Endoscopy in Older Adults: Risks,
Benefits, Considerations
23
Noelle O’Shea and Frank J. Lukens
Questions and Answer
1. Which of the following is not a high-yield indication for
esophagogastroduodenoscopy (EGD)?
A.Dysphagia and odynophagia
B.Persistent abdominal symptoms despite therapy
C.Acute or chronic bleeding
D.Abnormal imaging
E.Metastatic adenocarcinoma if results do not alter
management
Answer: E
While answers A–D require further investigation with
EGD, answer E does not. If the patient has a known diagnosis of metastatic adenocarcinoma, and an EGD would
not change the management of the patient’s current treatment/therapy, then an EGD would not be a high-yield
study to perform.
2. Although studies have found polyethylene glycol (PEG)
and sodium phosphate equally effective in bowel preparation in the elderly, the FDA has highlighted safety concerns with regards to sodium phosphate because it was
found to be associated with which one of the following?
A.Decreased glomerular filtration rate in elderly patients
B.Decreased hepatic function
C.Increased glomerular filtration rate in the elderly
patients
D.Increased hepatic function
E.Life threatening hyperkalemia
Answer: A
In the elderly patients aged 75 years and above, two studies found PEG and oral sodium phosphate equally effective in bowel preparation; however, sodium phosphate
was found to be associated with lowering the glomerular
filtration rate highlighting safety concerns. Furthermore,
elderly patients are at an increased risk of phosphate
intoxication and calcium/phosphate deposits in tissues.
Hypokalemia, but not hyperkalemia, is an adverse event
from any bowel preparation and hypokalemia.
3. Which of the following agents are used for sedation/analgesia during endoscopic procedures?
A.Lidocaine, tetracaine, benzocaine
B.Midazolam, diazepam
C.Fentanyl
D.Propofol
E.All of the above
Answer: E
Topical pharyngeal anesthetic sprays (lidocaine, tetracaine, benzocaine) may be used for upper endoscopy. The
most common benzodiazepines used are midazolam and
diazepam; however, most endoscopists prefer midazolam
due to fast onset of action, short duration of action, and
high amnestic properties. The most common opioid used
is ­fentanyl, which has a faster onset of action and clearance with a lower incidence of nausea. Meperidine is not
used today in view of CNS side effects. Propofol is an
ultrashort acting agent that provides sedative, amnestic,
and hypnotic effects with no analgesic properties that
should be dose reduced in the elderly due to decreased
clearance of the medication.
4. A 56-year-old male with a past medical history of hypertension and coronary artery disease has a deep venous
thrombosis and is to undergo a colonoscopy with polypectomy. What recommendations could you make with
regards to anticoagulation in this patient?
A.Consider continuing ASA and NSAID
B.Warfarin therapy should be discontinued 3–5 days
before procedure
C.LMWH therapy should be discontinued at least 8 h
pre-procedure
D.Reinstitution of clopidogrel therapy should be
individualized
E.All of the above
C.S. Pitchumoni and T.S. Dharmarajan (eds.), Geriatric Gastroenterology,
DOI 10.1007/978-1-4419-1623-5_23, © Springer Science+Business Media, LLC 2012
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Answer: E
Anticoagulation recommendations in this case are based
upon a high bleeding risk (colonoscopy with polypectomy) and a low thromboembolic risk (deep venous
thrombosis). There is no need to discontinue aspirin or
N. O’Shea and F.J. Lukens
NSAIDs for routine colonoscopy and polypectomy; warfarin may be discontinued 3–5 days prior to the procedure,
and LMWH at least 8 h prior to the procedure; individualize the reinstitution of clopidogrel therapy.