Preprocedural considerations in gastrointestinal endoscopy

The Saudi Gastroenterology Association guidelines for quality indicators in gastrointestinal endoscopic procedures

The quality and safety of gastrointestinal endoscopy varies considerably across regions and facilities worldwide. In this field, quality management has traditionally focused on individual performance of endoscopists, with most indicators addressing process measures and limited evidence of improvement in health outcomes. Indicators of quality can be classified according to their nature and sequence. The various professional societies and organizations have proposed many systems of indicators, but a universal system is necessary so that healthcare professionals are not overburdened and confused with a variety of quality improvement approaches. In this paper, we propose guidelines by the Saudi Gastroenterology Association pertaining to quality in endoscopic procedures aiming to improve the awareness of endoscopy unit staff toward important quality indications to enhance and standardize quality of care provided to our patients.

How to measure quality in endoscopic ultrasound

Quality is a key focus for gastrointestinal endoscopy and main international gastroenterology societies instituted specific task forces focused on this issue. Endoscopic ultrasound (EUS) represents one of the most fascinating fields to explore in gastrointestinal endoscopy due to its relatively limited availability out of high-volume centers. This leads to a particular need to define widely accepted quality indicators (QIs) and the ways to measure them. The current manuscript reviews these indicators in light of their impact on common clinical practice.

Risk factors associated with complications in cirrhotic patients undergoing endoscopic retrograde cholangio-pancreatography

OBJECTIVE

Endoscopic retrograde cholangio-pancreatography (ERCP) is useful for the management of biliary tract diseases; in patients with cirrhosis, portal hypertension may increase the risk for complications from ERCP. We evaluated the outcome and risk factors related to ERCP in patients with cirrhosis and portal hypertension.

PATIENTS AND METHODS

In this case-control study, 37 patients (71 procedures) with cirrhosis and portal hypertension (group 1) and 37 controls (group 2) undergoing ERCP were included. Logistic regression and receiver operating characteristic curve analysis were used to predict the risk factors.

RESULTS

Mean Child-Pugh and model for end-stage liver disease (MELD) score were 9±2.1 and 17.8±6, respectively. Ascites was present in 46% of the patients, esophageal varices in 63% (large esophageal varices 43.7%), and hepatic encephalopathy in 16%. The main indication for ERCP in both groups was choledocholithiasis. Successful cannulation rate was 97% in both groups. Biliary sphincterotomy was performed more frequently in group 2 than in group 1 (60 vs. 35%, P=0.036); there was no difference in the frequency of complications related to ERCP between cirrhotics and noncirrhotics (10 vs. 8%, P=0.677). Complications in patients with cirrhosis were related to lower alkaline phosphatase and sphincterotomy rate; in the multivariable analysis only sphincterotomy was independently associated with complications [odds ratio 9.8 (1.7-56.3)]. Receiver operating characteristic curve analysis yielded a MELD score of more than 16 to best predict complications after ERCP in cirrhosis.

CONCLUSION

Outcomes after ERCP in patients with cirrhosis are similar to those of noncirrhotics despite the alteration in coagulation parameters and the presence of disease-specific complications; however, a more cautious approach in patients with cirrhosis undergoing sphincterotomy and MELD of more than 16 is needed.

An open-access endoscopy screen correctly and safely identifies patients for conscious sedation

BACKGROUND AND AIMS

Open-access scheduling is highly utilized for facilitating generally low-risk endoscopies. Preprocedural screening addresses sedation requirements; however, procedural safety may be compromised if screening is inaccurate. We sought to determine the reliability of our open-access scheduling system for appropriate use of conscious sedation.

METHODS

We prospectively and consecutively enrolled outpatient procedures booked at an academic center by open-access using screening after in-office gastroenterology (GI) consultation. We collected the cases inappropriately booked for conscious sedation and compared the characteristics for significant differences.

RESULTS

A total of 8063 outpatients were scheduled for procedures with conscious sedation, and 5959 were booked with open-access. Only 78 patients (0.97%, 78/8063) were identified as subsequently needing anesthesiologist-assisted sedation; 44 (56.4%, 44/78) were booked through open-access, of which chronic opioid (47.7%, 21/44) or benzodiazepine use (34.1%, 15/44) were the most common reasons for needing anesthesiologist-assisted sedation. Patients on chronic benzodiazepines required more midazolam than those not on chronic benzodiazepines (P = .03) of those patients who underwent conscious sedation. Similarly, patients with chronic opioid use required more fentanyl than those without chronic opioid use (P = .04). Advanced liver disease and alcohol use were common reasons for patients being booked after in-office consultation and were significantly higher than those booked with open-access (both P < .01).

CONCLUSIONS

We observed that the majority of patients can be triaged for conscious sedation using a multi-tiered screening process. Importantly, few patients (<1.0%) were inappropriately booked for conscious sedation. The most common reasons for considering anesthesiologist-assisted sedation were chronic opioid, benzodiazepine and/or alcohol use and advanced liver disease. This suggests that these entities could be included in screening processes for open-access scheduling.

Effects of midazolam or tramadol premedication on early cognitive function in endoscopic retrograde cholangiopancreatography (ERCP): A randomized, controlled, double-blind study

OBJECTIVE

To evaluate the sedative efficacy and effects on early period cognitive function of premedication in endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Forty patients (18-70 years; American Society of Anesthesiology risk category I-III) undergoing elective ERCP were randomized to receive oral premedication with 0.15 mg/kg midazolam or 1 mg/kg tramadol. Cognitive function was determined by mini-mental test (MMT). Target scores for effective sedation were determined as a Bispectral index score of 70-90 and modified Ramsay Sedation Scale score (mRSS) of 2-4.

RESULTS

Global MMT score was not significantly different between treatment groups at 60 min post-ERCP. A significant deterioration in the MMT subcategory of recall was determined in with midazolam versus tramadol. Level of sedation (mRSS) was higher in with midazolam compared with tramadol reaching statistical significance at 30 min after drug administration.

CONCLUSIONS

Although more effective sedation was obtained with midazolam in patients undergoing ERCP, there was a dysfunction in memory recall. It was concluded, however, that early cognitive functions were generally preserved with both drugs.

Relationship between vomiting reflex during endoscopy and upper gastrointestinal symptoms

AIM: To explore the incidence of the vomiting reflex during endoscopy and related factors, especially upper gastrointestinal symptoms.

METHODS: Subjects included 428 adults who were assigned into a vomiting-reflex-positive group or a vomiting-reflex-negative group according to the presence of vomiting reflex or not during clinic endoscopy between August 2012 and January 2014. Based on a questionnaire survey using the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG), scores of symptoms (dyspepsia and gastroesophageal reflux) as well as the general factors and clinical factors of all subjects were recorded.

RESULTS: Approximately 53.7% (230/428) of subjects developed vomiting reflexes (5.6 times ± 2.3 times). This reflex-positive group was significantly younger than the reflex-negative group (t = 5.59, P < 0.01). The incidence of gastroesophageal reflux and dyspepsia in the reflex-positive group was significantly higher than that in the reflex-negative group (χ² = 35.60, 45.64, P < 0.01). The dyspepsia score and gastroesophageal reflux score in the reflex-positive group were significantly higher than those in the reflex-negative group (t = 3.11, 5.24, P < 0.01). The incidence of esophageal hiatal hernia during esophagogastroduodenoscopy (EGD) was significantly higher in the reflex-positive group (χ² = 19.30, P < 0.01). Multivariate logistic regression analysis also showed a significant correlation between these four factors and the occurrence of vomiting reflexes. Using an FSSG dyspepsia score of 1 as the cut-off offered a 65% sensitivity and a 59% specificity for predicting the occurrence of vomiting reflexes.

CONCLUSION: Upper gastrointestinal symptoms, especially dyspepsia symptoms, are related to the presence of vomiting reflexes during EGD.

Is there a need for bacterial endocarditis prophylaxis in patients undergoing gastrointestinal endoscopy?

Heart valve repair or replacement is a serious problem. Patients can benefit from an open dialogue between both cardiologists and gastroenterologists for the optimal effective patients care. The focused update on infective endocarditis of the American College of Cardiology/American Heart Association 2008 (ACC/AHA guidelines) and guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009) of the European Society of Cardiology (ESC guidelines) describe prophylaxis against infective endocarditis (IE) as not recommended for gastroscopy and colonoscopy in the absence of active infection but increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardio-oncology prevention. New evidences concerning infective endocarditis due to Streptococcus bovis, Streptococcus agalactiae, Enterococcus faecalis, Enterococcus faecium, Enterococcus durans, and new findings indicate that there is a need for bacterial endocarditis prophylaxis in patients undergoing gastrointestinal endoscopy especially in elderly patients and in cancer and immunocompromised patients, to avoid serious consequences.