Gastrointestinal Endoscopy Introduction

Neil H. Stollman M.D. Chief of Gastroenterology (Interim) San Francisco General Hospital

Outline
Indications / Contraindications Informed consent Risks of endoscopy Conscious sedation Infection control issues
Risks/prophylaxis for bacterial endocarditis Risk of infx transmission via endoscopy

Documentation

Indications for upper endoscopy

Dyspepsia / heartburn
refractory to trial of therapy associated w/ alarm symptoms in patients > 45-50 years

Nausea/vomiting of unknown cause Dysphagia or odynophagia Hematemesis or melena Chest pain w/ negative cardiac evaluation IDA/chronic blood loss with neg colonoscopy or sxs c/w UGI source Caustic ingestion Supected malabsorption

Abnormal X-ray study Survey for CA (Barrett, FAP) Therapeutic endoscopy UGIB Stent insertion PEG Polypectomy Treatment of varices Dilation of stricture Tumor cauterization Foreign body Follow-up endoscopy GU or esophageal ulcer, to assess healing

Indications for Flexible Sigmoidoscopy

Survey for neoplasms Asymptomatic avg risk >50 yrs (Q3-5 years) Asymptomatic <50 w/
Pos family history Pre hernia repair FamHx FAP (age 12)

Ureterosigmoidostomy In conjunction with BE for colon CA screening

Non-bloody diarrhea >2wks Unless Abx use, known IBD, Immunosuppressed Bloody diarrhea > 1 wk with features above Hematochezia or suspected distal colonic dz (in young pt when colonoscopy not indicated)

Indications for colonoscopy

Abnormal BE Iron deficiency anemia Melana (negative EGD) Hematochezia (neg F/S) Heme Positive stool Chronic diarrhea (neg F/S) Screening / Surveillance
Asymptomatic, avg risk pts After polypectomy After CRC resection In UC Positive family history

Therapeutic colonoscopy
Polyp removal Palliation of neoplasm Dilation of stricture or stoma Reduction of volvulus Decompression Foreign body removal

IBD to determine extent or activity of disease

Indications for ERCP

Obstructive jaundice (diagnostic / therapeutic) Abnormal radiological imaging of biliary or pancreatic system Unexplained / idiopathic pancreatitis Preoperative evaluation of chronic pancreatitis or pseudocyst Evaluation of SOD by manometry and ES as Rx Choledocholithiasis / cholangitis Palliative stent placement Dilation of biliary stricture

Contraindications to GI Endoscopy
When the results will not change management When the risks to pt health or life outweigh the most favorable benefits of the procedure When adequate cooperation cant be obtained When a perforated viscus is known or suspected

Informed Consent
California requires lay standard; ie. MD must disclose information that a reasonable person would require prior to making an informed decision about the procedure.

Generally NOT delegatable

ELEMENTS OF INFORMED CONSENT: Nature of procedure (what?) Reason being performed/benefits (why?) Limitations Risks / complications (why not?) Alternatives (what else?)

Exceptions to Informed Consent

Emergency Exception Incompetency (not really exception) Therapuetic privilege (rare) Waiver Legal mandate Informed Refusal; document reasons/consequences

Complications of upper endoscopy

Silvis 1976 Miller 1987

USA
Perforation Bleeding Infection Cardiopulmonary Total 70 (0.03%) 63 (0.03%) 17 (0.008%) 129 (0.06%) 279 (0.13%)

Europe
20 (0.008%) --183 (0.073%) 203 (0.08%)

Total procedures

211,410

252,888

Mortality of upper endoscopy

Silvis 1976 Miller 1987

USA
Perforation Bleeding Infection Cardiopulmonary Total procedures 3 (0.001%) 1 (0.003%) 0 6 (0.003%) 211,410

Europe
4 (0.002%) --12 (0.005%) 252,888

Complications after PEG/PEJ

Overall complication rate: Mortality rate: Major complications: Aspiration pneumonia: Minor complications: Local wound infections: 4-38% <1% 3-9% 12-46% 13-15% 6-29%

Complications after diagnostic colonoscopy

Perforation: Bleeding: Infection: Cardiopulmonary: Total: Total Procedures:

From: Silvis et al., 1976

50 (0.2%) 23 (0.09%) 3 (0.01%) 10 (0.04%) 86 (0.34%) 25,298

Complications after polypectomy

Overall complication rate: Mortality rate: Perforation rate: Major hemorrhage rate: 0.4-2.6% 0.1% 0.1-0.5% 0.9-2.2%

Complications of ERCP
Diagnostic ERCP: pancreatitis 3-10%
Freeman et al, Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996. Overall, 229/2347 pts (10%) had complication
pancreatitis 5.4% hemorrhage 2.0% Predictive pt factors: suspected SOD, cirrhosis Not predictive: age, coexistant illness, CBD diameter Predictive case factors: difficult access, pre-cut

30 day mortality = 55/2347 = 2.3%

Bacteremia after endoscopy

Gastroscopy ERCP Colonoscopy Sigmoidoscopy Esophageal dilation Sclerotherapy 4.2% 5.6% 2.2% 4.9% 45% 31%

Antibiotic Prophylaxis - ASGE 5/95

Patient condition Procedure Prophylaxis
Prosthetic valve Dilation or sclerotherapy RECOMMENDED Hx endocarditits __________________________________________ Pulm-syst shunt Others (including EGD, Insufficient data to Synth vasc graft (<1yr) colon +/- bx/polyp make firm recommendation. -----------------------------------------------------------------------------------------------------Rheumatic Heart Disease Dilation or sclero Insufficient data MVP w/ MR ________________________________________ IHSS Others NOT RECOMMENDED ------------------------------------------------------------------------------------------------------CABG, PPM, AICD All procedures NOT RECOMMENDED ------------------------------------------------------------------------------------------------------Obstucted CBD, pseudocyst ERCP RECOMMENDED ------------------------------------------------------------------------------------------------------Cirrhosis, ascites, Dilation or sclero Insufficient data Immunocompromised ____________________________________________ patients Others NOT RECOMMENDED ----------------------------------------------------------------------------------------------------All patients PEG RECOMMENDED ------------------------------------------------------------------------------------------------------Prosthetic joints All procedures NOT RECOMMENDED

Cardiac Conditions Associated With Endocarditis-AHA 1997

Endocarditis prophylaxis recommended High-risk category
Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease Surgically constructed systemic pulmonary shunts or conduits

Moderate-risk category
Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfunction (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

Cardiac Conditions Associated With Endocarditis-AHA 1997

Endocarditis prophylaxis not recommended
Negligible-risk category (no greater risk than the general population) Isolated secundum atrial septal defect Surgical repair of ASD, VSD, or PDA (without residua beyond 6 mo) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation Physiologic, functional, or innocent heart murmurs Previous Kawasaki disease without valvar dysfunction Previous rheumatic fever without valvar dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

Other (GI) Procedures & Endocarditis-AHA 1997

Endocarditis prophylaxis recommended
(for high-risk patients, optional for medium-risk patients) Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangiography with biliary obstruction

Endocarditis prophylaxis not recommended

(optional for high-risk patients) Endoscopy with or without gastrointestinal biopsy

Prophylactic Regimens for Dental, Oral, Resp Tract, or Esophageal Procedures-AHA 1997
Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures

Situation
Standard general prophylaxis Unable to take oral medications Allergic to penicillin

Agent
Amoxicillin Ampicillin Clindamycin or Cephalexin or Azithro/Clarithromycin

Regimen
Adults: 2.0 g; children: 50 mg/kg orally 1 h before procedure Adults: 2.0 g IM or IV; children: 50 mg/kg IM or IV within 30 min before procedure Adults: 600 mg; children: 20 mg/kg orally 1 h before procedure Adults: 2.0 g; children; 50 mg/kg orally 1 h before procedure Adults: 500 mg; children: 15 mg/kg orally 1 h before procedure Adults: 600 mg; children: 20 mg/kg IV within 30 min before procedure Adults: 1.0 g; children: 25 mg/kg IMor IV within 30 min before procedure

Allergic to penicillin and unable to take oral medications

Clindamycin or Cefazolin

Prophylactic Regimens for GU / GI (Excluding Esophageal) Procedures-AHA 1997

Situation
High-risk patients 1.5mg/kg

Agents
Ampicillin plus gentamicin

Regimen
Adults: ampicillin 2.0 g IM or IV plus gentamicin (not to exceed 120 mg) w/in 30 of starting procedure; 6 h later, ampicillin 1 g IM/IV or amoxicillin 1 g orally Children: ampicillin 50 mg/kg IM or IV (not to exceed g) plus gentamicin 1.5 mg/kg w/in 30 of starting; 6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg PO

2.0

High-risk patients allergic to PCN

Vancomycin & gentamicin

Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete infusion within 30 min of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM; complete w/in 30 Adults: amoxicillin 2.0 g orally 1 h before procedure, or ampicillin 2.0 g IM/IV w/in 30 of starting procedure Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within

Moderate-risk patients

Amoxicillin or ampicillin

30 Mod-risk patients allergic to PCN infusion Vancomycin Adults: vancomycin 1.0 g IV over 1-2 h complete within 30 min of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h; complete

Pre-Procedure Laboratory Testing

No data on pre-endoscopy lab testing Extrapolation from surgical literature suggests that they are over-utilized, , inappropriately ordered, and rarely reveal abnormalities that influence management Abnormals MUCH more likely to be false positive Should be used selectively, ie. in patients on anticoagulants, w/ hx liver disease etc.

Pre-Procedure Laboratory Testing

Screening tests should not be ordered routinely prior to endoscopic procedures. Even for higher-risk endoscopic procedures like sphincterotomy, there is no evidence to support routine preprocedure testing, which should be used selectively, based on a patients medical history and physical examination ASGE Position Statement 1999

Transmission of Infection via Endoscopy

253 cases reported before 1988 1988: ASGE, SGNE guidelines on endoscope disinfection 1988 onward: 28 cases reported Most cases can be traced to procedural errors in cleaning and disinfection Rate estimated at 1:1,800,000 cases No HBV since 1988; no HIV ever

Transmission of Infection via Endoscopy

Endoscopes are semi-critical devices (do not breach mucosal surface): standard is HIGHLEVEL DISINFECTION (not sterilization) Accessories that breach mucosa (bx, snare etc) are critical devices: STERILIZED Mechanical cleaning: most important Disinfection (20 glutaraldehyde or equivalent) Air drying and storage

Sedation and Monitoring

Cardiopulmonary complications account for >50% of all endoscopic complications Combination agents (eg benzos and opiates) potentiate effect and risk of complications Antagonists should be present, and staff familiar with use; remember, T of drug may exceed T of reversal agent. Monitoring: pulse ox, EKG, BP, respirations

Documentation
If you didnt write it down, you didnt do it The World According to Garp: Malpractice Attorneys JCAHO Medicare et al.