they were doing before. And you continue their standard dose of things like Plavix and aspirin and so forth. Now, if the endoscopy-induced bleeding risk is considered to be high and the patient is somebody who you think is at low risk for cardiovascular complications, you may want to discontinue their anticoagulation, such as Coumadin. Once you're done with the procedure, you can restart Coumadin, usually on the same day, because it usually takes a few days for INR to actually become therapeutic afterwards. And you delay reinitiating other agents until you think the adequate hemostasis is achieved after whatever it is you did. For antiplatelet agents, you continue, again, the emphasis is continue aspirin and NSAIDs. Don't stop them. If the cardiovascular risk is low, you basically stop the Plavix at least five days before or switch to aspirin, if possible. For patients who are on dual antiplatelet agents, such as Plavix and aspirin, the preference is to hold the Plavix for five days while continuing the aspirin, so that mitigates the risk a little bit. For patients at high risk for cardiovascular complications, and it's a high-risk procedure, first of all, you want to make sure you're actually needing to do the procedure at this time, and you can't delay it. But if you do, you try to discontinue their anticoagulation, such as Coumadin, and you provide some sort of a bridge therapy, such as Lovenox, for example. This is usually something that can be handled by the cardiologist or the hematologist who's prescribing the therapy, so usually you don't have to do that on your own, but you may want to contact those providers to help you out. Again, restart Coumadin on the same day of the procedure is helpful, because it takes a few days, as I said, and then waiting to reinitiate the other agents until hemostasis has been achieved. Again, this kind of goes over that a little bit more. So again, low-bleeding-risk procedure, where you're not anticipating the bleeding risk to be high, you don't have to do much of anything, with the exception of delaying the procedure if INR happens to be above the therapeutic range. High-risk-bleeding procedures with low thrombotic risk, you want to stop the anticoagulation with Coumadin three to five days prior, or if it's low molecular weight, Haparin eight hours prior to the procedure, and stop antiplatelet medications with the exception of aspirin five to seven days before the procedure. High-bleeding-risk procedures with high thromboembolic risk, again, you want to bridge. So again, these people with mechanical heart valves, for example, they may need to be bridged with Lovonox, and you hold their antiplatelet medications five to seven days before the procedure, with the exception of aspirin, again, because that should be continued. This is advisory from Major Heart Cardiology Association, because again, oftentimes, because we may not know the patient's history very well, which is where that comes into play, so if they are on Plavix, or some sort of antiplatelet agency, you want to find out why they're on it, and exactly when, if they had stents placed, for example, when those were placed, because oftentimes, we'd stop antiplatelet agent prematurely, which then increases the risk of instant thrombosis, which does carry a fairly high mortality rate, and also the cardiologist will be very unhappy with you if you've done that, and their patient had a heart attack. So you want to try to make sure that it's absolutely necessary to do your procedure, and it can be delayed for a little bit, and if it can't, then if it can, you want to position at least a year out from the patient's stenting procedure, if possible. So sedation and procedural monitoring. So most patients are sedated for endoscopic procedures. It's either done by the endoscopist, or oftentimes by anesthesia providers, so this more applies to the endoscopist-provided sedation. So you want to make sure that, you know, basically you're prepared, you have a pulse ox in the room, you have a blood pressure monitor, you have some sort of continuous EKG monitoring of the patient's heart, and know where the resuscitation equipment is located in your endoscopy unit. Obviously, observing the patient closely is important. This is where your nurses will be also quite helpful. You want to assess the patient before the procedure to determine if they are at higher risk for anesthesia complications. So, you know, and some of this will be done by your nurses who do the pre-op assessment of the patient, but some of this will be done by you as well. So if they have any history of snoring, stridor, or diagnosed sleep apnea, any significant drug allergies, obviously review their current medications and potential for interactions with the drugs you're going to give them. History of any adverse reactions to sedation or anesthesia in the past. Obviously, they will be asked about the time and contents of their last meal, which hopefully wasn't right before the procedure. History of tobacco, alcohol, and substance abuse as well. Airway assessment, so you basically want to check and see how easy it will be to control their airway if things go wrong. And keep in mind that patients who are elderly who have renal disease or on dialysis or patients with cirrhosis may need lower doses of sedating medications than other people who are healthier or younger. So again, you want to make sure you know where your suctioning devices or airway equipment is. Usually most rooms will be equipped with an ambu bag in case you need to use that and where the reversal agents are located. Complications of sedation, which you want to inform the patients about are things like local and systemic allergic reactions, which can happen with any medication. Skin reactions, which are not infrequent. And obviously the most common one would be desaturation when the patient is over sedated. In most cases, usually it's very transient and you can correct that just by giving the patient more oxygen. Complications, so if you're doing enough procedures, you will encounter complications at some point in your career no matter how hard we try to avoid them. Obviously we try to avoid them as best we can. So we assess patients before going into the procedure, patient characteristics. Obviously knowing the limits of what you're doing and knowing when to quit is very important, something you learn with experience. Not being a hero, meaning that if you do encounter a complication that you can't necessarily fix yourself, you don't need to take a lot of time trying to do that, but maybe stopping at that point and going ahead with the other steps. You do have to have a high level of suspicion for a complication, which sometimes is obvious, sometimes it's not. If you see the patient after the procedure screaming in pain, you probably should take that seriously and not ignore that. Although some patients may be somewhat dramatic in how they express pain. And again, you will learn with experience how to distinguish that from an actual complication. So you do a physical exam, obviously, and you see if there are signs of things like peritonitis, vital signs changing, et cetera. Strongly consider the use of imaging if there's any doubts. Again, it's better to be, always better to be safe than sorry. There's no harm of getting an x-ray or even a CT if it turns out to be normal. And if high level of suspicion or concern if you're not located, whether you're located in the hospital or an outpatient setting, sending the patient to the ER, again, would be advisable even if nothing is ultimately found. So, you basically assess the patient at the bedside. And if you are very concerned that a complication has occurred, make sure that they're not eating. Obviously that they're getting IV fluids. Antibiotics should be started as soon as possible with broad coverage. You obviously wanna communicate with the patient and the family as honestly as you can. Try not to make excuses and just explain what happened, what you think has happened, what the next steps would be. If surgery input is required, it's better to just call them directly and speak to them and explain what happened, what you need them to do. Communication with other providers, such as, for example, if you're sending the patient to the ER, it'd be helpful to let the ER doctor know what happened and why you're sending the patient over. So, in conclusion, again, informed consent. So, patient education goes a long way towards a successful procedure, meaning if the patient is well prepped and understands what's going on, why they're doing the procedure and so forth, they're much more likely to, A, show up and be well prepped and so forth. Make the informed consent a dynamic process. Document, basically, if something is not documented, it may as well as it has never happened. Obviously, remind patients that cleaning their colon thoroughly before the colonoscopy is essential because it will prevent them from coming back prematurely or missing lesions such as polyps. Antibiotics, again, less is more. There's very few cases where they're actually necessary, but most of the time, we don't need them. I think that's all I got. And you guys can rate this, I suppose. So, see how I did? All right. There's a question from the virtual audience. All right. So, the question from the virtual audience is, we need to stop clopidogrel before therapeutic procedures like polyp removal, but not before routine endoscopy, correct? That's the question. Right. Generally, that is correct, but at some times, it's hard to say what will be routine endoscopy or not. For example, if you're doing screening colonoscopy, you may not find anything, but you may find large polyps. So, generally, unless you really know well ahead of time what you're going to do, for example, you're just doing biopsies for H. pylori or something in the ED and you know the patient well enough to say that most likely nothing else will need to be done, you probably don't need to stop the plavix. However, if you don't know ahead of time exactly what you will encounter and the risk of thromboembolism is low, it would be advisable to stop the plavix in that case. Interesting, thank you. Thank you so much. Thank you.

pre-endoscopy

informed consent

patient preparation

antibiotics

sedation

complications