Perforation/abdominal compartment syndrome
Endoscopic therapy-related conditions (e.g., post-band ligation, post-stent placement, post-polypectomy syndrome, post-APC treatment)
Splenic laceration and rupture
Ogilvie’s syndrome (acute colonic pseudo-obstruction)
Chilaiditi’s syndrome (interposition of large bowel between the liver and diaphragm)
The risk of bleeding from endoscopy is related to both patient and procedural factors. Low-risk procedures include upper endoscopy, colonoscopy, ERCP without sphincterotomy, and endoscopic ultrasound (EUS) without fine needle aspiration. Polypectomy, sphincterotomy, percutaneous endoscopic gastrostomy, and dilation therapy are high-risk procedures. The decision to hold antithrombotic agents should be titrated to the patient’s risk for a thromboembolic event and is discussed in detail in a separate chapter. The two more common bleeding adverse events after high-risk endoscopy (i.e., post-polypectomy and post-sphincterotomy bleeding) are reviewed below.
Bleeding following colonoscopy is usually related to polypectomy. The incidence of post-polypectomy bleeding ranges from 0.6 % to 8.6 %, depending on the setting and the definition of bleeding . Delayed post-polypectomy bleeding has been reported up to 16 days after colonoscopy . The morphology, size and location of colorectal polyps, number of polyps removed, and post-polypectomy anticoagulation have been associated with the risk of post-polypectomy bleeding [12–14]. The role of various therapeutic techniques and their incidence on post-polypectomy bleeding remain controversial. Endoscopic mucosal resection (EMR) is a useful technique for removing large colon polyps, but it is associated with increased risk of bleeding (6–7 %) and perforation (1–2 %) . Failure to create a sufficiently large submucosal fluid safety cushion using saline (or other) lift technique is the usual cause of EMR-related complications .
Peri-procedural anticoagulation and antiplatelet management is discussed in a separate chapter. A careful medical history and physical examination may help determine patients with risk factors (such as anticoagulation use and certain comorbidities) and help guide the proper management plan. Endoscopists should perform pre-procedural coagulation testing (platelet count, INR, partial thromboplastin time) selectively on the basis of the patient’s medical history (bleeding, liver disease, malabsorption, malnutrition), physical examination (bruising or petechiae), and associated risk factors (anticoagulation, prolonged antibiotic use) . Platelet transfusion should be considered in patients with platelets less than 50,000/μL.
Desmopressin acetate (DDAVP®) should be considered in patients with platelet function disorders, such as von Willebrand disease. Eltrombopag , a thrombopoietin receptor agonist, reduces the need for platelet transfusions and should be considered in patients with chronic liver disease or idiopathic thrombocytopenic purpura with platelets less than 50,000/μL . Post-polypectomy bleeding risk seems to be increased in patients taking warfarin or resuming warfarin or heparin within 1 week after polypectomy. Clopidogrel and warfarin should be discontinued 5–10 days and 3–5 days, respectively, before the procedure, or the endoscopy should ideally be postponed if the procedure is an elective one .
Post-polypectomy bleeding tends to be associated with the removal of large polyps, use of cutting rather than coagulation current, and transection of a stalk or neck of tissue without cautery or with insufficient cautery . Coagulation (or blended) current instead of cutting current is typically used . When a large polyp with a thick stalk is encountered, epinephrine or saline submucosal injection, placement of a detachable snare (EndoLoop™, Olympus America, Center Valley, PA, USA), and/or endoscopic clip placement may be considered [16, 19]. When a visible vessel is present following polypectomy, clips should be applied . There is no defined “standard of care” in this situation . Nine randomized studies have compared various techniques in the prevention of post-polypectomy bleeding. All studies to date have limitations and, therefore, the results should be interpreted with caution.
In summary, (1) the submucosal injection of saline-epinephrine solution prior to polyp resection can prevent early but not delayed bleeding; (2) loop placement can prevent bleeding, especially in large polyps, but mostly early bleeding; (3) clips may prevent delayed post-polypectomy hemorrhage, but this has not been proven in a randomized trial; and (4) combination modalities may be more effective than a single technique .
Patients who undergo uneventful polypectomy need to be informed that delayed post-polypectomy bleeding can occur up to 14 days after their procedure. Resuscitation takes priority when assessing a patient with post-procedural bleeding. The abdomen should be examined for evidence of peritoneal signs. Complete blood count, coagulation parameters, and blood type and crossmatch should be obtained. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants should be stopped, if feasible. Patients on warfarin may require reversal with prothrombin complex concentrate or fresh frozen plasma.
Delayed post-polypectomy bleeding most commonly stops spontaneously. If bleeding does not stop, then repeat colonoscopy should be performed. Most post-polypectomy bleeding can be controlled endoscopically. The skill set of any endoscopist who performs colonoscopy must include the ability to achieve hemostasis. Injection of the polypectomy site with dilute epinephrine solution is helpful for persistent venous oozing . Mechanical hemostatic methods, such as hemoclip and EndoLoop™ placement, seem to be effective and are favored over thermal therapies, but controlled data are insufficient to make firm recommendations [12, 16]. The main premise to preferably use mechanical hemostatic devices is to avoid further thermal damage to the post-polypectomy area and potentially decrease the risk of perforation (Fig. 10.1). Band ligation has been successfully applied in a few case reports [20–22]. Careful discharge instructions and extended observation are necessary. Aspirin, NSAIDs, and clopidogrel should be discontinued for 7–10 days, and warfarin should be withheld for at least 48–72 h, if possible .
(a) Post-polypectomy bleeding site with visible vessel. (b) Hemostasis secured with clip placement
Blood transfusion, hospitalization, and multidisciplinary involvement (GI, interventional radiology, and surgery) may be required in complicated cases. In our institution, we have developed a GI bleeding protocol with multidisciplinary involvement. The protocol is used for any GI bleeding, including post-endoscopy bleeding. The key concepts of our GI bleeding protocol are as follows:
Multidisciplinary involvement should be considered in any patient with hemodynamic instability, transfusion requirements of more than 4 units packed red blood cell over 24 h or 8 units in total, rebleeding, no clear source of bleeding identified on initial endoscopy, high risk for rebleeding, and difficult to match blood type or who is a Jehovah’s witness. If any of the above factors is present, the “GI bleeding protocol” is activated.
The first step in the bleeding protocol is to conduct a conference call that includes the senior staff from GI, surgery, interventional radiology, and intensive care unit specialties. Any service can initiate the protocol, but typically this is done most commonly by the GI attending. The hospital telephone operators have an established process to page all the appropriate physicians covering the four respective services at that particular moment and place them individually on hold in a “virtual room” until all services have responded. Once all four services have been reached, a conference call is carried out, and a decision is made for the most appropriate next step in management.
One person is designated to be in charge of communicating to the patient the recommended management strategy. This is typically the GI staff because, as a rule, he or she already has been involved in the case and has an established rapport with the patient and family.
The implementation of this GI bleeding protocol has greatly improved communication and has streamlined patient care at our institution. Importantly, we are no longer caught up in a vicious cycle of one provider recommending a specific therapy (e.g., GI team recommends angiography to be done by interventional radiology) and another provider recommending an alternative strategy (e.g., interventional radiology recommends a bleeding radionuclide scan first instead of angiography). Furthermore, the patient and family do not receive conflicting information. Most importantly, the patient is treated with the agreed upon consensus therapy in a timely manner. We believe that every institution should strongly consider the establishment of such a GI bleeding protocol. The specific criteria to initiate the protocol and the following steps may be different than those described above based on local resources and expertise. The establishment of a multidisciplinary management strategy, however, tends to be labor-intensive. Nevertheless, a multidisciplinary predetermined plan will improve patient care and facilitate communication between physicians and the patient.
Bleeding complications of ERCP are usually related to sphincterotomy. The incidence of post-endoscopic sphincterotomy bleeding is 0.5–2 % and has been reported in up to 12 % of cases . A number of risk factors for post-ERCP bleeding have been identified, which are related to patient comorbidities (hemodialysis, cholangitis before the procedure, coagulopathy, Billroth II anatomy) and intervention (length of sphincterotomy, precut sphincterotomy, anticoagulation within 3 days after procedure, endoscopist’s low case volume) [24, 25]. Immediate bleeding at the time of sphincterotomy is also a known risk factor for delayed bleeding . The risk of bleeding can be minimized by identifying patients at risk and optimizing coagulation abnormalities and attention to technique.
Identifying patients at risk and optimizing coagulation abnormalities are mandatory. Controversy remains regarding the appropriate use of platelet and coagulation factor transfusions in high-risk patients, and data are limited. Recommendations regarding warfarin and clopidogrel are similar to those mentioned in the post-polypectomy section .
Hemorrhage can be limited by careful technique, including proper orientation of the wire, avoidance of unnecessarily long cuts, and judicious use of the electrosurgical current. The use of pure-cut current has been shown to increase the risk of bleeding. Blended or coagulation current reduces the bleeding risk but may increase the risk of post-ERCP pancreatitis . The Endocut™ mode (ERBE USA, Marietta, GA, USA) or Pulse mode™ (Olympus America, Center Valley, PA, USA) provides computerized control of the electrosurgical generator, and these modes are commonly used due to relative safety in bleeding reduction and a lower incidence of pancreatitis compared to blended current . Balloon dilation of the native papilla is associated with a decreased rate of bleeding, but is to be avoided because of well-documented increased risk of post-ERCP pancreatitis. It may be considered in highly selected cases where sphincterotomy is particularly risky. Specific examples include patients with bile duct stones and significant coagulopathy that cannot be easily corrected and those in whom location of the papilla makes sphincterotomy technically difficult (e.g. intra-diverticular papilla or Billroth II anatomy) . Endoscopic papillary large balloon dilation (EPLBD) following limited endoscopic sphincterotomy is a relatively new technique which has been shown to be effective and safe for the removal of large biliary duct stones [29–31]. Importantly, the use of EPLBD can not only facilitate the extraction of difficult stones, but has not been associated with increased risk of post-ERCP pancreatitis. The use of a covered sphincterotome and prophylactic submucosal injection of hypertonic saline-epinephrine have also been reported to decrease the risk of post-sphincterotomy bleeding, but these techniques have not been incorporated into routine practice [32, 33].
Post-sphincterotomy bleeding often stops spontaneously, except in patients with a bleeding diathesis. Delayed bleeding is defined as occurring after the completion of ERCP, which can happen up to several weeks after the procedure. With delayed bleeding, repeat endoscopic evaluation is recommended before using other modalities. Most immediate and delayed bleeding can be managed with medical treatment and/or endoscopic therapy. Endoscopic techniques include injection therapy with dilute epinephrine, mechanical hemostasis with hemoclip, balloon tamponade or temporary fully covered self-expandable metal stent, and thermal methods (Fig. 10.2). Angiography with embolization or surgery is reserved for patients with refractory bleeding.
(a) Active post-sphincterotomy bleeding . (b) Hemostasis achieved with combined bipolar coagulation and clip placement
Perforations of the GI lumen are relatively uncommon but are considered one of the most serious and potentially life-threatening adverse events in endoscopy. The incidence of esophageal dilation-related perforation is about 0.1–0.4 % and is associated with a mortality rate of up to 20 % [34, 35]. Malignant perforations, sepsis, mechanical ventilation at presentation, and high burden of comorbidities have been reported to impact the overall survival in patients with esophageal perforation . Colonic perforation rates vary from 0.01 % to 0.8 % for diagnostic procedures and up to 5 % for therapeutic procedures . Risk factors include advanced age, female gender, multiple comorbidities, diverticulosis, prior abdominal surgery, colonic obstruction, and therapeutic interventions [11, 37]. The ERCP-related perforation rate is less than 1 % in patients with normal anatomy . The reported incidence of ERCP-related perforations varies (0.3–1.3 %), appears to be related to the indication for the procedure and the technical skill of the endoscopist, and carries a mortality rate as high as 25 % .
The rarity of endoscopic perforation makes it a challenging clinical problem. It is difficult for an endoscopist to build an extensive individual experience that is backed by firm scientific evidence with regard to patient management. A predetermined plan of action can help streamline the management process in order to reduce morbidity and mortality. The choice of the appropriate management protocol, however, remains controversial [38, 39]. Surgical treatment remains an important option. Improved endoscopic visualization and endoscopic closure devices have permitted nonsurgical management as a viable option in a significant proportion of cases, particularly if the perforation is recognized at the time of endoscopy. Colonic perforations related to therapeutic procedures (e.g., EMR) tend to be smaller and more amenable to endoscopic closure than diagnostic-related perforations (e.g., cecal barotrauma) .
The patient should be informed with the overall rate of perforation and cited an increased risk of perforation with specific therapeutic interventions. A thorough understanding of the various devices available for endoscopic closure of perforations is of paramount importance. These devices tend to be rarely used, and, as a result, the endoscopist and assistant typically are not as proficient with their setup and operation compared with devices that are utilized on a routine basis. Periodic in-service training can help to maintain competency and lessen technical mishaps in device deployment. Since perforations are rare occurrences, a predetermined plan of action that is developed as a unit policy is highly advisable. We have developed an endoscopic perforation management strategy at our institution and have reported our experience in the hope that it may form a useful framework for other endoscopists .
The pain associated with perforation is usually acute and sudden in onset . About 25 % of patients with esophageal perforation have associated vomiting and shortness of breath . Cervical esophageal perforation causes neck pain and may result in subcutaneous crepitus. Management differs based on whether the perforation is detected during the procedure or is diagnosed at a later time.
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Perforation Detected at the Time of Endoscopy
Colonic perforation is obvious when a mural tear with visualization of intra-abdominal organs or serosal fat is seen at endoscopy. Failure to maintain adequate visualization of the lumen due to poor distention may be due to perforation and leakage of air into the peritoneum. It is important to recognize markers, such as the target sign following EMR (Fig. 10.3), and close the defect accordingly . Careful analysis of the post-EMR specimen and resection defect may reveal a target sign, which is an endoscopic finding of inadvertent muscularis propria resection and potential perforation . Recognition of this endoscopic sign allows for prompt endoscopic treatment.
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