CHAPTER 8 Complications of gastrointestinal endoscopy
Key Points
• Endoscopists need to implement strategies to minimize complications of endoscopy and be able to recognize and treat them efficiently and effectively.
• There are currently no data to prove a causal link between endoscopic procedures and infective endocarditis. In like manner, there are no data to demonstrate that antibiotic prophylaxis in the peri-endoscopic period decreases the risk of infective endocarditis.
• Immediate endoscopic closure of perforation and in case of failure, early treatment is key to successful conservative management. Delay in the diagnosis is associated with a poor outcome.
• Drainage of infection and fluid collections is paramount for successful endoscopic closure of a perforation.
Introduction
1 Complications of upper gastrointestinal endoscopy
1.1 Infection complications
Endoscopy related infection may occur under the following circumstances:
• Exogenous infections: microorganisms may be spread from patient to patient by contaminated equipment.
• Endogenous infections: microorganisms may spread from the GI tract through the bloodstream during an endoscopy to susceptible organs or prostheses, or may spread to adjacent tissues that are breached as a result of the endoscopic procedure.
• Microorganisms may be transmitted from patients to endoscopy personnel and perhaps from endoscopy personnel to patients.
Recently, the American Society for Gastrointestinal Endoscopy (ASGE) published guidelines on infection control in gastrointestinal endoscopy (Box 1).
Box 1 ASGE guidelines on infection control during GI endoscopy
• Endoscopes should undergo high-level disinfection as recommended by governmental agencies and all pertinent professional organizations for the reprocessing of GI endoscopes.
1.1.1 Endogenous complications
Bacteremia can occur after any endoscopic procedure due to bacterial translocation as a result of mucosal trauma that occurs during endoscopy. Bacteremia is thought of as a surrogate marker for infective endocarditis (IE) risk. However, there are currently no data to prove a causal link between endoscopic procedures and IE. In like manner, there are no data to demonstrate that antibiotic prophylaxis in the peri-endoscopic period decreases the risk of IE (see Ch. 2.2). Although previous recommendations have been to administer antibiotic prophylaxis prior to procedures with high risk of bacteremia, namely esophageal dilation and sclerotherapy, the most recent ASGE guidelines stated that this policy to prevent IE is no longer recommended before endoscopic procedures. Notable exceptions to this guideline are detailed in Box 2.
1.2 Perforation
• Perforation related to diagnostic upper endoscopy is rare and occurs at a rate of 0.03%, with a mortality rate of 0.001%.
• Box 3 lists known factors that increase perforation risk during upper endoscopy.
• Signs and symptoms of perforation include pain, pleuritic chest pain, fever, crepitans, leukocytosis and/or pleural effusion
• Early recognition of the perforation is key to successful conservative (least-invasive) management. Delay in the diagnosis is associated with a poor outcome
• Water-soluble esophagogram is the initial test of choice for the localization of suspected perforations. If the site of perforation is not recognized, endoscopy or computed tomography may be used.
Clinical Tip• Stable patients may be managed conservatively with nothing per os, placement of a nasogastric tube, administration of broad-spectrum antibiotics, and with parenteral hyperalimentation.
Clinical Tips1.2.1 Endoscopic management of perforations
Clinical Tip• Currently, endoscopic clips are the only devices available in the market for closure of perforations, whereas suturing and stapling devices are not available for clinical use. Clips can be used to close perforations that are <2 cm in size. Five different designs of clips are currently available:
1 Resolution Clip (Boston Scientific, Natick, MA) has the ability to reopen up to five times before final deployment, thus maximizing the chance to realign the clip for better tissue approximation.
2 TRICLIP (Cook Medical Inc, Winston-Salem, NC) is a tri-pronged single-use clip device with a flushing mechanism designed to orient on the target site without the need for rotation of the prongs.
3 QuickClip2 (Olympus Corp, Melville, NY) is a rotatable clip device that is ready for use immediately after taking out of the package, unlike its predecessor that required loading of clips on a reusable applicator.
• Clip closure of perforations should not be performed by endoscopists with no prior experience with the use of clips. It is critical for both the endoscopist and his assistant to be conversant with the use of clips before undertaking endoscopic closure of perforations. Attention to the details as outlined below is critical for successful clip closure of perforations. Technique of clip closure of perforations is detailed in Box 4.
Box 4 Technique of closure of perforations with clips (Figs 2–5)
• Keep the clip close to the end of the endoscope with the clip and the endoscope acting as a single unit.
• Gently push the clip-endoscope unit as one unit while applying gentle suction to collapse the lumen so that as much tissue away from the edge of perforation as possible could be grasped while slowly closing the clip.
• Be patient and confirm satisfactory clip closure of the perforation with approximation of the edges before deployment of the clip. A misplaced clip might render placement of additional clips technically difficult.
• Place additional clips from top-to-bottom in linear perforations or left-to-right in circular perforations after satisfactory application of the first clip.
• Over inflating the lumen with air can widen the defect: avoid over inflation and decompress the lumen before withdrawal of the endoscope.
Clinical Tips
• Drainage of infection and fluid collections is paramount for successful endoscopic closure of perforations.
• If an en-face approach to the perforation is unsuccessful, the use of a rotatable clip may be helpful. In addition, the use of a cap-fitted endoscope may render tissue approximation feasible in these instances. It is often possible to bring the defect en-face by drawing it into the cap even when it is situated tangential to the endoscope. Moreover, the transparent cap maintains a certain distance between the endoscope lens and the defect, enabling a more effective clip placement.
• Large perforations (>2 cm in diameter) cannot be approximated effectively with clips because all current available clips have a wingspan <2 cm. In addition, the edges of a malignant perforation may not be effectively approximated with clips, which tend to tear through cancerous tissue rather than grip the edges of the perforation.
• Covered self-expandable metal stents (SEMS) can be used to seal esophageal perforations, especially larger perforations that are not amenable to closure by clips (Fig. 6). To prevent mechanical complications, including stent embedment into the esophageal wall, the stent should be removed preferably within 8 weeks after placement.
• Although a covered self-expanding plastic stent (SEPS) (Polyflex, Boston Scientific, Natick, MA) is commercially available, it is not the stent of choice in the setting of a perforation because its delivery system is cumbersome.
• The different FDA-approved SEMS and the technique of stent placement are discussed in detail in Chapter 7.3.
1.3 Bleeding
• Risk factors for bleeding include coagulopathy and/or severe thrombocytopenia (platelet count <20 000).
• Mucosal biopsies should be performed with caution in patients with severe thrombocytopenia and platelet transfusion prior to endoscopy should be strongly considered.
• Diagnostic upper endoscopy can be performed safely in anticoagulated patients, as long as the anticoagulant levels are within therapeutic range.
1.3.1 Management of antithrombotic agents in patients undergoing upper endoscopic procedures
• Management of antiplatelet agents (e.g. aspirin, NSAIDs, thienopyridines, e.g. clopidogrel and ticlopidine) and anticoagulants (e.g. warfarin, heparin, and LMWH) in patients undergoing endoscopy requires the endoscopist to be cognizant of bleeding risk associated with endoscopy and thromboembolic risk associated with interruption of antithrombotic agents (Box 5) (see also Ch. 2.1).
• Aspirin and other NSAIDs can be continued in the peri-endoscopic period, even after high-risk endoscopic procedures
• Current guidelines recommend withholding clopidogrel for at least 7 days prior to high-risk procedures. This often requires consultation with patients’ cardiologist
• For anticoagulated patients undergoing high-risk procedures and who are at low risk of thromboembolic events, warfarin is withheld 3–5 days prior to the procedure. For patients who are at high risk for thromboembolism, bridging therapy (Box 6) with heparin or LMWH is required.
2 Complications related to specific upper gastrointestinal procedures
2.1 Dilation and enteral stenting
Complications related to dilation of benign and malignant strictures of the gastrointestinal tract and of pneumatic dilation in achalasia patients are detailed in Chapter 7.1. Complications of enteral stenting are discussed in Chapter 7.3.
2.2 Hemostatic technique
2.2.1 Endoscopic non-variceal hemostasis
2.2.2 Endoscopic variceal hemostasis
• Endoscopic variceal band ligation (EVBL) is a safe procedure with low rate of serious complications (mortality and perforation risk <1%).
• Superficial ulcerations occur commonly (5–15%) after EVBL. Treatment with proton pump inhibitors after EVBL may decrease the risk of bleeding from resulting esophageal ulcerations.
• Superficial ulceration is more common with sclerotherapy (90%). Deep ulceration may also occur and results in re-bleeding in 5% of cases.
2.3 Polypectomy and endoscopic mucosal resection
• The ASGE has published its recommendations on management of gastric polyps (Box 7).
Box 7 ASGE recommendations for the management of gastric polyps
• Polyps causing symptoms, such as obstruction and bleeding, should be removed, preferably endoscopically.
• When multiple gastric polyps are encountered, the largest polyps should be biopsied or excised, and representative sample biopsies taken from some others. Further management should be based on histologic results.
• Complications after endoscopic resection of duodenal adenomas are similar in nature to complications of colonoscopic polypectomy and include perforation, bleeding, and complications related to sedation.
• Submucosal injection of saline or epinephrine and the application of loops and clips have been used during resection of large gastroduodenal polyps.
2.3.1 Endoscopic mucosal resection (EMR)
| Bleeding | Most common complication of EMR (up to 17% of cases). Most bleeding is immediate, but can be delayed (>24 h). Most important risk factor for delayed bleeding is immediate bleeding. Size >1–2 cm has been reported to be another risk factor for bleeding. No association has been found between risk of bleeding and EMR technique, lesion morphology (flat, raised, or depressed), type of electrocautery current used, amount of saline injected, and location of lesion except in duodenum. Bleeding is best managed with epinephrine injection and clip placement, because this method eliminates the risk of additional cautery injury to the EMR site. |
| Perforation | Gastric EMR perforation rate is high (1–5%). Avoid performing EMR in patients who had prior attempts at endoscopic resection. Scar tissue may prevent adequate lifting of the lesion and, thus, may increase risk of perforation. Small perforations that are recognized early in stable patients can be managed conservatively with clip placement (Fig. 7). Patients should be placed nil per os and treated with broad spectrum antibiotics. |
| Luminal stenosis | It has been described after extensive luminal resections, mainly when more than three-fourths of the luminal circumference has been excised in one endoscopic session. Luminal stenosis occurs most commonly after EMR of esophageal lesions. Incremental resections in multiple treatment sessions may decrease the risk of post-EMR strictures. Post-EMR strictures can be treated successfully with serial dilations and/or temporary stent placement. |
2.4 Ablative techniques
Complications associated with various ablative techniques are described in Table 2.
Table 2 Complications associated with different ablative techniques
| Laser light | Mortality 1% Perforation rate: 1–9% Major bleeding: up to 12% Others: Stricture and fistula formation |
| Photodynamic therapy (PDT) | Strictures: up to 30% Prolonged skin sensitivity Perforation and fistula formation Others: dysphagia, odynophagia, chest pain, fever, nausea (all occur commonly) |
| Argon plasma coagulation (APC) | Serious complications are very uncommon Abdominal distention is common Strictures are uncommon but can occur as a late complication |
3 Complications of endoscopic ultrasonography (EUS)
3.1 Non-FNA related complications
3.2 FNA-related complications
3.2.1 Infectious complications
• The incidence of EUS-FNA related bacteremia is approximately 5%, which is comparable with that of diagnostic upper endoscopy.
• In contrary, there is evidence supporting the routine administration of prophylactic antibiotics during EUS-FNA of cystic lesions. The ASGE recommends that prophylaxis with antibiotics, such as a fluoroquinolone, be administered before or during EUS-FNA of cystic lesions, and may be continued for 3–5 days after the procedure.
Clinical Tip
Clinical Tip3.2.3 Hemorrhage
• EUS-FNA-induced intracystic bleeding is usually self-limited and recognition of this complication and cessation of further FNA attempts appear to be adequate management. Prophylactic antibiotics are recommended since the intracystic hematoma can serve as a nidus for bacterial infection.
• Cessation of anticoagulants and antiplatelet medications for at least 5 days prior to the procedure is generally recommended prior to EUS procedures with anticipated FNA. Limiting the number of passes, use of Doppler mode to identify and avoid large vascular structures, and use of smaller gauge needles may decrease the risk and limit the severity of bleeding.
3.2.4 Celiac plexus blockade and neurolysis
• EUS-guided celiac plexus blockade (using corticosteroids) and neurolysis (using absolute alcohol) are used as a means of achieving analgesia in patients with chronic pancreatitis and pancreatic cancer, respectively.
• Both procedures appear to be generally safe and associated with fewer complications compared to the percutaneous approach.
4 Complications of device-assisted enteroscopy and capsule endoscopy
4.1 Device-assisted enteroscopy
• Complications that can be associated with DE comprise complications common to all endoscopic procedures including sedation-related adverse events, infection, and aspiration pneumonia.
Clinical Tip4.2 Capsule endoscopy
• Since its introduction at the turn of the century, capsule endoscopy (CE) has gained worldwide acceptance.
• CE has proven to be a useful tool for evaluating patients with suspected small bowel disorders, and has made it possible to view the entire small bowel in about 83% of patients.
• Although capsule endoscopy can visualize the entire small intestine, a main disadvantage is the inability to obtain biopsies, navigate altered anatomy or perform therapeutic maneuvers.
• Capsule retention, perforation, aspiration (Fig. 8), and small bowel obstruction are reported complications of CE. Among these, capsule retention is the most common complication and occurs in 1.2–2.6% of cases.
• Although retained capsules can eventually pass spontaneously or by drug promotion in a few patients, surgical intervention is needed in most cases due to obstructing lesions, such as malignant or Crohn’s strictures. Crohn’s disease accounts for 37% of capsule retention cases. Box 8 lists factors associated with increases capsule retention risk.
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Siersema PD, Homs MY, Haringsma J, et al. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc. 2003;58:356-361.
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