MANAGEMENT OF GASTROINTESTINAL BLEEDING INDUCED BY GASTROINTESTINAL ENDOSCOPY
Section snippets
INFORMED CONSENT ABOUT BLEEDING RISKS
The endoscopist must obtain informed and written consent for endoscopy.152 If the patient is unable to provide consent, consent should be obtained from the patient's health care proxy. The consent should be witnessed. If the patient does not comprehend English, consent should be obtained via a translator who speaks the patient's language. The patient should be told about the general risks of endoscopy, in layperson's terms. In particular, the patient should be informed of the risks of
Before Endoscopy
The physician should inquire about recent use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), including nonprescription use, particularly when polypectomy or sphincterotomy is contemplated. Aspirin should be withheld for 1 week before elective endoscopy whenever possible. The patient should be questioned about a history of coagulopathy and anticoagulation therapy before endoscopy.
The authors routinely obtain a complete hemogram before endoscopy. Determination of prothrombin
BLEEDING CLASSIFICATION
Bleeding from endoscopy is classified as immediate when observed during (or appreciated within 1 hour after) endoscopy or as delayed when first noted (>1 hour) after endoscopy. Delayed bleeding is classified as early when observed within 24 hours after endoscopy or as late when observed more than 24 hours after endoscopy. Bleeding is classified as minor when hemodynamically insignificant, when not requiring transfusion of packed erythrocytes, and when accompanied by a hematocrit decline of less
Clinical Evaluation
Significant bleeding after endoscopy mandates hospitalization. Blood loss during endoscopy is roughly estimated by the amount aspirated in suction bottles. Bleeding severity is assessed by the patient history, physical examination, and laboratory tests. A small amount of red blood on the toilet paper or in the toilet bowel usually indicates self-limited bleeding, often from hemorrhoids. Multiple bloody bowel movements, whether consisting of bright red blood per rectum or melena, indicate
Diagnostic and Therapeutic Esophagogastroduodenoscopy
Bleeding from diagnostic esophagogastroduodenoscopy (EGD) is uncommon but not rare (Table 1). Diagnostic endoscopy may induce bleeding from iatrogenic Mallory-Weiss tears194, 276 and endoscopic biopsies.239, 242 Bleeding from endoscopic biopsies is rarely clinically significant.157, 273 Therapeutic procedures, such as sclerotherapy or gastroduodenal polypectomy, have much higher bleeding complication rates. For example, bleeding complications from gastroduodenal polypectomies have been reported
Endoscopic Procedures and Anticoagulation
Anticoagulation with warfarin reduces the risk of thromboembolism in patients with atrial fibrillation, prosthetic heart valves, deep vein thrombosis, pulmonary embolism, and hypercoagulopathies. Concomitant anticoagulation therapy complicates the management of gastrointestinal endoscopy. Although withholding of anticoagulation is desirable for endoscopic procedures, withholding of anticoagulation poses a significant risk of thromboembolism. Additionally, withholding of warfarin for elective
MEDICOLEGAL CONSIDERATIONS IN ENDOSCOPICALLY INDUCED GASTROINTESTINAL BLEEDING
Endoscopic complications can occur despite faultless technique, particularly in high-risk procedures. An endoscopic complication does not by itself constitute or imply malpractice. As Gerstenberger74 has said, “Complications are normal events in the practice of endoscopy and do not in and of themselves indicate or imply deviation from the standard of care.”
The cost of malpractice has skyrocketed during the past 25 years, with the average malpractice premium rising more than 30-fold.288 Perhaps
References (294)
- et al.
Endoscopic band ligation for non-variceal non-ulcer gastrointestinal bleeding
Gastrointest Endosc
(1998) Complications related to diagnostic and therapeutic endoscopic retrograde cholangiopancreatography
Gastrointest Endosc Clin N Am
(1996)- et al.
Angiography: Its contribution to the emergency management of gastrointestinal hemorrhage
Radiol Clin North Am
(1976) - et al.
Complications of colonoscopy and polypectomy
Gastroenterology
(1974) - et al.
Techniques and complications of esophageal foreign body extraction in children and adults
Gastrointest Endosc
(1993) - et al.
Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage: Retrospective analysis of risks and outcomes
Chest
(1998) Eesophageal foreign bodies
Gastroenterol Clin North Am
(1991)- et al.
Factors predicting failure of endoscopic injection therapy in bleeding duodenal ulcer
Gastrointest Endosc
(1996) Intestinal (mesenteric) vasculopathy: II. Ischemic colitis and chronic mesenteric ischemia
Gastroenterol Clin North Am
(1998)- et al.
Delayed hemorrhage after hot biopsy [letter]
Gastrointest Endosc
(1990)
Complications of upper gastrointestinal endoscopy
Gastrointest Endosc Clin N Am
Thrombocytopenia and hemorrhage in the cancer patient: Prevalence of unmasked lesions
Gastrointest Endosc
Complications of endoscopic gastrointestinal dilation techniques
Gastrointest Endosc Clin N Am
Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: A meta-analysis
Gastroenterology
Endoscopic sphincterotomy complications and their management: An attempt at consensus
Gastrointest Endosc
Endoscopic complications: The Texas experience
Gastrointest Endosc
Poor results with percutaneous endoscopic jejunostomy
Gastrointest Endosc
Major colonic hemorrhage following electrocoagulating (hot) biopsy of diminutive colonic polyps: Relationship to colonic location and low dose aspirin therapy
Gastrointest Endosc
Prospective evaluation of complications in an endoscopy unit: Use of the ASGE quality case guidelines
Gastrointest Endosc
Stigmata of hemorrhage in bleeding peptic ulcers
Gastrointest Endosc Clin N Am
Resume of a seminar on endoscopic retrograde sphincterotomy (ERS)
Gastrointest Endosc
Malpractice in gastrointestinal endoscopy
Gastrointest Endosc Clin N Am
Malpractice claims in gastrointestinal endoscopy: Analysis of an insurance industry data base
Gastrointest Endosc
Complications of colonoscopy and polypectomy
Surg Clin North Am
Randomized trial of variceal banding ligation versus injection sclerotherapy for bleeding oesophageal varices
Lancet
Selective arterial embolization for the control of lower gastrointestinal bleeding
Am J Surg
Medical-legal consultation in gastroenterology
Gastrointest Endosc Clin N Am
Endoscopic ligation of esophageal varices compared with injection sclerotherapy: A prospective randomized trial
Gastrointest Endosc
Guidelines on the management of anticoagulation and antiplatelet therapy for endoscopic procedures
Gastrointest Endosc
Valleylab Force 2 Electrosurgical Instruction Manual
Complications of endoscopy
Endoscopy
La region odienne: Anatomie millimetrique
Presse Med
Colonoscopic excision of large and giant colorectal polyps: Technical implications and results over eight years
Dis Colon Rectum
Disseminated intravascular coagulation (DIC) after endoscopic injection sclerotherapy with ethanolamine oleate [letter]
Endoscopy
“Pinch” injury during overtube placement in upper endoscopy
Gastrointest Endosc
Sclerotherapy with or without octreotide for acute variceal bleeding
N Engl J Med
Endoscopic sphincterotomy for the palliation of ampullary carcinoma
Br J Surg
Endoscopic snare excision of “giant” colorectal polyps
Gastrointest Endosc
Management of clinically relevant bleeding following endoscopic sphincterotomy
Endoscopy
Management of severe bleeding after endoscopic sphincterotomy [abst]
Gastrointest Endosc
Randomized, double-blind comparison of famotidine with ranitidine in treatment of acute, benign gastric ulcer disease: Community-based study coupled with a patient registry
Dig Dis Sci
Long term results of endoscopic dilatation for corrosive esophageal strictures
Gut
Needle-knife sphincterotomy as a precut procedure: A retrospective evaluation of efficacy and complications
Endoscopy
A study of the syndrome of simultaneous acute upper gastrointestinal bleeding and myocardial infarction in 36 patients
Am J Gastroenterol
Endoscopy for gastrointestinal bleeding associated with profound thrombocytopenia [abstr]
Gastroenterology
Esophageal bleeding after percutaneous endoscopic gastrostomy
J Clin Gastroenterol
Gastrointestinal endoscopy in high risk patients
Dig Dis
Angiographic management of bleeding following transcolonoscopic polypectomy
Am J Dig Dis
Endoscopic management of esophageal variceal hemorrhage: Injection, banding, glue, octreotide, or a combination?
Semin Gastrointest Dis
Complications of upper endoscopy, colonoscopy, enteroscopy and endoscopic ultrasound and risk management of endoscopic procedures
Cited by (63)
Acute intestinal bleeding after endoscopic polypectomy: Super-selective endovascular embolization in a clinically unstable patient
2017, Revista de Gastroenterologia de MexicoTranscatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes
2015, Diagnostic and Interventional ImagingHemostatic Aspects of Cardiovascular Medicine
2013, Consultative Hemostasis and Thrombosis: Third EditionRigorous scientific study of endoscopic adverse events requires not only a lexicon but a reliable reporting system
2010, Gastrointestinal EndoscopyManaging complications of percutaneous tracheostomy and gastrostomy
2021, Journal of Thoracic Disease
Address reprint requests to Mitchell S. Cappell, MD, PhD, Division of Gastroenterology, Administration Building, 4th Floor, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219