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