AT the AGA Spring Postgraduate Courses the final session of the course focused on a variety of imaging and quality issues related to the small bowel and colon.
Dr. Brian Jacobson, associate professor of medicine at Boston University, emphasized the importance of grading colonoscopy preparations and the consequences of inadequate preparations. He stressed the proven superiority of split dosage preparation regimens to insure the optimal quality colon examination or the alternative of same-day preparations administered at 6:00 a.m. for afternoon cases. Lastly, he emphasized the misconception that monitored anesthesia care with propofol enhances adenoma detection rates.
By Dr. Gary W. Falk
Dr. Jonathan Leighton, chair of the division of gastroenterology at the Mayo Clinic Arizona, provided a state of the art perspective on the various imaging modalities of the small bowel in the setting of obscure bleeding, an area of considerable confusion. Capsule endoscopy is considered the initial step after a negative esophagogastroduodenoscopy and colonoscopy, although a second-look endoscopy is reasonable to consider first. If the capsule is found to be positive, Dr. Leighton advised using it to guide the deep enteroscopy approach. He said it is reasonable to consider an antegrade approach if at 0%-75% of small bowel and a retrograde approach if at 75-100% of the small bowel. In the setting of a negative capsule and a high index of suspicion, one should proceed right to deep enteroscopy. Lastly, newer cross sectional imaging tests such as CT angiography, CT enterography, or MR angiography are reasonable considerations in patients with ongoing bleeding despite negative endoscopic imaging.
Dr. Michael Wallace, chairman of the division of gastroenterology at the Mayo Clinic, Jacksonville, Fla., provided a perspective on advanced imaging techniques of the colon. First, he reminded attendees that chromoendoscopy improves neoplasia detection in inflammatory bowel disease and should be considered for cancer surveillance programs in those patients. Adenoma detection rates can be improved by using multimodal imaging platforms already available with an emphasis on high-definition, white light endoscopy with wide angle imaging accompanied by narrow band imaging. Finally, Dr. Wallace pointed out that confocal endomicroscopy, as part of a multimodality imaging platform, has the potential to reduce or even eliminate the need for biopsies, allow for real time diagnosis, and guide therapy.
The final presentation in the session came from Dr. Dawn Francis, associate professor of medicine at the Mayo Clinic, Jacksonville, Fla., who examined quality measures in colonoscopy. She emphasized the importance of appropriate screening intervals, commencing at 50 years for average risk individuals and then every 10 years until life expectancy is less than 5 years, although a starting age of 45 years has been recommended for African Americans. The appropriate surveillance interval depends on the type, number, and completeness of removal of any polyps. Finally, Dr. Francis emphasized the metric of a cecal intubation rate of at least 95% in healthy adults with an adenoma detection rate of 25% or greater in males and 15% or greater in females.
Gary W. Falk, M.D., M.S., is clinical co-director, Joint Center for Digestive, Liver and Pancreatic Medicine at the University of Pennsylvania and the Children’s Hospital of Philadelphia. He also is co-director of both the GI motility/physiology program and the GI physiology laboratory at the Hospital of the University of Pennsylvania, Philadelphia.
