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New Colonoscopy Recommendation Makes Gastroenterologist Consider His Options

The right side of the colon seems to be the Achilles heel of colonoscopy because polyps there tend to be flat and harder to find, and we confer the least protection from later colon cancer in that zone.

A recent article summary in Journal Watch Gastroenterology concludes that when we see a right-sided colon polyp, we may have missed another, so we should go back and look again.

This provocative recommendation represents a major change in the way we normally perform colonoscopy. But the issue is, and always has been, how to identify and remove all polyps from the colon.

So the questions I have Read more »

*This blog post was originally published at Gut Check on Gastroenterology*

Physician Compares Ablation Techniques For Barrett’s Esophagus

The first cases of Barrett esophagus (BE) ablation in the late 1980s used YAG and Argon laser. Since then, a myriad of ablation techniques have been described, including multipolar electrocautery (MPEC), argon plasma coagulation (APC), cryotherapy, radiofrequency ablation (RFA), and endoscopic mucosal resection (EMR). Each technique has had its advocates, and some of the techniques appear to have certain advantages in certain types of BE: e.g., long segment, nodular, etc.

Most cases of BE are short segment, and most neoplastic cases do not have nodules or erosions. So the question I would like to see discussed is: In a patient with 1–2 cm of otherwise featureless flat but neoplastic BE:

What ablation technique would you use, and what do you feel makes this technique advantageous? Read more »

*This blog post was originally published at Gut Check on Gastroenterology*

Variations In Retrieving A Foreign Body From The Stomach

I have observed extreme variation in how my colleagues manage GI foreign-body retrieval from the stomach. Some always use general anesthesia and endotracheal intubation; others (myself included) use conscious sedation. Some use an overtube to withdraw the object into if possible; others simply pull it up to the endoscope and use the endoscope to guide it through the esophagogastric junction and upper esophageal sphincter. The reasons for this variation are clearly related to the perceived risk of airway compromise or gastrointestinal wall injury during withdrawal of the object from the stomach.

So my questions to you are:

1)      When do you ask for endotracheal intubation during foreign-body retrieval?

2)      Do you use an overtube when removing foreign bodies from the stomach, and, if so, always or in what situations?

3)      If you don’t use an overtube, what technique do you use during withdrawal of the object?

4)      What is your favorite “tool” or endoscopic accessory to grab objects from the stomach?

I look forward to hearing your thoughts on this issue.

*This blog post was originally published at Gut Check on Gastroenterology*

How To Tell If Your Doctor Is Talented At Endoscopy

I have noticed that we all think we are the best endoscopist around (in my case, that is indeed true!). However, we really never measured colonoscopy skill as a “patient-centered” metric and instead often use speed, efficiency, sedation needs, etc. when judging our colleagues. What is more important than these measures, however, is whether we find and remove adenomas, thereby preventing colon cancer downstream in our patients.

A number of surrogate markers for quality colonoscopy and polyp detection have been used in the past, including scope-withdrawal time from the cecum. But the one measure that has been the best predictor of quality is an endoscopist’s ADR (adenoma detection rate). In fact, this is the most reliable quality measure yet determined, and it may become the basis for being paid for these procedures in the not so distant future.

So I need to ask you:

1)      Do you know your ADR?

2)      Do you or does your group compare your ADR to other endoscopists within your endoscopy unit or practice?

3)      Is there a program to increase ADR in low performers in your endoscopy unit?

4)      Do you use your ADR as a marketing tool?

5)      What is your take on the ADR as a quality measure?

I look forward to hearing from you on this topic!

*This blog post was originally published at Gut Check on Gastroenterology*

Heartburn Bugs Have Become Antibiotic-Resistant

H. pylori dominated the GI news in the 1990s, and despite it disappearing from the front pages, it remains a common and important clinical problem. The dominant recommended initial treatment strategy has been a clarithromycin-based PPI triple therapy, with either amoxicillin or metronidazole as the third drug. This approach was based on clinical studies, ease of use, and tolerability factors. Bismuth-based quadruple therapy (a bismuth agent, metronidazole, tetracycline, and a PPI), despite demonstrating excellent activity, was usually relegated to second-line therapy because of the complexity of the dosing as well as compliance and tolerability issues.

However, duringthe last decade, the widespread use of macrolides in the general population has led to rising resistance to clarithromycin (by 30% or more of H. pylori strains in some areas), and when clarithromycin resistance is present, the efficacy of clarithromycin-containing triple therapy falls from about 80% to 50% or even lower. However, clarithromycin resistance does not affect the efficacy of bismuth-based quadruple therapy, and that efficacy of those regimens remains at about 90% when patients are compliant with the treatment.

So the questions for you to consider are:
1) Do you know what the clarithromycin resistance rate in H. pylori is in your community?
2) What first-line H. pylori treatment regimen do you use?
3) Are you planning to change your H. pylori treatment strategy now that clarithromycin resistance rates are rising?

Let us know what you think.

*This blog post was originally published at Gut Check on Gastroenterology*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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