101
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Abstract
PURPOSE OF REVIEW This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care. RECENT FINDINGS In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions. SUMMARY This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?
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Affiliation(s)
- Noel B Martins
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
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102
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Abstract
Sedation impacts every aspect of endoscopy practice--the quality fo the examination, the satisfaction of endoscopist and of patient, the efficiency and cost of delivering services, and the compliance of patients with surveillance guidelines. New sedation agents and improved patient-monitoring and drug-delivery technologies are challenging traditional practices. Increasing demand for endoscopic services, shrinking reimbursements, and competing diagnostic technologies are prompting recognition that new approaches to sedation can improve practice efficiency and patient outcome. This article discusses new developments in endoscopic sedation and their implications for practice management.
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Affiliation(s)
- James Aisenberg
- Department of Medicine (Gastroenterology), The Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA.
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103
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Simón MA, Bordas JM, Campo R, González-Huix F, Igea F, Monés J. [Consensus document of the Spanish Association of Gastroenterology on sedoanalgesia in digestive endoscopy]. GASTROENTEROLOGIA Y HEPATOLOGIA 2006; 29:131-49. [PMID: 16507280 DOI: 10.1157/13085143] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- M A Simón
- Unidad de Endoscopia Digestiva, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
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104
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Tu RH, Grewall P, Leung JW, Suryaprasad AG, Sheykhzadeh PI, Doan C, Garcia JC, Zhang N, Prindiville T, Mann S, Trudeau W. Diphenhydramine as an adjunct to sedation for colonoscopy: a double-blind randomized, placebo-controlled study. Gastrointest Endosc 2006; 63:87-94. [PMID: 16377322 DOI: 10.1016/j.gie.2005.08.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2004] [Accepted: 08/03/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intravenous benzodiazepines in combination with opiates are used to achieve moderate sedation for colonoscopy. Although effective, these agents have potential adverse effects, such as respiratory depression and hypotension. Diphenhydramine hydrochloride possesses central nervous system depressant effects that theoretically could provide a synergistic effect for sedating patients. OBJECTIVE The objective was to assess the efficacy of adding diphenhydramine hydrochloride as an adjunct to improve sedation and to reduce the amount of standard sedatives used during colonoscopy. DESIGN We conducted a prospective, randomized, double-blind, placebo-controlled study. SETTING The study was conducted in a university hospital with an active GI fellowship training program. PATIENTS The study group comprised 270 patients undergoing screening/diagnostic/therapeutic colonoscopy were enrolled. INTERVENTIONS Patients were randomized to receive either 50 mg of diphenhydramine or placebo, given intravenously 3 minutes before starting conscious sedation with intravenous midazolam and meperidine. MAIN OUTCOME MEASUREMENTS The main outcome measure was anesthetic effect as assessed by the endoscopy team and by the patient; quantity of adjunctive sedatives to achieve adequate sedation. RESULTS Of 270 patients, data were analyzed for 258 patients, with 130 patients in the diphenhydramine group and 128 patients in the placebo group. There was a 10.1% reduction in meperidine usage and 13.7% reduction in midazolam usage in favor of the diphenhydramine group. The mean evaluation scores as judged by the faculty, the fellows, and the nurses were statistically significant in favor of the diphenhydramine group. In addition, patient scores for overall sedation and pain level favored the group that received diphenhydramine. CONCLUSIONS Intravenous diphenhydramine given before initiation of standard sedation offers a significant benefit to conscious sedation for patients undergoing colonoscopy.
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Affiliation(s)
- Raymond H Tu
- Department of Transplantation, The Permanente Medical Group, Inc, Santa Teresa Medical Center, San Jose, California, USA
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105
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Abstract
PURPOSE OF REVIEW This review is an update of key issues in gastric interventional endoscopy. It focuses on the areas of patient preparation, endoscopic mucosal resection, gastroduodenal stenting, and endoscopic placement of enteric feeding tubes. RECENT FINDINGS Clopidogel (Plavix), a newer antiplatelet agent, can increase the risk of bleeding. Therefore, in selected cases, it should be held for 7-10 days prior to interventional procedures. In experienced hands, endoscopic mucosal resection (success rate, 76-100%; complication rate, 4-28%) and gastroduodenal stenting (success rate, 81-92%; complication rate, 1-17%) seem to be safe and effective techniques. SUMMARY The field of interventional endoscopy continues to advance and to conquer new frontiers. These advances create new problems that need to be addressed and studied by researchers, however. It is only through these types of reviews that our state of knowledge can be updated to help provide the latest information for clinicians in the field and to challenge researchers with future problems that need to be studied.
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Affiliation(s)
- Wahid Wassef
- University of Massachusetts Medical School, UMass Memorial Health Care, Worcester, 01655, USA.
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106
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Ciriza de los Ríos C, Fernández Eroles AL, García Menéndez L, Carneros Martín JA, Díez Hernández A, Delgado Gómez M. [Sedation in upper gastrointestinal endoscopy. Analysis of tolerance, complications and cost-effectiveness]. GASTROENTEROLOGIA Y HEPATOLOGIA 2005; 28:2-9. [PMID: 15691461 DOI: 10.1157/13070376] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION AND AIM Sedation of patients is an important complement to endoscopic procedures. The aim of this study was to analyze tolerance, complications and cost-effectiveness in patients undergoing diagnostic upper gastrointestinal endoscopy. PATIENTS AND METHOD A total of 357 patients were prospectively studied: 138 non-sedated, 116 sedated with midazolam and 103 sedated with midazolam and meperidine. Subjective tolerance, tolerance perceived by the endoscopist, complications, and cost-effectiveness were evaluated. The Chi-square test was used for the statistical analysis. P-values of less than 0.05 were considered statistically significant. RESULTS Subjective tolerance was greater in patients sedated with midazolam and meperidine than in the other groups (p < 0.05). Tolerance perceived by the endoscopist was greater in the group sedated with both drugs than in the group sedated with midazolam (p < 0.05). Subjective tolerance was better in sedated men and women but there was no association between sedation and perceived tolerance according to sex. Subjective tolerance was better in sedated patients older than 70 years than in those younger than 40 years (p < 0.05). Complications were more frequent in sedated patients and the most frequent complication in all the groups studied was mild desaturation; there was a significant difference between the group sedated with midazolam and meperidine and the non-sedated group (p < 0.05). Non-sedation had the best cost-effectiveness ratio but sedation with midazolam and meperidine was the most effective alternative. CONCLUSION From the point of view of the endoscopist, endoscopy can be performed without sedation, although subjective tolerance is greater in patients sedated with midazolam and meperidine. Non-sedation is more cost-effectiveness than sedation but if sedation is required midazolam and meperidine achieve better results in terms of effectiveness than midazolam alone.
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107
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Rockey DC, Koch J, Yee J, McQuaid KR, Halvorsen RA. Prospective comparison of air-contrast barium enema and colonoscopy in patients with fecal occult blood: a pilot study. Gastrointest Endosc 2004; 60:953-8. [PMID: 15605011 DOI: 10.1016/s0016-5107(04)02223-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The utility of air-contrast barium enema and colonoscopy for evaluation of the colon has been debated. Air-contrast barium enema is less expensive and invasive than colonoscopy, but it also is less sensitive and specific. Further, although air-contrast barium enema may be less painful than colonoscopy, it often is poorly tolerated by patients. Thus, this study compared the sensitivity and the specificity of air-contrast barium enema and colonoscopy for detection of colonic lesions in patients with fecal occult blood. METHODS Over a 30-month period, patients with fecal occult blood were recruited. Patients underwent standard air-contrast barium enema, followed by colonoscopy 7 to 14 days later. Colonoscopists were blinded to the results of air-contrast barium enema until the colonoscopy was completed, after which the results were disclosed. If the findings were discrepant, colonoscopy was repeated. RESULTS A total of 100 patients were evaluated. Nine air-contrast barium enemas were reported to be inadequate, and the cecum was not intubated at colonoscopy in two patients. In the remaining patients, 5 cancers were identified (1 each cecum, transverse colon, descending colon, sigmoid colon, and rectum) by both studies. Sixty-six polypoid lesions were identified in 30 patients. Diverticula were identified in 42 patients by air-contrast barium enema and in 18 patients by colonoscopy. Air-contrast barium enema detected 3 of 36 polypoid lesions 5 mm or less in diameter, 5 of 15 adenomas 6 to 9 mm in size, and 4 of 15 adenomas 10 mm or greater in diameter (sensitivity 8%, 33%, and 27%, respectively). After excluding patients with diverticula, air-contrast barium enema detected 3 of 7 adenomas 10 mm or greater in size. Overall, 12 polypoid lesions or filling defects were identified by air-contrast barium enema that could not be verified by colonoscopy. The specificity of air-contrast barium enema for lesions 1.0 cm or greater in size was 100%; for those 6 mm or greater, it was 97%. CONCLUSIONS Air-contrast barium enema accurately detects colon cancer and diverticula. Its sensitivity for detection of polypoid lesions or adenomas is poor and was confounded by the presence of diverticula.
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Affiliation(s)
- Don C Rockey
- Liver Center, Duke University Medical Center, Sands Building Room 334, Research Drive, Durham, NC 27710, USA
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108
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Wassef W. Upper gastrointestinal bleeding. Curr Opin Gastroenterol 2004; 20:538-45. [PMID: 15703679 DOI: 10.1097/00001574-200411000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW This review discusses key issues in the management of upper gastrointestinal bleeding including patient preparation, sedation, hemostatic techniques, disposition, and recommended pharmacologic interventions. RECENT FINDINGS Optimal resuscitation before endoscopy and proper pharmacologic interventions after endoscopy seem to be as crucial to the management of patients with upper gastrointestinal bleeding as meticulous hemostatic techniques during the procedure. In a retrospective evaluation of patients with upper gastrointestinal bleeding, multivariate analysis demonstrated significantly reduced morbidity and mortality in those who underwent aggressive preendoscopic resuscitation. In a prospective, randomized clinical trial, patients who received intravenous proton pump inhibitor therapy after endoscopic intervention had a significantly reduced rebleeding rate compared with their placebo control group. SUMMARY The algorithms described in this review can be applied clinically today and should directly lead to improved outcome. Nevertheless, even with the latest care available, results are not optimal. This review points to two major areas where we can benefit from improvement: primary hemostasis and recurrent bleeding. By pointing to these limitations, it is hoped that this review can help stimulate research in the field by applying new technologies to solve these problems. Endoscopic ultrasound, for example, could be used to help identify feeding vessels that can be treated endoscopically, thus potentially decreasing the incidence of failed primary hemostasis. Endoscopic suturing, when more fully developed, may provide a better hemostatic technique that can reduce the incidence of recurrent bleeding. It is only through these reviews that our state of knowledge in the field can be constantly reevaluated to update today's clinician with the latest knowledge and stimulate tomorrow's researchers with challenging problems.
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Affiliation(s)
- Wahid Wassef
- Division of Gastroenterology, University of Massachusetts Medical School, University of Massachusetts Memorial Health Care, Worcester, Massachusetts 01655, USA.
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109
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Abstract
Sedation and monitoring are key elements of the endoscopy process. There continues to be intense study of better methods for sedation and monitoring to improve the endoscopic "experience" for both patient and physicians alike. Our current practices will likely change in the future with technologic advances (monitoring) and expansion of our pharmacologic armamentarium (sedation).
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Affiliation(s)
- Charles M Wilcox
- Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, 1530 3rd Avenue South, ZRB 633, Birmingham, AL 35294-0007, USA.
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110
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Yusoff IF, Raymond G, Sahai AV. Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients. Gastrointest Endosc 2004; 60:356-60. [PMID: 15332023 DOI: 10.1016/s0016-5107(04)01711-0] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The administration of propofol for endoscopic sedation by a qualified person, other than the endoscopist, is safe and effective. The aim of this study was to determine if propofol can be administered safely and effectively by the endoscopist performing the procedure. METHODS All patients referred for upper-GI EUS were eligible for inclusion in the study. Exclusion criteria included the following: age less than 18 years, American Society of Anesthesiology physical status class greater than 2, a potential for difficulty in airway maintenance, and allergy to propofol constituents. The endoscopist administered propofol as an intravenous bolus followed by a constant infusion. Adverse events, drug dosage, complications, and patient/endoscopist satisfaction were recorded. RESULTS A total of 500 patients (285 women, 215 men; mean age 53.4 [14.8 years]) were enrolled. Mean propofol dose was 301 mg (range 100-1000 mg). Mean procedure time was 19 minutes (range 3-70 minutes). The required examination was completed in all cases. There was no major adverse event. Oxygen desaturation (oxygen saturation < 95%) occurred in 16 (3%) patients. There were 4 (1%) cases of mild hypoxemia (saturation < 90%) but no case of severe hypoxemia (saturation <85%). The endoscopist rated the 92% of the procedures as "very smooth" or "smooth" and regarded administration of propofol as "easy" for 92%. All patients said they would prefer the same method of sedation if the procedure were repeated. CONCLUSIONS Endoscopist-administered propofol is safe and effective in selected patients.
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Affiliation(s)
- Ian F Yusoff
- Department of Gastroenterology, Centre Hospitalier de l'Université de Montréal-Hôpital Saint Luc, 1058 Rue St. Denis, Montréal, Québec H2X 3J4, Canada
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111
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Cohen LB, Hightower CD, Wood DA, Miller KM, Aisenberg J. Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endosc 2004; 59:795-803. [PMID: 15173791 DOI: 10.1016/s0016-5107(04)00349-9] [Citation(s) in RCA: 157] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Propofol provides several benefits over benzodiazepine and narcotic agents as a sedative medication for endoscopic procedures, including faster recovery and improved patient satisfaction. However, its use generally has been limited to anesthesiologists because of the risks associated with deep sedation. METHODS One hundred patients undergoing colonoscopy or EGD were sedated with low-dose propofol, midazolam, and fentanyl (or meperidine). Depth of sedation was assessed at 2-minute intervals by an independent observer by using the American Society of Anesthesiologists criteria. Recovery time was determined by using paired neuropsychometric tests. A post-procedure satisfaction survey and 24-hour follow-up questionnaires were administered. RESULTS For colonoscopy and EGD, respectively, the mean propofol dose was 98 mg and 79 mg, the mean midazolam dose was 0.9 mg and 0.8 mg, the mean fentanyl dose was 69 mcg and 63 mcg, and the mean meperidine dose was 42 mg (for both procedures). There were 628 assessments of the level of sedation performed during 74 colonoscopies and 101 assessments during 26 EGDs. The level of sedation was minimal in 77%, moderate in 21%, and deep in 2% of assessments. Nine of the 13 episodes of deep sedation were recorded during colonoscopy and 4 during EGD. In no instance was more than a single assessment of deep sedation recorded during one procedure. Ninety-eight percent of patients were satisfied with the sedation, and 71% returned to their usual activities within 2 hours of discharge. There was no serious adverse event. CONCLUSIONS Endoscopic sedation with low-dose propofol, a narcotic agent, and midazolam produces a moderate level of sedation. The quality of sedation and measures of recovery are comparable with the results reported with standard-dose propofol.
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Affiliation(s)
- Lawrence B Cohen
- Department of Medicine (Gastroenterology), The Mount Sinai School of Medicine, New York, New York, USA
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