Complications of gastrointestinal endoscopy

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CHAPTER 8 Complications of gastrointestinal endoscopy

Mouen Khashab, Jean Marc Canard

Summary

Introduction 264
1. Complications of upper gastrointestinal endoscopy 264
2. Complications related to specific upper gastrointestinal procedures 268
3. Complications of endoscopic ultrasonography (EUS) 270
4. Complications of device-assisted enteroscopy and capsule endoscopy 272

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.
• Complications of endoscopic ultrasound include FNA-related and non-FNA-related complications.
• Complications that appear to be increased after double-balloon enteroscopy include acute pancreatitis, gastrointestinal hemorrhage, and perforation. Perforation risk is increased in patients with altered surgical anatomy.
• Capsule retention, perforation, aspiration, and small bowel obstruction are reported complications of capsule endoscopy. Among these, capsule retention is the most common complication and occurs in 1.2–2.6% of cases.

Introduction

Complications are inherent to gastrointestinal endoscopy and do not signify negligence by the endoscopist. Due to the technical and invasive nature of endoscopic procedures and the recent trend towards aggressive therapeutic interventions, post-procedural complications may occur, ranging from minor (requiring brief hospitalization) to severe, with permanent disability or death. Endoscopists need to be cognizant of complications that may occur with any endoscopic procedure and those that are specific to the procedure being performed. In addition, endoscopists need to implement strategies to minimize these untoward occurrences and be able to recognize and treat them efficiently and effectively.

This chapter summarizes the complications that are associated with various upper endoscopic procedures, including endoscopic ultrasonography (EUS), with emphasis on strategies aimed at minimizing and treating these complications. Complications related to sedation and those related to the performance of colonoscopy, percutaneous endoscopic gastrostomy (PEG) tube placement, and endoscopic retrograde cholangiopancreatography (ERCP) are discussed elsewhere (see Chapter 8).

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

Transmission of infection as a result of endoscopes is extremely rare, and reported cases are invariably attributable to lapses in currently accepted endoscope reprocessing protocols or to defective equipment.

• Endoscopes should undergo high-level disinfection as recommended by governmental agencies and all pertinent professional organizations for the reprocessing of GI endoscopes.
• Extensive training of staff involved in endoscopic reprocessing is obligatory for effective infection control.
• General infection control principles should be adhered to at the endoscopy unit.
• Transmission of infection from patients to endoscopy personnel can be avoided by application of standard precautions.

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.

Box 2 Procedures for which peri-procedural antibiotic prophylaxis is recommended

• ERCP with anticipated incomplete drainage (e.g. primary sclerosing cholangitis, hilar strictures).
• ERCP in the setting of a communicating pseudocyst.
• Transmural drainage of pancreatic fluid collection.
• EUS-guided fine-needle aspiration (EUS-FNA) of cystic lesions.
• PEG tube placement.
• Cirrhosis with acute GI bleeding (required regardless of endoscopic procedures).

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.

Box 3 Factors predisposed to perforation during upper endoscopy

• Anterior cervical osteophytes.
• Zenker’s diverticulum (Fig. 1).
• Malignant esophageal obstruction.
• Complex esophageal strictures (defined as strictures with at least one of the following features: asymmetry, diameter ≤12 mm, or inability to pass the endoscope).
• Radiation-induced strictures.
• Eosinophilic esophagitis.
• Inexperienced endoscopist.
image

Figure 1 (A) Zenker’s diverticulum: barium esophagogram showing a large diverticulum arising from the posterior wall of the upper esophagus (long arrow) producing extrinsic narrowing of the anterior esophageal lumen (short arrow). (B) Endoscopic picture showing a large Zenker’s diverticulum. The black arrow points at the lumen. Zenker’s diverticulum is a risk factor for perforation of the cervical esophagus during EUS.

• 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.

image Clinical Tip

Endoscopy is safe to diagnose esophageal perforations and should be undertaken, if necessary, after a negative CT scan or esophagogram, to exclude the diagnosis.

• Stable patients may be managed conservatively with nothing per os, placement of a nasogastric tube, administration of broad-spectrum antibiotics, and with parenteral hyperalimentation.

image Clinical Tips

Management

• Surgical consultation should be implemented early even if conservative management is undertaken.
• Surgical management is usually required for larger perforations, when the pleural space is involved, and in patients who fail to respond to conservative therapy.

1.2.1 Endoscopic management of perforations

Although interest in endoscopic closure began in the early 1990s with the first description of clip closure of gastric perforation, Natural Orifice Transluminal Endoscopic Surgery (NOTES) has provided the momentum for development of this field. NOTES has opened the realm for new endoscopic techniques, innovative endoscopic instruments, and pioneering treatment modalities, which made endoscopic closure of perforations possible.

image Clinical Tip

Management

Tension pneumoperitoneum or pneumothorax may complicate GI perforations, should be checked for, and if present, should be managed with immediate decompression with a wide-bore needle puncture.

• 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.
4 InScope Multiclip Applier (Ethicon Endosurgical Inc, Cincinnati, OH) has the ability to deliver four clips, 1 : 1 rotation to align the jaw openings across the defect and reopening of the clip if necessary.
5 Over-the-scope clip (Ovesco Endoscopy, Tuebingen, Germany) is a nitinol clip loaded at the tip of the endoscope that can capture small perforations.

• 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)

• The most critical component of closure of perforations is the placement of the first clip.
• Keep the clip close to the end of the endoscope with the clip and the endoscope acting as a single unit.
• Place the wide-open clip across the defect at 90° to the defect.
• 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.
• Use carbon dioxide (CO2) rather than air for insufflation.
image

Figure 2

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