Show notes
Episode four closes the chapter on four topics that each test one recognition: when the reflexive answer is wrong because the underlying principle has shifted. Antibiotic prophylaxis turns on closed-space infection, not the prosthetic device, so the 2007 AHA guideline took GI endoscopy off the endocarditis list. Cardiac device management turns on electromagnetic interference, so modern pacemakers tolerate routine polypectomy without reprogramming while ICDs need arrhythmia detection suspended. Capsule endoscopy lives or dies on retention risk addressed by the patency capsule, and the ASGE Cotton lexicon grades adverse events by intensity of intervention.
Topics covered
Endocarditis prophylaxis off the GI list
The closed-space infection principle
Incomplete ERCP drainage and cyst FNA prophylaxis
Pacemakers and monopolar electrosurgery
ICDs and arrhythmia detection
Capsule endoscopy retention
The patency capsule workup
The ASGE Cotton adverse event lexicon
Key decisions
Give no endocarditis prophylaxis for GI endoscopy, including prosthetic valves, pacemakers, ICDs, prosthetic joints, and vascular grafts, because the transient bacteremia risk is too low to justify antibiotics.
Reserve prophylaxis for closed-space scenarios: incomplete biliary drainage at ERCP, EUS-FNA of cystic lesions, PEG or PEJ placement with a single dose of cefazolin, cirrhotic UGI bleeding with ceftriaxone, and PD-patient lower endoscopy.
Withhold prophylaxis for solid-lesion EUS-FNA, diagnostic EGD and colonoscopy, and non-bleeding variceal band ligation, because none creates a closed space the immune system cannot clear.
Do not reprogram pacemakers for routine polypectomy; place the grounding pad away from the heart on the thigh or lower back, and add backup pacing only for the pacemaker-dependent patient in the cardiac field.
Suspend ICD arrhythmia detection with a magnet or formal reprogramming during electrosurgery, leaving the pacing function untouched and placing external defibrillator pads as backup.
Define capsule retention as failure to pass within two weeks (about one to two percent baseline, five to thirteen percent with strictures) and screen with the patency capsule when Crohn or prior surgery raises stricture risk.
Grade adverse events by intervention intensity on the ASGE Cotton lexicon: mild (under three nights, no transfusion), moderate (four to ten nights or transfusion or repeat endoscopy), severe (over ten nights, surgery, or disability), and fatal (death within thirty days).
For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.
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