Michael Saunders, MD
Clinical Professor of Medicine
Director, Digestive Disease Center
Division of Gastroenterology
University of Washington Medical Center
Case 1
Endoscopy


36yo male with chronic
dysphagia and multiple
food impactions (earliest
at age 6)
Ongoing dysphagia
 Constant, primarily solids
 has to drink water with
bread to get it to go down
 Last food impaction 3
months ago


No heartburn
PmHx includes asthma
and ectopic dermatitis
Correct statements regarding this condition
include which of the following?
a) Typically affects white, middle-aged men
b) High prevalence of co-existing allergic
disorders (allergic rhinitis and asthma)
c) Characterized by eosinophilic infiltration of
the mucosa (>15-20 eosinophils/hpf)
d) Corticosteroid therapy produces
symptomatic, endoscopic and histologic
improvement in the majority of patients
e) All of the above
Approach to dysphagia
Eosinophilic esophagitis (EoE):





Chronic inflammatory disorder of the esophagus characterized
by eosinophilic infiltration of the mucosa
 >15-20 eosinophils/hpf
Presenting symptoms:
 dysphagia (>90%)
 food impaction (62%)
 heartburn (25%)
 children: vomiting, regurgitation, abd pain
In adults, typically presents in white, middle-aged men (average
age 38)
High prevalence of allergies (allergic rhinitis and asthma) in both
pediatric and adult EoE pts
Suggests food allergies may play a role in pathogenesis
EoE: Treatment

Systemic or topical corticosteroids
 produces symptomatic, endoscopic and histologic
improvement/resolution in the majority of pts
 sxs and eos return w/in 3–6mo after d/c

endoscopic dilation

Allergy testing

dietary therapy
 Elimination diet leads to symptom and histologic
improvement
 Most common identified food triggers:
○ milk, wheat, soy, egg
J Clin Gastroenterol. 2010 ;44(1):22-7; Gastroenterol 2012; 142:1451
A 53 year old female with chronic GERD presents to
establish care. Her symptoms are completely resolved on
PPI therapy. You recommend continued therapy with a
PPI. The patient inquires about long-term efficacy and
safety of PPIs. Which of the following statements is correct?
a)
b)
c)
d)
Co-administration with clopidrogel should be avoided due
to increased risk of cardiovascular outcomes
Therapy should be limited to 6 months as there is gastric
atrophy with an  risk of adenocarcinoma in long-term
users
PPI therapy may be associated with an increased risk of
infections in hospitalized patients
Long term therapy should be avoided due to the increased
risk of hip fracture with long term use
Safety of PPI’s
Concern
Reality
Gastric cancer
No atrophic gastritis, metaplasia or dysplasia
Infections
Slight  risk of dysentery during foreign travel
 risk of C. diff
↑ infections in cirrhotic patients
B12 malabsorption
No cases of Pernicious anemia
Osteoporois
No bone density changes or calcium
malabsorption evident in prospective trials
Hypomagnesemia
Rare, clinical significance uncertain
Reduced effectiveness
of clopidrogel
Conflicting data
No association with adverse events in
prospective studies
Fioca et al. Aliment Pharm Ther 2012;36:959; Brunner et al. Aliment Pharm Ther 2012;
36:372007; 5:1418; Bajaj et al. Aliment Pharmacol Ther 2012; 36:866
Calcium and acid secretion



Acid facilitates the release of ionized calcium from
insoluble calcium salts
gastrectomy and pernicious anemia are linked to
increased risk of osteopenia and fracture
Calcium carbonate absorption decreases at higher pH




People with achlorhydria have decreased absorption of
calcium carbonate on an empty stomach
Absorption is normal when calcium carbonate is ingested
with a meal
Therapy with a full dose of omeprazole did not reduce the
absorption of calcium contained in milk and cheese in
normal controls
In vitro osteoclast activity impaired by PPIs
Yang and Metz. GASTROENTEROLOGY 2010;139:1115–1127
Is acid reducing therapy associated with
risk of hip fracture?
Data is confusing at best likely due to
confounding variables
 No convincing data available that PPI’s
decrease calcium absorption or bone
density
 Premature to avoid prescribing acidreducing agents to those who have a clear
indication
 Weigh risk of fracture to benefit of acid
suppression

Yang and Metz. GASTRO 2010;139:1115–1127
11/17/09 Press Release

“Until further information is available
FDA recommends the following:
 Healthcare providers should re-evaluate the
need for starting or continuing treatment with
a PPI, including Prilosec OTC, in patients
taking clopidogrel.
 Patients taking clopidogrel should consult
with their healthcare provider if they are
currently taking or considering taking a PPI,
including Prilosec OTC. “
Clopidogrel and the Optimization of
Gastrointestinal Events Trial (COGENT)
Probability of Remaining Free of Primary Cardiovascular events
Bhatt et al. N Engl J Med 2010;363:1909-17
Clopidogrel and the Optimization of
Gastrointestinal Events Trial (COGENT)
Probability of Remaining Free of Primary Gastrointestinal Events
Bhatt et al. N Engl J Med 2010;363:1909-17
The potential of PPIs to attenuate the efficacy of
clopidogrel could be minimized by the use of
dexlansoprazole or lansoprazole
Frelinger et al. J Am Coll Cardiol 2012;59:1304–11
Which of the following statements pertaining to
esophageal cancer and GERD are correct?
a)
b)
c)
d)
The incidence of esophageal cancer is rising,
surpassing that of colon cancer.
Approximately 10% of patients with chronic GERD
develop esophageal cancer
Acid suppression and antireflux surgery do not
eliminate BE or its cancer risk
Most patients with Barrett’s esophagus will present
with chronic GERD symptoms and be detected at
upper endoscopy
Incidence of Esophageal
Adenocarcinoma

In 2009, ~16,400
new cases of
esophageal cancer
 60% adeno-
carcinomas
 5-year survival
rate, 15 to 20%
Sharma. N Engl J Med 2009;361:2548-56
Barrett’s esophagus






premalignant lesion detected in the majority of
patients with esophageal adenocarcinoma
Occurs in ~10% of patients having
endoscopies for chronic GERD
The reported incidence of Barrett’s esophagus
is rising
Risk factors include advanced age, male sex,
white race, symptoms of reflux, and obesity
30 fold  risk of esophageal cancer
Acid suppression/antireflux surgery do not
eliminate BE or its cancer risk
Sharma. N Engl J Med 2009;361:2548-56
What is the best estimate of annual risk for
developing adenocarcinoma with Barrett’s
esophagus?
a)
b)
c)
d)
e)
100%
50%
25%
5%
0.5%
How often does non-dysplastic Barrett’s
(NDBE) progress to cancer?
Incidence of Dysplasia and EAC in 1204 patients with NDBE1


Diagnosis
No. of cases
Incidence rate
Mean time to
development
LGD
217
3.6%
4.59y
HGD
32
0.48%
5.6y
EAC
18
0.27%
5.297
HGD/EAC
42
0.63%
5.41y
the annual incidence of EAC would need to be >1.9% per year for
surveillance of NDBE at 5-year intervals to be cost-effective2
low rate of progression to cancer reinforces the current expert
consensus that routine endoscopic ablation of NDBE is not justified
1-Wani et al. Clin Gastroenterol Hepatol 2011 Mar; 9:220; 2 – Inadomi et al. Ann
Intern Med 2003; 138:176
Incidence of Cancer in Barrett’s
dysplasia
Mean annual incidence <0.5%
Paulson, Reid. Cancer Cell. 2004 Jul;6(1):11-6.
Management of Barrett’s esophagus
Sharma. N Engl J Med 2009;361:2548-56
Management of Barrett’s dysplasia
*HGD should be treated
Sharma. N Engl J Med 2009;361:2548-56; Spechler et al. Gastroenterol 2011
Endoscopic treatments for
Barrett’s esophagus
Endoscopic mucosal resection (ER)*
 Radiofrequency ablation (RFA)*
 Photodynamic therapy (PDT)*
 Cryotherapy
 Other (argon plasma coagulation, multipolar
electrocautery, laser)

* Prospective data available
EMR in early esophageal cancer
Radiofrequency ablation (RFA)
Multi-modality therapy for early Barrett’s
neoplasia: endoscopic resection followed
by radiofrequency energy ablation.
Case Presentation
An 52-year-old woman with sudden onset of
epigastric/RUQ pain
 PE: temp 37.0 C; HR 90, BP 110/70 mm Hg; no
scleral icterus; Abdominal exam reveals mild RUQ
tenderness without guarding or rebound
 Labs:

 WBC 12,000;
 aminotransferases: AST 935 ALT 1346;
 alk phos 98 , amylase 143, bilirubin (total) 1.8

abd u/s reveals a CBD 9 mm; No gallstones pericholecystic fluid are noted
What is the most likely diagnosis?
1.
2.
3.
4.
5.
Acute viral hepatitis
Ischemic hepatitis
Acute common bile
duct obstruction
Acute pancreatitis
Acute cholecystitis
Differential diagnosis of acute
transaminase elevation > 1000
Viral hepatitis
 Toxin/drug
 Ischemia
 Acute CBD obstruction (stone)

Biliary tract stone disease
•Cholelithiasis :
•symptomatic cholelithiasis
•acute cholecystitis
•Choledocholithiasis
•symptomatic CBD stone
• cholangitis
•pancreatitis
An 82-year-old woman presents with sudden onset of
right upper quadrant abdominal pain, fever, and
shaking chills.
PE: temperature is 39.0 C (102.2 F). Pulse rate is
110 per minute, and blood pressure is 90/70 mm Hg.
Slight jaundice is noted. Heart and lungs are normal.
Abdominal examination reveals mild right upper
quadrant tenderness without guarding or rebound.
Mental status is normal.
Leukocyte count 12,000 ; AST 235 ALT 343, alkaline
phosphatase 298 , amylase 78, bilirubin (total) 4.5
Abd u/s : common bile duct measuring 15 mm in
diameter; distended gallbladder with sludge, no pericholecystic fluid or stones are noted.
The most likely diagnosis is?
1.
2.
3.
4.
Acute cholangitis
Acute cholecystitis
Perforated peptic
ulcer disease
Acute mesenteric
ischemia
25%
1
25%
25%
2
3
25%
4
Cholangitis - infection in biliary tree

Cholangitis requires:
• Bacteria (Bile is normally sterile)
 Source of bacteria in bile:
• intestinal translocation and portal bacteremia
• reflux from duodenum
• gallbladder/stones
• Obstruction of biliary tract
Death may result within hours of presentation
 Associated with significant morbidity/mortality
 Early recognition and treatment are essential
 Urgent biliary decompression

Acute cholangitis:
Clinical Presentation and diagnosis
Charcot’s Triad (~70%):
• Abdominal pain
• Fever
• Jaundice
Labs:
 Leukocytosis
 Abnormal LFT’s
 Blood cultures
Imaging: Ultrasound/CT scan
- choledocholithiasis (<50%)
- biliary dilation (~75%)
Case (continued)
Broad spectrum ABx are begun, but the
patient develops rigors after receiving
the initial dose. Temperature is now
39.6 C (103.3 F). Pulse rate is 120 per
minute, and blood pressure is
82/60 mm Hg. She appears slightly
confused.
Which of the following is most
appropriate now?
1.
2.
3.
4.
Continuation of antibiotic
regimen with the addition
of imipenem
Immediate ERCP with
biliary drainage
Immediate percutaneous
transhepatic
cholangiography and
external biliary drainage
Immediate surgery
Management of Cholangitis
• Volume resuscitation
• Antibiotics (Pip/Tazo, Amp/Sul, Ticar/Clav,
3o Ceph, Imipenem, Levofloxacin, Cipro)
• Biliary decompression
Timing
Route (ERCP > PTC > Surgery)
Case Presentation
45 yo man developed acute onset of epigastric
pain requiring transport via ambulance to the
ER
 PMHX: unremarkable.
 No chronic meds. No EtOH.
 Exam: T 38.0, BP 150/100, HR 110

 Moderate distress, in obvious discomfort
 mod-severe tenderness with guarding, distention,
hypoactive BS, no peritoneal signs

LABS:
 WBC 20,000, Hct 50, BUN 60, Cr 2.2, AST 350, ALT
460, Total Bilirubin 5.0, Alk phos 270, Amylase 1200
The most likely diagnosis is?
Acute mesenteric
ischemia
2. Acute cholecysitis
3. Acute pancreatitis
4. Small bowel
obstruction
5. Rupture abdominal
aortic aneurysm
1.
Diagnosis of acute pancreatitis

Clinical (requires 2 of the following):
 Characteristic epigastric pain
 Elevated pancreatic enzyme levels (>3x upper
limits of normal)
 Abnormal imaging (inflammatory changes in
pancreas)
Evaluation of acute pancreatitis
Edematous/Interstitial (IP) vs. Necrotizing (NP)
Organ failure in 15% compared with 80%
The most likely cause of the pancreatitis is?
Alcohol abuse
b) Gallstones
c) Hypertriglyceridemia
d) Trauma
e) idiopathic
a)
Etiology of acute pancreatitis
Obstructive
Toxins/drugs
Metabolic
Infection
Vascular
Trauma
Idiopathic
ALT 3x normal has a 95% PPV for biliary pancreatitis
Am J Gastro 1994; 89:1863
The most appropriate management of the
patient includes?
1.
2.
3.
4.
5.
Admission to the ICU
Aggressive volume
resuscitation
Empiric broad
spectrum antibiotics
Urgent ERCP for
biliary
decompression
All of the above
20%
1
20%
20%
2
3
20%
4
20%
5
Principles of treatment of acute
pancreatitis
• Intravascular volume
• Analgesia
• Put pancreas to "rest"
• Treat complications–pulmonary, shock, renal, metabolic
• ERCP for biliary obstruction/cholangitis
• Antibiotics for severe disease
• Percutaneous aspiration of pancreas to document infection in
patient who fails to respond
• Drainage/debridement for infected necrosis
Step up approach for necrotizing pancreatitis
17 (40%)
Open necrosectomy
31 (69%)
Minimally invasive
step-up approach
17 (40%)
Major complications/death
N Engl J Med. 2010;362(16):1491
Management of Severe Acute Pancreatitis
Clinical Assessment
of severity
Severe
Contrast-enhanced
CT scan
> 30% necrosis
Mild
Supportive therapy
< 30% necrosis
Antibiotics (imipenem)
Improvement
Yes
Continue ABX for 7-14 days
No
CT guided aspiration
Yes
Infected
Percutaneous, endoscopic
and/or surgical debridement
No
Continued supportive therapy
True statements regarding celiac disease include
all of the following except?
20%
1.
2.
3.
4.
5.
20%
20%
2
3
20%
20%
The prevalence in the U.S. is 1:300
Diagnosis requires a compatible
small bowel biopsy with clinical
response to gluten withdrawal
Tissue transglutaminase IgA is the
most sensitive serologic test
Is strongly associated with HLA DQ
locus
Serologic tests are not affected by
dietary gluten restriction
1
4
5
Answer 5
 Pearls:

 20% of patients > 60 years at diagnosis
 HLA-DQ2 and/or DQ8 > 95%*
 IgA tissue transglutaminase and endomysial
antibodies have sensitivities and specificities >
95%
 Anti-gliadin non specific (PPV ~30%)
 Levels fall with adherence to gluten-free diet
*Kaukinen et al. Am J Gastroenterol 2002
Case presentation
67 yo male w/ 2-3 days of increasing
abdominal pain, distention, fever, and
non-bloody diarrhea
 Admitted to ICU 2 weeks earlier for
urgent cardiac bypass
 Course complicated by bacterial
pneumonia with respiratory failure
 Temp 38.5, WBC 16,000

The most appropriate
management includes?
20%
1.
2.
3.
4.
5.
20%
20%
2
3
20%
20%
Neostigmine IV
Surgical resection
Colonoscopy
Empiric antibiotics
with oral vancomycin
and IV metronidazole
Fecal transplantation
1
4
5
Pseudomembranous colitis
Differential diagnosis of nosicominal
diarrhea
Medications (antibiotics!)
 Infectious (C. diff)
 Dietary (tube feedings)
 Ischemic colitis

Clostridium difficile infection
Rate of hospital acquired C. diff is ~3%
 Incidence of refractory cases and
multiple relapses is rising
 Probiotics prevent CDAD
 Fecal transplantation:

 associated with 94% cure rate
 safe and effective treatment for refractory C.
difficile infection
Johnson et al. Ann Intern Med 2012; 13. Mattila et al. Gastroenterol 2012; 142:490
67 year old male from a NH with prior CVA and COPD is
admitted for treatment of pneumonia with antibiotics.
He has been receiving tube feedings via a PEG placed
3 months ago. After 5 days of IV abx he develops
watery, non-bloody diarrhea, low grade fever, and
elevated WBC count (32 K). Stool is positive for fecal
leukocytes. C difficile toxin A is negative, but antigen is
positive. What is the most likely explanation for his
clinical findings?
a)
b)
c)
d)
He is a carrier for C difficile
He has uncomplicated antibiotic-associated diarrhea
He has toxin A (-), B (+) C difficile
His diarrhea is due to hyperosmolar tube feeds
Answer C
 Pearls:

 Many commericial EIA tests will test for toxin A and
antigen
 3-4% of C difficile strains produce toxin B only
 Elevated WBC, fecal leukocytes, and fever suggest
C difficile infection
 Risk factors for infection include older age, use of
antibiotics, PPI’s, and virulent NAPI strain
Johnson et al. J Clin Microbiol 2003; 41:1543-1547
Loo et al. N Engl J Med 2011; 365:1693

57 year old male with long-standing diabetes mellitus
type 1 presents with over 5 years of daily diarrhea and
weight loss (35 lbs). His course has been complicated
by poor glucose control and peripheral neuropathy. A
quantative stool collection yielded a fecal fat output of
24g/24h.

Possible causes for this picture include all of the
following except:
a)
Diabetic enteropathy
Excessive sorbitol ingestion
Small bowel bacterial overgrowth
Celiac disease
Pancreatic exocrine insufficiency
b)
c)
d)
e)

Answer B
Diarrhea is a frequent complication of long
standing IDDM, occurring in ~ 20%
 Bacterial overgrowth, celiac disease, and
exocrine pancreatic insufficiency occur with a
greater frequency in diabetics than in the
general population
 Sorbitol produces an osmotic diarrhea
without steatorrhea

24 year old female with a new
diagnosis of Crohn’s disease
after presenting with chronic
abdominal pain, diarrhea and
weight loss of 2 years
duration
 Colonoscopy revealed
moderate-severe terminal
ileal and right colon disease

True statements regarding management of her disease include which of the
following?
a) Therapy should be initiated with 5-ASA agents because of the favorable side
effect profile
b) Steroids are the treatment of choice for maintenance of remission in Crohn’s
disease
c) Therapy should be initiated with anti-TNF therapy as this has the greatest
likelihood of achieving and maintaining remission
d) No therapy for Crohn’s disease has been shown to improve long term outcomes
and reduce need for surgery
Disease
Complications
Goals of Therapy Have Expanded

Induce and maintain
gastrointestinal healing
(Mucosal Healing)

Prevent strictures and
penetrating complications

Prevent extra-intestinal
complications

Avoid/reduce corticosteroid use

Decrease hospitalization

Decrease surgery

Decrease long-term cost
Natural Course
Years
TREAT
Mortality in Crohn’s disease
Logistic Regression Data (Multivariate)
Odds Ratio
95% CI
P-Value
Current use of infliximab
1.015
0.531-1.942
P=0.96
Current use of 6MP/AZA/MTX
0.731
0.398-1.340
P=0.31
Current use of corticosteroids
2.096
1.147-3.832
P=0.016
Current use of narcotic
analgesics
0.946-3.379
1.787
P=0.74
Lichtenstein G et al. Clin Gastroenterol Hepatol. 2006;4:621-630.
Top-Down vs. Step-Up Endoscopic Results
100
% of patients
80
73
P=0.0028
60
40
30
20
0
Step-up
Top-down
Complete endoscopic healing at 2 years
D’Haens et al. Lancet. 2008;371:660-667.
Key Messages: Early Intervention
with Biologic Therapy
Early intervention with immunotherapies
improves likelihood of response/remission.
 Steroid sparing strategies early in the
disease course are associated with mucosal
healing
 Biologics are current best therapy for Crohn’s
Disease
 Intervention with anti-TNF therapy improves
outcomes in Crohn’s disease

Which of the following are correct
statements regarding the safety of
medical therapy for Crohn’s disease?
a) Long term therapy with anti-TNF should
be avoid due to the risk of serious
infections
b) Long term therapy with anti-TNF should
be avoided due to the risk of lymphoma
c) Anti-TNF therapy is contraindicated in
pregnancy
d) Steroid use is the most important risk
factor for serious infections in Crohn’s
disease

Risk of Serious Infections in Crohn’s
Disease: Meta-Analysis of All Controlled
Trials
Anti-TNF
Serious Infections
Control
70 (2.09%) 43 (2.13%)
Peyrin-Biroulet et al CGH 2008;6:664.
95% CI
0.45-0.65
TREAT
Serious Infections
Logistic Regression Data (Multivariate)
Odds
Ratio
95% CI
P-Value
Current use of infliximab
0.991
0.641- 1.535
P=0.97
Current use of 6MP/AZA/MTX
0.782
0.519- 1.179
P=0.24
Current use of corticosteroids
2.212
1.464-3.342
P<0.001
Current use of narcotic
analgesics
2.380
1.560-3.631
P<0.001
Lichtenstein G et al. Clin Gastroenterol Hepatol. 2006;4:621-630.
Key Messages: Risk/Benefit of Therapy in
IBD





Risks of therapy must be considered in the
context of the risk of untreated disease and
progression of disease.
Steroids remain the most dangerous
medical therapy for IBD.
Lymphoma risk in IBD is associated with
thiopurine therapy and concomitant
therapy with biologics and thiopurines.
Disease control at conception improves
pregnancy outcomes
anti-TNF therapies are safe during
pregnancy

A 35-year-old man asks your advice about screening for
colon cancer. His father had colon cancer at age 61. An
older brother had asymptomatic adenomatous polyps
found on a screening colonoscopy at age 50. No other
family members have had colon polyps or cancer. The
patient has no gastrointestinal symptoms. Physical
examination is normal.
Which of the following should you recommend?
(A) Screening for an average-risk individual beginning at
age 50
(B) Fecal occult blood testing annually beginning at age 40;
screening colonoscopy beginning at age 50 and every
ten years thereafter
(C) Screening colonoscopy beginning at age 40 and every
five years thereafter
(D) Screening colonoscopy beginning at age 40 and every
ten years thereafter

American College of Physicians (ACP) guidance
statement for colorectal cancer (CRC)







Average-risk individuals should begin screening at age 50
High-risk adults should begin at age 40 or 10 years younger than
the age at which their youngest affected relative received a
diagnosis of CRC.
The screening for average risk:
 annual stool-based test, flexible sigmoidoscopy every 5 years
 or optical colonoscopy every 10 years
Optical colonoscopy every 5 years in high-risk patients.
Clinicians should select the test based on the benefits and harms of
the screening test, availability of the test, and patient preferences.
Clinicians should stop screening for CRC in adults >75 or with a life
expectancy of <10 years.
Screening in blacks is appropriate beginning at age 40
Ann Intern Med 2012 Mar 6; 156:378
Screening for Persons with Familial Risk
Familial risk category
Recommendation*
Second or third degree relatives
with colorectal cancer
Same as average risk
First-degree relative with colon
cancer or polyps diagnosed at
age  60 yr
Same as average risk but begin at
age 40 yr
Two or more first degree relatives
with colon cancer, or first degree
relative with colon cancer or
polyps diagnosed at age < 60 yr
Colonoscopy q 5 yr, begin at age
40 yr or 10 yr younger than
earliest diagnosis in family
* Synthesis of guidelines from Multidisciplinary expert panel and ACS
A 55-year-old man has a history of a 0.5-cm
pedunculated tubular adenoma removed a screening
colonoscopy 5 years previously. A follow up colonoscopy is normal with no polyps evident.
When should you recommend that the next surveillance
colonoscopy be performed?
a)
b)
c)
d)
e)
In 6 months
In 1 year
In 3 years
In 5 years
In 10 years
Recommendation for Surveillance Colonoscopy
in Patients with Neoplasia
Most serious baseline
exam findings
1-2 small adenomas
(<10 mm)
3 or more small tubular
adenomas
Advanced adenoma
Recommended
surveillance interval
5 years or more
Cancer, post-resection
1 year, then every 3-5
years
3 years
3 years
Lieberman. Gastroenterol 2004; 126:1167
New guidelines for postpolypectomy
surveillance after colonoscopy
Intervals are now based on results not
only from most recent exam but also
from baseline exam that identified
neoplasia
 Patients with low risk findings at
baseline, and no subsequent adenomas
on surveillance should be returned to
average risk with next surveillance at 10
years

Lieberman et al. Gastroenterol 2012; 143:844
Common mistakes made in colon
cancer screening/surveillance



Restarting annual FOBT after normal
screening colonoscopy
What constitutes a worrisome family hx
Under utilization of surveillance in high risk
subjects
~50-60% of patients with advanced baseline findings
had f/u exam at 5 years

Over utilization of surveillance in low risk
subjects
 ~25% with no polyps had f/u exams within 5 years
 Inappropriate f/u for non neoplastic (hyperplastic)
lesions
Schoen et al. Gastroenterol 2010; 138:73