Tuesday, 13 September 2016

Complications of Upper Endoscopy

What are the Possible Complications of Upper Endoscopy?

Endoscopy is generally safe.  Complications can occur, but are rare when the test is performed by physicians with specialized training and experience in this procedure.  Bleeding may occur from a biopsy site or where a polyp was removed.  It is usually minimal and rarely requires blood transfusions or surgery.  Localized irritation of the vein where medication was injected may rarely cause a tender lump lasting for several weeks, but this will go away eventually.  Applying heat packs or hot moist towels may help relieve discomfort.  Major complications, e.g., perforation (a tear that might require surgery for repair) are very uncommon.

Upper GI (UGI) endoscopy is commonly performed and carries a low risk of adverse events. Large series report adverse event rates of 1 in 200 to 1 in 10,000 and mortality rates ranging from none to 1 in 2000.1-6 Data collected from the Clinical Outcomes Research Initiative database show a cardiopulmonary event rate of 1 in 170 and a mortality rate of 1 in 10,000 from among 140,000 UGI endoscopic procedures.7 The variability in rates of adverse events may be attributed to the method of data collection, patient populations, duration of follow-up, and definitions of adverse events. Some authors include minor incidents, such as transient hypoxemia or self-limited bleeding as adverse events, whereas others report only significant adverse events that prevent completion of the procedure or result in hospitalization.8 Additionally, the majority of publications rely on self-reporting, and most reported data collected only from the immediate periprocedure period, thus the rate of late adverse events and mortality may be underestimated.8,9 Major adverse events related to diagnostic UGI endoscopy are rare and include cardiopulmonary adverse events, infection, perforation, and bleeding

Cardiopulmonary adverse events

Most UGI procedures in the United States and Europe are performed with patients under sedation (moderate or deep).12 Cardiopulmonary adverse events related to sedation and analgesia account for as much as 60% of UGI endoscopy adverse events.1-4,7 The rate of cardiopulmonary adverse events in large, national studies is between 1 in 170 and 1 in 10,000.1-4,6,7 Reported adverse events range from minor incidents, such as changes in oxygen saturation or heart rate, to significant adverse events such as aspiration pneumonia, respiratory arrest, myocardial infarction, stroke, and shock. Patient-related risk factors for cardiopulmonary adverse events include preexisting cardiopulmonary disease, advanced age, American Society of Anesthesiologists class III or higher, and an increased modified Goldman score.13,14 Procedurerelated risk factors for hypoxemia include difficulty with intubating the esophagus, a prolonged procedure, and a patient in the prone position.7,8,15,16 For a detailed discussion and specific recommendations, the reader is referred to the ASGE document “Sedation and Anesthesia in GI Endoscopy”17 and the “American Society of Anesthesiology Practice Guidelines for Sedation and Analgesia by Nonanesthesiologists


Clinically significant bleeding is a rare adverse event of diagnostic UGI endoscopy.31 Mallory-Weiss tears occur in less than 0.5% of diagnostic UGI endoscopic procedures and usually are not associated with significant bleeding.32 Bleeding may be more likely in individuals with thrombocytopenia and/or coagulopathy.1 The minimum threshold platelet count for the performance of diagnostic UGI endoscopy has not been established. UGI endoscopy with biopsy was shown to be safe in 1 study of adults with solid malignancies and platelet counts greater than 20,000/mL.33 Two case series of UGI endoscopy with or without biopsies in children with platelet counts greater than 50,000/mL reported no bleeding adverse events.34,35 However, a larger study of 198 UGI endoscopies in children after stem cell transplantation demonstrated that the risk of bleeding requiring red blood cell transfusions after UGI endoscopic biopsies was 4% despite a minimum platelet count of 50,000/mL.36 Four of these 8 patients were found to have duodenal hematomas. Thus, some authors have concluded that diagnostic UGI endoscopy can be performed when the platelet level is 20,000/mL or greater and that a threshold of 50,000/mL should be considered before performing biopsies.3

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