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58. Complications of Upper Gastrointestinal Endoscopy

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58. Complications of Upper Gastrointestinal Endoscopy 58. Complications of Upper Gastrointestinal Endoscopy Brian J. Dunkin, M.D., F.A.C.S. A. General Considerations Flexible upper gastrointestinal endoscopy is a safe procedure with a com- plication rate well below 2% and a mortality rate of 0.004%. The incidence of complications increases when biopsy, polypectomy, or other invasive diagnostic or therapeutic maneuvers are performed. Proper preparation for esophagogastroduodenoscopy (EGD) begins with a thorough history and physical examination. Both physician and patient should understand the indications for the procedure and possible complications. Patients who undergo EGD are frequently older and may have multiple medical prob- lems or be taking medications that increase the risk of complications. General risk factors include advancing age, history of cardiac disease, or history of chronic obstructive pulmonary disease. Specific problems that are likely to be encountered and the manner in which they increase risk are given in Table 58.1. 1. Cardiopulmonary complications. Although the overall complication rate from EGD is low, 40% to 46% of serious complications are car- diopulmonary, related to hypoxemia, vasovagal reflexes, and relative hypotension. a. Hypoxemia is common. Up to 15% of patients experience a decrease in oxygen saturation below 85% during EGD. i. Cause and prevention. Hypoxemia is due to sedation and to encroachment upon the airway. ii. Recognition and management. Routine monitoring of oxygen saturation gives the diagnosis (remember that hyper- carbia is usually present before oxygen desaturation is observed). Supplemental oxygen should be administered but may result in carbon dioxide retention if chronic obstructive pulmonary disease is present. Constant observation by a second individual who monitors vital signs, oxygen satura- tion, and level of consciousness (and reminds the patient to take periodic deep breaths) can help minimize this problem. A jaw thrust maneuver, performed by this assistant, will often improve airflow and oxygen saturation. Remove the endoscope if necessary. b. Bradycardia i. Cause and prevention. The vasovagal reflex from gastric distention or pressure against the stomach wall from the endoscope can trigger bradycardia and hypotension. Pre- 618 B.J. Dunkin Table 58.1. Medical problems that may increase the risk of EGD. Medical problem Nature of complication Valvular heart disease Bacterial endocarditis Diabetes Hypoglycemia (due to NPO status) Liver disease Oversedation (inability to metabolize narcotics and benzodiazepines) Depression Hypertensive crisis (monoamine oxidase inhibitors react with meperidine) Renal insufficiency Oversedation, seizures (inability to excrete normeperidine, a meperidine metabolite) Cardiac dysrhythmias Dysrhythmia, hypotension Obesity, chronic obstructive Hypoxemia, hypercarbia, carbon dioxide pulmonary disease retention Bleeding diatheses Bleeding treatment with atropine combats the bradycardia, but the resulting tachycardia may increase myocardial oxygen demand. Patients who are taking b-adrenergic-blockers may be unable to manifest a tachycardia in response to pain and hypovolemia. This relative bradycardia then contributes to hypotension (see item c). ii. Recognition and management. Continuous electrocardio- graphic monitoring allows early recognition. Evacuation of gastric air and reduction of gastric wall pressure from the endoscope is the first intervention. If this is unsuccessful, atropine is generally the drug of choice. Further manage- ment should follow advanced cardiac life support (ACLS) protocols. c. Hypotension i. Cause and prevention. Hypovolemia, cardiac dysrhyth- mias, myocardial ischemia, drug interactions, and overseda- tion are all potential causes. Monitoring, adequate hydration, and attention to medications and level of sedation are all crucial. Take a careful history, including medication usage, prior to EGD. ii. Recognition and management. Frequent blood pressure checks during the procedure and in the recovery phase will allow early detection. Administer a fluid bolus and search for other treatable causes (e.g., bradycardia). 2. Medications that cause bleeding diatheses. Many medications have the potential to cause bleeding problems. A list of common medica- tions, problems, and suggestions for management follows. a. Aspirin irreversibly poisons platelets, and the effect lasts until new platelets have replaced the affected platelets. With an average life span of 10 days in the circulation, a significant replacement 58. Complications of Upper Gastrointestinal Endoscopy 619 effect can be noted after about 7 days. Aspirin should be stopped 1 week prior to the procedure if possible. If therapy is performed, aspirin should not be restarted for another 14 days. b. Other nonsteroidal anti-inflammatory drugs (NSAIDs) also inhibit platelet function, but the effect is variable and reversible. Piroxicam (Feldene) has an effect similar to aspirin in duration. Most other NSAIDs can be stopped 48 hours prior to the procedure. c. Warfarin is another drug commonly encountered in the EGD patient. As in open surgery, there is no consensus about its periprocedure management. Anticoagulated patients undergoing diagnostic EGD alone are not at increased risk for bleeding. Those undergoing therapeutic EGD, however, may be. There are basically four options for management of anticoagulated patients undergoing therapeutic EGD: stop the warfarin with no parenteral anticoagulation coverage (heparin or low-molecular-weight heparin), stop the warfarin with parenteral anticoagulation coverage, continue warfarin at the usual dose, or continue at a reduced dose. In deciding which option to choose, it is important to assess the patient’s risk for a thromboembolic complication when anticoagulation medication is withdrawn and to be clear on the indications for a therapeutic EGD. Patients at highest risk for thromboembolism are those with mechanical heart valves, coro- nary artery disease with persistent exertional angina, and overt arterial disease at more than one site, as well as those with a history of experiencing a thromboembolic event while anticoag- ulated. The risk–benefit ratio of the four anticoagulation options must be individualized for each patient. d. Ticlopidine (Ticlid) is commonly given to patients with cardio- vascular problems. It retards platelet aggregation. A single dose will effect the platelets for 4 to 36 hours. The bleeding time is maximally increased after 5 to 6 days of therapy and will take 4 to 8 days to normalize after stopping the drug. The drug should therefore be managed the same as aspirin. In an emergency situ- ation, the time to normalization of the bleeding time can be decreased to less than 2 hours by administering intravenous methylprednisolone. e. Clopidogral (Plavix) inhibits platelet aggregation and is fre- quently used in patients with cardiovascular or cerebralvascular disease. Inhibition of platelet aggregation can be seen within 2 hours of a single dose, with steady state reached at 3 to 7 days. This drug irreversibly inhibits platelet function and should be managed similar to aspirin. 3. Infectious complications a. Endocarditis, infection of prostheses (including joint prosthe- ses), systemic infection. Both diagnostic and therapeutic EGD have been demonstrated to cause bacteremia. Certain groups of patients are considered at risk and should receive antibiotics prior to endoscopic procedures (Table 58.2). Carefully seek any past 620 B.J. Dunkin Table 58.2. American Society for Gastrointestinal Endoscopy (ASGE) recom- mendations for antibiotic prophylaxis for endoscopic procedures. Antibiotic Patient condition Procedure prophylaxis Prosthetic valve, Stricture dilation, varix Recommended history of endocarditis, sclerosis, ERCP for systemic-pulmonary obstructed biliary tree shunt, synthetic vascular Other endoscopic Insufficient data to graft <1 year old procedures including make firm EGD and colonoscopy recommendation; (with or without biopsy endoscopists may or polypectomy), choose on case- variceal ligation by-case basis Cirrhosis and ascites, Stricture dilation, varix Insufficient data to immunocompromised sclerosis, ERCP for make firm patient obstructed biliary tree recommendation; endoscopists may choose on case- by-case basis Other endoscopic Not recommended procedures including EGD and colonoscopy (with or without biopsy or polypectomy), variceal ligation Prosthetic joint or All endoscopic Not recommended orthopedic prosthesis procedures ERCP: endoscopic retrograde cholangiopancreatography. history of endocarditis, valvular heart disease, or recent valve or vascular replacement surgery. An acceptable prophylactic regimen for these high-risk patients is 2g of parenteral ampicillin and 1.5mg/kg gentamicin (up to 80mg) 30 minutes before the procedure. This should be followed by a single 1.5-g dose of oral amoxicillin 6 hours after the procedure. One gram of parenteral vancomycin may be substituted for the preprocedure ampicillin, with omission of the post procedure amoxicillin in patients aller- gic to penicillin. b. Transmission of infection. Strict adherence to proper disinfec- tion procedures is important to avoid iatrogenic transmission of bacterial or viral infection. i. Pseudomonas aeruginosa infections caused by contami- nated scopes or water bottles have been frequently reported and have a high mortality rate. 58. Complications of Upper Gastrointestinal Endoscopy 621 ii. Contamination by Salmonella, Helicobacter, and Mycobac- terium has also been documented. iii. Viral
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