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Indications of Emergency Endoscopy Archives of the Balkan Medical Union vol. 53, no. 2, pp. 299-302 Copyright © 2018 Balkan Medical Union June 2018 LETTER TO THE EDITOR INDICATIONS OF EMERGENCY ENDOSCOPY Ruxandra OPRITA1 , Daniel BERCEANU2 1 University of Medicine and Pharmacy „Carol Davila“, Gastroenterology Clinic, Clinical Emergency Hospital of Bucharest, Romania 2 Gastroenterology Clinic, Clinical Emergency Hospital of Bucharest, Romania Received 01 Apr 2018, Accepted 09 May 2018 ABSTRACT RÉSUMÉ Emergency endoscopy is a life-saving procedure of tre- Indications pour l’endoscopie d’urgence mendous importance. It is a long-standing minimal invasive technique utilized for diagnosis and treat- L’endoscopie d’urgence est un procédé vital d’une im- ment of gastrointestinal tract diseases. Endoscopy is portance majeure. C’est une technique invasive mini- the most precise and practical method for diagnosing male de longue date utilisée pour le diagnostic et le the source of upper gastrointestinal bleeding, grading traitement des maladies du tractus gastro-intestinal. the lesions induced by ingested caustic substances or L’endoscopie est la méthode la plus précise et la plus removing foreign bodies from the esophagus or the pratique pour diagnostiquer la source de saignement stomach. Controversy exists regarding the timing of gastro-intestinal supérieur, classer les lésions induites endoscopy, defined by the period of time between the par les substances caustiques ingérées ou éliminer patient presentation and performing the endoscopy. les corps étrangers de l’œsophage ou de l’estomac. Il Hypothetically, an early endoscopy (generally defined existe une controverse concernant le moment de l’en- as within 24 hours from presentation) compared with doscopie, défini par la période de temps entre la pré- routine endoscopy may translate into an improved sentation du patient et la réalisation de l’endoscopie. patient outcome, because early hemostasis should re- Hypothétiquement, une endoscopie précoce (générale- duce the quantity of blood loss. Also, there are reasons ment définie comme celle effectuée dans les 24 heures for worse outcomes with urgent endoscopy: absence suivant la présentation) par rapport à l’endoscopie de of back-up support available at the time of endoscopy routine peut se traduire par un meilleur résultat pour (surgery or radiology), emergency endoscopy may be le patient, car l’hémostase précoce devrait réduire la associated with insufficient resuscitation. Regarding quantité de perte de sang. De même, il existe des rai- caustic ingestions, most authors suggest a delay of only sons d’aggraver l’issue d’une endoscopie urgente: l’ab- 12 hours and a total wait of no more than 24 hours sence de soutien de secours disponible au moment de after ingestion for early assessment and treatment. l’endoscopie (chirurgie ou radiologie), l’endoscopie d’ur- Endoscopy past 48 hours is discouraged because of gence peut être associée à une insuffisance de la réani- progressive wall weakening and increased risk of per- mation. En ce qui concerne les ingestions caustiques, la foration. Sharp esophageal foreign bodies or complete plupart des auteurs suggèrent un délai de seulement 12 obstruction of the esophagus should prompt an en- heures et une attente totale de 24 heures tout au plus doscopy within 2 hours from patient’s presentation. après l’ingestion pour une évaluation et un traitement Corresponding author: Ruxandra OPRITA Clinical Emergency Hospital of Bucharest, Calea Floreasca no. 8, Bucharest, Romania Email: [email protected] Indications of emergency endoscopy – OPRITA et al In acute purulent cholangitis, timely performed endo- précoces. L’endoscopie dépassant les 48 dernières scopic retrograde cholangiopancreatography is a reli- heures est déconseillée en raison de l’affaiblissement able option with increased diagnostic and therapeutic progressif des parois et de l’augmentation du risque de effectiveness and decreased morbidity and mortality perforation. Des corps étrangers affilés ou une obstruc- rates. tion complète de l’œsophage devraient provoquer une endoscopie dans les deux heures suivant la présenta- Keywords: emergency, digestive endoscopy, indica- tion du patient. Dans la cholangite aiguë purulente, tions. la cholangiopancréatographie endoscopique rétrograde réalisée en temps opportun est une option fiable avec une efficacité diagnostique et thérapeutique accrue et une diminution des taux de morbidité et de mortalité. Mots-clés: urgence, endoscopie digestive, indications. INTRODUCTION in length of hospitalization, no difference in need of surgical intervention, no difference in blood trans- Emergency endoscopy is a long-standing mini- fusion requirements and no difference in mortality. mal invasive technique utilized for diagnosis and Patients were 3.6 times more likely to require surgery treatment of gastrointestinal tract diseases and is or die if endoscopy was done early (within 6 hours) a life-saving procedure of tremendous importance. compared to >24 hours. Time to endoscopy was not Furthermore, it is a precise and a practical tool for associated with better outcomes and most patients viewing the source of upper gastrointestinal bleed- could be effectively managed within 24 hours2. ing, grading the lesions induced by ingested caustic In a patient with gastrointestinal bleeding, us- substances or removing foreign bodies from the es- ing the nasogastric tube has a minimal diagnostic ophagus or the stomach. Controversy exists regard- and prognostic value and does not alter therapeutic ing the timing of endoscopy defined as the period decision. As such, 50% of duodenal lesion bleedings of time between the patient’s presentation and the have a false negative aspirate; 15% of the patients performance of the endoscopy. with clear or bile aspirate have high risk lesions3. For an endoscopy to be performed effectively An upper digestive endoscopy should be per- in emergency, a team of physicians has to be en- formed in less than 12 hours in case of hemodynamic gaged: emergency physician, anesthesiologist and instability that persists despite resuscitation, the oc- endoscopist. The need to perform the emergency currence of gastrointestinal bleeding or the presence endoscopy is debatable. There is still to be defined of blood in the nasogastric tube during hospitaliza- the time between the patient’s presentation and the tion, or a contraindication for the interruption of emergency procedure. Most studies propose a time anticoagulants4. span of 24 h as the emergency time, while some of To support the clinical decision, it is possible them define a period of 72 h (especially in cases of to rely on the definition of the Rockall score which acute pancreatitis)1. identifies patients at risk of adverse outcome fol- lowing acute upper gastrointestinal bleeding (≥5 Five main indications are established for emer- especially in cases of chronic renal failure) or the gency endoscopy: Glasgow-Blatchford score (≥12, which takes into ac- 1. a). Gastrointestinal bleeding without portal count urea, hemoglobin, systolic blood pressure and hypertension clinical markers)5. Even in case of active hemorrhage, the endos- In case of minor bleeding (Rockall <3, Glasgow˝- copy should not be carried out in a rush – without Blatchford <5), performing an endoscopy within 24 waiting for resuscitation and gastric emptying – as it hours reduces the length of hospital stay5. When the can be ineffective or even dangerous. risk is very low, it is possible to let the patient go home In a retrospective study on 502 patients with by planning a return in the following days and inform- gastrointestinal bleeding (375 patients with a ing on the need to hospitalize in case of recurrence5. non-variceal cause of bleeding, 10% variceal), Sarin et Contraindications – that nevertheless should be al (2009) evaluated the different outcomes associated discussed on a case-by-case basis – with emergency with the timing of endoscopy. Performing the endos- endoscopy remain limited: suspicion of associated copy in less than 6 hours (early) after patient’s presen- perforation, acute coronary artery disease associated tation vs. 6-24 hrs vs. >24 hrs showed: no difference or induced, anticoagulant overdose. 300 / vol. 53, no. 2 Archives of the Balkan Medical Union In the specific case of gastrointestinal bleeding remain in the stomach 48 hours after ingestion, an associated with anticoagulant overdose, the clinician endoscopic gesture is necessary without urgency9. is faced with the decision to stop the anticoagulation These recommendations are limited because the with thromboembolic consequences deriving from it vast majority of foreign bodies present in the stomach or to continue the anticoagulation with the risk of ex- are eliminated within 4 to 6 days after ingestion by sanguination. Upper gastrointestinal endoscopy with natural routes. Emergency endoscopy may obviate the endoscopic hemostasis is very effective even in patients need for surgery in foreign body ingestion. with a moderately increased INR; INR normalization did not reduce the risk of rebleeding and only delayed 4). Acute cholangitis / acute biliary pancreatitis endoscopic intervention. In case of massive bleeding, Endoscopic retrograde cholangiopancreatog- an INR less than 2.5 is considered reasonable for prac- raphy (ERCP)is indicated in less than 12 hours in ticing emergency hemostasis within safety limits6. case of severe cholangitis that does not respond to resuscitation and the use of antibiotics. A delay of The main point to have in
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