Chapter 8 Patient Preparation and Pharmacotherapeutic Considerations
Informed Consent
The process of informed consent varies from country to country. In many parts of Europe, a formal consent is not required before endoscopic examinations. If the patient comes to have the procedure performed, these systems assume an implied consent. In other parts of the world, such as the United States and Australia, the consent process is a very detailed and potentially complex process that requires considerable attention by the endoscopist (see Chapter 9).
General Information about Patient Preparation
The endoscopist must have knowledge of the indication for the procedure because this determines not only what procedure is performed but also what interventions or treatment might be required during the procedure. Implicit also is an understanding of the patient’s clinical history and the results of any recent investigations. The preprocedure assessment must extend to the patient’s past medical and surgical history, previous endoscopy results, current medical therapy (including over-the-counter and intermittent medications), and drug allergies. Specific clinical history such as diabetes, a personal or family history of bleeding disorder, anesthetic reactions, or previous adverse reactions to other medical interventions (including reactions to radiologic contrast agents) should also be considered. Armed with this information, the endoscopist is able to determine the proper preparation and any specific modifications that might be required for the individual patient (see Chapter 7).
Preparation for Endoscopy and Enteroscopy
Patients should not eat solid food for 6 hours or drink fluids for at least 4 hours before an elective endoscopy.1 If a delay in gastric emptying is known or suspected, longer fasting or a period of a fluid-only diet should be considered. Many centers use prokinetic agents to speed gastric emptying in patients when fasting time is inadequate (see subsequent section on special circumstances). In situations in which there is a delay in gastric emptying or in which there is inadequate fasting time, there is a significant risk of pulmonary aspiration, and airway protection with airway intubation should be considered. Normally, it is acceptable for patients to take their usual medicines with a sip of water before endoscopy. Special consideration must be given to patients taking anticoagulant medication or medication to treat diabetes (see separate section).
Preparation for Endoscopic Retrograde Cholangiopancreatography
The preparation of patients for endoscopic retrograde cholangiopancreatography (ERCP) is similar to the preparation for endoscopy.1 Generally, patients undergoing ERCP almost always require sedation, and the duration of the procedure is longer; this should be taken into account for purposes of discharge planning. Patients with suspected or proven biliary or pancreatic duct obstruction generally are given prophylactic intravenous antibiotics if there is a clinical suspicion of inadequate duct drainage. Antibiotics may also be given in patients with sclerosing cholangitis and in patients after liver transplantation. Before ERCP, it is important to determine if the patient has a known history of reaction to iodinated contrast agents. Although reaction to the contrast agent in allergic patients during ERCP is rare, it is generally considered appropriate to administer prophylactic steroids, often in combination with an intravenous antihistamine agent. In severe cases, enlisting support of an anesthetist in case of a reaction is a prudent precaution. The use of a noniodinated contrast agent is an alternative strategy.
Preparation for Colonoscopy
Of all endoscopic procedures, the quality of the preparation before colonoscopy has the greatest effect on the outcome of the procedure.1 The preparation is often regarded as the most unpleasant part of colonoscopy, and many patients are more concerned about this aspect than having the procedure performed. It is vital that the patient be given detailed verbal and written instructions to complete the preparation safely. If the correct preparation is not followed, the procedure usually has to be deferred. The American Society for Gastrointestinal Endoscopy (ASGE) published a technology status evaluation report on colonoscopy preparation that reviews the various bowel preparations in detail.2 Good bowel preparation is essential to provide an optimal view for colonic examination and to minimize the risk of colonic trauma during the procedure resulting from poor view.
To determine the correct preparation, the clinician requires a careful patient assessment to determine which bowel cleansing agent should be used and what modifications to the patient’s diet and regular medications are required. The addition of simethicone to the bowel preparation does not improve cleansing but does reduce bubbles, which may improve the endoscopic view.3 As part of the preparation, most patients are advised to have only a clear liquid diet for 24 hours before the examination.1 Routine blood testing before colonoscopy is not required. Management of patients taking antiplatelet and anticoagulation medications should be carefully considered before the examination to minimize the risk of procedure-related bleeding (see later guidelines). In addition, any medication that might be associated with constipation should be temporarily stopped to facilitate the bowel cleansing process. In particular, oral iron can make the stool black and viscous, and iron should be stopped at least 5 days before the colonoscopy.1 Lastly, specific instructions should be given to diabetic patients who are taking oral hypoglycemic medications or insulin to avoid periprocedural hypoglycemia.
There are many independent predictors for a potential inadequate bowel preparation, such as a late colonoscopy start time; failure to follow preparation instructions; inpatient status; procedural indication of constipation; use of drugs that impair gut motility (e.g., tricyclic antidepressants, calcium channel blockers, iron); male gender; and a history of cirrhosis, stroke, dementia, obesity, or diabetes mellitus.4–7 A prior history of failed colonoscopy preparation is also highly predictive of a failed second or subsequent attempt at preparation.8 In these various patient groups, a more prolonged bowel preparation may be required. Many studies have shown an improved effect of the preparation if half is given the day before the procedure and half is given on the day of the examination. This approach also improves patient adherence and tolerance and is a useful strategy if difficulties with the preparation are anticipated. Other options include abstinence from dietary fat for 1 week and a morning procedure time. In patients who develop nausea, vomiting, or excessive bloating and patients who do not tolerate the preparation, one of the following measures can be used:
Currently, the three widely accepted bowel preparations for colonoscopy are polyethylene glycol (PEG)–based solutions, sodium phosphate–based solutions, and sulfate-based preparations. Stimulant and hyperosmotic laxatives, such as castor oil, senna, mannitol, sorbitol, and lactulose, are no longer used because they are ineffective. Nonabsorbable sugars may be metabolized by colonic bacteria, generating hydrogen, and carry the risk of explosion during electrosurgical procedures.9
Polyethylene Glycol–Based Preparations
Golytely, developed in 1980, was the first osmotically balanced electrolyte purge solution. Since then, several modifications of the solution have been made to improve tolerability. An oral purge using 4 L of a PEG-based solution, given the day before colonoscopy at the rate of approximately 1 L/hr, is associated with a good cleansing efficacy and reasonable patient tolerance.10–12 Adding a flavor to the preparation is often preferred by patients. Approximately 19% of patients are unable to complete the preparation because of its large volume and unpalatable taste.13 Newer PEG-based solutions such as MoviPrep (supplied by Norgine in Europe and Australia and Salix Pharmaceuticals in the United States) are better tolerated because the ingested volume has been reduced (2 L), and the taste has been significantly improved.14 The efficacy of the lower volume preparation is similar to the standard 4-L products, and the side-effect profile is similar. Metoclopramide may be helpful in selected patients to decrease nausea and vomiting, although routine use of metoclopramide did not confer any significant benefit in a small, randomized trial.15 PEG-based oral lavage (or any form of bowel preparation) is contraindicated in patients with an ileus, significant gastric retention, suspected or established mechanical bowel obstruction, severe colitis, or neurologic impairment that prevents safe swallowing.1 For patients with swallowing difficulties, a nasogastric tube can be used to administer the solution.
Sodium Phosphate–Based Preparations
The sodium phosphate–based bowel preparation is a smaller volume and can be safely given to most healthy individuals. Traditionally, sodium phosphate preparations have been available in liquid form, but more recently Diacol (Pharmatel Fresenius Kabi, Australia, and Dr Falk Pharma, Europe) and Visicol and OsmoPrep (Salix Pharmaceuticals, United States) have been released with sodium phosphate in a tablet form. Less taste than the liquid formulations may improve tolerance, and efficacy seems comparable. Sodium phosphate preparations are administered in split doses before colonoscopy with the exact timing depending on the time that the colonoscopy is to be performed. The preparation acts by exerting a hyperosmotic effect and by indirectly stimulating stretch receptors to increase peristalsis.13 Sodium phosphate–based preparations have been shown to be superior in tolerance and at least as effective as PEG-based preparation.13,16–19
Because of its rapid osmotic effect and the possibility of significant hyperphosphatemia, it is recommended that sodium phosphate–based bowel preparation be avoided in patients sensitive to sudden volume shifts, such as patients with congestive heart failure and renal impairment. Caution is also required in patients with the potential for disordered sodium or phosphate balance, such as patients with decompensated cirrhosis, small or large bowel dysmotility, and other preexisting electrolyte imbalances.1,16,17,19 In addition, this preparation is not recommended in patients with proven or suspected inflammatory bowel disease because it can cause colonic inflammation and aphthous ulceration in 25% of cases compared with 2% to 3% in PEG-prepared patients.20 Patients in whom this preparation is prescribed must be advised to drink as much clear fluids as can be tolerated to reduce the risk of dehydration and to facilitate the cleansing effect of the medication. For this reason, it has been suggested that sodium phosphate–based preparations are inappropriate for elderly patients, but Thomson and coworkers21 found that this preparation was safe, effective, and well tolerated in most elderly patients (mean age 72 years). Caution is nonetheless advised because a more recent study has shown sodium phosphate–based solutions are associated with a decline in glomerular filtration rate in elderly patients with creatinine levels in the normal range.22
Other Preparations
Colocap Balance was released more recently; this is a capsule that contains magnesium sulfate. The capsules have no taste and may be easier for patients who are unable to tolerate the taste of the liquid bowel preparation regimens. This product is currently undergoing clinical trials. Oral sulfate solutions are also available. A randomized controlled trial showed that these agents are as effective as low-volume PEG-based regimens.23 There seemed to be an advantage if the preparation was split with half administered the day before colonoscopy and half administered on the day of the procedure.
Preparation for Flexible Sigmoidoscopy
Preparation before flexible sigmoidoscopy generally requires cleansing of only the left colon.1 In most cases, this cleansing can be achieved by administering one or two enemas 1 hour before the procedure. Several types of enemas are available:
Preparation for Endoscopic Ultrasound
Patient preparation for endoscopic ultrasound is similar to preparation for upper gastrointestinal (GI) endoscopy.1 Patients must fast for at least 4 hours before the procedure. In patients in whom a biopsy or therapeutic intervention is considered necessary, a platelet count and coagulation studies may be appropriate before the procedure if a bleeding disorder is suspected. In addition, antiplatelet and anticoagulation therapies must be reviewed, and where appropriate modification or cessation of this therapy may be required. Antibiotic prophylaxis generally is not required unless fine needle aspiration (FNA) of a cystic lesion is being performed. FNA of cystic lesions is considered high risk for infection, and antibiotics are recommended. FNA of solid lesions in the upper GI tract24,25 or in the lower GI tract26 has been shown to be a low-risk procedure and does not warrant antibiotic prophylaxis.
Preparation for Capsule Endoscopy
Optimizing conditions for capsule endoscopy continues to be an area of interest. Most centers prefer a slightly longer fasting time than for routine endoscopy. Generally, clear fluids are given after lunch on the day before the examination, and the patient fasts for 12 hours before the examination is scheduled to begin. No medication should be taken within 2 hours of ingestion of the capsule. In some centers, 2 L of a PEG-based bowel preparation regimen is given before the patient begins the 12-hour fast.27,28 This additional step might be particularly important if the patient has had a recent barium study or has had some other form of oral radiologic contrast agent. Some units ask the patient to ingest a small amount of simethicone preparation before the procedure,29 and some units use a prokinetic such as metoclopramide. The use of a purgative preparation improves the quality of the small bowel images obtained during the capsule endoscopy study and diagnostic yield.30 The purgative preparation does not seem to influence completion rate of the study, however. The optimal preparation regimen is not yet established, so instructions may be individualized for the patient. It is prudent to review the patient’s medications and consider holding any medication that might slow GI motility. Iron supplements should be stopped at least 3 days before the examination.
Preparation for Endoscopic Procedures in Patients with Diabetes
There are no controlled trials to guide preparation for endoscopic procedures in diabetic patients.1 The approach to these patients must be individualized, and factors such as usual glycemic control and the patient’s ability to manage his or her diabetes are important considerations. There are no specific requirements in diabetic patients who are controlled on diet alone. In patients taking oral hypoglycemic agents, medications are generally withheld during preparation for the procedure. During this time, the patient must monitor his or her serum glucose and be able to manage or get assistance if there is evidence of progressive hyperglycemia. Hypoglycemia is managed with sugar-containing clear fluids or candy. In patients taking insulin, dose reduction while undergoing the preparation is normal. For upper GI procedures, the usual dose may be given the evening before the procedure, but only half the dose is given on the morning of the examination. The remaining dose can be given if appropriate after the procedure has been completed.
Special Circumstances
Preparation for Endoscopy in Case of Ingestion of a Foreign Body or for Food Bolus Obstruction
Ingestion of foreign bodies occurs mainly in children and mentally disabled patients. Food bolus obstruction is relatively common in adults.31,32 Endoscopic assessment and removal is the main modality of treatment for objects below the level of the cricopharyngeal muscle. The nature of the patient’s symptoms determines the urgency of the procedure. Emergency procedures should be performed for patients who are unable to swallow their saliva, patients with sharp objects (e.g., fish bones, pins, dentures, razor blades), and patients with impacted disk batteries.32,33 The procedure is probably technically easier if performed early. Plain x-rays of the chest and neck may be advisable before the endoscopic procedure if the nature of the object or the site of obstruction is unclear from the history. The x-ray film may also show ectopic gas patterns to indicate a silent perforation. Oral radiologic contrast material generally is best avoided because of the risk of aspiration and because it may obscure the endoscopic field.34,35
With regard to food bolus impaction, glucagon or another prokinetic can be given while the patient is waiting for endoscopy, but this is usually unsuccessful and should not delay endoscopy.36,37 Special attention should be given to airway protection to avoid the risk of airway obstruction during the procedure. Continuous oral suction and the availability of a laryngoscope are also important. General anesthesia with endotracheal intubation is usually required if airway protection is needed, but this is required in less than 25% of cases.38 An alternative strategy to protect the airway is the use of an esophageal overtube. General anesthesia with muscle relaxation often facilitates removal of difficult or large items, particularly as they pass through the upper esophageal sphincter; this is particularly true for swallowed dentures (see Chapter 19).
Preparation for Endoscopy in Patients with Upper Gastrointestinal Bleeding
Preparation of an acutely bleeding patient for endoscopy requires additional precautions and care. The first step is to ensure that the patient is adequately resuscitated because any subsequent endoscopy is best performed when the patient is hemodynamically stable. Volume replacement and correction of any coagulation or platelet function disturbance are important. If there is evidence of ongoing bleeding, urgent endoscopy with airway protection, even in an unstable patient, may be the best way of getting better clinical control of the situation. If time permits, a 6-hour fast is desirable because this would improve the endoscopic view. However, a fast is often not practical, particularly if there is evidence of active bleeding. Sometimes gastric lavage can be used to empty the stomach of blood before endoscopy is performed. Care must be taken not to suck too aggressively with the gastric lavage tube because significant mucosal trauma can occur, and this can make interpretation of the subsequent endoscopic findings difficult. One randomized, placebo-controlled study showed improved endoscopic view with intravenous erythromycin administered 2 hours before endoscopy.39
Endoscopy in patients with upper GI bleeding is usually performed after the patient has received intravenous sedation.40 Endotracheal intubation should be considered in patients with active hematemesis or other perceived increased risk of aspiration. If the patient is suspected to have a bleeding peptic ulcer, an intravenous proton pump inhibitor before the endoscopy should be considered. Studies have suggested that a proton pump inhibitor can significantly improve outcome in these patients.41–44 Similarly, patients suspected to have variceal bleeding may benefit from an octreotide infusion (see Chapter 13).45–47
Preparation for Colonoscopy in Patients with Lower Gastrointestinal Bleeding
In patients with lower GI bleeding, colonoscopy is the procedure of choice to identify the site of bleeding and in some circumstances allows therapeutic intervention (see Chapter 14).48 Before the procedure, patients should be resuscitated, and their general condition should be stabilized. Routine blood tests and coagulation profile are generally performed in patients with GI bleeding, and these should be corrected if abnormal. Generally, most colonoscopies in patients with lower GI bleeding are performed on a semiurgent basis to allow time for some form of bowel preparation. The view at colonoscopy is often a problem in procedures performed urgently, although some studies suggest that urgent colonoscopy is not only technically possible and safe but also effective in controlling bleeding.49,50 Blood itself is a cathartic; many clinicians perform the procedure in an unprepared bowel.51 Other clinicians preferring a bowel preparation generally give 4 L of PEG over 4 hours before the procedure.49,52–54 This solution can be given orally or via a nasogastric tube. In elective procedures, the colon can be prepared in a standard fashion. Because these patients are at higher risk of a disturbance of intravascular volume, it is generally advisable to avoid sodium phosphate–based preparations. A prokinetic agent may facilitate the bowel preparation. In general, patients should not have barium studies before colonoscopy because it would interfere with the view and may obscure flat mucosal lesions such as angiodysplasia. If an obstructive lesion is suspected, a clear water-soluble contrast agent such as Gastrografin should be used.
Antiplatelet and Anticoagulation Therapy
The decision to discontinue antiplatelet or anticoagulation therapy depends on two important factors: the risk of bleeding related to an endoscopic intervention and the risk of a thromboembolic event related to interruption of these medications. The risk stratification of these two factors is summarized in Table 8.1.55 If anticoagulation therapy is temporary, elective procedures should be delayed until the anticoagulation has been stopped. For patients receiving warfarin who undergo a low-risk procedure, no adjustment to the anticoagulation therapy is needed, regardless of the underlying condition. In contrast, anticoagulation therapy should be discontinued 3 to 5 days before the procedure in patients who undergo high-risk procedures, and anticoagulation therapy generally can be resumed the night of the procedure. The decision to obtain a preprocedure international normalized ratio (INR) should be individualized.
Table 8.1 Risk Stratification of Bleeding from Endoscopic Procedures and the Condition Risk for Thrombosis and Embolism
| High-Risk Procedures | Low-Risk Procedures |
|---|---|
| PROCEDURE RISK FOR BLEEDING | |
| Polypectomy | Diagnostic endoscopy ± biopsy |
| Biliary sphincterotomy | Diagnostic flexible sigmoidoscopy ± biopsy |
| Pneumatic or bougie dilation | Diagnostic colonoscopy ± biopsy |
| PEG or PEJ placement | Enteroscopy ± biopsy |
| EUS-guided fine needle biopsy | ERCP without sphincterotomy |
| Laser ablation and coagulation | Biliary/pancreatic stenting without sphincterotomy |
| Variceal treatment | EUS without fine needle biopsy |
| CONDITION RISK FOR THROMBOSIS OR EMBOLISM | |
| Atrial fibrillation with valvular heart disease | Deep venous thrombosis |
| Mechanical valve in mitral position | Uncomplicated nonvalvular atrial fibrillation |
| Mechanical valve with prior thromboembolic event | Bioprosthetic heart valve |
| Mechanical valve in aortic position | |
ERCP, endoscopic retrograde cholangiopancreatography; EUS, endoscopic ultrasound; PEG, percutaneous endoscopic gastrostomy; PEJ, percutaneous endoscopic jejunostomy.
Adapted from Eisen GM, Baron TH, Dominitz JA, et al; American Society for Gastrointestinal Endoscopy: Guideline on management of anticoagulation and antiplatelet therapy for endoscopic procedures. Gastrointest Endosc 55:775–779, 2002, with permission from the American Society for Gastrointestinal Endoscopy.
Increasingly, patients who require anticoagulation therapy are being managed with low-molecular-weight heparin (LMWH) because therapy is more reliable and easier to manage. The ASGE has published a guideline on management of LMWH and nonaspirin antiplatelet agents before endoscopic procedures.56 For elective procedures, no specific modification is required for low-risk procedures. For high-risk procedures, LMWH should not be given for at least 8 hours before the procedure and then restarted when deemed safe for the individual patient. LMWH is often used as a bridge in patients taking warfarin for high-risk cardiovascular or thrombotic conditions before an endoscopic procedure. In these patients, LMWH is started 3 to 5 days before the endoscopic procedure when the warfarin is stopped. LMWH is then stopped at least 8 hours before the procedure. The decision when to restart therapy should be individualized.
Generally, endoscopic procedures may be performed in patients taking aspirin or other nonsteroidal antiinflammatory drugs (NSAIDs) in standard doses, provided that they do not have a preexisting bleeding disorder.55 This recommendation is based on limited published studies suggesting that aspirin and NSAIDs in standard doses do not increase the risk of significant bleeding after gastroscopy or colonoscopy with biopsy, polypectomy, and biliary sphincterotomy.57,58
For newer antiplatelet agents, such as clopidogrel, ticlopidine, and glycoprotein (GP) IIb/IIIa inhibitors, limited data are available to make firm recommendations. As mentioned, the ASGE has published a guideline on management of LMWH and nonaspirin antiplatelet agents before endoscopic procedures.56 Decision making should be individualized. These agents generally should be stopped in patients who present with acute GI hemorrhage. The risks of this decision should be balanced against the risk of an ischemic or thrombotic event, especially if the patient has recently had implantation of a drug-eluting coronary stent. If rapid reversal is required, a platelet transfusion may be appropriate. For low-risk procedures, adjustment to clopidogrel and ticlopidine therapy is not required. For high-risk procedures, one approach is to stop the agent for 7 to 10 days before the procedure.
Management of Disorders of Hemostasis before Endoscopic Examinations
Management of patients with hemostasis disorders should be individualized and when possible should be in close collaboration with an experienced hematologist in a specialized center with a specialist coagulation laboratory. The endoscopist must assess the risk of bleeding based on the procedural risk and the severity of the underlying disorder of hemostasis and plan the endoscopic procedure accordingly.59
Von Willebrand’s Disease
von Willebrand’s disease (vWD) is the most common inherited disorder of hemostasis; therapy before endoscopic procedures depends on the type of vWD. For less severe type I disease, treatment with DDAVP starting 1 hour before the procedure and once daily thereafter for 2 to 3 days is adequate for patients undergoing diagnostic procedures and mucosal biopsies. However, for therapeutic procedures, infusion of factor VIII 1 hour before the procedure to achieve a factor VIII activity of 0.80 to 1.20 U/mL is required. After the procedure, factor VIII activity of at least 0.30 to 0.50 U/mL must be maintained for up to 2 weeks to minimize the risk of rebleeding.46 For more severe type II and type III disease, the same factor VIII replacement regimen is required for diagnostic (maintenance duration of 2 to 3 days) and therapeutic procedures (up to 2 weeks).59
Hemophilia A and B
Preprocedural assay of factor VIII or IX activity is essential to determine the dosage of replacement therapy in patients with hemophilia. Before the procedure, factor VIII infusion is required to achieve an activity of 0.80 to 1.20 U/mL. Postinfusion factor assay should be obtained to determine the patient’s response to the infusion. For purely diagnostic procedures, no further infusion is required. If mucosal biopsies are performed, 75% of the initial dose should be given every 24 hours for an additional 2 to 3 days. If therapeutic procedures are performed, twice-daily factor VIII infusion is required to achieve a maintenance activity of 0.30 to 0.50 U/mL for up to 2 weeks. Adequate factor VIII maintenance activity must be confirmed by at least daily factor VIII assay. Indications for factor IX replacement are identical to the indications for factor VIII infusion except that the maintenance dose is administered at intervals of 24 hours because the half-life of factor IX is longer.59
Liver Disease
The possible hemostatic defects in patients with liver disease are coagulopathy and thrombocytopenia. Correction is usually not required for diagnostic endoscopic procedures, but most centers would consider correction if the INR is greater than 2.5. Correction is necessary if therapeutic maneuvers are needed. These recommendations are based on limited data. If high-risk procedures are done, correction of an INR to less than 1.4 to 1.7 is advisable59; this can be accomplished by a combination of fresh frozen plasma and vitamin K replacement. Correction of significant thrombocytopenia is discussed later.
Renal Failure
The main hemostatic defect in patients with renal failure is an acquired qualitative platelet defect secondary to uremia. Bleeding complications in these patients undergoing renal biopsy, abdominal surgery, liver and bone biopsies, or tooth extraction are rare.60 In addition, measurement of preprocedural bleeding time is not helpful because it does not predict outcome.60 Platelet infusion is not routinely recommended, unless concurrent significant thrombocytopenia exists.59 Because uremia is thought to be the cause of platelet dysfunction, dialysis with limited heparin shortly before high-risk procedures is recommended to reduce serum urea nitrogen to less than 50 to 75 mg/dL.59,61
Thrombocytopenia
There are no prospective data on the need for prophylactic platelet transfusion, and the following guidelines have been based on decision analysis.59,62,63 Platelet transfusion to increase the platelet count to greater than 20 × 109 platelets/L is required for low-risk procedures, and a count greater than 50 × 109 platelets/L is required for high-risk therapeutic procedures. For patients with immune thrombocytopenia, elective procedures should be postponed until an appropriate improvement in platelet count (20 to 30 × 109 platelets/L) is observed with standard therapy. If endoscopic procedures cannot be postponed and immediate intervention is necessary, a platelet transfusion should be given just before the procedure.59 If bleeding occurs after the procedure, further platelet transfusion should be given. Input from a hematologist is recommended if response to platelet transfusion is poor.59
Antibiotic Prophylaxis
The British Society of Gastroenterology more recently released guidelines for antibiotic prophylaxis in GI endoscopy.64 The executive summary includes the following recommendations:
Patients undergoing ERCP for treatment of cholangitis should be established on antibiotics before the procedure, and an additional single dose of antibiotic is not recommended (the collection of a bile sample for culture to guide subsequent therapy should be considered).
Specific circumstances in which antibiotic therapy should be used to cover ERCP include:
Antibiotic Prophylaxis for Prevention of Infective Endocarditis
The practice of antibiotic prophylaxis in GI endoscopy to prevent infective endocarditis has previously been common. Antibiotic guidelines have previously recommended antibiotic prophylaxis for the prevention of infective endocarditis.65 For more than 50 years, patients and physicians have been accustomed to this practice. However, the data on which this practice has been based have been scanty. In addition, the risk of infective endocarditis as a result of a GI procedure is extremely low, and true causality is usually lacking in the few case reports that do exist.
A consensus document has been published looking at the role of antibiotic prophylaxis for the prevention of infective endocarditis.66 These guidelines were prepared in collaboration with many learned societies and advisory groups and have been broadly adopted internationally. The guidelines conclude that:
Only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis.
Antibiotic Prophylaxis for Patients with Vascular Grafts and Other Implanted Devices
It has been suggested that some delayed infections of orthopedic, neurosurgical, and other prostheses may be due to bacteremia associated with endoscopic procedures.64 However, the risk from endoscopic procedures is negligible compared with other daily activities associated with bacteremia, such as chewing or oral hygiene measures such as tooth brushing. Any benefit of antibiotics to cover these activities would be outweighed by the adverse effects. The British Society of Gastroenterology, the ASGE, and the American Society of Colon and Rectal Surgeons do not recommend the use of antibiotics before endoscopy in patients with orthopedic prostheses, central nervous system vascular shunts, vascular grafts or stents, penile prostheses, intraocular lenses, pacemakers, or local tissue augmentation materials.
Antibiotic Prophylaxis for Percutaneous Endoscopic Gastrostomy or Percutaneous Endoscopic Jejunostomy
A single dose of an appropriate antibiotic given 30 minutes before percutaneous endoscopic gastrostomy or jejunostomy insertion is routinely recommended for all patients who are not already receiving antibiotics because the risk of peristomal wound infection is significantly reduced.64 However, for patients who are already receiving appropriate antibiotics, no additional prophylaxis may be required. Patients known to be colonized with multiple resistant organisms or patients who have been hospitalized for some time before percutaneous endoscopic gastrostomy or jejunostomy insertion and who are likely to be colonized with resistant organisms should receive antibiotic prophylaxis appropriate to cover multiple resistant organisms. Local guidelines should be followed when choosing the antibiotic before percutaneous endoscopic gastrostomy or jejunostomy insertion. The choice of drug should be carefully considered in patients who are allergic to penicillin.
Antibiotic Prophylaxis for Patients with Variceal Bleeding or Patients with Decompensated Liver Disease Who Develop Acute Gastrointestinal Bleeding
Prophylactic antibiotics in patients with variceal bleeding or in patients with decompensated liver disease who develop acute GI bleeding improves short-term survival and may be associated with a reduced risk of rebleeding.64 It is recommended that patients receive antibiotics before endoscopy. The choice of antibiotics is determined by local guidelines, but ceftriaxone is frequently used.
Antibiotic Prophylaxis for Patients with Neutropenia or Who Are Immunocompromised
Neutropenia (<0.5 × 109/L) predisposes to sepsis after procedures such as endoscopy, but the level of risk is unclear.64 Patients who are febrile should already be treated with empiric antibiotics according to local hematology guidelines. In afebrile patients, antibiotic prophylaxis should be offered for high-risk procedures such as sclerotherapy, esophageal dilation, or ERCP with duct obstruction. Gram-negative aerobic and, less frequently, anaerobic organisms are likely pathogens, and the choice of antibiotic should reflect local sensitivities. No data support the use of prophylactic antibiotics in patients who have a normal neutrophil count but who are nonetheless immunocompromised (e.g., organ transplants). Routine antibiotic prophylaxis is not recommended in patients with human immunodeficiency virus (HIV) infection.
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18 Cohen SM, Wexner SD, Binderow SR, et al. Prospective, randomized, endoscopic-blinded trial comparing pre-colonoscopy bowel cleansing methods. Dis Colon Rectum. 1994;37:689-692.
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