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Alternatives and adjuncts to moderate procedural sedation for gastrointestinal endoscopy

Author: Jonathan Cohen, MD

Section Editors: John R Saltzman, MD, FACP, FACG, FASGE, AGAF, Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editor: Kristen M Robson, MD, MBA, FACG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2018. | This topic last updated: Dec 04, 2017.

INTRODUCTION — The development of gastrointestinal endoscopy has greatly expanded the diagnostic and
therapeutic capabilities of gastroenterologists. Adequate patient tolerance is essential for successful
completion of a safe examination and compliance with subsequent follow-up. As a result, endoscopists have
developed skills in administering a variety of sedative and analgesic agents to facilitate procedures and
enhance patient comfort.

Most of the attention has been placed on selecting the optimal regimen for producing procedural sedation and
monitoring patients adequately during the procedures. Many procedures are performed using intravenous
benzodiazepines and opiates (previously referred to as intravenous conscious sedation), which typically result
in moderate degrees of sedation. There have been attempts to determine which patients and procedures
require deeper sedation. In addition, there has been an effort to make some diagnostic procedures more
tolerable to avoid the cost and risk of procedural sedation altogether.

Endoscopists occasionally encounter individuals who are difficult to adequately sedate for endoscopy using
standard agents. In addition, certain therapeutic endoscopic procedures require deeper levels of sedation.
There are multiple options in these settings:

● Addition of diphenhydramine to standard procedural sedation

● Administration of propofol

● General anesthesia with endotracheal intubation

This topic will review the use of these alternative and adjunctive approaches for sedation for gastrointestinal
endoscopy. An overview of procedural sedation for gastrointestinal endoscopy, the adverse events related to
sedation, and the performance of endoscopic procedures without sedation are discussed elsewhere. (See
"Overview of procedural sedation for gastrointestinal endoscopy" and "Adverse events related to procedural
sedation for gastrointestinal endoscopy" and "Sedation-free gastrointestinal endoscopy".)

PATIENTS WHO ARE LIKELY TO BE DIFFICULT TO SEDATE — Characteristics of patients who are difficult
to sedate using standard regimens have not been well established in controlled trials. However, several
characteristics are generally considered to be risk factors for difficult sedation, including [1-4]:

● A history of prior difficulty with procedural sedation

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● Prescribed or illicit benzodiazepine or opioid use or other illicit drug use

● Heavy alcohol use (see "Screening for unhealthy use of alcohol and other drugs in primary care", section
on 'Alcohol')

Difficulty with sedation has been observed in up to 30 percent of such patients. Other factors that have been
associated with difficult sedation include patient anxiety and procedure duration [3,5,6]. Furthermore,
paradoxical agitation in response to benzodiazepines has been well described.

Alternatives to standard procedural sedation such as propofol and general anesthesia are particularly useful
in patients who cannot be adequately sedated using standard regimens or who are perceived to be at high
risk for agitation unless a deeper level of sedation is achieved. In certain settings, assistance from an
anesthesiologist may be required (table 1).

ADJUNCTS TO MODERATE PROCEDURAL SEDATION — Adjuncts to moderate procedural sedation are

used to decrease the doses of benzodiazepines and opiates required for gastrointestinal endoscopy and/or to
improve sedation in patients who are difficult to sedate. The use of pharyngeal anesthesia in patients
undergoing endoscopic procedures of the upper gastrointestinal tract is discussed elsewhere. (See "Overview
of procedural sedation for gastrointestinal endoscopy", section on 'Pharyngeal anesthesia'.)

Diphenhydramine — Diphenhydramine is a histamine 1 antagonist that has central nervous system

depressant effects and has been used as an adjunct to sedation with benzodiazepines and opiates.
Diphenhydramine is often used for patients who may not adequately respond to standard procedural
sedation, such as those who use benzodiazepines or opiates chronically. Typically, 25 to 50 mg of
diphenhydramine is given intravenously prior to or concurrent with starting procedural sedation.

Side effects associated with diphenhydramine include dizziness, blurred vision, dry mouth, epigastric
discomfort, thickening of bronchial secretions, and urinary retention. Respiratory depression is a concern with
combinations of diphenhydramine and a benzodiazepine and/or opioid, particularly in patients with obesity or
sleep apnea.

Data are limited on the use of diphenhydramine for gastrointestinal endoscopy. In a randomized trial, 270
patients undergoing colonoscopy were assigned to receive either 50 mg of intravenous diphenhydramine or
placebo given three minutes prior to starting procedural sedation with midazolam and meperidine [7]. Patients
in the diphenhydramine group had a 10 percent reduction in meperidine use and a 14 percent reduction in
midazolam use. In addition, more favorable patient scores for overall sedation and pain were seen in the
diphenhydramine group. There were no differences between the groups with regard to procedure time,
recovery time, or total time from study drug administration to discharge from the endoscopy unit.

Other drugs — Droperidol, a first generation antipsychotic, was previously used with opioids and
benzodiazepines for procedural sedation [8-15], but it has been associated with QTc prolongation and the
development of torsades de pointes, prompting the US Food and Drug Administration to issue a box warning
in 2001 [16]. We do not use droperidol for procedural sedation, and the drug was removed from the European
market in 2001.

DEEP PROCEDURAL SEDATION — One alternative to moderate sedation is deep sedation using propofol.
This approach is used for patients who are difficult to sedate or who are undergoing procedures that require
deep sedation. In many centers, propofol is also being used for routine endoscopy to improve patient
tolerance and to decrease recovery times. However, in many areas, propofol must be administered by an
anesthesiologist, limiting its use for routine endoscopic procedures.

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Other agents that have been studied for sedation for procedures other than endoscopy include ketamine,
dexmedetomidine, and nitrous oxide. The use of these agents is discussed elsewhere. (See "Procedural
sedation in adults outside the operating room".)

Patient monitoring during deep sedation — Recommendations for the appropriate personnel and
equipment needed for propofol sedation have been issued in a consensus statement from the American
Society for Gastrointestinal Endoscopy (table 2) and in recommendations from the European Society for
Gastrointestinal Endoscopy [17-19]. It is important to remember that sedation levels occur along a continuum
progressing to a state of general anesthesia, so appropriate monitoring is crucial (table 3).

Capnography — While the guidelines do not include the routine use of capnography for monitoring
patients receiving propofol, studies suggest that the use of capnography results in less hypoxia and leads to
earlier detection of hypoxia when it occurs [20]. (See "Overview of procedural sedation for gastrointestinal
endoscopy", section on 'Monitoring'.)

The Anesthesiology Society of America (ASA) has advocated the use of capnography for all patients
undergoing deep sedation [21], and it is our practice to do so whenever propofol is used.

Bispectral (BIS) monitoring — Bispectral monitoring uses continuous electroencephalogram recordings

to generate an objective assessment of the degree of sedation. A value on a linear scale from 100 (fully
awake) to 0 (no brain-wave activity) is continually updated during a procedure to reflect recent brain wave
activity. BIS values correlated well with the Observer's Assessment of Alertness/Sedation (OAA/S) scale in a
study of 50 patients undergoing endoscopy [22]. This technology has the potential to prevent oversedation
and may have a role in making propofol safer to administer in the future [23].

Propofol — We generally use propofol for patients who cannot be adequately sedated with standard
medications. We are more likely to choose this approach for elective cases in which we have time to arrange
for assistance from an anesthesiologist. We also favor propofol for some patients with risk factors such as
advanced age, obstructive sleep apnea, chronic opioid use and/or longer or more complex procedures,
although the decision to use propofol may be individualized.

While propofol may be used as a single agent, it is often administered along with small bolus doses of a short-
acting opioid (such as fentanyl) and a benzodiazepine, a combination termed "balanced propofol sedation."
For longer procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), propofol is
typically given as an intravenous drip. (See 'Propofol administration techniques' below.)

Efficacy of propofol — Benefits of propofol include a rapid onset of action (two to four minutes for an
intravenous drip and much faster when a loading bolus is administered) and rapid reversibility of effect once
the drip is shut off. It has some anti-emetic effect and has a weaker amnestic effect than midazolam but has
no analgesic activity [24].

Upper endoscopy and colonoscopy — Multiple studies have demonstrated that propofol is well-
tolerated and associated with faster recovery times compared with the combination of opioid- and midazolam-
based sedation for upper endoscopy and colonoscopy [25-32]. Patient satisfaction, an important metric,
appears to be greater in patients who receive propofol anesthesia for colonoscopy [33].

A meta-analysis of 20 trials comparing propofol with other sedation regimens for colonoscopy found that
propofol sedation was associated with faster recovery and discharge times and increased patient satisfaction
without an increase in adverse events [29]. In a trial of 600 patients who underwent outpatient colonoscopy at
an ambulatory surgery center, more patients who received propofol anesthesia were “very satisfied” with their

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procedure compared with those who received a combination of fentanyl and midazolam (86 versus 74
percent; RR 1.2, 95% CI 1.1-1.3) [33].

Studies in patients undergoing colonoscopy mostly evaluated patients who were not at increased risk for
having difficulty with moderate sedation. With improved patient satisfaction and increased efficiency in the
unit, the use of propofol could improve the overall rate of colorectal cancer screening. Added costs per
procedure must be weighed against the potential savings resulting from increased screening of the at-risk
population. It remains an unresolved issue whether the use of propofol for routine colonoscopy sedation is
worth the added per-case cost and risks associated with its administration, either by an anesthesiologist or by
another trained healthcare provider.

Advanced procedures — A number of studies have demonstrated the utility of propofol in sedating
patients for advanced endoscopic procedures (ie, endoscopic retrograde cholangiopancreatography [ERCP]
and endoscopic ultrasound [EUS]) [32,34-38].

In a meta-analysis of three studies of 182 patients undergoing ERCP, patients receiving propofol had better
sedation (defined as the absence of resistance to the procedure) compared with those receiving non-propofol
or traditional sedation (OR 11.1, 95% 3.3-37.8) [32]. In a trial of 75 patients undergoing ERCP and EUS,
patients receiving propofol had faster induction time, shorter recovery time, and improved recovery of both
baseline activity and dietary intake at 24 hours [36]. Propofol did not influence the sphincter of Oddi pressure
reading in a study of 10 patients [39] and can be used in patients who are undergoing sphincter of Oddi
manometry.

Potential adverse effects — The major potential drawback of propofol is its effect as a respiratory
depressant. Reversal is only possible by stopping the medication and maintaining ventilation until the
medication effect elapses. The administration of propofol and details regarding its narrow therapeutic index
are discussed separately. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Propofol'.)

While earlier observational studies suggested that propofol may be associated with an increased risk of
aspiration pneumonia [40,41], a meta-analysis of several randomized trials concluded that the risk of
cardiopulmonary adverse events (hypoxia, hypotension or arrhythmia) was not increased in patients who
received propofol versus traditional anesthesia (ie, intravenous benzodiazepines and opiates) (OR 0.82, 95%
CI, 0.63-1.07) [42].

Propofol administration techniques

Standard techniques — Propofol is often used in combination with low-dose opioids and/or
benzodiazepines (balanced propofol sedation). The goal is to achieve moderate levels of sedation rather than
the deep levels of sedation typically produced using propofol monotherapy [43]. As such, it can be used for
routine endoscopic procedures that do not typically require deep sedation.

In a randomized trial with 222 patients, balanced propofol sedation was compared with conventional sedation
[44]. Patients in the balanced propofol sedation arm received a combination of propofol, midazolam, and
meperidine, whereas patients in the conventional sedation arm received midazolam and meperidine. There
was no difference between the groups with regard to adverse events or patient satisfaction. However,
clinicians and nurses reported better satisfaction with balanced propofol sedation.

In a second randomized trial, 110 patients undergoing outpatient upper endoscopy were assigned to receive
either balanced propofol sedation or conventional sedation [45]. Patients who received balanced propofol
sedation reported higher median procedural satisfaction (99 versus 85 on a 100-point scale). Balanced

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propofol sedation was also associated with a shorter median recovery time (11 versus 23 minutes).

It is important to realize that for complicated, longer procedures and in difficult-to-sedate patients,
anesthesiologists employ a wide variety of strategies (eg, a continuous intravenous infusion of propofol, with
or without supplemental doses of opioids and/or benzodiazepines).

Patient-controlled sedation — Propofol has been administered in the setting of patient-controlled

sedation (PCS). However, while patients do control when additional amounts of drug are administered, the
amount of propofol administered is strictly limited, and patients still must be continuously monitored by
personnel trained in airway management in the event of oversedation.

• Two controlled trials of PCS for colonoscopy (using different protocols) concluded that regimens
involving PCS with propofol were associated with faster recovery compared with standard
approaches and good patient-satisfaction [46,47].

• A small study investigated the feasibility of using propofol PCS for ERCP; while 16 out of 20
examinations could be completed using this technique, the infusion took up to 28 minutes before
adequate levels of sedation could be reached to start the procedure [48].

• A randomized trial also looked at using patient-administered propofol and remifentanil for ERCP [49].
Eighty patients were assigned to receive either PCS with propofol and remifentanil or
anesthesiologist-managed propofol sedation. Patients in the PCS arm received less propofol and
were not as deeply sedated as patients in the anesthesiologist managed arm. There were no
differences between the groups with regard to endoscopist or patient satisfaction. However, two
patients in the PCS required additional doses of propofol administered by an anesthesiologist. There
was one case of respiratory depression in the PCS arm.

Administration by non-anesthesiologists — The major drawback of propofol is its effect as a respiratory

depressant. Reversal is only possible by stopping the medication and maintaining ventilation until the
medication effect elapses. Propofol also inhibits an individual's protective airway reflex; as a result, whenever
propofol is administered, the person responsible for managing the sedation must be fully trained and capable
of protecting the airway. For these reasons, the use of propofol has been limited to anesthesiologists in most
centers in the United States. On the other hand, there is growing experience and literature establishing
outstanding safety data for the administration of propofol-based sedation by non-anesthesiologist nurses and
clinicians highly trained in airway management [43,50-53].

In a study looking at 646,080 endoscopic cases performed with propofol administered by non-
anesthesiologist nurses and clinicians, there were only four deaths, with bag-mask ventilation being required
in 0.1 percent of upper endoscopies and 0.01 percent of colonoscopies [54]. However, much of this
experience has been with use during routine endoscopy in low-risk patients. Whether administration of
propofol by non-anesthesiologists is appropriate in older adults or in patients with comorbidities such as
obesity, obstructive sleep apnea, heart failure, or potentially difficult airway anatomy requires additional study.
(See "Adverse events related to procedural sedation for gastrointestinal endoscopy", section on 'Adverse
events related to medications used for sedation'.)

In a 2009 position statement, the use of non-anesthesiologist-administered propofol for gastrointestinal

endoscopy in healthy, low-risk patients was endorsed by the American Society for Gastrointestinal
Endoscopy, the American College of Gastroenterology, the American Gastroenterological Association, and
the American Association for the Study of Liver Diseases [55]. The position statement stresses that anyone
administering propofol needs specialized training in its use, including instruction in airway management.

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Despite this recommendation, there remain many barriers to administration of propofol by non-
anesthesiologists, such as state nursing boards, state licensing regulation, the Centers for Medicaid and
Medicare Services requirement that propofol be administered by a practitioner qualified to administer
anesthesia, and the FDA-approved drug labeling for propofol.

While the need for an anesthesiologist increases the cost of endoscopy and can be difficult logistically, these
costs may be justified in selected patients since propofol permits deep sedation and rapid recovery of
otherwise difficult-to-sedate patients.

GENERAL ANESTHESIA — General anesthesia is used most commonly in children and in patients who are
unable to cooperate or tolerate procedural sedation. (See "Overview of anesthesia", section on 'General
anesthesia'.)

Settings in which general anesthesia is used — Studies have shown that general anesthesia is used in a
small minority of procedures:

● In a retrospective study of 2711 upper and lower endoscopies in 2026 children, adolescents, and young
adults, 3.5 percent of procedures were performed under general anesthesia [56]. The indications for
general anesthesia in this series were failed previous attempts at examination using procedural sedation,
mental retardation, simultaneous procedures with another procedure requiring anesthesia, and an
expected long, difficult examination. Scheduling difficulties, cost considerations, concern about airway
trauma, and anesthetic-related adverse events all contribute to the reluctance to use general anesthesia,
even in children.

● During a two-year period at four teaching hospitals, 65 of 1200 patients undergoing ERCP (5.4 percent)
received general anesthesia and endotracheal intubation, and data were available for analysis for 63
patients [57]. Seven of these were children. Fifty-three of the remaining 56 evaluated had failed one or
more prior attempted endoscopic retrograde cholangiopancreatography (ERCP) using procedural
sedation. Forty-eight percent of those with failed prior attempts were current abusers of alcohol and/or
drugs. Significantly more substance abusers failed ERCP under procedural sedation compared with non-
substance abusers (30 versus 2 percent). Other reasons for general anesthesia included prior failed
procedure attempts due to agitation in patients who were not substance abusers, adverse reactions to
prior procedural sedation, septic shock, and myasthenia gravis.

This study underscores the fact that adults who required general anesthesia for ERCP had
characteristics that were generally considered to be risk factors for difficult sedation (see 'Patients who
are likely to be difficult to sedate' above). This supports the conclusion that these patient-related factors
are important considerations in choosing the sedation regimen. However, no prospective or good
retrospective analyses have been published to confirm which patient characteristics are significant
predictors of inadequate sedation with standard medications alone.

In adults, general anesthesia is usually the technique of last resort with a few major exceptions. In patients
who are obtunded, those with high aspiration risk, and those with active hematemesis, endotracheal
intubation provides the best available airway protection.

Airway assessment — Assessment of the airway and the patient's risk of aspiration are essential prior to the
administration of sedation. An elective intubation by an anesthesiologist may be preferable to a potential
emergency intubation in an individual deemed to be at risk for a difficult intubation, undergoing a procedure
that requires a deep level of sedation [24]. Careful assessment of the patient's airway and risk factors for
aspiration are best performed well in advance of the procedure to permit an opportunity to select the

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appropriate setting to perform the endoscopy and to arrange for anesthesiology assistance if needed. (See
"Overview of procedural sedation for gastrointestinal endoscopy", section on 'Pre-procedure preparation and
assessment'.)

Laryngeal mask airway — The laryngeal mask airway (LMA) is a device approved by the FDA that is placed
perorally to make a seal over the vocal cords. It is used as an alternative to endotracheal intubation during
general anesthesia. It has the advantage of not traversing the vocal cords, thus reducing airway stimulation
so muscle relaxants are not required.

The use of an LMA during endoscopy, especially for esophagogastroduodenoscopy (EGD) and ERCP, while
feasible, is not widely used in current clinical practice. Issues may be limited endoscopist familiarity with
passing a scope alongside an LMA and concerns that doing so might dislodge the seal. While some data
suggest that an LMA can be used to facilitate airway protection during therapeutic ERCP with deep sedation
without interfering with the examination [58], it remains controversial whether non-anesthesiologists can be
properly trained to use an LMA to allow for the administration of propofol for procedures requiring prolonged
deep sedation. This is another significant obstacle to the more widespread use of this device for ERCP and
other therapeutic endoscopic procedures.

Further study is warranted to determine whether the LMA will facilitate propofol-based sedation by non-
anesthesiologists and whether the LMA confers safety benefits (eg, reduced airway issues and decreased
incidence of aspiration) over standard nasal cannula oxygenation for patients receiving deep levels of
sedation during colonoscopy.

SUMMARY AND RECOMMENDATIONS

● Endoscopists occasionally encounter patients who are difficult to adequately sedate for endoscopy using
standard agents. In addition, certain therapeutic endoscopic procedures require deeper levels of
sedation. (See 'Introduction' above.)

● Characteristics of patients who are difficult to sedate using standard regimens have not been well
established. However, several characteristics are generally considered to be risk factors for difficult
sedation, including (see 'Patients who are likely to be difficult to sedate' above):

• A history of prior difficulty with procedural sedation

• Prescribed or illicit benzodiazepine or opioid use or other illicit drug use

• Heavy alcohol use

● Adjuncts to moderate procedural sedation are used to decrease the doses of benzodiazepines and
opiates required for gastrointestinal endoscopy and/or improve sedation in patients who are difficult to
sedate. Diphenhydramine may be used as an adjunct for patients who may not adequately respond to
standard sedation. (See 'Adjuncts to moderate procedural sedation' above.)

● Alternatives to moderate procedural sedation include propofol, ketamine, dexmedetomidine, and general
anesthesia. These approaches are used for patients who are difficult to sedate or who are undergoing
procedures that require deep sedation. In some centers, propofol is also being used for routine
endoscopy to improve patient tolerance and to decrease recovery times. However, in many areas,
propofol must be administered by an anesthesiologist, limiting its use for routine endoscopic procedures.
(See 'Deep procedural sedation' above.)

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GRAPHICS

Guideline for anesthesiology assistance during gastrointestinal endoscopy

Anesthesiologist assistance may be considered in the following situations:

Prolonged or therapeutic endoscopic procedure requiring deep sedation

Anticipated intolerance to standard sedatives

Increased risk for complication because of severe comorbidity (ASA class III or greater)

Increased risk for airway obstruction

The routine assistance of an anesthesiologist for average-risk patients undergoing standard upper and lower
endoscopic procedures is not warranted and is cost prohibitive.

ASA: American Society of Anesthesiologists.

Modified with permission from: Faigel DO, Baron TH, Goldstein JL, et al. Guidelines for the use of deep sedation and
anesthesia for GI endoscopy. Gastrointest Endosc 2002; 56:613. Copyright © 2002 Elsevier Science.

Graphic 78317 Version 3.0

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Appropriate personnel and equipment for propofol use in an endoscopic

procedure room

At least one person who is qualified in both basic and advanced life support skills (ie, tracheal intubation,
defibrillation, use of resuscitation medications)

Physiologic monitoring should include pulse oximetry, electrocardiography, and automated blood pressure
measurement. Monitoring oxygenation by pulse oximetry is not a substitute for monitoring ventilatory function

Equipment for airway management and resuscitation

Trained personnel dedicated to the continuous and uninterrupted monitoring of the patient's physiologic parameters
and administration of propofol

Extended monitoring with capnography should be considered as it may decrease the risks during deep sedation

Reproduced with permission from: Faigel DO, Baron TH, Goldstein JL, et al. Guidelines for the use of deep sedation and
anesthesia for GI endoscopy. Gastrointest Endosc 2002; 56:613. Copyright © 2002 Elsevier Science.

Graphic 62941 Version 2.0

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American Society of Anesthesiologists (ASA) definitions of levels of

sedation/anesthesia

1. Minimal sedation (anxiolysis)

a. Drug-induced sedation
b. Patient responds normally to verbal commands
c. Cognitive and motor function may be impaired
d. Ventilatory and cardiovascular functions maintained normally

2. Moderate sedation/analgesia (conscious sedation)

a. Drug-induced sedation
b. Patient responds purposefully to verbal commands either alone or with light tactile stimulation
c. Patient maintains a patent airway and spontaneous ventilation
d. Cardiovascular function maintained

3. Deep sedation/analgesia
a. Drug-induced sedation
b. Patient cannot be easily aroused but can respond purposefully to repeated or painful stimulation
c. Ventilatory function may be impaired, requiring assistance in maintaining a patent airway, and spontaneous
ventilation may be inadequate
d. Cardiovascular function is usually maintained

4. General anesthesia
a. Drug-induced loss of consciousness
b. Patients are not aroused by painful stimulation
c. Ventilatory function is often impaired; patient may require assistance in maintaining a patent airway
d. Spontaneous ventilation may be impaired, as well as neuromuscular functioning
e. Positive pressure ventilation is often required
f. Cardiovascular function may be impaired

Definitions of levels of sedation/anesthesia by the American Society of Anesthesiologists (adopted October 13,
1999, by the House of Delegates).

Reproduced with permission from: Hausman LM, Rosenblatt MA. Office-Based Anesthesia. In: Clinical Anesthesia, 7th ed,
Barash PG, Cullen BF, Stoelting RK, et al (Eds), Lippincott Williams & Wilkins, Philadelphia 2013. Copyright © 2013
Lippincott Williams & Wilkins. www.lww.com.

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Contributor Disclosures
Jonathan Cohen, MD Speaker's Bureau: Otsuka Pharmaceuticals [Helicobacter pylori breath testing];
Ferring Pharmaceuticals [Gastrointestinal endoscopy (bowel preparation)]. Consultant/Advisory Boards:
Boston Scientific [ERCP]; Olympus [Gastrointestinal endoscopy (narrow band imaging)]. Equity
Ownership/Stock Options: GI Windows [magnetic anastomosis (stock)]; Virtual Health Partners
[obesity]. John R Saltzman, MD, FACP, FACG, FASGE, AGAF Consultant/Advisory Boards: Iterative scopes
[Artificial intelligence (AI) applied to polyp detection during colonoscopy]. Girish P Joshi, MB, BS, MD,
FFARCSI Speaker's Bureau: Mallinckrodt Pharmaceuticals [pain management (intravenous acetaminophen)];
Baxter [anesthesia (desflurane)]. Consultant/Advisory Boards: Pacira Pharmaceuticals [pain management
(bupivacaine); Merck [anesthesia (sugammadex)]. Kristen M Robson, MD, MBA, FACG Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy

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