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## Complete Summary

#### GUIDELINE TITLE

Role of endoscopy in the evaluation and treatment of patients with
pancreaticobiliary malignancy.

#### BIBLIOGRAPHIC SOURCE(S)

Baron TH, Mallery JS, Hirota WK, Goldstein JL, Jacobson BC, Leighton JA,
Waring JP, Faigel DO. The role of endoscopy in the evaluation and
treatment of patients with pancreaticobiliary malignancy. Gastrointest
Endosc 2003 Nov;58(5):643-9. \[50 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14595292)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Pancreaticobiliary malignancy including ampullary carcinoma, pancreatic
adenocarcinoma (head; body/tail), cholangiocarcinoma (hilar; non-hilar),
and metastatic disease

**Note**: The approach to patients with purely intrahepatic
malignancies, suspected cystic neoplasms, or islet cell tumors is not
addressed.

#### GUIDELINE CATEGORY

Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Gastroenterology\
Oncology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To review the approach to the evaluation and treatment of the patient
with suspected pancreaticobiliary malignancy

#### TARGET POPULATION

Patients with suspected pancreaticobiliary malignancy

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Serum bilirubin

2.  Serum alkaline phosphatase

3.  Complete physical examination

4.  Serum tumor markers (i.e., CA 19-9 and carcinoembryonic antigen
    \[CEA\])

5.  Chest x-ray

6.  Transabdominal ultrasonography (TUS)

7.  Helical computed tomography (CT) scan

8.  Endoscopic ultrasound (EUS)

9.  Endoscopic retrograde cholangiopancreatography (ERCP)

10. Magnetic resonance cholangiopancreatography (MRCP)

11. Fine-needle aspiration (FNA) tissue sampling

12. Biopsy

13. Magnetic resonance imaging (MRI) including MRI, MR
    cholangiopancreatography (MRCP), or MR angiography

14. Percutaneous transhepatic cholangiography (PTC)

15. Intraductal ultrasonography (IDUS)

**Management**

1.  Pancreaticoduodenectomy

2.  Surgical resection

3.  Nonoperative palliation of obstructive jaundice

4.  Chemotherapy and/or radiation therapy

5.  PTC with stent placement

6.  Endoscopic palliation

#### MAJOR OUTCOMES CONSIDERED

-   Signs and symptoms

-   Sensitivity and specificity of diagnostic tests

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

In preparing this guideline, a MEDLINE literature search was performed,
and additional references were obtained from bibliographies of the
identified articles and from recommendations of expert consultants.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Guidelines for appropriate utilization of endoscopy are based on a
clinical review of the available data and expert consensus.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Recommendations are followed by evidence grades (A-C) identifying the
type of supporting evidence. Definitions of the evidence grades are
presented at the end of the \"Major Recommendations\" field.

**[Presentation, Clinical Evaluation]{.underline}**

Patients with suspected pancreaticobiliary malignancy may present
clinically with obstructive jaundice, abdominal pain, anorexia, abnormal
liver enzymes, weight loss, new onset diabetes mellitus, or steatorrhea.
Elevations in the levels of serum bilirubin and alkaline phosphatase
suggest biliary obstruction. Conversely, patients with pancreatic
malignancy and no biliary involvement usually have normal liver enzymes.
A history of inflammatory bowel disease or previously diagnosed
malignancies should be sought. A complete physical examination including
assessment for abnormal lymph nodes, jaundice, hepatomegaly, palpable
gallbladder, or mass should be performed. A chest X-ray may be
appropriate to exclude pulmonary metastases. Obtaining serum tumor
markers such as CA 19-9 and carcinoembryonic antigen (CEA) may be
appropriate. Once there is a clinical suspicion of a pancreaticobiliary
malignancy, further investigation with abdominal imaging studies is
appropriate.

**Types of Pancreaticobiliary Malignancies**

*Ampullary Adenocarcinoma*

-   Pancreatic Adenocarcinoma

    -   Head

    -   Body/tail

-   Cholangiocarcinoma

    -   Hilar

    -   Non-hilar

-   Metastatic Disease

**Ampullary Carcinoma**

Ampullary carcinoma is suspected based upon demonstration of obstructive
jaundice, often with dilation of the pancreatic and biliary ducts seen
on abdominal imaging studies. A discrete mass may or may not be
identifiable using standard transabdominal ultrasound or helical
computed tomography (CT) scanning. Endoscopic retrograde
cholangiopancreatography (ERCP) allows for direct identification and
biopsy confirmation, although biopsy is not 100% accurate . Magnetic
resonance cholangiopancreatography (MRCP) may allow identification of
the lesion and obviate diagnostic ERCP. Endoscopic ultrasound (EUS)
allows for more accurate diagnosis and staging of these lesions than CT,
and also allows for forceps and fine-needle aspiration (FNA) tissue
sampling. EUS may also allow selection of patients that can undergo
local resection instead of pancreaticoduodenectomy (Whipple operation).
Once the lesion is identified and staged, palliation of jaundice or
operative resection for cure is similar as is discussed for carcinoma of
the pancreatic head, below.

**Pancreatic Malignancy**

The approach to the patient with pancreatic carcinoma involving the
pancreatic head is different than the patient with body/tail lesions in
terms of curative potential and accessibility as well as palliation.
They will be discussed separately.

*Pancreatic Head*

Most patients with cancer of the pancreatic head present with
obstructive jaundice. Radiological imaging studies are performed
allowing for:

a.  Detection of the tumor

b.  Determination of tumor resectability

c.  Tissue acquisition under imaging guidance

The American Joint Committee on Cancer staging system has recently been
updated:

  -------------------------------------------------------------------------
  **PRIMARY    
  TUMOR (T)**  
  ------------ ------------------------------------------------------------
  TX           Primary tumor cannot be assessed

  TO           No evidence of primary tumor

  Tis          Carcinoma in situ

  T1           Tumor limited to the pancreas 2 cm or less in greatest
               dimension

  T2           Tumor limited to the pancreas more than 2 cm in greatest
               dimension

  T3           Tumor extends beyond the pancreas but without involvement of
               the celiac axis or superior mesenteric artery

  T4           Tumor involves the celiac axis or superior mesenteric artery
               (unresectable primary tumor)

  **REGIONAL   
  LYMPH NODES  
  (N)**        

  NX           Regional lymph nodes cannot be assessed

  N0           No regional lymph node metastasis

  N1           Regional lymph node metastasis

  **DISTANT    
  METASTASIS   
  (M)**        

  MX           Distant metastasis cannot be assessed

  M0           No distant metastasis

  M1           Distant metastasis
  -------------------------------------------------------------------------

 

  ------------------------------------------------------------------------
  **Stage                                                     
  Grouping**                                                  
  ------------- ---------------------- ---------------------- ------------
  0             Tis                    N0                     M0

  IA            T1                     N0                     M0

  IB            T2                     N0                     M0

  IIA           T3                     N0                     M0

  IIB           T1                     N1                     M0

  \--           T2                     N1                     M0

  \--           T3                     N1                     M0

  IIII          T4                     Any N                  M0

  V             Any T                  Any N                  M1
  ------------------------------------------------------------------------

[Transabdominal Ultrasonography (TUS)]{.underline}

TUS will suggest biliary obstruction by the demonstration of biliary
ductal dilation. It may also identify the presence of obvious liver
metastases. However, standard TUS is operator dependant and has a poor
sensitivity for detecting small neoplasms of the pancreatic head. Recent
advances in TUS such as color-power Doppler ultrasonography,
ultrasonographic angiography, harmonic imaging (tissue harmonic imaging
and contrast harmonic imaging), and 3-dimensional ultrasonography
(including virtual endoscopy) may improve the usefulness of this
modality in the staging of pancreatic cancer. Nonetheless, more
information regarding staging and extent of disease, and possible nodal
or vascular involvement is obtainable with other imaging modalities.

[Computed Tomography]{.underline}

Helical CT scanning of the abdomen with fine cuts through the pancreas
during the arterial and portal phases of contrast enhancement has a high
sensitivity and specificity for the detection of pancreatic carcinoma.
It allows for detection of tumor extension, liver metastases, and
invasion of vascular structures. Helical CT is an accurate means for the
detection of pancreatic adenocarcinoma and determining resectability.
Multislice (multidetector) CT has been introduced and may improve the
accuracy even further than helical CT. If the CT findings are found to
be highly suggestive of resectable pancreatic carcinoma in the
appropriate clinical setting and the patient is felt to be an operative
candidate, a reasonable approach is to refer the patient directly for
surgical resection (pancreaticoduodenectomy) without further imaging or
diagnostic testing. Transabdominal or CT-guided biopsy of the pancreatic
mass may rarely result in tumor seeding at the needle track or within
the peritoneum and has been reported to increase the risk of
postoperative recurrence.

If the CT scan reveals overt evidence of unresectable pancreatic cancer
or the patient is a nonoperative candidate because of comorbid medical
conditions, nonoperative palliation of obstructive jaundice should be
performed at the time of ERCP (see below). If a definitive tissue
diagnosis is required for the administration of chemo and/or radiation
therapy, tissue acquisition can be performed at the time of palliative
ERCP. If a tissue diagnosis cannot be made at that time, then
transabdominal biopsy (CT-guided or ultrasound) of the mass or
metastatic disease sites (i.e. liver lesions), or EUS-guided FNA of the
mass or metastatic sites should be performed.

[Magnetic Resonance Imaging (MRI)]{.underline}

MRI of the pancreas may include MRI, MRCP, or MR angiography. Standard
abdominal MRI appears to be an accurate modality for staging pancreatic
carcinoma, though it does not appear to be more specific or sensitive
than helical CT. Additionally, it is more expensive and more time
consuming to perform than CT.

[Endoscopic Ultrasound (EUS)]{.underline}

If expertise in EUS is readily available, it should be used as a
preoperative staging modality in patients with suspected pancreatic
cancer. This is particularly important in patients with equivocal
findings on CT or those with comorbidities and therefore at higher risk
for intraoperative or postoperative complications. EUS allows
identification of vascular invasion as well as sampling of suspicious
appearing lymph nodes, which if positive may change the treatment
approach as it alters prognosis. EUS appears to be complementary to
helical CT with EUS better at detecting small (\<3 cm) masses, staging
the portal vein, and detecting lymph node metastases, while helical CT
is superior for staging arterial involvement and distant metastases.
EUS-guided FNA biopsy allows for a definitive tissue diagnosis of a
pancreatic mass when results on other biopsy methods are negative but
pancreatic cancer is suspected. If EUS suggests resectability,
EUS-guided biopsy of the mass is not necessary prior to proceeding with
operative resection, although this point remains controversial.
Advantages of needle biopsy of the mass include identification of
alternative diagnoses to primary pancreatic adenocarcinoma (lymphoma,
islet cell tumors, metastatic disease). It also allows for preoperative
patient counseling. Potential disadvantages of preoperative EUS-guided
FNA include the risks of pancreatitis, bleeding, and tumor seeding. The
latter has never been reported and appears to be inconsequential in most
cases since the needle path will usually be within the resected
specimen. Ideally EUS should be performed prior to ERCP with stent
placement since this may interfere with the accuracy of EUS staging and
EUS findings of unresectable carcinoma allows patient selection for
self-expanding metallic stent placement. In patients with unresectable
cancer EUS-guided celiac plexus neurolysis has been shown to control
disabling abdominal pain.

[ERCP]{.underline}

The pathognomonic findings on ERCP of a pancreatic head cancer are
strictures of the bile and pancreatic ducts with proximal dilation
(\"double-duct\" sign). While ductal abnormalities are almost invariably
present in patients with adenocarcinoma, other imaging modalities (CT,
MR, EUS) have supplanted ERCP in the diagnosis of pancreatic cancer.
Preoperative ERCP does not add further staging information and may
result in complications (pancreatitis, perforation) that may make
operative intervention more difficult and/or considerably delay
operative intervention resulting in a decreased potential for curative
resection. Furthermore, even if no ERCP-related complications occur,
several studies suggest postoperative complications following
pancreaticoduodenectomy are higher when a preoperative ERCP is
performed. However, if the patient suffers from cholangitis or severe
pruritus, or if there is a substantial delay in operative resection,
preoperative ERCP with biliary drainage should be performed.

Palliation of obstructive jaundice can be achieved with ERCP and biliary
stent placement. Randomized trials comparing ERCP and biliary stenting
to surgery demonstrate equal palliation of jaundice with ERCP, though
more frequent recurrence of jaundice. Unfortunately, these studies were
performed prior to the advent of self-expandable metal biliary stents or
duodenal stents (for palliation of gastric outlet obstruction). A recent
meta-analysis suggests that surgical or endoscopic palliation is
appropriate and should be tailored to the individual patient. In those
patients in whom ERCP is unsuccessful, percutaneous transhepatic
cholangiography (PTC) and stent placement should be offered for
palliation of obstructive jaundice. Plastic stents occlude from the
deposition of bacterial biofilm resulting in cholangitis and recurrence
of jaundice. Biliary self-expandable metal stents (SEMS) have a
significantly longer patency rate than 10Fr plastic stents. This
advantage will only be realized if the patient survives more than the
anticipated time to stent occlusion of 3 to 4 months. Since biliary SEMS
are significantly more expensive than plastic stents, their use should
be reserved for patients whose estimated survival is greater than three
to four months and/or those patients without liver metastases.

In patients with unresectable pancreatic carcinoma who develop malignant
gastric outlet obstruction, endoscopic palliation may be achieved using
self-expandable gastroduodenal stents.

*Pancreatic Body/Tail*

Patients with pancreatic cancer involving the body and tail are less
likely to have resectable tumors since symptoms generally do not occur
until they have advanced disease. A similar approach to the patient with
pancreatic carcinoma of the head is in order, though ERCP has little, if
any, role in the diagnosis and palliation of these patients. EUS allows
for tissue diagnosis and staging.

**Suspected Cholangiocarcinoma**

A primary tumor of the bile duct should be suspected based upon clinical
and imaging findings. Abdominal CT scans will show biliary dilation
without an associated pancreatic mass or pancreatic ductal dilation, and
the level of obstruction can usually be localized to a level above the
pancreatic head, but at or below the level of the hepatic bifurcation.

The differentiation of hilar versus non-hilar tumors is important
because of both the difficulty in resection of hilar tumors as well as
the approach to endoscopic palliation in these patients. The Bismuth
classification of cholangiocarcinoma is useful for determining surgical
resectability and type of surgery. Please refer to the figure titled
\"The Bismuth classification of cholangiocarcinoma\" in the original
guideline document.

*Non-Hilar Cholangiocarcinoma*

If the level of obstruction is traced to below the level of the
bifurcation (Bismuth type I lesions, see figure titled \"The Bismuth
classification of cholangiocarcinoma\" in the original guideline
document) by imaging studies, operative resection should be considered
in fit patients without metastatic disease. If the patient is a poor
operative candidate, then palliation using plastic or metal stents as
for pancreatic carcinoma should be undertaken.

*Hilar Cholangiocarcinoma*

The approach to the patient with cholangiocarcinoma involving the
bifurcation requires definition of the biliary anatomy to determine
operative resectability. Extensive injection of contrast during ERCP to
define the anatomy usually results in contrast injection into both
intrahepatic systems. This should be avoided as it increases the risk of
post-procedural cholangitis since the entire biliary tree may not be
amenable to drainage. Therefore after an abdominal CT scan has suggested
hilar cholangiocarcinoma, MRCP and MRI should be performed to determine
ductal anatomy. If the CT and MRI suggest resectable disease, the
patient should be sent for surgery if their health status permits. If
the lesion is deemed unresectable by MRI or the patient is unfit for
surgery, unilaterally directed endoscopic biliary stent placement
directed by MRI should be performed since unilateral stent placement
offers palliation of jaundice equal to bilateral placement but with less
risk of cholangitis. This method also appears to be more cost-effective.

[Endoscopic Ultrasonography]{.underline}

EUS has not been proven to offer more information than that which may be
obtained using other imaging modalities in patients with suspected
cholangiocarcinoma. One small series suggests that EUS may allow a
definitive tissue diagnosis to be made in patients with hilar tumors.
Intraductal ultrasonography (IDUS) at the time of ERCP may add useful
information in the patient with a suspected pancreaticobiliary
malignancy, especially cholangiocarcinoma. However, there are limited
data to date, the exact role has yet to be defined, and the availability
of this technology is limited to specialized centers.

**Metastatic Disease**

A variety of malignant diseases may metastasize to and around the
biliary tree resulting in obstruction. These may lead to biliary
obstruction either intrinsically or extrinsically (porta hepatic
involvement) from the level of the bifurcation to the ampulla. The
diagnosis may be obvious, based upon known widespread malignancy, or
more occult and discovered at the time of surgical resection or
endoscopic evaluation. CT scan findings may mimic primary malignant
disease of the bile ducts or pancreas. MRI may be useful in establishing
perihilar obstructive disease. If disease is widespread, palliation of
obstruction is achieved as discussed for primary malignancies. Surgical
resection may be indicated in selected cases.

A suggested algorithm for evaluation and management of patients with
pancreaticobiliary malignancy can be found in the figure titled \"A
suggested algorithm for diagnosis and management of pancreaticobiliary
malignancy\" of the original guideline document.

**Summary**

-   The evaluation of patients with suspected pancreaticobiliary
    malignancy should include helical or multislice CT of the abdomen
    **(B)**.

-   EUS, if available, should be performed for further staging and
    possible FNA of the primary or tumor and/or suspicious lymph nodes
    unless obvious metastatic disease is present **(B)**.

-   If the disease is resectable and the patient is fit, surgical
    resection of the lesion should be performed **(B)**.

-   If the lesion is unresectable or the patient is unfit for surgery,
    then endoscopic palliation of jaundice **(A)** or gastric outlet
    obstruction should be undertaken **(B)**.

-   Preoperative ERCP should be avoided unless there is cholangitis or
    significant delay in surgery and the patient is symptomatic **(B)**.

-   If the CT suggests cholangiocarcinoma, particularly of the
    bifurcation, an MRCP should be obtained to assess for resectability.
    If unresectable, endoscopic palliation of jaundice should be
    performed using the MRCP as a guide to unilateral drainage to
    minimize cholangitis **(A)**.

**[Definitions]{.underline}**

**A**: Prospective controlled trials\
**B**: Observational studies\
**C**: Expert opinion

#### CLINICAL ALGORITHM(S)

A clinical algorithm is provided in the original guideline document for
the diagnosis and management of pancreaticobiliary malignancy.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and classified for the
recommendations using the following scheme:

**A** = Prospective controlled trials\
**B** = Observational studies\
**C** = Expert opinion

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate utilization of endoscopy in the evaluation and treatment of
patients with pancreaticobiliary malignancy

#### POTENTIAL HARMS

-   Standard transabdominal ultrasonography (TUS) is operator dependent
    and has a poor sensitivity for detecting small neoplasms of the
    pancreatic head.

-   Potential disadvantages of preoperative endoscopic ultrasonography
    (EUS)-guided fine-needle aspiration (FNA) include the risks of
    pancreatitis, bleeding, and tumor seeding. The latter has never been
    reported and appears to be inconsequential in most cases since the
    needle path will usually be within the resected specimen.

-   Preoperative endoscopic retrograde cholangiopancreatography (ERCP)
    does not add further staging information and may result in
    complications (pancreatitis, perforation) that may make operative
    intervention more difficult and/or considerably delay operative
    intervention resulting in a decreased potential for curative
    resection. Furthermore, even if no ERCP-related complications occur,
    several studies suggest postoperative complications following
    pancreaticoduodenectomy are higher when a preoperative ERCP is
    performed.

-   Extensive injection of contrast during ERCP to define the anatomy
    usually results in contrast injection into both intrahepatic
    systems. This should be avoided as it increases the risk of
    post-procedural cholangitis since the entire biliary tree may not
    amenable to drainage.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Further controlled clinical studies are needed to clarify aspects of
    this statement, and revision may be necessary as new data appear.
    Clinical consideration may justify a course of action at variance to
    these recommendations.

-   The information in this guideline is intended only to provide
    general information and not as a definitive basis for diagnosis or
    treatment in any particular case. It is very important that
    individuals consult their doctors about specific conditions.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Baron TH, Mallery JS, Hirota WK, Goldstein JL, Jacobson BC, Leighton JA,
Waring JP, Faigel DO. The role of endoscopy in the evaluation and
treatment of patients with pancreaticobiliary malignancy. Gastrointest
Endosc 2003 Nov;58(5):643-9. \[50 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14595292)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Nov

#### GUIDELINE DEVELOPER(S)

American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Douglas O. Faigel MD (*Chair*); Todd H. Baron MD;
J. Shawn Mallery MD; William K. Hirota MD; Jay L. Goldstein MD; Brian C.
Jacobson MD; Jonathan A. Leighton MD; J. Patrick Waring MD

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society for Gastrointestinal Endoscopy (ASGE) Web
site](http://www.asge.org/PublicationsProductsIndex.aspx?id=352).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on October 18, 2004. The
information was verified by the guideline developer on November 5, 2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008