Procedure Clinic

1
Procedure Clinic

• Susana A. Alfonso, M.D.
• October 2, 2008
• Assistant Professor
• Emory University Department of Family Medicine

2
Learning Objectives

• Increase awareness of the procedures performed by
  Emory Family Medicine
• Become familiar with the indications for
  colposcopy, ETST, and flexible sigmoidoscopy
• Become familiar with the common complications
  associated with the above

3
Procedures We Do

• Flexible Sigmoidoscopy
• Nasopharyngolaryngoscopy
• Colposcopy
• Circumcision
• Toenail excision
• Endometrial biopsy
• Splinting

• Exercise treadmill stress testing
• IUD
• Vasectomy
• Skin surgery-punch, shave, excision, ID
• Joint injections
• Trigger point injections

4
Case Number 1

• 28 yo female presents for a CPE with pap.
• She has no significant PMHx. Her Gyn Hx is as
  follows 13/q mo/4-5d. She is a G2P1011. She had
  an elective Ab following a rape in 2000. She has
  never had an abnormal pap or an STD. Her pap
  comes back ASC-US

5
Who gets a colpo?

• ASC-US with HPV positivity for high risk types
• ASC-H, LSIL, HSIL, and atypical glandular cells
• Postmenopausal women and women with
  immunosuppression should be managed the same as
  the general population. This is a change
• ASC-US patients who are managed with repeat
  cytology and show ASC-US

6
Contraindications

• Cervicitis or severe inflammation - treat first,
  wait for healing.
• Active bleeding or menses - wait until end of
  menses, if continuous bleeding colposcopy.
• Significant atrophy - use vaginal estrogen cream
  first
• Lack of an expert colposcopist -refer to someone
  with special training/skills

7
Preparation

• Two advil two hours before procedure
• CONSENT
• Instruct patient that she will be in the
  lithotomy position. Saline, acetic acid and
  Lugols solution will be used and if neccessary a
  biopsy will be done. An ECC will complete the
  procedure
• Use the colpo form

8

• Remember if patient is midcycle or on hormones
  that the cervical mucous will be thick
• Nothing in the vagina for two weeks afterward
• Follow up visit to discuss results in two weeks

9
Normal cervix Ectopy
10
Postmenopausal cervix Normal Cervix

11
HPV infection Nabothian cysts

12
Cervical cancer Infiltrating ca.

13

• 45 YO male with rectal bleeding intermittently
  for three months associated with eating hot spicy
  food and a flare of hemorrhoids.
• 55 YO female without significant past medical
  history or family history who states shes
  noticed skinny stools

14
Flexible Sigmoidoscopy Indications

• Screening of asymptomatic individuals at average
  risk beginning at age 50
• Screening options include
• FOBT annually
• Flexible sigmoidoscopy and FOBT q 5yrs
• Colonoscopy every 10 years
• DCBE every 5 years

15
Contraindications

• Family history of nonpolyposis colorectal cancer
  Examine the entire colon q 1-2 years when
  patient is 20-30 and yearly after 40 YOA
• History of adenomatous polyps
• History of colorectal cancer
• Ulcerative colitis
• Acute peritonitis, acute diverticulitis, toxic
  megacolon, and recent bowel surgery

16
Complications

• Abdominal cramping and bloating are the most
  common
• Increased in patients who have had prior
  abdominal surgery
• Postprocedure bleeding usually mild and self
  limited secondary to trauma
• Perforation RARE one in 5,000-10,000 requires
  surgery

17
Preparation

• Golytely 4Liters the night before
• One oral Dulcolax the night before and two Fleets
  Enemas that morning
• Sedatives or antispasmodics not needed
• SBE prophylaxis in high risk patients

18
Procedure

• The patient is placed in left lateral decubitus
• Rectal exam
• Change gloves
• Insertion and visualization
• Withdrawal and retroflexion
• Post procedure the patient may have abdominal
  cramping, watery stools, or gas

19
Normal Mucosa

20
Malignant Polyps

21
Adenocarcinoma

22
Invasive adenocarcinoma Ulcerative colitis

23
Internal hemorrhoids Internal
hemorrhoids with superficial
necrosis

24

• 45 YO male with HTN and DM comes to you for an
  initial visit. He has been previously
  noncompliant with meds, exercise and visits but
  is ready to change. He denies any chest pain.

25

• You schedule your patient for an ETST but the
  morning of the procedure he states that for the
  last two weeks since you told him to start
  exercising he has been feeling tight in his
  chest. He believes it is caused by the cold air.
  He remembers feeling the same way when he was a
  child and had asthma

26
Exercise Treadmill Stress Testing

• Class I Conditions for which there is evidence
  and/or
• general agreement that a given procedure or
• treatment is useful and effective.
• Class II Conditions for which there is
  conflicting evidence
• and/or a divergence of opinion about
• the usefulness/efficacy of a procedure or
• treatment.
• Class IIa Weight of evidence/opinion is in
• favor of usefulness/efficacy.
• Class IIb Usefulness/efficacy is less well
• established by evidence/opinion.
• Class III Conditions for which there is evidence
  and/or
• general agreement that the procedure/treatment
• is not useful/effective and in some cases
• may be harmful.

27
Indications

• Class I
• 1. Adult patients (including those with complete
  right
• bundle-branch block or less than 1 mm of resting
  ST
• depression) with an intermediate pretest
  probability
• of CAD (Table 4) on the basis of gender, age,
  and
• symptoms (specific exceptions are noted under
• Classes II and III below).
• Class IIa
• Patients with vasospastic angina.

28
Class IIb

• 1. Patients with a high pretest probability of
  CAD by
• age, symptoms, and gender.
• 2. Patients with a low pretest probability of CAD
  by age, symptoms, and gender.
• 3. Patients with less than 1 mm of baseline ST
  depression and taking digoxin.
• 4. Patients with electrocardiographic criteria
  for left
• ventricular hypertrophy (LVH) and less than 1 mm
  of
• baseline ST depression.

29
Class III

• 1. Patients with the following baseline ECG
  abnormalities
• Pre-excitation (Wolff-Parkinson-White)
  syndrome
• Electronically paced ventricular rhythm
• Greater than 1 mm of resting ST depression
• Complete left bundle-branch block
• 2. Patients with documented MI or CAD

30
Class III

• Patients with severe comorbidity likely to limit
  life expectancy and/or candidacy for
  revascularization
• High risk unstable angina patients

31
ETST and WOMEN

• ST segment changes is less specific
• More false positives
• Less CAD
• Less ability to maximally exerciseBUT
• there are currently insufficient data to justify
  routine stress imaging tests as the initial test
  for CAD in women

32
Age Gender Typical Atypical Non-anginal Asymptom-atic
30-39 Men Int Int Low Very Low
Wmn Int Very Low Very Low Very Low
40-49 Men High Int Int Low
Wmn Int Low Very low Very low
50-59 Men High Int Int Low
Wmn Int Int Low Very low
60-69 Men High Int Int Low
Wmn High Int Int Low
33
Angina Typical

• Defined as
• 1) substernal chest pain or discomfort that is
• 2) provoked by exertion or emotional stress and
• 3) relieved by rest and/or nitroglycerin.

34
Atypical/Probable Angina

• Defined as chest pain or discomfort that lacks
  one of the three characteristics of definite or
  typical angina

35
Screening of Healthy Asymptomatic patients

• Persons in high risk jobs Pilots, mass transit
  operators, law enforcement, firefighters
• American College of Sports Medicine recommends
  screening for all women over age 50 and men over
  age 40 who are sedentary and plan to start
  vigorous exercise
• Persons with multiple risk factors or chronic
  disease

36
Other Indications

• Evaluation of patients with known CAD after MI or
  after intervention
• Evaluation of patients with valvular heart
  disease (except severe aortic stenosis)
• Evaluation of exercise induced arrhythmia and
  response to treatment
• Evaluation of rate-adaptive pacemaker setting

37
Absolute Contraindications

• Acute myocardial infarction (within 2 d)
• High-risk. Unstable angina
• Uncontrolled cardiac arrhythmias causing
  symptoms or
• hemodynamic compromise
• Symptomatic severe aortic stenosis
• Uncontrolled symptomatic heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis
• Acute aortic dissection

38
Relative Contraindications

• Left main coronary stenosis
• Moderate stenotic valvular heart disease
• Electrolyte abnormalities
• Severe arterial hypertension
• Tachyarrhythmias or bradyarrhythmias
• Hypertrophic cardiomyopathy and other forms of
  outflow
• tract obstruction
• Mental or physical impairment leading to
  inability to exercise adequately
• High-degree atrioventricular block
• In the absence of definitive evidence, the
  committee suggests systolic blood pressure of
  gt200 mm Hg and/or diastolic blood pressure of
  gt110 mm Hg.

39
Before Scheduling an ETST

• Evaluate the resting EKG!!! If patients have
  LBBB or depressed S-T segments due to
  medications, electrolyte abnormalities, etc.
  Consider another test

40
Preparation

• Equipment
• Crash Cart
• Providers trained in ACLS
• NPO except water and medications
• Loose fitting clothes and comfortable walking
  shoes
• Caution with Insulin and oral hypoglycemics,
  digoxin, nitrates, alpha blockers, beta blockers
  etc.

41
Procedure

• Pts. Undergo supine, standing and
  hyperventilating EKG
• Bruce protocol
• Increase in speed and incline q three minutes
• Continuous monitoring of pts with blood pressure
  and pulse in the last minute of 3 minute cycle

42
Absolute Indications for Stopping Test

• Drop in systolic blood pressure of gt10 mm Hg
  from baseline blood
• pressure despite an increase in workload, when
  accompanied by
• other evidence of ischemia
• Moderate to severe angina
• Increasing nervous system symptoms (eg,
  ataxia, dizziness, or
• near-syncope)
• Signs of poor perfusion (cyanosis or pallor)
• Technical difficulties in monitoring ECG or
  systolic blood
• pressure
• Subjects desire to stop
• Sustained ventricular tachycardia
• ST elevation (1.0 mm) in leads without
  diagnostic Q-waves
• (other than V1 or aVR)

43
Relative Indications for Stopping Test

• Drop in systolic blood pressure of (10 mm Hg
  from baseline
• blood pressure despite an increase in workload,
  in the absence of
• other evidence of ischemia
• ST or QRS changes such as excessive ST
  depression (gt2 mm of
• horizontal or downsloping ST-segment depression)
  or marked
• axis shift
• Arrhythmias other than sustained ventricular
  tachycardia, including
• multifocal PVCs, triplets of PVCs,
  supraventricular tachycardia,
• heart block, or bradyarrhythmias
• Fatigue, shortness of breath, wheezing, leg
  cramps, or claudication
• Development of bundle-branch block or IVCD
  that cannot be
• distinguished from ventricular tachycardia
• Increasing chest pain
• Hypertensive response
• In the absence of definitive evidence, the
  committee suggests systolic blood pressure of
• gt250 mm Hg and/or a diastolic blood pressure of
  gt115 mm Hg.

44
Interpretation

• Maximal or Submaximal HR, METS, Double Product
• Positive
• Negative
• Equivocal
• Uninterpretable

45
Procedures We Do

• Flexible Sigmoidoscopy
• Nasopharyngolaryngoscopy
• Colposcopy
• Circumcision
• Toenail excision
• Endometrial biopsy
• Splinting

• Exercise treadmill stress testing
• IUD
• Vasectomy
• Skin surgery-punch, shave, excision, ID
• Joint injections
• Trigger point injections

46
So You Want to Order a Procedure

• Please precept all procedure request forms
• Give them to the patient to take to scheduling
• PREPARE YOURSELF
• FOLLOW UP ON YOUR PROCEDURES

47
References

• Darrow, Mark D. Ordering and Understanding the
  Exercise Stress Test. American Family Physician
  199959(2) 401-414.
• Johnson, Brett A. Flexible Sigmoidoscopy
  Screening for Colorectal Cancer. American Family
  Physician 199959(2) 313-330.
• Guidelines for the Early Detection of Colon
  Cancer. Reprinted from Ca-A Cancer Journal for
  Clinicians 200151(1) 44-53.
• ACC/AHA 2002 Guideline Update for Exercise
  Testing. Journal of the American College of
  Cardiology http//www.americanheart.org/presenter.
  jhtml?identifier3005237 (9 March 2005)
• Wright, Thomas C. Jr MD et al. 2006 Concensus
  Guidelines for the Management of Women with
  abnormal cervical cancer screening tests. AJOG
  2007346-355.