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Zhao HY, Cai XF, Chen PP, Wang XB, Liu CX, Chen D, Xu J. Efficacy of linaclotide in combination with polyethylene glycol for bowel preparation in Chinese patients undergoing colonoscopy polypectomy: protocol for a randomised controlled trial. BMJ Open 2024; 14:e080723. [PMID: 39043596 DOI: 10.1136/bmjopen-2023-080723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Adequate bowel preparation is essential for successful colonoscopy and polypectomy procedures. However, a significant proportion of patients still exhibit suboptimal bowel preparation, ranging from 18% to 35%. The effectiveness of bowel preparation agents can be hampered by volume and taste, adversely affecting patient compliance and tolerance. Therefore, exploring strategies to minimise laxative volume and improve patient tolerance and adherence is imperative to ensure optimal bowel preparation quality. METHODS AND ANALYSIS This study is a two-arm, single-blinded, parallel-group randomised controlled trial designed to compare the efficacy of 2 L polyethylene glycol (PEG) combined with linaclotide with 4 L PEG in bowel cleansing. A total of 422 participants will be randomly assigned in a 1:1 ratio to either the intervention group (2 L PEG combined with 580 µg linaclotide) or the control group (4 L PEG). The primary outcome measure is bowel cleansing efficacy, which is assessed using the Boston Bowel Preparation Scale. Secondary outcomes include evaluating the tolerability and safety of the bowel preparation regimens, bowel diary assessments, postpolypectomy complications (such as bleeding and perforation) and the size and number of removed polyps. ETHICS AND DISSEMINATION The study has received approval from the Clinical Research Ethics Committee of The First Affiliated Hospital, Zhejiang University School of Medicine. The findings of this trial will serve as a valuable resource for clinicians and patients undergoing colonoscopy polypectomy by guiding the selection of appropriate bowel preparation regimens. Study findings will be disseminated to participants, presented at professional society meetings, and published in peer-reviewed journals. This trial was registered on the Chinese Clinical Trial Registry with registration number ChiCTR2300075410.
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Affiliation(s)
- Hui-Ying Zhao
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiao-Feng Cai
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Ping-Ping Chen
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiao-Bin Wang
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Chao-Xu Liu
- Department of Colorectal Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Dong Chen
- Department of Colorectal Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jing Xu
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Zouk AN, Batra H. Managing complications of percutaneous tracheostomy and gastrostomy. J Thorac Dis 2021; 13:5314-5330. [PMID: 34527368 PMCID: PMC8411191 DOI: 10.21037/jtd-19-3716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 08/05/2020] [Indexed: 01/02/2023]
Abstract
Percutaneous tracheostomy and gastrostomy are some of the most commonly performed procedures at bedside in the intensive care unit. While they are generally considered safe, they can be associated with numerous short and long-term complications, many of which can occur long after their placement and cause significant morbidity. Performers of these procedures should possess a comprehensive understanding of procedural indications and contraindications, and know how to recognize and manage complications that may arise. In this review, we highlight complications of percutaneous tracheostomy and describe strategies for their prevention and management, with a special focus on post-tracheostomy tracheal stenosis. Other complications reviewed include bleeding, pneumothorax and subcutaneous emphysema, posterior wall injury, tube displacement, tracheomalacia, tracheoinominate artery fistula, tracheo-esophageal fistula, and stomal cellulitis. Gastrostomy complications and their management are also discussed including bleeding, internal organ injury, necrotizing fasciitis, aspiration pneumonia, buried bumper syndrome, tumor seeding, wound infection, tube displacement, peristomal leakage, and gastric outlet obstruction. In light of the potentially serious outcomes associated with complications of percutaneous tracheostomy and gastrostomy, the emphasis should be placed on risk-reduction strategies to minimize morbidity and mortality. We therefore present detailed pragmatic and comprehensive checklists to serve as a reference for clinicians involved in performing these procedures.
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Affiliation(s)
- Aline N Zouk
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hitesh Batra
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
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3
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Sahu T, Mehta A, Ratre YK, Jaiswal A, Vishvakarma NK, Bhaskar LVKS, Verma HK. Current understanding of the impact of COVID-19 on gastrointestinal disease: Challenges and openings. World J Gastroenterol 2021; 27:449-469. [PMID: 33642821 PMCID: PMC7896435 DOI: 10.3748/wjg.v27.i6.449] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/28/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023] Open
Abstract
The novel coronavirus disease-2019 (COVID-19) is caused by a positive-sense single-stranded RNA virus which belongs to the Coronaviridae family. In March 2019 the World Health Organization declared that COVID-19 was a pandemic. COVID-19 patients typically have a fever, dry cough, dyspnea, fatigue, and anosmia. Some patients also report gastrointestinal (GI) symptoms, including diarrhea, nausea, vomiting, and abdominal pain, as well as liver enzyme abnormalities. Surprisingly, many studies have found severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral RNA in rectal swabs and stool specimens of asymptomatic COVID-19 patients. In addition, viral receptor angiotensin-converting enzyme 2 and transmembrane protease serine-type 2, were also found to be highly expressed in gastrointestinal epithelial cells of the intestinal mucosa. Furthermore, SARS-CoV-2 can dynamically infect and replicate in both GI and liver cells. Taken together these results indicate that the GI tract is a potential target of SARS-CoV-2. Therefore, the present review summarizes the vital information available to date on COVID-19 and its impact on GI aspects.
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Affiliation(s)
- Tarun Sahu
- Department of Physiology, All India Institute of Medical Science, Raipur 492001, Chhattisgarh, India
| | - Arundhati Mehta
- Department of Biotechnology, Guru Ghasidas Vishwavidyalaya, Bilaspur 495001, Chhattisgarh, India
| | - Yashwant Kumar Ratre
- Department of Biotechnology, Guru Ghasidas Vishwavidyalaya, Bilaspur 495001, Chhattisgarh, India
| | - Akriti Jaiswal
- Department of Physiology, All India Institute of Medical Science, Raipur 492001, Chhattisgarh, India
| | - Naveen Kumar Vishvakarma
- Department of Biotechnology, Guru Ghasidas Vishwavidyalaya, Bilaspur 495001, Chhattisgarh, India
| | | | - Henu Kumar Verma
- Developmental and Stem Cell Biology Lab, Institute of Experimental Endocrinology and Oncology CNR, Naples, Campania 80131, Italy
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4
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. [Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2020; 76:282-296. [PMID: 33361705 DOI: 10.4166/kjg.2020.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/04/2020] [Accepted: 11/09/2020] [Indexed: 11/03/2022]
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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5
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Lim H, Gong EJ, Min BH, Kang SJ, Shin CM, Byeon JS, Choi M, Park CG, Cho JY, Lee ST, Kim HG, Chun HJ. Clinical Practice Guideline for the Management of Antithrombotic Agents in Patients Undergoing Gastrointestinal Endoscopy. Clin Endosc 2020; 53:663-677. [PMID: 33242928 PMCID: PMC7719428 DOI: 10.5946/ce.2020.192] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/08/2020] [Indexed: 12/13/2022] Open
Abstract
Antithrombotic agents, including antiplatelet agents and anticoagulants, are increasingly used in South Korea. The management of patients using antithrombotic agents and requiring gastrointestinal endoscopy is an important clinical challenge. Although clinical practice guidelines (CPGs) for the management of patients receiving antithrombotic agents and undergoing gastrointestinal endoscopy have been developed in the Unites States, Europe, and Asia Pacific region, it is uncertain whether these guidelines can be adopted in South Korea. After reviewing current CPGs, we identified unmet needs and recognized significant discrepancies in the clinical practice among regions. This is the first CPG in Korea providing information that may assist endoscopists in the management of patients on antithrombotic agents who require diagnostic or elective therapeutic endoscopy. This guideline was developed through the adaptation process as an evidence-based method, with four guidelines retrieved by systematic review. Eligible guidelines were evaluated according to the Appraisal of Guidelines for Research and Evaluation II process, and 13 statements were established using a grading system. This guideline was reviewed by external experts before an official. It will be revised as necessary to cover changes in technology, evidence, or other aspects of clinical practice.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Byung-Hoon Min
- Department of Gastroenterology, Samsung Medical Center, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, Seoul, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency, Seoul, Korea
| | - Chan Guk Park
- Department of Gastroenterology, Chosun University Hospital, Gwangju, Korea
| | - Joo Young Cho
- Department of Gastroenterology, Cha University Bundang Medical Center, Seongnam, Korea
| | - Soo Teik Lee
- Department of Gastroenterology, Jeonbuk National Hospital, Jeonju, Korea
| | - Ho Gak Kim
- Department of Gastroenterology, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Hoon Jai Chun
- Department of Gastroenterology, Korea University Anam Hospital, Seoul, Korea
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6
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Karatzas PS, Rösch T, Papanikolaou IS, de Heer J, Schachschal G, Groth S. Recognizing Post-Endoscopy Complications: A Database Filter Reduces Quality Assurance Workload for Inpatients. Dig Dis 2020; 39:171-178. [PMID: 32777788 DOI: 10.1159/000510757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 08/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND AIMS Documentation of complications of gastrointestinal endoscopy within the commonly used endoscopy documentation systems are mostly limited to acute complications during endoscopy included in the post-procedural endoscopy report. We tested a documentation system-based filter to reduce the workload by maintaining a high sensitivity to recognize post-endoscopy complications. METHODS Of all inpatient endoscopic resections during 1 year and all endoscopic retrograde cholangiopancreatography (ERCP) procedures during 4 months in 1 tertiary referral centre, post-procedural complications during hospital stay were individually analyzed retrospectively from the hospital databases (gold standard). In comparison, information technology-based filters were assessed searching for specific tests and data within 2 days after endoscopy and/or until discharge. These were second endoscopy, surgery, or an abdominal computed tomography (CT) or haemoglobin drop ≥2 g/dL for endoscopic resection. For ERCP cases, any case with lipase determination and post-ERCP CT scan was selected. Main outcomes were the sensitivity of these filters to recognize post-endoscopy complications and the percentage of workload reduction. RESULTS Three hundred twenty-two inpatients who underwent endoscopic resections and 302 ERCP cases (all inpatients) were included. Post-endoscopy complications occurred in 7.14% (endoscopic resection) and 3.7% (ERCP). The above-mentioned filters identified 100% of all resection and post-ERCP complications compared to detailed case file analysis, at the same time reducing the quality management workload to 14 and 31%, respectively. CONCLUSIONS Post-procedural monitoring of advanced endoscopic procedures performed on inpatient procedures has a high sensitivity (100%) and reduces case-by-case screening workload for complications by 70-85%. Outpatient interventions, however, require a different system for monitoring of post-endoscopy complications after discharge.
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Affiliation(s)
- Pantelis S Karatzas
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany.,Hepatogastroenterology Unit, Second Department of Internal Medicine, Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany,
| | - Ioannis S Papanikolaou
- Hepatogastroenterology Unit, Second Department of Internal Medicine, Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Jocelyn de Heer
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
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7
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Heublein V, Pannach S, Daschkow K, Tittl L, Beyer-Westendorf J. Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry. J Gastroenterol 2018; 53:236-246. [PMID: 28493007 DOI: 10.1007/s00535-017-1346-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 04/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients receiving direct-acting, non-vitamin K oral anticoagulants (NOAC) frequently undergo gastrointestinal endoscopies (GIE) but little is known on the management and outcome of these interventions. METHODS With use of data from an ongoing, prospective, noninterventional registry of NOAC patients, the management and outcome of GIE were evaluated with use of standard event definitions. Patients undergoing GIE were categorized into two subgroups: (1) scheduled GIE (scheduled appointment, no acute bleeding) and (2) unscheduled GIE (unscheduled including management of acute gastrointestinal bleeding). The rates of major bleeding complications, cardiovascular complications, and all-cause death within 30 days after the procedure were evaluated. RESULTS Between October 1, 2011, and March 31, 2015, 492 patients underwent a total of 713 GIE (44.5% gastroscopies, 53.0% colonoscopies, 2.5% endoscopic retrograde cholangiopancreatography procedures), with 70.0% being scheduled procedures and 30.0% being unscheduled procedures. Endoscopies were performed within 24 h after the last NOAC intake in 45 of 713 cases (6.3%), between 24 and 48 h after the last intake in 336 cases (47.1%), and after NOAC therapy interruption for more than 48 h in 213 cases (29.9%). Heparin bridging therapy was used in 180 of 713 procedures (25.3%) and predominantly (170/180; 94.4%) in cases of NOAC therapy interruption for longer than 72 h. Until day 30 after the procedure, the event rates were 1.4% for cardiovascular events and 0.7% for major bleeding events. CONCLUSION Continuation or short-term interruption of NOAC therapy seems to be a safe strategy for GIE. Heparin bridging therapy is predominantly used in cases of prolonged NOAC therapy interruption.
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Affiliation(s)
- Vera Heublein
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sven Pannach
- Division of Gastroenterology, Department of Medicine I, Carl Gustav Carus University Hospital, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Katharina Daschkow
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Luise Tittl
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, Carl Gustav Carus University Hospital , Fetscherstrasse 74, 01307, Dresden, Germany.
- Kings Thrombosis Service, Department of Hematology, Kings College London, London, UK.
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8
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Hanafy AS, Badawi R, Basha MAA, Selim A, Yousef M, Elnawasany S, Mansour L, Elkhouly RA, Hawash N, Abd-Elsalam S. A novel scoring system for prediction of esophageal varices in critically ill patients. Clin Exp Gastroenterol 2017; 10:315-325. [PMID: 29263686 PMCID: PMC5724407 DOI: 10.2147/ceg.s144700] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background and aims Patients with advanced systemic illness or critically ill patients may present with upper gastrointestinal tract (GIT) bleeding which may need endoscopic intervention; however, this may expose them to unnecessary endoscopy. The aim was to validate a novel scoring system for risk stratification for urgency of GIT endoscopy in critically ill patients. Methods This is an observational study conducted from January 2013 to January 2016 to analyze 300 patients with critical medical conditions and presenting with upper gastrointestinal bleeding. Meticulous clinical, laboratory, and sonographic evaluations were performed to calculate Glasgow Blatchford score (GBS) and variceal metric score for risk stratification and prediction of the presence of esophageal varices (OV). Finally, this score was applied on a validation group (n=100). Results The use of GBS and variceal metric scores in critically ill patients revealed that patients who showed a low risk score value for OV (0-4 points) and GBS <2 can be treated conservatively and discharged safely without urgent endoscopy. In patients with a low risk for varices but GBS >2, none of them had OV on endoscopy. In patients with intermediate risk score value for OV (5-8 points) and with GBS >2, 33.33% of them had varices on endoscopy. In patients with high risk score value for varices (9-13) and GBS >2, endoscopy revealed varices in 94.4% of them. Finally, in patients with very high risk score for varices (14-17), endoscopy revealed varices in 100% of them. Conclusion GBS and variceal metric score were highly efficacious in identifying critically ill patients who will benefit from therapeutic endoscopic intervention.
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Affiliation(s)
- Amr Shaaban Hanafy
- Internal Medicine Department, Hepatology Division, Zagazig University, Zagazig
| | - Rehab Badawi
- Tropical Medicine Department, Tanta University, Tanta
| | | | - Amal Selim
- Internal Medicine Department, Tanta University, Tanta, Egypt
| | | | | | - Loai Mansour
- Tropical Medicine Department, Tanta University, Tanta
| | | | - Nehad Hawash
- Tropical Medicine Department, Tanta University, Tanta
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Rossi UG, Rubis-Passoni G, Torcia P, Cariati M. Acute intestinal bleeding after endoscopic polypectomy: Super-selective endovascular embolization in a clinically unstable patient. REVISTA DE GASTROENTEROLOGIA DE MEXICO 2017; 82:341-343. [PMID: 28684030 DOI: 10.1016/j.rgmx.2017.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Accepted: 01/12/2017] [Indexed: 06/07/2023]
Affiliation(s)
- U G Rossi
- Unidad de Radiología y Radiología Intervencionista, Departamento de Ciencias Diagnósticas ASST Santi Paolo y Carlo-Hospital San Carlo Borromeo, Milán, Italia.
| | - G Rubis-Passoni
- Unidad de Diagnóstico y Endoscopia Intervencionista, Departamento de Gastroenterología ASST Santi Paolo y Carlo-Hospital San Carlo Borromeo, Milán, Italia
| | - P Torcia
- Unidad de Radiología y Radiología Intervencionista, Departamento de Ciencias Diagnósticas ASST Santi Paolo y Carlo-Hospital San Carlo Borromeo, Milán, Italia
| | - M Cariati
- Unidad de Radiología y Radiología Intervencionista, Departamento de Ciencias Diagnósticas ASST Santi Paolo y Carlo-Hospital San Carlo Borromeo, Milán, Italia
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10
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Rossi U, Rubis-Passoni G, Torcia P, Cariati M. Acute intestinal bleeding after endoscopic polypectomy: Super-selective endovascular embolization in a clinically unstable patient. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2017. [DOI: 10.1016/j.rgmxen.2017.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Abstract
OPINION STATEMENT Management of patients on anticoagulant or antiplatelet therapy undergoing endoscopy presents a balance of risks between haemorrhage due to the procedure, and thrombosis due to discontinuation of antithrombotic therapy. Haemorrhage is usually controllable endoscopically, but thrombosis could, on occasion, result in myocardial infarction or stroke, with permanent disability or death. For elective procedures, there is adequate time to plan best management of antithrombotic therapy. International guidelines have been published, but recommendations are based on limited evidence and consultation with appropriate medical specialists, and the patient is important. Patients on dual antiplatelet therapy for coronary stents are at particularly high risk of thrombosis if therapy is interrupted. Direct oral anticoagulants have been a great advance in the management of anticoagulation but can present an increased risk of spontaneous gastrointestinal haemorrhage, as well as a difficult management situation in haemorrhage following endoscopic therapy. For elective endoscopic procedures, there may be a suitable alternative investigation, and some patients can have therapy deferred if high-risk antithrombotic therapy is temporary. Gastrointestinal haemorrhage on antithrombotic therapy can present a life-threatening situation from potential thrombosis as well as haemorrhage. Management is particularly challenging on direct oral anticoagulants (DOACs), but a reversal agent is available for dabigatran, and others are in development. The safest time to restart antithrombotic therapy after therapeutic procedures or haemorrhage has been little studied, and the relevant risk factors are discussed together with advice on management. Although guidelines have been produced, there remains much uncertainty in the management of antithrombotic therapy for endoscopy, particularly for newer agents, and further research is required.
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Veitch AM, Vanbiervliet G, Gershlick AH, Boustiere C, Baglin TP, Smith LA, Radaelli F, Knight E, Gralnek IM, Hassan C, Dumonceau JM. Endoscopy in patients on antiplatelet or anticoagulant therapy, including direct oral anticoagulants: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guidelines. Gut 2016; 65:374-89. [PMID: 26873868 PMCID: PMC4789831 DOI: 10.1136/gutjnl-2015-311110] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
UNLABELLED The risk of endoscopy in patients on antithrombotics depends on the risks of procedural haemorrhage versus thrombosis due to discontinuation of therapy. P2Y12 RECEPTOR ANTAGONISTS CLOPIDOGREL, PRASUGREL, TICAGRELOR: For low-risk endoscopic procedures we recommend continuing P2Y12 receptor antagonists as single or dual antiplatelet therapy (low quality evidence, strong recommendation); For high-risk endoscopic procedures in patients at low thrombotic risk, we recommend discontinuing P2Y12 receptor antagonists five days before the procedure (moderate quality evidence, strong recommendation). In patients on dual antiplatelet therapy, we suggest continuing aspirin (low quality evidence, weak recommendation). For high-risk endoscopic procedures in patients at high thrombotic risk, we recommend continuing aspirin and liaising with a cardiologist about the risk/benefit of discontinuation of P2Y12 receptor antagonists (high quality evidence, strong recommendation). WARFARIN The advice for warfarin is fundamentally unchanged from British Society of Gastroenterology (BSG) 2008 guidance. DIRECT ORAL ANTICOAGULANTS DOAC For low-risk endoscopic procedures we suggest omitting the morning dose of DOAC on the day of the procedure (very low quality evidence, weak recommendation); For high-risk endoscopic procedures, we recommend that the last dose of DOAC be taken ≥48 h before the procedure (very low quality evidence, strong recommendation). For patients on dabigatran with CrCl (or estimated glomerular filtration rate, eGFR) of 30-50 mL/min we recommend that the last dose of DOAC be taken 72 h before the procedure (very low quality evidence, strong recommendation). In any patient with rapidly deteriorating renal function a haematologist should be consulted (low quality evidence, strong recommendation).
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Affiliation(s)
- Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Geoffroy Vanbiervliet
- Department of Gastroenterology, Hôpital Universitaire L'Archet 2, Nice Cedex 3, France
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Glenfield Hospital, Leicester, UK
| | | | - Trevor P Baglin
- Department of Haematology, Addenbrookes Hospital, Cambridge, UK
| | - Lesley-Ann Smith
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - Franco Radaelli
- Unità Operativa Complessa di Gastroenterologia, Servizio di Endoscopia Digestiva, Ospedale Valduce, Como, Italy
| | | | - Ian M Gralnek
- Institute of Gastroenterology and Liver Diseases, Ha'Emek Medical Center, Afula, Israel,Rappaport Faculty of Medicine Technion, Israel Institute of Technology, Israel
| | - Cesare Hassan
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
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Loffroy R, Favelier S, Pottecher P, Estivalet L, Genson P, Gehin S, Cercueil J, Krausé D. Transcatheter arterial embolization for acute nonvariceal upper gastrointestinal bleeding: Indications, techniques and outcomes. Diagn Interv Imaging 2015; 96:731-44. [DOI: 10.1016/j.diii.2015.05.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 05/06/2015] [Indexed: 02/08/2023]
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Lee SW, Lee JH, Cho H, Ha Y, Lim H, Ahn JY, Choi KS, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY, Kim JH. Comparison of clinical outcomes associated with pull-type and introducer-type percutaneous endoscopic gastrostomies. Clin Endosc 2014; 47:530-7. [PMID: 25505719 PMCID: PMC4260101 DOI: 10.5946/ce.2014.47.6.530] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 09/19/2013] [Accepted: 11/12/2013] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Percutaneous endoscopic gastrostomy (PEG) is a method of providing enteral nutrition using endoscopy. The PEG techniques differ according to the insertion method, and include the pull type, push type, and introducer type. The aim of this study was to compare the clinical outcomes associated with the pull-type and introducer-type PEG insertion techniques, which included the adverse events, at our tertiary care center in Korea. Methods We retrospectively reviewed 141 cases that had undergone PEG insertion at our center from January 2009 to June 2012. The indications for PEG insertion and the acute and chronic complications caused by each type of PEG insertion were analyzed. Results The indications for PEG insertion in our cohort included neurologic disease (58.7%), malignancy (21.7%), and other indications (19.6%). Successful PEG insertions were performed on 136 cases (96.5%), and there were no PEG-associated deaths. Bleeding was the most frequent acute complication (12.8%), and wound problems were the most frequent chronic complications (8.8%). There were no statistically significant differences between the pull-type and introducer-type PEG insertion techniques in relation to complication rates in our study population. Conclusions PEG insertion is considered a safe procedure. The pull-type and introducer-type PEG insertion techniques produce comparable outcomes, and physicians may choose either of these approaches according to the circumstances.
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Affiliation(s)
- Sin Won Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyungjin Cho
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeonjung Ha
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Lim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Yong Ahn
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwi Sook Choi
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hoon Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kee Don Choi
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho June Song
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gin Hyug Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Ho Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Blomberg J, Lagergren J, Martin L, Mattsson F, Lagergren P. Complications after percutaneous endoscopic gastrostomy in a prospective study. Scand J Gastroenterol 2012; 47:737-42. [PMID: 22471958 DOI: 10.3109/00365521.2012.654404] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Insertion of a percutaneous endoscopic gastrostomy (PEG) is an increasingly common procedure in patients with nutritional needs and dysphagia. Better knowledge of rates and patterns of complications after PEG might influence decision-making. MATERIAL AND METHODS The objective was to prospectively evaluate the rate of six pre-defined complications (leakage, diarrhea, constipation, abdominal pain, fever and peristomal infection) and mortality occurring within 2 months after PEG in an unselected sample of patients. All patients (n = 484) who had a PEG inserted at the hospital during the study period were included. Kaplan-Meier curves were used to estimate mortality over the first 60 days following PEG and Fisher's exact test was used to test equality of proportions. RESULTS Of the 484 patients included, 85 (18%) died within 2 months after PEG insertion. The risk of early mortality was higher in the group with neurological disease than in the group with a tumor as indication (p < 0.001). After excluding mortality, the overall complication rates at 2 weeks and 2 months were 39% and 27%, respectively. The most common complications within 2 weeks were abdominal pain (13%), peristomal infection (11%), diarrhea (11%) and leakage (10%). At 2 months the most frequent complications were diarrhea (10%), leakage (8%) and peristomal infection (6%). CONCLUSIONS In the short-term perspective, there is a substantial risk of complications, including mortality, after PEG insertion. This should be considered during clinical decision-making and when informing the patients and caregivers.
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Affiliation(s)
- John Blomberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Upper Gastrointestinal Research, Stockholm, Sweden.
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Singh D, Laya AS, Vaidya OU, Ahmed SA, Bonham AJ, Clarkston WK. Risk of bleeding after percutaneous endoscopic gastrostomy (PEG). Dig Dis Sci 2012; 57:973-80. [PMID: 22138961 DOI: 10.1007/s10620-011-1965-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 10/29/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on anticoagulation and/or antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. Data on the safety of peri-procedural use of these drugs is limited. AIMS To assess the risk and to identify any predictive factors for post-PEG bleeding, and to determine if clopidogrel increases the risk of bleeding following PEG. METHODS A retrospective chart audit was conducted from January 1, 2002 to June 30, 2011. RESULTS A total of 1,541 patients underwent PEG placement during this period. Gastrointestinal bleeding after PEG placement occurred in 51 cases (3.3%) and bleeding directly attributed to PEG was noted in six patients (0.4%). Multivariate logistic regression analysis of variables (age, gender, length of hospitalization, indication for PEG, antiplatelet or anticoagulant medications) showed that heparin infusion (P = 0.018) and length of hospitalization (P = 0.029) were statistically significant predictors of bleeding. The mean period for cessation and resumption of clopidogrel with PEG placement were 2.2 and 1.3 days, respectively. CONCLUSION Although PEG is classified as a high-risk endoscopic procedure, bleeding with PEG placement was rare, even with use of anticoagulation and antiplatelet medications. In selected patients on heparin infusion undergoing PEG, delaying the procedure, alternative use of low-molecular-weight heparin or close monitoring and frequent assessments should be considered. Clopidogrel did not contribute to an increase in bleeding risk, despite being held for a much shorter peri-procedural period as recommended by expert consensus.
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Affiliation(s)
- Dushyant Singh
- Section of Gastroenterology, University of Missouri Kansas City, Kansas City, MO, USA.
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Abstract
OBJECTIVES The benefit of repeat colonoscopy in managing delayed postpolypectomy bleeding is unknown. This study aimed to assess the outcome of repeat colonoscopy to achieve hemostasis. METHODS Endoscopic management of postpolypectomy bleeding is modeled as a decision tree, measuring the expected overall fraction of patients who benefit from therapeutic hemostasis and the number of patients needed to treat (NNT) in order to achieve one beneficial hemostasis. RESULTS A repeat colonoscopy to identify and treat postpolypectomy bleeding is beneficial in about 22% of patients, corresponding to an NNT of 4.5 patients. The outcome of the model is sensitive to assumptions underlying the fractions of patients who need treatment and would benefit from successful endoscopic hemostasis. Varying these probabilities over a broad range changes the fraction of patients benefiting from endoscopy between 3% and 33% and the NNT between 28 and 3 patients, respectively. CONCLUSIONS The expected outcome of repeat colonoscopy justifies the endoscopic attempts at therapeutic hemostasis. The results also suggest that in many patients expectant management aimed at spontaneous resolution of the bleeding remains a valid option.
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Loffroy RF, Abualsaud BA, Lin MD, Rao PP. Recent advances in endovascular techniques for management of acute nonvariceal upper gastrointestinal bleeding. World J Gastrointest Surg 2011; 3:89-100. [PMID: 21860697 PMCID: PMC3158888 DOI: 10.4240/wjgs.v3.i7.89] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 07/09/2011] [Accepted: 07/15/2011] [Indexed: 02/06/2023] Open
Abstract
Over the past two decades, transcatheter arterial embolization has become the first-line therapy for the management of upper gastrointestinal bleeding that is refractory to endoscopic hemostasis. Advances in catheter-based techniques and newer embolic agents, as well as recognition of the effectiveness of minimally invasive treatment options, have expanded the role of interventional radiology in the management of hemorrhage for a variety of indications, such as peptic ulcer bleeding, malignant disease, hemorrhagic Dieulafoy lesions and iatrogenic or trauma bleeding. Transcatheter interventions include the following: selective embolization of the feeding artery, sandwich coil occlusion of the gastroduodenal artery, blind or empiric embolization of the supposed bleeding vessel based on endoscopic findings and coil pseudoaneurysm or aneurysm embolization by three-dimensional sac packing with preservation of the parent artery. Transcatheter embolization is a fast, safe and effective, minimally invasive alternative to surgery when endoscopic treatment fails to control bleeding from the upper gastrointestinal tract. This article reviews the various transcatheter endovascular techniques and devices that are used in a variety of clinical scenarios for the management of hemorrhagic gastrointestinal emergencies.
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Affiliation(s)
- Romaric F Loffroy
- LE2I Laboratory, CNRS UMR 5158, Department of Vascular and Interventional Radiology, University of Dijon School of Medicine, Bocage Teaching Hospital, 2 Bd Maréchal de Lattre de Tassigny, BP 77908, 21079 Dijon, France
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How Should Patients Requiring Dual Antiplatelet Therapy be Managed When Undergoing Elective Endoscopic Gastrointestinal Procedures? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 13:46-56. [PMID: 21136215 DOI: 10.1007/s11936-010-0107-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OPINION STATEMENT The following are general guidelines for the management of patients on dual antiplatelet therapy as they undergo gastrointestinal procedures with potential for bleeding complications: Avoid cessation of all antiplatelet therapies after percutaneous coronary intervention (PCI) with stent placement when possible. Avoid cessation of clopidogrel (even when aspirin is continued) within the first 30 days after PCI and either drug-eluting stent (DES) or bare metal stent placement. Defer elective endoscopic procedures, possibly up to 12 months, if clinically acceptable from the time of PCI and DES placement. Perform endoscopic procedures, particularly those associated with bleeding risk, 5 to 7 days after thienopyridine drug cessation. Aspirin should be continued when possible. Resume thienopyridine and aspirin drug therapy after the procedure once hemostasis is achieved. A loading dose of the former should be considered among patients at risk for thrombosis. Continue platelet-directed therapy in patients undergoing elective endoscopy procedures associated with a low risk for bleeding.
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20
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Cappell MS. Rigorous scientific study of endoscopic adverse events requires not only a lexicon but a reliable reporting system. Gastrointest Endosc 2010; 72:1324. [PMID: 21111877 DOI: 10.1016/j.gie.2010.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 04/01/2010] [Indexed: 12/10/2022]
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Abstract
Endoscopy is the primary diagnostic and therapeutic tool for upper gastrointestinal bleeding (UGIB). The performance of endoscopic therapy depends on findings of stigmata of recent hemorrhage (SRH). For peptic ulcer disease-the most common etiology of UGIB-endoscopic therapy is indicated for findings of major SRH, such as active bleeding, oozing, or the presence of a nonbleeding visible vessel, but not indicated for minor SRH, such as a pigmented flat spot or a simple ulcer with a homogeneous clean base. Endoscopic therapies include injection, ablation, and mechanical therapy. Monotherapy reduces the risk of rebleeding in patients with peptic ulcer disease with major SRH to about 20%. Combination therapy, especially injection followed by either ablation or mechanical therapy, is generally recommended to further reduce the risk of rebleeding to about 10%. Endoscopic dual hemostasis by an experienced endoscopist reduces the risk of rebleeding, the need for surgery, the number of blood transfusions required, and the length of hospital stay. This Review article comprehensively analyzes the principles, indications, instrumentation, techniques, and efficacy of endoscopic hemostasis.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, MOB 233, William Beaumont Hospital, 3535 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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22
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Becker RC, Scheiman J, Dauerman HL, Spencer F, Rao S, Sabatine M, Johnson DA, Chan F, Abraham NS, Quigley EMM. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. J Am Coll Cardiol 2010; 54:2261-76. [PMID: 19942393 DOI: 10.1016/j.jacc.2009.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 09/09/2009] [Accepted: 09/15/2009] [Indexed: 01/02/2023]
Abstract
The periprocedural management of patients with atherosclerotic coronary heart disease, including those who have heart disease and those who are undergoing percutaneous coronary intervention and stent placement who might require temporary interruption of platelet-directed pharmacotherapy for the purpose of an elective endoscopic gastrointestinal procedure, is a common clinical scenario in daily practice. Herein, we summarize the available information that can be employed for making management decisions and provide general guidance for risk assessment.
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Affiliation(s)
- Richard C Becker
- Duke University Medical Center, Duke Clinical Research Institute, Durham, NC 27705, USA.
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Becker RC, Scheiman J, Dauerman HL, Spencer F, Rao S, Sabatine M, Johnson DA, Chan F, Abraham NS, Quigley EMM. Management of platelet-directed pharmacotherapy in patients with atherosclerotic coronary artery disease undergoing elective endoscopic gastrointestinal procedures. Am J Gastroenterol 2009; 104:2903-17. [PMID: 19935784 DOI: 10.1038/ajg.2009.667] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The periprocedural management of patients with atherosclerotic coronary heart disease, including those who have heart disease and those who are undergoing percutaneous coronary intervention and stent placement who might require temporary interruption of platelet-directed pharmacotherapy for the purpose of an elective endoscopic gastrointestinal procedure, is a common clinical scenario in daily practice. Herein, we summarize the available information that can be employed for making management decisions and provide general guidance for risk assessment.
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Affiliation(s)
- Richard C Becker
- Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina 27705, USA.
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Kwok A, Faigel DO. Management of anticoagulation before and after gastrointestinal endoscopy. Am J Gastroenterol 2009; 104:3085-97; quiz 3098. [PMID: 19672250 DOI: 10.1038/ajg.2009.469] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The management of anticoagulants and antiplatelet agents in patients undergoing gastrointestinal endoscopic procedures is a common clinical problem. Although guidelines have been published, they are supported by little prospective or randomized trial data, but are primarily based on observational studies, expert opinion, and best clinical practices. As a general principle, the risks of thromboembolism need to be balanced against the risks of bleeding during the endoscopic procedure. By understanding these risks, management plans for individual cases may be made. This article reviews the current data and guidelines on the management of anticoagulants, antiplatelet agents, use of reversal agents, and the role and risks of concomitant proton pump inhibitors.
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Affiliation(s)
- Avelyn Kwok
- Department of Gastroenterology, Concord Hospital, University of Sydney, Sydney, Australia
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25
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Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am 2008; 92:491-509, xi. [PMID: 18387374 DOI: 10.1016/j.mcna.2008.01.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute upper gastrointestinal bleeding is a relatively common, potentially life-threatening medical emergency responsible for more than 300,000 hospital admissions and about 30,000 deaths per annum in America. The initial assessment focuses on bleeding activity, bleeding severity, hemodynamic compromise from the bleeding, and differentiating upper from lower gastrointestinal bleeding. The initial supportive therapy includes fluid resuscitation to reverse the hypovolemia, blood transfusions to replete the lost blood, respiratory support as necessary, and proton pump inhibitor therapy to stabilize mucosal blood clots and promote hemostasis. Esophagogastroduodenoscopy is the best test to determine the bleeding site and cause.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Cappell MS, Friedel D. Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy. Med Clin North Am 2008; 92:511-50, vii-viii. [PMID: 18387375 DOI: 10.1016/j.mcna.2008.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Cappell MS. Reducing the incidence and mortality of colon cancer: mass screening and colonoscopic polypectomy. Gastroenterol Clin North Am 2008; 37:129-60, vii-viii. [PMID: 18313544 DOI: 10.1016/j.gtc.2007.12.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Most colon cancers arise from conventional adenomatous polyps (conventional adenoma-to-carcinoma sequence), while some colon cancers appear to arise from the recently recognized serrated adenomatous polyp (serrated adenoma-to-carcinoma theory). Because conventional adenomas and serrated adenomas are usually asymptomatic, mass screening of asymptomatic patients has become the cornerstone for detecting and eliminating these precursor lesions to reduce the risk of colon cancer. Colonoscopy has become the primary screening test because of its high sensitivity and specificity, and the ability to perform polypectomy. Other screening tests include guaiac tests or fecal immunochemical tests (FIT) for fecal occult blood, and flexible sigmoidoscopy. A minimal colonoscopic withdrawal time of 6 minutes is important to maximize polyp detection at colonoscopy. Chromoendoscopy is an experimental technique used to highlight abnormal colonic areas to identify neoplastic tissue and to potentially determine the histology of colonic polyps at colonoscopy based on superficial pit anatomy.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Masaoka T, Suzuki H, Hori S, Aikawa N, Hibi T. Blatchford scoring system is a useful scoring system for detecting patients with upper gastrointestinal bleeding who do not need endoscopic intervention. J Gastroenterol Hepatol 2007; 22:1404-8. [PMID: 17716345 DOI: 10.1111/j.1440-1746.2006.04762.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Several scoring systems have been devised to identify patients with upper gastrointestinal (UGI) bleeding who are at a high risk of adverse outcomes. We retrospectively evaluated the accuracy of the Blatchford scoring system for assessing the need for clinical intervention in cases of UGI bleeding admitted to the emergency department (ED). METHODS This was a retrospective study conducted on patients who underwent emergency GI endoscopy at the ED of our hospital. Those who needed blood transfusion, operative or endoscopic interventions to control the hemorrhage were classified into the 'high risk' group. RESULTS Of the 93 enrolled patients, 70 (75.3%) were classified into the high risk group. The Blatchford score was significantly higher in the high risk group than in the low risk group. When a cut-off value of 2 was used, the sensitivity and specificity of the Blatchford scoring system were determined to be 100% and 13%, respectively. Thus, the Blatchford scoring system was deemed to be useful for distinguishing between the high risk group and the low risk group of patients with GI hemorrhage admitted to the ED. CONCLUSION The Blatchford scoring system is accurate for identifying definitively low-risk patients of GI hemorrhage, even prior to the performance of emergency UGI endoscopy at the ED.
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Affiliation(s)
- Tatsuhiro Masaoka
- Department of Emergency Medicine, Keio University School of Medicine, Tokyo, Japan
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Ringold DA, Jonnalagadda S. Complications of Therapeutic Endoscopy: A Review of the Incidence, Risk Factors, Prevention, and Endoscopic Management. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2007. [DOI: 10.1016/j.tgie.2007.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Fatima H, Rex DK. Minimizing endoscopic complications: colonoscopic polypectomy. Gastrointest Endosc Clin N Am 2007; 17:145-56, viii. [PMID: 17397781 DOI: 10.1016/j.giec.2006.10.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Current polypectomy tools and techniques are inadequate to prevent all postpolypectomy bleeding, perforation, and postpolypectomy syndrome; however, adherence to certain principles can substantially reduce the risk of these complications. This review does not focus on technical aspects of colonoscopy that are directed toward preventing complications of failed eradication. Rather, the authors focus on the classic complications of bleeding, perforation, and their prevention. New technologies that could further reduce or eliminate perforation and bleeding after polypectomy are sorely needed.
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Affiliation(s)
- Hala Fatima
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, 550 N University Boulevard, UH 4100, Indianapolis, IN 46202, USA
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Auroux J, Fogliani J, Miguet E, Morcillo JL, Bretagnolle P. [Major hemorrhage following colonic cold biopsies]. ACTA ACUST UNITED AC 2006; 30:794-5. [PMID: 16801907 DOI: 10.1016/s0399-8320(06)73318-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kuran S, Parlak E, Oguz D, Cicek B, Disibeyaz S, Sahin B. Endoscopic sphincterotomy-induced hemorrhage: treatment with heat probe. Gastrointest Endosc 2006; 63:506-11. [PMID: 16500411 DOI: 10.1016/j.gie.2005.09.039] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2004] [Accepted: 09/16/2005] [Indexed: 12/15/2022]
Abstract
BACKGROUND Endoscopic sphincterotomy (ES)-induced hemorrhage is a serious complication of ERCP and occurs in 1% to 2% of all procedures. A heat probe has been used effectively for many causes of GI hemorrhages. We prospectively investigated the efficacy and the safety of heat probe usage in patients with ES-induced hemorrhage. METHODS Between July 2002 and March 2004, ERCP procedures with ES were evaluated prospectively for complications. A heat probe was used to control ES-induced hemorrhages. RESULTS ES was performed in 703 of a total of 1262 (55.7%) ERCP procedures. ES-induced hemorrhage occurred in 16 patients (2.3%; 10 men, 6 women; 59.6 +/- 15.2 years). Six of 16 patients bled during ERCP, and all bleeding was controlled by heat probe. Ten patients hemorrhaged after ERCP: 6 patients needed endoscopic treatment with heat probe, and 4 were followed up with supportive treatment without the need for any further treatment. There was no complication caused by the heat probe in this series. CONCLUSIONS Heat probe is an easy, safe, and effective procedure for ES-induced hemorrhage treatment.
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Affiliation(s)
- Sedef Kuran
- Gastroenterology Department, Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey
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Esrailian E, Gralnek IM. Nonvariceal upper gastrointestinal bleeding: epidemiology and diagnosis. Gastroenterol Clin North Am 2005; 34:589-605. [PMID: 16303572 DOI: 10.1016/j.gtc.2005.08.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Nonvariceal upper gastrointestinal bleeding remains an important cause of patient morbidity, mortality, and use of considerable health care resources. An early and accurate diagnosis is critical for guiding appropriate management and facilitating patient care. This article reviews the most recent epidemiologic data on acute nonvariceal upper gastrointestinal bleeding and outlines important aspects of making the diagnosis.
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Affiliation(s)
- Eric Esrailian
- David Geffen School of Medicine at UCLA, VA Greater Los Angeles Healthcare System, UCLA/VA Center for Outcomes Research and Education, CA 90073, USA
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Affiliation(s)
- Gilles Lesur
- Fédération des Spécialités Digestives, Hôpital Ambroise Paré, 92104 Boulogne Cedex, France.
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35
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Abdulla A, Thomas A, Jenkins A. Imaging the large bowel in the elderly. Geriatr Gerontol Int 2004. [DOI: 10.1111/j.1447-0594.2004.00258.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: technique, indications, and contraindications. Med Clin North Am 2002; 86:1217-52. [PMID: 12510453 DOI: 10.1016/s0025-7125(02)00076-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Flexible sigmoidoscopy and colonoscopy have revolutionized the clinical management of colonic diseases. Colonoscopy has a broad range of indications, including evaluating lower GI symptoms such as lower GI bleeding, evaluating abnormal radiographic findings, and screening and surveillance for colon cancer. Colonoscopy is increasingly being used therapeutically. Patient evaluation, patient instructions, and colonic preparation before colonoscopy are essential for safe and efficient colonoscopy. Intravenous sedation reduces patient pain and anxiety during colonoscopy, but requires monitoring by pulse oximetry and automated measurements of vital signs. An experienced colonoscopist can complete colonoscopy in 90% or more of cases, using maneuvers to maintain the colonic lumen in view, straighten the colonoscope, and avoid looping during colonic intubation.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, Department of Medicine, State University of New York, Downstate Medical School, Brooklyn, NY, USA
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Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: endoscopic findings, therapy, and complications. Med Clin North Am 2002; 86:1253-88. [PMID: 12510454 DOI: 10.1016/s0025-7125(02)00077-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Flexible sigmoidoscopy and colonoscopy have revolutionized the clinical management of colonic diseases. Colonoscopy is a highly sensitive and specific test. Colonic diseases often produce characteristic colonoscopic findings, as well as characteristic histologic findings, as identified in colonoscopic biopsy or polypectomy specimens. Colonoscopy is relatively safe, with a low incidence of serious complications, such as colonic perforation, hemorrhage, cardiopulmonary arrest, or sepsis. Colonoscopy is becoming more important clinically because of more widespread use of screening colonoscopy for colon cancer, application of therapeutic colonoscopy, and exciting new technical improvements.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, Department of Medicine, State University of New York, Downstate Medical School, Brooklyn, NY, USA
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Cappell MS, Friedel D. The role of esophagogastroduodenoscopy in the diagnosis and management of upper gastrointestinal disorders. Med Clin North Am 2002; 86:1165-216. [PMID: 12510452 DOI: 10.1016/s0025-7125(02)00075-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, Department of Medicine, State University of New York, Downstate Medical School, Brooklyn, NY, USA
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Abstract
Gastrointestinal bleeding in elderly individuals is a frequent cause of consultation with a physician and of hospital admissions. Co-morbidity and greater medication use in this steadily growing patient group influence the clinical course and adversely affect outcome. Clinical presentation is often predictable and guides subsequent patient management. Due to a surprising lack of prospective controlled data in the area of gastrointestinal bleeding, the selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithmic approach. Advances in endoscopic, medical, radiological and surgical treatment modalities offer promising new diagnostic and therapeutic tools, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. This chapter will address clinical presentation, aetiology, diagnosis and treatment of both upper and lower gastrointestinal bleeding in the elderly.
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Affiliation(s)
- T Lingenfelser
- Klinik für Gastroenterologie, Universitätsklinik Magdeburg, Leipziger Strasse 44, D-39120 Magdeburg, Germany
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Abstract
OBJECTIVE To review the use of proton-pump inhibitors for acute peptic ulcer bleeding. DATA SOURCES Articles were obtained through computerized searches of MEDLINE (1966-September 2000). Additionally, several textbooks containing information on the diagnosis and management of acute peptic ulcer bleeding were reviewed. The bibliographies of retrieved publications and textbooks were reviewed for additional references. STUDY SELECTION All randomized studies and pharmacoeconomic evaluations that used proton-pump inhibitor therapy for acute peptic ulcer bleeding were included. Randomized controlled trials and meta-analyses involving other therapies for treating peptic ulcer bleeding were also reviewed for possible inclusion. DATA EXTRACTION The primary outcomes extracted from the literature were persistent or recurrent bleeding, transfusion requirements, need for endoscopic intervention or surgery, length of stay, and mortality. DATA SYNTHESIS Data from double-blind, placebo-controlled trials involving more than 1000 patients demonstrate that short-term, high-dose omeprazole therapy is effective for reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding. The patients most likely to benefit from this therapy are hospitalized patients at high risk for rebleeding and patients in whom endoscopic evaluation must be delayed or is unavailable. CONCLUSIONS Omeprazole (and likely other proton-pump inhibitors) is useful in reducing bleeding and transfusion requirements in patients with acute peptic ulcer bleeding, although better delineation of appropriate candidates is needed.
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Affiliation(s)
- B L Erstad
- Department of Pharmacy Practice & Science, College of Pharmacy, 1703 E. Mabel St., Tucson, AZ 85721-0207, USA.
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Abstract
Lower gastrointestinal tract bleeding is a frequent cause of physician consultations and hospital admissions. Clinical presentation is predictable and significantly influences subsequent patient management. Controversy surrounding diagnosis and treatment of lower gastrointestinal bleeding results from a surprising lack of prospective controlled data. Thus, selection of diagnostic and therapeutic manoeuvres often depends more on local expertise and availability than on an algorithm approach. Advances in endoscopic, radiological and surgical equipment and techniques offer promising new diagnostic and therapeutic modalities, particularly in concerted applications. Outcome studies on the appropriate sequence and linking of these modalities are urgently needed. The present chapter will address clinical presentation, aetiology, diagnosis and treatment of lower gastrointestinal tract bleeding.
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Affiliation(s)
- T Lingenfelser
- Innere Medizin II, Dr.-Horst-Schmidt-Kliniken, Department of Gastroenterology and Hepatology, Ludwig-Erhard-Str.100, Wiesbaden, Germany.
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