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Gastrointestinal Endos
Gastrointestinal Endos
Neil H. Stollman M.D. Chief of Gastroenterology (Interim) San Francisco General Hospital
Outline
Indications / Contraindications Informed consent Risks of endoscopy Conscious sedation Infection control issues
Risks/prophylaxis for bacterial endocarditis Risk of infx transmission via endoscopy
Documentation
Nausea/vomiting of unknown cause Dysphagia or odynophagia Hematemesis or melena Chest pain w/ negative cardiac evaluation IDA/chronic blood loss with neg colonoscopy or sxs c/w UGI source Caustic ingestion Supected malabsorption
Abnormal X-ray study Survey for CA (Barrett, FAP) Therapeutic endoscopy UGIB Stent insertion PEG Polypectomy Treatment of varices Dilation of stricture Tumor cauterization Foreign body Follow-up endoscopy GU or esophageal ulcer, to assess healing
Non-bloody diarrhea >2wks Unless Abx use, known IBD, Immunosuppressed Bloody diarrhea > 1 wk with features above Hematochezia or suspected distal colonic dz (in young pt when colonoscopy not indicated)
Therapeutic colonoscopy
Polyp removal Palliation of neoplasm Dilation of stricture or stoma Reduction of volvulus Decompression Foreign body removal
Contraindications to GI Endoscopy
When the results will not change management When the risks to pt health or life outweigh the most favorable benefits of the procedure When adequate cooperation cant be obtained When a perforated viscus is known or suspected
Informed Consent
California requires lay standard; ie. MD must disclose information that a reasonable person would require prior to making an informed decision about the procedure.
USA
Perforation Bleeding Infection Cardiopulmonary Total 70 (0.03%) 63 (0.03%) 17 (0.008%) 129 (0.06%) 279 (0.13%)
Europe
20 (0.008%) --183 (0.073%) 203 (0.08%)
Total procedures
211,410
252,888
USA
Perforation Bleeding Infection Cardiopulmonary Total procedures 3 (0.001%) 1 (0.003%) 0 6 (0.003%) 211,410
Europe
4 (0.002%) --12 (0.005%) 252,888
Complications of ERCP
Diagnostic ERCP: pancreatitis 3-10%
Freeman et al, Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996. Overall, 229/2347 pts (10%) had complication
pancreatitis 5.4% hemorrhage 2.0% Predictive pt factors: suspected SOD, cirrhosis Not predictive: age, coexistant illness, CBD diameter Predictive case factors: difficult access, pre-cut
Moderate-risk category
Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfunction (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets
Prophylactic Regimens for Dental, Oral, Resp Tract, or Esophageal Procedures-AHA 1997
Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures
Situation
Standard general prophylaxis Unable to take oral medications Allergic to penicillin
Agent
Amoxicillin Ampicillin Clindamycin or Cephalexin or Azithro/Clarithromycin
Regimen
Adults: 2.0 g; children: 50 mg/kg orally 1 h before procedure Adults: 2.0 g IM or IV; children: 50 mg/kg IM or IV within 30 min before procedure Adults: 600 mg; children: 20 mg/kg orally 1 h before procedure Adults: 2.0 g; children; 50 mg/kg orally 1 h before procedure Adults: 500 mg; children: 15 mg/kg orally 1 h before procedure Adults: 600 mg; children: 20 mg/kg IV within 30 min before procedure Adults: 1.0 g; children: 25 mg/kg IMor IV within 30 min before procedure
Clindamycin or Cefazolin
Agents
Ampicillin plus gentamicin
Regimen
Adults: ampicillin 2.0 g IM or IV plus gentamicin (not to exceed 120 mg) w/in 30 of starting procedure; 6 h later, ampicillin 1 g IM/IV or amoxicillin 1 g orally Children: ampicillin 50 mg/kg IM or IV (not to exceed g) plus gentamicin 1.5 mg/kg w/in 30 of starting; 6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg PO
2.0
Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete infusion within 30 min of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM; complete w/in 30 Adults: amoxicillin 2.0 g orally 1 h before procedure, or ampicillin 2.0 g IM/IV w/in 30 of starting procedure Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within
Moderate-risk patients
Amoxicillin or ampicillin
30 Mod-risk patients allergic to PCN infusion Vancomycin Adults: vancomycin 1.0 g IV over 1-2 h complete within 30 min of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h; complete
253 cases reported before 1988 1988: ASGE, SGNE guidelines on endoscope disinfection 1988 onward: 28 cases reported Most cases can be traced to procedural errors in cleaning and disinfection Rate estimated at 1:1,800,000 cases No HBV since 1988; no HIV ever
Documentation
If you didnt write it down, you didnt do it The World According to Garp: Malpractice Attorneys JCAHO Medicare et al.