Post on 28-Sep-2020
EndoscopicProcedureComplications:EarlySignsandSymptoms
09/24/2016
ConflictofInterest:None
SriGaddamMDMPHAssistantProfessorofMedicine
InterventionalEndoscopyCedars-SinaiMedicalCenter
Case#1
• 56yearoldmalewithhistoryofanesophagealstrictureunderwentesophagealdilationupto15mmusingaCREballoon.Inthepost-proceduralarea,patient’sfaceappearsbloated.
Case#2
• 64yearoldmanwithhistoryofpancreaticcancerandintractableabdominalpainunderwentEUSwithceliacplexusblockandwasfoundtobehypotensivepost-procedurally.
Case#3
• 33yearoldfemalewithhistoryofsphincterofOddidysfunctionpresenttothepost-procedureareawithepigastricabdominalpainradiatingtotheback.
ComplicationsofEndoscopy
• Complications– EGD– Colonoscopy– ERCP– EUS
• Whattowatchoutforin:– Pre-oparea– Procedureroom– Post-oprecoveryarea
ComplicationsofUpperEndoscopy
• Overall,lowriskofadverseevents• Complicationrateof1in200to1in10,000• Mortalityrateof1in2,000• 60%ofadverseeventsarecardiopulmonaryandrelatedtosedation
• Commoncomplications:– 1.Infection:extremelylow– 2.Bleeding:Mallory-WeissTearin0.5%– 3.Perforation:1in2500to1in11,000
ComplicationsofUpperEndoscopy
• HighercomplicationsfromtherapeuticEGD:– Dilation:higherriskofperforation(2– 10%)• Fever,pain,chestpain,orsubcutaneousemphysema
– Foreignbodyretrieval:superficiallaceration,hemorrhageorperforation
– PEG:aspiration,bleeding,injurytootherorgans,perforation,ileum,fasciitis,death(overall5– 10%risk)
– Otherhighriskprocedures:banding,ablationandEMR
ComplicationsofColonoscopy• Overallalowriskprocedure• Seriousadverseeventsoccurredin3per1000procedures• Mortalityrateof0.03%• Commoncomplications:– 1.Abdominalpain(common)– 2.Infection(rare)– 3.Gasexplosion(rare)– 4.Perforation(rare)– 5.Others(splenicrupture,appendicitis,diverticulitis,intraabdominalhemorrhage).
ComplicationsofColonoscopy
• Higherrisksfromtherapeuticcolonoscopy:– Tattoo– Dilation(2%to10%riskofperforation)– Colonicstentplacement(higherrisk)– Foreignbodyremoval– AVMtherapyintherightcolon(2.5%perforationrisk)– EMR/ESDoflargecolonpolyps
ComplicationsofERCP• Higherriskprocedure.• OnlytherapeuticERCPsareperformed• Mortalityrateof0.33%• Commoncomplications:– Pancreatitis(3.5%)– Hemorrhage(1.3%)– Peroration(0.3%)– Infection(<1%)– Cardiopulmonary(rare)– Others(liverabscess,acutecholecystitis,ductalstricturesetc)
ComplicationsofERCP
• Rateofcomplicationsaredependenton:– Indicationforprocedure– Biliaryorpancreaticprocedure– Lengthofprocedure– Technique– Experienceofendoscopist
ComplicationsofERCP
• Riskfactorsforpost-ERCPpancreatitis
ComplicationsofEUS
• Safeprocedure• Similarsafetyprofileasupperendoscopy• Safetyofrectal/colonicEUShasnotbeenstudied• Commoncomplications:– Infection(1%)– Acutepancreatitis(0.4%)– Bleeding– Perforation(0.03%)– Bileperitonitis
ComplicationsofEUS
• Increasedriskswiththerapeuticmaneuvers– FNA:increasedriskofinfection,pancreatitisandbleeding.– Celiacplexusneurolysis:hypotension,infection,worseningofabdpain
– LiverFNA:bleeding,cholangitis,bileleak– EUS-guidedbiliaryandpancreaticaccess
Summary
• Diagnosticproceduresaresafe• Commonriskstoallprocedures:– Cardiovascular(mostcommon)– Bleeding– Infection– Perforation
Summary
• Higherriskswiththerapeuticprocedures• AllERCPsaretherapeuticprocedures• Thetypeoftherapyperformedcanpredictpotentialcomplications.
Summary
• Complicationsarerare• Easytomiss• Constantawarenessforpotentialharm
Summary
• Complicationsarerare• Easytomiss
• Constantawarenessforpotentialharm
Howtominimizecomplications?
• Non-modifiableriskfactors
• Modifiableriskfactors– Qualityofbowelpreparation– Anticoagulation– Cardiovascularinstability– Correctequipment– Proceduralpreparedness– Physicianfatigue
Howtominimizecomplications?
• Pre-procedurearea:– Listofmedications– Anticoagulants– Arrhythmias– Vitalsigns– Volumestatus– Labs– Understandingoftheprocedure/expectations
Howtominimizecomplications?
• Intheendoscopyroom:– Position–Watchfornausea– Suction– Airway–Watchforevidenceofdeepsedation– Examinethepatientduringlongprocedures
Howtominimizecomplications?
• Inthepost-procedurearea:– Thoroughhand-off– Knowledgeofprocedure– Assessment• Vitalsigns• Headandneck• Chest• Abdomen• Extremities
Case#1
• 56yearoldmalewithhistoryofanesophagealstrictureunderwentesophagealdilationupto15mmusingaCREballoon.Inthepost-proceduralarea,patient’sfaceappearsbloated.
Case#2
• 64yearoldmanwithhistoryofpancreaticcancerandintractableabdominalpainunderwentEUSwithceliacplexusblockandwasfoundtobehypotensivepost-procedurally.
Case#3
• 33yearoldfemalewithhistoryofsphincterofOddidysfunctionpresenttothepost-procedureareawithepigastricabdominalpainradiatingtotheback.
• Constantawarenessforpotentialharm