Emergencies after endoscopic procedures

Abstract

Keywords:GI endoscopy adverse events GI emergencies Bleeding Haemorrhage Perforation Infection Embolization Diagnosis and management of severe complications a b s t r a c t Endoscopy adverse events (AEs), or complications, are a rising concern on the quality of endoscopic care, given the technical advances and the crescent complexity of therapeutic procedures, over the entire gastrointestinal and bilio-pancreatic tract. In a small percentage, not established, there can be real emergency conditions, as perforation, severe bleeding, embolization or infection. Distinct variables interfere in its occurrence, although, the awareness of the operator for their potential, early recognition, and local organized facilities for immediate handling, makes all the difference in the subsequent outcome. This review outlines general AEs' frequencies, important predisposing factors and putative prophylactic measures for specific procedures (from conventional endoscopy to endoscopic cholangio-pancreatography and ultrasonography), with comprehensive approaches to the management of emergent bleeding and perforation.

The role of surgery in the treatment of endoscopic complications

“…Indeed, many authors advocate initial use of CT for the assessment of perforation [14,15,47,53]. If enteric contrast is to be used, it should be rectal and water-soluble [14]. Although many important findings may be missed without adequate enteric and IV contrast, free gas is not one of them and therefore the scan should not be delayed for the administration of oral contrast.…”

“…Serial abdominal examinations will help differentiate the development diffuse peritonitis warranting emergent operation from localized peritonitis amenable to nonoperative management. Recent advances in endoscopic management, with clipped closure of the perforation site, have been reported, especially in small (<2-cm) perforations without ragged edges, in a well-prepped and otherwise normal colon [14,15,46,47,56,57]. In select cases, extraperitoneal perforations may also be amenable to nonoperative management and can be identified based on CT imaging [46,52].…”

“…Upper GI bleeding complicating EGD, be it from esophageal varices or a nonvariceal source, is managed with endoscopic therapy and rarely requires surgical intervention [7,14]. If endoscopic and pharmacologic therapy initially give way to rebleeding, repeat endoscopic treatment is generally preferred to operation and many endoscopic modalities are available as reviewed elsewhere in this issue and in the literature [7,8,15].…”

“…If this study is inconclusive, then the much more sensitive computed tomography (CT) should be obtained to make a definitive diagnosis. Indeed, many authors advocate initial use of CT for the assessment of perforation [14,15,47,53]. If enteric contrast is to be used, it should be rectal and water-soluble [14].…”

Embolization of procedure-related upper gastrointestinal bleeding

“…34 Endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), as well as endoscopic ultrasound (EUS)-guided procedures are associated with the risk of bleeding that may necessitate endovascular management, as reported in published literature reports. 35 Furthermore, percutaneous endoscopic or radiologic gastrostomy (PEG, PRG) related bleeding is rare, but may be catastrophic when it occurs. 36,37 EMR and ESD EMR and ESD are effective and minimally invasive procedures for management of upper GI epithelial and subepithelial lesions.…”