Procedures



Procedures





Comment: Because the endoscopist may notmeet the pt until minutes before the procedure, particularly in open-access systems, it is important that a clinician be able to describe to the pt the experience and the more common complications of endoscopy prior to referral for the procedure. The list of complications listed here is notcomprehensive but is a reasonable list to use in discussions with pts.


18.1 Upper Endoscopy (EGD)

Description: The pt is kept npo, brought to the unit, and an iv is placed. The pt lies left lateral decubitus and is sedated. Moderate sedation with midazolam and a narcotic is commonly used, but deep sedation with propofol is becoming more popular. A mouthpiece is placed to protect the teeth and the endoscope. The endoscope is passed and the upper tract examined. Gagging and belching may occur but are usually minor. Breathing is notsignificantly affected by the instrument. The procedure is notgenerally painful and takes 10-15 min after sedation. Amnesia is common but notuniversal with moderate sedation. If abnormalities are seen, bxs (which are painless) may be taken and strictures may be dilated (p 44). Endoscopic rx is possible for bleeding ulcers (p 75) or varices (p 255). Pts cannot drive or work for 24 hr after the exam because of the sedation.

Complications: (Gastrointest Endosc Clin N Am 1996;6:287) Perforation (< 1/5000 if no dilatation, < 1/500 if esophageal dilatation is needed), bleeding, infection, adverse reaction to sedation, failure to detect important abnormalities. Minor problems include sore throat (notcommonly) and iv site phlebitis.


18.2 Colonoscopy

Description: The pt undergoes a bowel prep, generally with polyethylene glycol solution.

Na phosphate is out of favor as a prep due to concerns about renal injury. The pt is kept npo, brought to the unit, and an iv is placed. The pt lies left lateral decubitus and is sedated. Moderate sedation with midazolam and a narcotic is commonly used, but deep sedation with propofol is becoming more popular. The colonoscope is advanced to the cecum in >95% cases in competent hands. Cramps are common during the advance, but the sedation makes
it very tolerable for most pts. Sometimes the pt changes positions or the assistant palpates the abdomen to aid the advance of the scope. Polyps are removed and bxs are taken, both of which are generally painless. The exam lasts 15-30 min depending on the quality of the prep, the ease of the exam, and the need for rx. The pt may feel gassy, bloated, or crampy because of insufflated air for up to several hr after the procedure. Pts cannot drive or work for 24 hr after the exam because of the sedation.

Complications: (Gastrointest Endosc Clin N Am 1996;6:343) Risks include perforation (< 1/1000 if no polypectomy; higher with polypectomy) that may require urgent surgery, possibly with a temporary colostomy. Bleeding is uncommon and occurs in 0.07% of diagnostic studies and in 1.2% of procedures with polypectomy. Bleeding is more common after the removal of large polyps. Bleeding might require transfusion, a second procedure (for endoscopic control of bleeding), or surgery. Infection, adverse reaction to sedation, and failure to detect important abnormalities may occur. Minor problems include iv site phlebitis and perianal irritation from the prep and scope.


18.3 Sigmoidoscopy

Description: Same as colonoscopy, though the exam is often done without sedation and usually takes less than 10 min.

Complications: (Gastrointest Endosc Clin N Am 1996;6:343) Same as with colonoscopy, though the perforation rate is much lower (1-2/10,000).


18.4 Endoscopic Retrograde Cholangiopancreatography

Description: The pt experience for endoscopic retrograde cholangiopancreatography (ERCP) is the same as for EGD, but the position on the table is semiprone. The exam takes 10-60 min depending on complexity. Stones may be removed or stents placed, depending on the findings. The exam is generally done in situations where therapy is likely to be needed, and deep sedation is typically used.

Complications: (Gastrointest Endosc Clin N Am 1996;6:379) Pancreatitis is the most frequent complication of ERCP and occurs in 3-7% of pts. It can be severe but usually is not Perforation or bleeding may occur in 1-2% after sphincterotomy and is usually managed without surgery. Cholangitis may occur if the biliary tree is obstructed, and antibiotics are usually given prophylactically. The other complications are those of EGD.

Jul 21, 2016 | Posted by in GASTROENTEROLOGY | Comments Off on Procedures

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