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FES written exam questions with answers
1. Time frames for upper endoscopy - Familiar polyposis: 1-2 years
2. Patient positioning for ERCP: prone position with the head turn toward the right shoulder
3. patient positioning for upper endoscopy: left side down, head slightly up.
4. Maneuver to look at the GE junction: J maneuver (tip up), rotate the shaft of the scope CCW and withdraw,
pulling the scope into the proximal body and cardia, rotate the scope 360 around the GE jx,
5. techniques to decrease post ERCP pancreatitis: selective bile duct cannu- lation w/ guidewire, stenting
pancreatic dut w/ stent or guidewire for difficult CBD cannulation, limiting contrast injection into the pancreatic duct
6. Technique for billiary sphincterotomy: apply pressure w/ cutting wire toward 11 o'clock direction, continue the
sphincterotomy until the intramural portion is cut. Use blended current with cutting and coag at 15-20J. Alt: can use balloon dilation but a/w higher rate of post-ECRP pancreatitis
7. Direction of pancreatic cannulation during ERCP: 1 to 3 o'clock position
8. When to stop warfarin before ERCP: stop 5 days before and switch to heparin or lovenox if peri-procedural
anticoagulation is required. This can be stopped a day prior to the procedure
9. rate of post ERCP pancreatitis: 3-5%
10. Timing of colonoscopy for first degree relative w/ CRC or adenomas prior to age 60: colonoscopy at age 40 or
10 years before the youngest affected relative, whichever is earlier. Then repeat every 5 yrs
11. Indications for ECRP: Tissue sampling - bile duct, pancreatic duct, ampulla bx chronic pancreatitis/divisum
pancreatic malignancy billiary
2 / malignancy Benign strictures Ductal disruption/injury Jaundice cholangitis gallstone pancreatitis dilated CBD
12. maneuvers to enter IC valve: rotate the scope until the valve is at the bottom of the visual field, look down into
the valve, gently insufflate air to open up the valve, OR retroflex the tip in the cecum and shorten the scope (hook the IV valve)
13. cancer detection rate of brush biopsy: 20-60%
14. band ligation vs sclerotherapy for esophageal varices: equal efficacy but baldn ligation has lower
complication rate.
15. cancer detection rate of needle aspiration: 6-30%
16. how long after sphincterotomy can the bleeding complication manifest?: -
immediate up to 14 days
17. relative contraindications for colonoscopy: anal fissure, recent MI, PE, large bowel obstruction
18. Time frames for upper endoscopy - esophageal varices s/p sclerotherapy and banding: q6-8weeks
19. Indications for screening colonoscopies: over 50 y/o, repeat every 10 years
20. Time frames for upper endoscopy - pernicious anemia: single endoscopy w/o f/u
21. complication rate of diagnostic colonoscopy: 1:
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36. When is ballon temponde useful?: for controlling bleeding after endoscopic sphincterotomy particularly in
settings where a biliary stone extraction balloon is already in use
37. patency rate of plastic stents: 2-6mo. requires removal or exchange.
38. definite contraindication for colonoscopy: peritonitis
39. When to stop anti-platlet therapy before ERCP: 10days prior to the pro- cedures. Do not start for 5-
days after the ERCP IF sphincterotomy has been performed.
40. When is argon plasma coagulation useful: large mucosal area required for treatment such as gastric antral
vascular ectasia (GAVE), when risk of deeper thermal injury is heightened concern such as cecal angiodysplasia
41. epinephrine dilution for submucosal injection: 1:10,
42. Cancers seen in HNPCCC: stomach, small intestine, kidney, ovarian and HPB
43. Maneuver for retroflexion in the rectum: withdraw the scope into the rectal vault, turn the tip of the scope fully
into the up postion, advance the scope into the rectum with simultaneous torque as the tip is deflected upward.
44. first degree relative w/ CRC or adenomas after age 60 y/o: colonoscopy at age 40, repeat every 10 yrs
45. MAneuvers to pass the ascending colon: clockwise torque, sucking out any gas, shortening the scope, tip
deflection down and to the right, apply pressure to t-colon, turn patient to the right or onto their back
46. how long can a naso-biliary stent be left in place?: several days.
47. Diagnostic criteria for FAP: >100 adenomas at anytime endoscopically, pres- ence of any adenomas below age 40
5 / in an at-risk relative of someone diagnosed w/ FAP
48. Screening for HNPCC: begin at age 20-25 or 10 years younger than youngest age of CRCA diagnosis in the
family. Repeat every 1-2 year
49. Time frames for upper endoscopy - gastric ulcer: q6 weeks until healed with bx and brushings
50. What is the minimum time for the scope withdrawal: 6-8min
51. direction of biliary cannulation: 11 to 12 o'clock position
52. Patient positioning during ERCP if advancement of the scope into the duodenum is difficult: left lateral
decubitus position and then switch back to prone after the scope has pased through the pylorus
53. Time frames for upper endoscopy - esophageal ulcer: q6weeks until healed with bx and brushings
54. how to minimize contact between healthy tissues and a polyp when cau- terizing with a snare?: position the
polyp so that there is broad contact rather than very focal contact of its surface with the adjacent bowel wall
55. how do you apply cautery current when removing polyps with a snare?: - monopolar current in short bursts
using primary coag until the tissue at the base begins to turn white. Then tighten the snare while applying a final burst of cautery to allow excision.
56. methods of polyp retrieval: suction into a trap for small polyps, suction onto the scope tip with scope withdrawal
for slightly larger polyps, retriever nets for larger polyps
57. methods to inject saline to elevate sessile polyps: inject at the at end of the lesions as seen endoscopically (at the
proximal end for colon and at the distal end for foregut)
58. What does failure of the lesion to rise with saline injection indicate?: - submucosal involvement with the
pathology. Endoscopic resection might not be advisable.
7 / tissue. Endoscopically guided, specific wavelength laser light is then deployed, which causes a photochemical reaction of the porfimer sodium, leading to the production of singlet oxygen and targeted cell death.
71. What are the complications of photodynamic therapy: photosensitivity, stric- tures, fistulae, chest pain,
odynophagia
72. Radiofrequency ablative techniques have proven to be effective in the treatment of: dysplasic barrett's
epithelium
73. What is the most appropriate ablative technique for cecum: APC
74. PEG can be used as bridge for what duration: 1-3mo
75. What are the indications of PEG: any patients with a functional GI tract, but who is unable to take enteral
nutrition independently, patients requiring gastric decompression for gastric outlet or more dital bowel obstructions secondary to unresectable masses or other lesions, reduction of gastric volvulus in patients who are not candidates for surgical reduction
76. Indications for PEJ: gastroparesis, atony, a functional gastric outlet obstruc- tion, documented reflux and
aspiration pneumonia with intragastric feeding
77. absolute contraindications for PEG and PEJ: massive or poorly controlled ascietes, patients with diffuse
gastric cancer
78. relative contraindications for PEG/PEJ: patients who are combative or neu- rologically impaired that they are
at risk for pulling out the tubes. patients with a mechanical or functional bowel obstruction distal to a point of feeding unless indication is decompression for palliation. Those with poor nutrition
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79. what are the steps for choosing an appropriate site for PEG: insufflate the stomach w/ external palpation of the
bdominal wall visible endoscopically w/in the gastric lumen, transilluminate the anterior abdominal wall and externally palpate at a minimum two finger breaths below the costal margin to determine an appropriate site
80. What does safe tract technique entail: passage of a saline filled syringe from the anterior abdominal wall into the
gastric lumen under endoscopic visualization, aspiration of the syringe as it is passed this ensures no air or enteric contens are aspirated before the needle can be seen within the gastric lumen through the endoscope.
81. steps for PEG placement after an external site is chosen: prep and drape the abdominal wall, anesthesize the skin,
abx ppx, make a small transverse incision in the skin larger than the PEG tube to minimize the risk of wound infection, pass a 14G sheathed needle through the anterior abdominal wall into the gastric lumen, Grasp the sheathed needle with an endoscopic snare, then pass a guidewire through the needle, loosen the snare and grasp the guidewire separate from the needle, bring the guidewire, snare and endoscope out through the mouth
82. What are the steps of the pull technique for PEG placement: attach a pull PEG to the oral end of looped
guidewire and pull it retrograde through the mouth, esophagus and into the gastric lumen-->secure the PEG with an external bumper at an appropriate position to avoide undue tension on the gastrocutaneous tract as dictated by body habitus--> there should be at leat s0.5cm of play between the skin and the external bumper to ensure that the PEG is not too tight. Repeat the endoscopy after placement of the PEG is imperative to document appropraite placement and security of the site
83. What are the steps of Push technique for PEG placement: guidewire is not looped but single stiffer wire over
which the peg tube is advanced. As the tube assembly is advanced the dilating tip of the tube is pushed through the gastric wall and anterior abdomninal wall until the tube is seated.
84. What is russell approach?: commonly used by IR. uses T-fastners. Can be con- sidered in pts with oropharyngeal
malignancy or obstructing esophageal neoplasia.
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98. when are stents used?: 1. palliation for esophageal cancer
- reduce reflux (windsock at the GE jx) occlude TE fistula treat biliary obstruction
99. tumor ingrowth occurs more frequency with coated or noncoated stents?-
: noncoated
100. stent migration occurs more frequency with coated or noncoated stent: -
coated
101. what are contraindications for endoscopic foreign body removal: 1. for- eign body in the small bowel
sharp or irregular objects - serial exam patients with obstruction or perforation with peritonitis esophageal perforation with pneumomediastinum or mediastinitis
102. where in colon can foreign objects be lodged?: distal sigmoid colon anorectal canal particularly at the
sacral promontory
103. CBD stone removal w/ the lowest moridity: lap transcystic CBD exploration
104. which trocar is used for choledochoscope: medial subcostal port
105. what structure in the cystic duct can make the passage of the choledo- choscope difficult?: Heister's valves
106. what are the advantages of lap endobiliary stenting: 1. does not require advanced suturing skills
2. protects patients from the potential undesirable effects of residual choledocholithi- asis
3. allows outpatient cholecystectomy and later ERCP to be performed
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4. has few complications
107. steps for placing endobiliary stent: confirm CBD stone with cholangiography
-->advance the stent through the cystic duct under fluoro and position across the ampulla --> complete the cholecystectomy
108. to which layer is india ink injected: submucosa at the level of the lesion in two sites 180 degree opposed
109. what are some caveats in injecting colonic lesions with india ink: 1. clamping of the bowel to prevent
insufflation of the bowel proximal to the lesion
- patients must be placed in a modified lithotomy position for colonscopic access
110. best outcome for stone removal for common hepatic duct stone proximal to cystic duct takeoff: endobiliary
stenting with ERCP
111. what instrument is best for object lodged transrectally: delivery forecep
112. What are complications of colonoscopy in order of most common to least common:
hypoxia>arrythmia>bradycardia>hypotension
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126. Examples of hyperosmotic prep solution: mag citrate and sodium phos- phate
127. how does mag citrate work: causes cholecystokinin release to stimulate fluid secretion and promote intestinal
motility
128. how does sodium phosphate work: causes fluid retension and subsequent loss of fluid and electrolytes in stool.
May also bring on nephrocalcinosis
129. is there a difference in bowel prep quality between polyethylene glycol and sodium phosphate?: no
130. what are contraindications for sodium phosphate prep?: renal failure. acute coronary syndromes, CHF, ileus,
intestinal malabsorption, ascities, and chil- dren with these conditions
131. when is antibiotic ppx recommended for endoscopic procedures: patients w/ prosthetic valve, hx of
endocarditis, systemic-pulmonary shunt, synthetic vascular graft <1y/o, complex cyanotic congenital heart disease undergoing stricture dilation, variceal sclerotherapy, ERCP and has obstructed biliary tree those with obstructed bile duct undergoing ERCP, those with pancreatic cystic lesion undergoing ERCP or EUA-FNA, cirrhosis with acute GI bleeding undergoing any endoscopic procedure, all patients undergoing PEG placement
132. what is the risk of bacteremia after upper GI endoscopy: 4.4%
133. what is the endoscopic procedure a/w highest risk of bacteremia: -
esophageal stricture dilation and sclerotherapy of esophageal varices
134. what are cardiac lesions at highest risk for infective endocarditis: pros- thetic cardiac valves, previous
bacterial endocarditis, surgically constructed sys- temic-pulmonary shunt, complex cyanotic congenital heart disease such as TOF
135. what are endoscopic procedures a/w high risk of significant bleeding: - polypectomy, biliary sphincterotomy,
14 / pneumatic or bougie dilation, PEG placement, endosonographic guided FNA, laser ablation and coagulation, tx of varices
136. recommendation for anticoagulation for high VTE risk procedures: for high risk patient, d/c warfarin 3-
5days before the procedure, consider heparin while INR is below therapeutic level. For low risk patient, d/c warfarin 3-5 days before and restart warfarin after the procedure
137. what are endoscopic procedure with high bleeding risk: polypectomy, bil- iary sphincteromtomy, pneumatic
or bougie dilation, PEG placement, EUS guided FNA, laser ablation and coagulation, variceal treatment
138. what are endoscopic procedures with low bleeding risk: diagnostic pro- cedures, ECRP w/o
sphincterotomy, biliary/pancretaic stent, EUS w/o FNA, en- teroscopy
139. what are high VTE risk conditions: A fib a/w valvular heart disease, mitral mechanical valve, mechanical
valve with prior VTE event
