ABPS GI Endoscopy cheat sheet

Standard fasting before elective endoscopy: 2 hours for clear liquids and 6 hours for a light meal; fatty meals need about 8 hours.

Split-dose polyethylene glycol is preferred: the second half is completed 4-6 hours before colonoscopy; same-day single-dose regimens give inferior cleansing.

Boston Bowel Preparation Scale: each of the right, transverse, and left segments scored 0-3; total 0-9; a score of 2 or more per segment defines adequate preparation.

Antithrombotic rules: aspirin is usually continued; clopidogrel is held 5-7 days before high-risk procedures; warfarin is held 5 days with an INR check; DOACs are held 48 hours (low risk) to 72 hours (high risk) depending on renal function.

Antibiotic prophylaxis is not routine for GI endoscopy; it is indicated for ERCP with anticipated incomplete drainage, biliary obstruction with cholangitis, and cirrhotic patients with GI bleeding.

Endocarditis prophylaxis is limited to high-risk cardiac conditions: prosthetic valve or material, prior infective endocarditis, unrepaired cyanotic congenital heart disease, and repaired congenital disease within 6 months.

Consent documentation must record the indication, expected benefit, material risks (bleeding, perforation, sedation, missed lesion), alternatives, and planned sedation depth.

ASA class III or higher, known obstructive sleep apnea, or a predicted difficult airway favors anesthesia-provider sedation rather than endoscopist-directed moderate sedation.

Pregnancy: defer elective endoscopy; when required, the second trimester is preferred, with left lateral positioning and review of drug teratogenicity.

Sedation continuum: minimal (responds to voice), moderate (purposeful response to verbal or light tactile stimulus), deep (responds only to repeated or painful stimulus), and general anesthesia.

Typical moderate sedation dosing: midazolam 1-2 mg IV plus fentanyl 25-100 mcg IV, titrated in small increments; elderly and comorbid patients need reduced initial doses.

Monitor oxygen saturation, heart rate, blood pressure, and respiratory rate before, during (at least every 5 minutes), and after sedation; capnography is recommended for deep sedation.

Reversal: flumazenil 0.2 mg IV increments (maximum 1 mg) for benzodiazepines; naloxone 0.4 mg IV increments for opioids; both require monitoring for resedation.

Propofol produces deep sedation or general anesthesia and has no reversal agent, so it requires an anesthesia-trained provider with airway skills.

Sedation risk factors: ASA III or higher, obstructive sleep apnea, BMI above 35, advanced age, prolonged procedure, high cumulative drug dose, and emergency procedures.

Discharge criteria: stable vital signs, return to baseline consciousness, ability to ambulate and tolerate oral fluids, and presence of a responsible escort.

The procedure record documents the time-out, agents and doses with times, vital signs, oxygen delivery method, and any adverse events or interventions.

Landmarks from the incisors: upper esophageal sphincter about 15 cm, gastroesophageal junction about 40 cm, pylorus about 60-70 cm, second duodenal portion about 80 cm.

Erosive esophagitis is graded by the Los Angeles classification A through D; Barrett esophagus is described by the Prague C (circumferential) and M (maximal) extent.

Barrett surveillance uses the Seattle protocol: four-quadrant jumbo biopsies every 1-2 cm plus targeted biopsies of visible nodules.

Peptic ulcer stigmata follow the Forrest classification; active bleeding (Ia, Ib) and visible vessel or adherent clot (IIa, IIb) warrant endoscopic therapy, while flat spot (IIc) and clean base (III) do not.

Gastric ulcers require biopsy and follow-up to exclude malignancy; duodenal ulcers generally do not.

Helicobacter pylori testing: rapid urease, histology, or culture from antrum and body; stop proton pump inhibitors 2 weeks and antibiotics 4 weeks before breath or stool testing.

Celiac disease evaluation: at least four to six duodenal biopsies including the bulb, obtained while the patient is on a gluten-containing diet.

Esophageal varices are graded small versus medium/large; red wale marks and cherry-red spots mark high bleeding risk and favor band ligation.

Average-risk screening starts at age 45: colonoscopy every 10 years, annual FIT, multitarget stool DNA every 3 years, CT colonography every 5 years, or flexible sigmoidoscopy every 5 years.

Cecal intubation is confirmed by the appendiceal orifice, ileocecal valve, and triradiate fold, with photo documentation as a quality metric.

Adenoma detection rate benchmarks: 25% or more overall, 30% or more in men, 20% or more in women; withdrawal time should be at least 6 minutes.

Surveillance intervals: 1-2 low-risk adenomas under 10 mm gives 7-10 years; 3-4 adenomas or any adenoma 10 mm or larger gives 3 years; 5 or more adenomas or high-grade dysplasia gives 1 year.

Sessile serrated lesions 10 mm or larger or with dysplasia warrant a 3-year interval; serrated polyposis syndrome warrants 1-year surveillance.

Cold snare polypectomy is preferred for polyps under 10 mm; larger lesions need submucosal injection with hot snare or endoscopic mucosal resection.

Piecemeal resection of lesions 20 mm or larger requires a site check at 3-6 months to document complete resection.

A positive FIT requires colonoscopy; FIT is not appropriate for symptomatic or high-risk patients.

Peptic ulcer with active bleeding or a visible vessel: combination therapy (epinephrine plus thermal or clip) followed by high-dose proton pump inhibitor infusion for 72 hours.

Epinephrine is diluted to 1:10,000 and injected in 0.5-1 mL aliquots around the bleeding point; it is not used as monotherapy for high-risk stigmata.

Through-the-scope clips mechanically approximate tissue; over-the-scope clips close larger defects, fistulas, and refractory bleeding.

Hemostatic powder (TC-325) forms a mechanical barrier and serves as a temporizing option for malignancy-related or diffuse bleeding.

Argon plasma coagulation is a noncontact method for superficial vascular lesions such as angioectasia, radiation proctopathy, and gastric antral vascular ectasia.

Acute variceal bleeding: vasoactive drug plus prophylactic ceftriaxone, then band ligation within 12 hours; banding is repeated every 2-4 weeks until eradication.

Refractory variceal hemorrhage options include TIPS and balloon tamponade as a bridge to definitive therapy.

Post-polypectomy bleeding is treated with clips or injection; prophylactic clipping is considered for large pedunculated polyps and anticoagulated patients.

ERCP indications: choledocholithiasis, benign or malignant biliary obstruction, cholangitis, sphincterotomy, stent exchange, and pancreatic duct disease.

Post-ERCP pancreatitis occurs in roughly 3-10% of procedures; prophylaxis includes rectal indomethacin 100 mg, periprocedural lactated Ringer solution, and pancreatic stenting in high-risk cases.

High risk for post-ERCP pancreatitis: young women, sphincter of Oddi dysfunction, difficult cannulation, precut sphincterotomy, pancreatic injection, and prior post-ERCP pancreatitis.

Choledocholithiasis stratification: very strong predictors are a stone on imaging or cholangitis; strong predictors are a dilated duct plus bilirubin above 1.8 mg/dL; isolated abnormal liver enzymes are intermediate.

Acute cholangitis requires antibiotics, resuscitation, and biliary drainage within 24 hours.

Sphincterotomy bleeding risk factors: anticoagulation, cirrhosis or coagulopathy, renal failure, a small papilla, and precut access.

Plastic biliary stents require exchange about every 3 months; covered metal stents are used for malignant distal obstruction and removable covered stents for benign strictures.

Cannulation strategy: standard catheter first, then double-wire technique, and precut fistulotomy or transpancreatic sphincterotomy after failed standard access.

EUS indications: pancreatic masses and cysts, subepithelial lesions, staging of esophageal, gastric, and rectal cancer, mediastinal and celiac nodal evaluation, and adrenal lesions.

Radial echoendoscopes provide 360-degree imaging; linear echoendoscopes allow needle passage for FNA, FNB, and therapeutic drainage.

EUS-guided fine-needle biopsy is preferred over FNA for pancreatic masses because it preserves histologic architecture.

Pancreatic cyst fluid carcinoembryonic antigen above 192 ng/mL suggests a mucinous cyst; high amylase suggests a pseudocyst.

Rosemont criteria for chronic pancreatitis include hyperechoic strands and foci, lobularity, dilated or irregular ducts, and calculi.

EUS-guided drainage with a lumen-apposing metal stent is first-line for symptomatic pseudocyst and walled-off necrosis.

EUS-guided biliary drainage (choledochoduodenostomy or hepaticogastrostomy) is an alternative after failed ERCP.

Esophageal cancer staging: T stage from depth of wall layer disruption; N stage from node size, hypoechogenicity, and border characteristics.

Capsule endoscopy is contraindicated in known strictures; a patency capsule verifies luminal patency, and capsule retention risk is about 1-2%.

Device-assisted enteroscopy (double-balloon, single-balloon, spiral) allows deep small bowel access for biopsy, hemostasis, and dilation.

Small bowel angioectasia is treated with argon plasma coagulation or bipolar cautery; recurrent bleeding may respond to octreotide.

Peroral endoscopic myotomy (POEM) is a submucosal tunnel myotomy for achalasia; Z-POEM targets Zenker diverticulum.

Endoscopic submucosal dissection achieves en bloc resection of early neoplasia with higher perforation risk but lower recurrence than piecemeal mucosal resection.

Barrett esophagus ablation uses radiofrequency ablation or cryotherapy after endoscopic resection of visible nodules.

Endoscopic bariatric therapies include intragastric balloons and endoscopic sleeve gastroplasty.

Gastric peroral endoscopic pyloromyotomy is an option for refractory gastroparesis.

Reprocessing sequence: bedside precleaning, leak test, manual cleaning of all channels with brushes, high-level disinfection, rinse, alcohol flush with forced-air drying, and vertical storage.

Minimum high-level disinfection exposure: 2% glutaraldehyde 20 minutes at 20 degrees Celsius, ortho-phthalaldehyde 12 minutes, or peracetic acid about 5 minutes, following manufacturer instructions.

Duodenoscopes require meticulous cleaning of the elevator mechanism, and regulatory guidance supports double high-level disinfection or sterilization plus microbiologic surveillance.

Endoscopes are stored hanging vertically and uncapped to prevent moisture retention and biofilm formation.

Single-use items include biopsy forceps, snares, water bottles, and suction valves where specified; single-use devices are never reused.

Known or suspected Creutzfeldt-Jakob disease exposure requires prion-specific decontamination, quarantine, or destruction of the endoscope per policy.

Reprocessing staff wear gloves, fluid-resistant gown, face shield, and mask, working in a dedicated ventilated room.

High-level disinfection monitoring uses minimum recommended concentration test strips, temperature logs, and periodic ATP or microbiologic surveillance.

Colonoscopy perforation incidence is about 0.1-0.2% for diagnostic procedures and higher with polypectomy or dissection; the sigmoid and cecum are the most common sites.

Post-polypectomy bleeding occurs immediately in 0.5-1% and delayed in 0.3-1%; risk rises with lesions over 2 cm, right colon location, and anticoagulant use.

Major ERCP adverse events are post-ERCP pancreatitis, cholangitis, and hemorrhage; prophylaxis and management must be documented.

The procedure report includes indication, consent, sedation, extent of examination, findings, interventions, specimens, complications, and follow-up plan.

Quality metrics: cecal intubation 90% or more, adenoma detection rate 25% or more, adequate bowel preparation 85% or more, withdrawal time 6 minutes or more, and adherence to surveillance intervals.

A time-out before starting confirms patient identity, planned procedure, allergies, anticoagulation status, and documented consent.

Open-access endoscopy requires explicit referral criteria and pre-procedure review to avoid inappropriate or low-value procedures.

Adverse events are documented, disclosed to the patient, and tracked in a quality database, with serious events reported per institutional policy.

Fasting minima are 2 hours for clear liquids and 6 hours for light solids; longer intervals apply to fatty meals.

Split-dose polyethylene glycol with the second dose 4-6 hours before the procedure is the preferred bowel preparation regimen.

The Boston Bowel Preparation Scale scores three segments from 0-3 for a total of 0-9, with 2 or more per segment considered adequate.

Antiplatelet and anticoagulant holding decisions depend on procedure bleeding risk, thromboembolic risk, and renal function.

Antibiotic prophylaxis is reserved for specific situations such as ERCP with incomplete drainage, cholangitis, and GI bleeding in cirrhosis.

Endocarditis prophylaxis applies only to high-risk cardiac conditions, not to routine endoscopic procedures.

Consent documentation covers indication, benefits, material risks, alternatives, and the planned sedation level.

ASA class III or higher and suspected obstructive sleep apnea favor anesthesia involvement for sedation.

Moderate sedation is a drug-induced state with purposeful response to verbal or light tactile stimulation and preserved spontaneous ventilation.

Standard agents are midazolam 1-2 mg plus fentanyl 25-100 mcg titrated to effect, with reduced initial dosing in the elderly.

Vital signs, oxygen saturation, and respiratory rate are recorded at least every 5 minutes during sedation.

Flumazenil 0.2 mg increments reverses benzodiazepines; naloxone 0.4 mg increments reverses opioids; resedation monitoring is required.

Propofol causes deep sedation and requires an anesthesia-trained provider with airway management skills.

Risk factors for sedation adverse events include ASA III or higher, obesity, obstructive sleep apnea, advanced age, and prolonged procedures.

Discharge requires stable vitals, baseline mentation, ability to ambulate, and a responsible escort.

The record captures time-out, drugs with doses and times, monitoring data, and any interventions for adverse events.

Key distances from the incisors are about 15 cm to the upper esophageal sphincter and about 40 cm to the gastroesophageal junction.

Erosive esophagitis uses the Los Angeles A-D grading, and Barrett esophagus uses the Prague C and M description.

Seattle protocol biopsies sample four quadrants every 1-2 cm plus any visible nodule in Barrett esophagus.

Forrest Ia, Ib, IIa, and IIb ulcer stigmata require endoscopic hemostasis, while IIc and III do not.

Gastric ulcers are biopsied and followed to exclude malignancy, whereas duodenal ulcers usually are not.

Helicobacter pylori testing requires holding proton pump inhibitors for 2 weeks and antibiotics for 4 weeks before breath or stool tests.

Celiac disease diagnosis needs four to six duodenal biopsies including the bulb while on a gluten-containing diet.

Medium or large esophageal varices with red wale marks are treated with band ligation.

Average-risk colorectal cancer screening begins at age 45 with colonoscopy every 10 years or annual FIT among the options.

Cecal intubation requires seeing the appendiceal orifice, ileocecal valve, and triradiate fold, documented with a photograph.

Adenoma detection rate targets are at least 25% overall, 30% in men, and 20% in women, with withdrawal time of at least 6 minutes.

Surveillance after 1-2 low-risk adenomas is 7-10 years; 3-4 adenomas or a lesion 10 mm or larger gives 3 years; 5 or more adenomas or high-grade dysplasia gives 1 year.

Serrated polyposis syndrome requires 1-year surveillance intervals and counseling of family members.

Cold snare resection is preferred for polyps under 10 mm, while larger lesions use submucosal injection with hot snare or mucosal resection.

Piecemeal resection of lesions 20 mm or larger needs a follow-up site check at 3-6 months.

A positive FIT mandates colonoscopy, and FIT is not appropriate in symptomatic patients.

High-risk ulcer bleeding is treated with epinephrine plus a second modality and a 72-hour high-dose proton pump inhibitor infusion.

Epinephrine is diluted to 1:10,000 and injected in 0.5-1 mL aliquots around the bleeding point.

Through-the-scope clips compress vessels and approximate tissue; over-the-scope clips close larger defects.

Hemostatic powder (TC-325) provides temporary control of diffuse or malignant bleeding.

Argon plasma coagulation treats superficial vascular lesions such as angioectasia and gastric antral vascular ectasia.

Acute variceal bleeding is managed with vasoactive drugs, antibiotics, and band ligation within 12 hours, repeated every 2-4 weeks.

Balloon tamponade is a bridge therapy, and TIPS is used for refractory variceal hemorrhage.

Post-polypectomy bleeding is controlled with clips or injection, with prophylactic clipping considered in anticoagulated patients.

Post-ERCP pancreatitis occurs in 3-10% of procedures and is reduced by rectal indomethacin 100 mg and periprocedural lactated Ringer solution.

Prophylactic pancreatic stenting lowers pancreatitis risk in high-risk cases such as difficult cannulation or prior post-ERCP pancreatitis.

A common bile duct stone on imaging or cholangitis is a very strong predictor of choledocholithiasis, while a dilated duct with bilirubin above 1.8 mg/dL is a strong predictor.

Acute cholangitis requires biliary drainage within 24 hours after antibiotics and resuscitation.

Sphincterotomy bleeding risk is increased by anticoagulation, cirrhosis, renal failure, and a small papilla.

Plastic biliary stents are exchanged roughly every 3 months, while covered metal stents suit malignant and selected benign strictures.

Cannulation proceeds from standard catheter to double-wire technique to precut fistulotomy after failed access.

Cholangioscopy with electrohydraulic lithotripsy is an option for large or impacted bile duct stones.

EUS evaluates pancreatic masses and cysts, subepithelial lesions, cancer staging, mediastinal and celiac nodes, and adrenal lesions.

Linear echoendoscopes permit needle passage for FNA, FNB, and therapeutic drainage, while radial instruments provide 360-degree imaging.

EUS-guided fine-needle biopsy is preferred for pancreatic masses because it yields histologic tissue architecture.

Cyst fluid carcinoembryonic antigen above 192 ng/mL suggests a mucinous cyst, and high amylase suggests a pseudocyst.

Rosemont criteria for chronic pancreatitis include hyperechoic foci and strands, lobularity, and ductal calculi or irregularity.

Lumen-apposing metal stents are used for EUS-guided drainage of pseudocysts and walled-off necrosis.

EUS-guided biliary drainage is a rescue option after failed ERCP.

Esophageal cancer T staging depends on depth of wall layer disruption, and N staging uses node size, echogenicity, and borders.

Capsule endoscopy is contraindicated in known strictures, and a patency capsule is used when stenosis is suspected.

Double-balloon, single-balloon, and spiral enteroscopy provide deep small bowel access for biopsy, hemostasis, and dilation.

Small bowel angioectasia is treated with argon plasma coagulation or bipolar cautery, with octreotide for recurrent bleeding.

Peroral endoscopic myotomy treats achalasia through a submucosal tunnel, and Z-POEM targets Zenker diverticulum.

Endoscopic submucosal dissection achieves en bloc resection with lower recurrence but higher perforation risk than piecemeal resection.

Barrett esophagus ablation uses radiofrequency ablation or cryotherapy after resection of visible nodules.

Endoscopic bariatric therapies include intragastric balloons and endoscopic sleeve gastroplasty.

Gastric peroral endoscopic pyloromyotomy is used for refractory gastroparesis.

Reprocessing order is bedside precleaning, leak test, manual channel cleaning, high-level disinfection, rinse, alcohol and forced-air drying, then vertical storage.

High-level disinfection requires 2% glutaraldehyde for 20 minutes at 20 degrees Celsius or ortho-phthalaldehyde for 12 minutes per manufacturer instructions.

Duodenoscopes need special elevator cleaning and may require double high-level disinfection or sterilization plus surveillance cultures.

Endoscopes are stored vertically and uncapped to prevent retained moisture and biofilm.

Single-use items include biopsy forceps, snares, water bottles, and specified valves, and are never reused.

Suspected prion disease exposure requires prion-specific decontamination or quarantine and destruction of the endoscope.

Reprocessing areas are dedicated and ventilated, with gloves, gown, mask, and eye protection worn.

Monitoring includes minimum concentration test strips, temperature logs, and periodic ATP or microbiologic surveillance.

Diagnostic colonoscopy perforation risk is about 0.1-0.2% and rises with polypectomy or dissection, most often at the sigmoid or cecum.

Post-polypectomy bleeding is immediate in 0.5-1% and delayed in 0.3-1%, with higher risk for lesions over 2 cm and anticoagulated patients.

Post-ERCP pancreatitis, cholangitis, and hemorrhage are the dominant ERCP adverse events and prophylaxis must be documented.

Procedure reports contain indication, consent, sedation, extent, findings, interventions, specimens, complications, and follow-up.

Quality benchmarks include cecal intubation 90% or more, adenoma detection 25% or more, and adequate preparation 85% or more.

A pre-procedure time-out verifies identity, procedure, allergies, anticoagulation status, and consent.

Adverse events are disclosed to the patient, documented, tracked in a quality database, and reported per policy when serious.