Bronchospasm during upper gastrointestinal endoscopy under sedation

We experienced a case of bronchospasm during upper gastrointestinal endoscopy under sedation. An 80-year-old man came to our hospital with abdominal distension with pain, nausea and vomiting. He has the history of splenectomy, cholecystectomy for hemolytic anemia and thyroidectomy for thyroid cancer, surgery for bilateral shoulder joints and diabetes. Abdominal X-ray suggested obstruction of the small intestine. On the third hospital day, gastrointestinal endoscopy was scheduled for insertion of a long ileus tube. Under sedation with diazepam 10 mg and local anesthesia of the pharynx with lidocaine spray 24 mg, the endoscope was inserted and when it reached the esophageal-gastrojunction, respiratory rate increased to 30 breaths.min-1 with expiratory stridor. The endoscope was removed immediately. He was oro-tracheally intubated and artificially ventilated. On the fourth hospital day, he was extubated under bronchoscopy. No abnormalities were observed in the trachea, vocal cord, pharynx and larynx. Later, it was revealed that he had a history of hoarseness and dysphasia. His left recurrent nerve and cervical nerve had been resected with thyroid and right cervical nerve anastomosed to the rest of the left recurrent nerve. The insertion of upper gastrointestinal endoscope might have induced bronchospasm stimulating distal esophageal afferent vagal reflex partly by regurgitation of gastric acid under sedation.     

Hypoxia during upper gastrointestinal endoscopy with and without sedation and the effect of pre-oxygenation on oxygen saturation

In Study A, the incidence of arterial oxygen desaturation was studied using pulse oximetry (SaO2) in 100 sedated and 100 nonsedated patients breathing room air who underwent diagnostic upper gastrointestinal endoscopy. Hypoxia (SaO2 92% or less of at least 15 s duration) occurred in 17% and 6% of sedated patients and nonsedated patients, respectively (p < 0.03). Mild desaturation (SaO2 94% or less and less than 15 s duration) occurred in 47% of sedated patients compared with 12% of nonsedated patients (p < 0.001). In Study B, the effects of supplementary oxygen therapy and the effects of different pre-oxygenation times on arterial oxygen saturation (SaO2) in sedated patients were studied using pulse oximetry. One hundred and twenty patients who underwent diagnostic upper gastrointestinal endoscopy with intravenous sedation were studied. Patients were randomly allocated to one of four groups: Group A (n = 30) received no supplementary oxygen while Groups B-D received supplementary oxygen at 4 1 x min(-1) via nasal cannulae. The pre-oxygenation time in Group B (n = 30) was zero minutes, Group C (n = 30) was 2 min and Group D (n = 30) was 5 min before sedation and introduction of the endoscope. Hypoxia occurred in seven of the 30 patients in Group A and none in groups B, C and D (p < 0.001). We conclude that desaturation and hypoxia is common in patients undergoing upper gastrointestinal endoscopy with and without sedation. Sedation significantly increases the incidence of desaturation and hypoxia. Supplementary nasal oxygen at 4 1 x min(-1) in sedated patients abolishes desaturation and hypoxia. Pre-oxygenation confers no additional benefit.     

Examination of cardiorespiratory changes during upper gastrointestinal endoscopy

Critical events including hypoxaemia, arrhythmias and myocardial ischaemia may occur more frequently during endoscopic procedures than during anaesthesia. A study was undertaken to assess the cardiovascular changes and to evaluate suitable monitoring techniques to detect critical events during sedation and endoscopy. Twenty patients scheduled to undergo a prolonged endoscopic procedure which required deep sedation were studied. Continuous recordings of electrocardiogram, heart rate and arterial oxygen saturation were made and arterial pressure was recorded at one-minute intervals. The study commenced immediately before administration of sedatives, continued for the duration of the examination and for one hour following the examination. Oxygen saturation decreased in all patients during the examination to a mean of 82.9% (SD 11.9), and remained below baseline for the duration of the examination and into the recovery period. Statistically significant increases and reductions of systolic arterial pressure and rate-pressure product were found during the procedures compared with baseline values recorded before administration of sedatives. Sixteen of the 20 patients developed tachycardia during the examination. Ten patients developed ectopic foci which were supraventricular, ventricular or both in origin. Electrocardiogram changes resolved during the recovery period. Myocardial ischaemia was assessed by S-T segment depression and a significant correlation was found between S-T segment depression and hypoxaemia, although the magnitude of the S-T depression was small and may not have been detected clinically. No correlation was found between S-T segment depression and arterial pressure, heart rate or rate-pressure product.(ABSTRACT TRUNCATED AT 250 WORDS)     

Propofol-ketamine vs propofol-fentanyl for sedation during pediatric upper gastrointestinal endoscopy

BACKGROUND: The aim of this study was to compare the clinical efficacy and safety of propofol-ketamine with propofol-fentanyl in pediatric patients undergoing diagnostic upper gastrointestinal endoscopy (UGIE). METHODS: This was a prospective, randomized, double blinded comparison of propofol-ketamine with propofol-fentanyl for sedation in patients undergoing elective UGIE. Ninety ASA I-II, aged 1 to 16-year-old patients were included in the study. Heart rate (HR), systolic arterial pressure, peripheral oxygen saturation, respiratory rate (RR) and Ramsey sedation scores of all patients were recorded perioperatively. Patients were randomly assigned to receive either propofol-ketamine (PK; n = 46) or propofol-fentanyl (PF; n = 44). PK group received 1 mg x kg(-1) ketamine + 1.2 mg x kg(-1) propofol, and PF group received 1 microg x kg(-1) fentanyl + 1.2 mg x kg(-1) propofol for sedation induction. Additional propofol (0.5-1 mg x kg(-1)) was administered when a patient showed discomfort in either group. RESULTS: The number of patients who needed additional propofol in the first minute after sedation induction was eight in Group PK (17%), and 22 in Group PF (50%) (P < 0.01) and those who did not need additional propofol throughout the endoscopy were 14 in Group PK (30%) and three in Group PF (7%) (P < 0.01). HR and RR values after induction in Group PF were significantly lower than Group PK (P < 0.01). CONCLUSIONS: Both PK and PF combinations provided effective sedation in pediatric patients undergoing UGIE, but the PK combination resulted in stable hemodynamics and deeper sedation though more side effects.     

Emergent and therapeutic upper gastrointestinal endoscopy in children

Pediatric patients with upper gastrointestinal disorders have benefited significantly from recent advances in endoscopic technology. Improved techniques of esophageal endosclerosis and dilatation have reduced the morbidity associated with these 2 procedures. Twenty-five patients underwent 136 endosclerosis treatments, with effective control of bleeding in all. Three of four deaths were caused by primary organ failure and one was due to a complication of endosclerosis. Fifty-seven patients with esophageal stricture have undergone successful dilatation with uniformly good results and no major complications. Virtually all foreign bodies may now be successfully removed endoscopically from the esophagus or stomach and formerly unrecognized mucosal lesions have been defined as a common source of gastrointestinal hemorrhage. Continued advances in therapeutic pediatric endoscopy will be limited only by the imagination of the pediatric endoscopist.

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Resumen Los pacientes pediátricos con desórdenes gastrointestinales han venido a beneficiarse en forma significativa con los recientes avances en la tecnología endoscópica. Desde hace tiempo las lesiones mucosales no identificadas fueron definidas como una fuente común de hemorragia, gastrointestinal, especialmente en niños pequeños. Las avanzadas técnicas de endosclerosis esofágica y dilatación han reducido la morbilidad asociada con tales condiciones patológicas. Veinticinco pacientes fueron sometidos a 136 tratamientos de endosclerosis, con control efectivo de la hemorragia en la totalidad. Tres de cuatro muertes fueron causadas por falla orgánica primaria y una se debió a complicaciones de la endosclerosis. Cincuenta y siete pacientes con estrechez esofágica han sido sometidos a dilatación exitosa con resultados uniformemente buenos y sin complicaciones mayores. Virtualmente todos los cuerpos extraños pueden ser exitosamente removidos del esófago o estómago por vía endoscópica, con lo cual se evita la operación. El futuro continuado avance de la endoscopia terapéutica pediátrica se verá limitado solamente por la imaginación del endoscopista pediátrico.

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Résumé Les enfants qui présentent des troubles gastrointestinaux ont bénéficié des progrès récents de l'endoscopie. En premier lieu des lésions muqueuses méconnues ont pu être reconnues comme source des hémorragies gastro-intestinales, spécialement chez le jeune enfant. L'amélioration des techniques de sclérose endo-oesophagienne et de dilatation ont réduit leur morbidité. Vingt-cinq malades ont subi 136 séances de sclérothérapie avec un contrôle efficace de l'hémorragie. Trois morts sur quatre enregistrées ont eu pour cause une déficience organique; une a été le fait de la complication de la méthode. Cinquante-sept sujets porteurs d'une sténose oesphagienne ont subi avec succès et sans complications majeures des dilatations. Tous les corps étrangers ont pu être extirpés avec succès de l'oesophage ou de l'estomac, évitant ainsi le recours à la chirurgie. Les progrès de l'endoscopie chez l'enfant auront pour seule limite l'imagination des endoscopistes.

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Supported in part by Grants RR-00051 and RR-00069 from the General Clinical Research Centers Program of the Division of Research Resources, National Institutes of Health.     

Midazolam for upper gastrointestinal endoscopy.

A water-soluble benzodiazepine, midazolam, was used in 400 patients undergoing upper gastrointestinal endoscopy, alone or in combination with pentazocine and compared with 68 patients given diazepam (Valium). In the last 200 patients the endoscopist used midazolam without the presence of an anaesthetist. The absence of injection pain was the most notable feature of midazolam. The degree of co-operation was similar in all groups but the operating conditions were significantly better when midazolam was combined with pentazocine. There was no significant difference in recovery times between the groups as assessed by the pegboard test. Midazolam is an acceptable alternative to diazepam for upper gastrointestinal endoscopy.     

Oxygen saturation monitoring during endoscopy

Summary The role of monitoring during endoscopy is not clearly defined. We have prospectively investigated continuous arterial oxygen saturation (S _aO₂) monitoring in 326 patients undergoing upper endoscopy (EGD) and 90 undergoing colonoscopy. Automated blood pressure recording was evaluated in 278 of these patients.S _aO₂ desaturation (<90%) occurred in 17.8% of patients undergoing EGD and 12.9% undergoing colonoscopy. Systolic blood pressure abnormalities (>200 or <90 mmHg) occurred in 19.8% of EGD patients and 19.6% of colonoscopy patients. Treatment based on these abnormalities was required in 4.3% of patients during EGD and 8.8% during colonoscopy. A history of pulmonary or cardiac disease predicted increased risk during colonoscopy, while cardiac disease and age 60 years or above predicted desaturation during EGD. Pulse oximetry and automated blood pressure monitoring was especially valuable during endoscopy in the elderly and patients with cardiac or pulmonary disease. It may be used as a guide to therapeutic intervention and to avert major cardiopulmonary complications.     

The aims of endoscopy in upper gastrointestinal hemorrhage

FOR DIAGNOSIS AND FOR TREATMENT: Endoscopy for upper gastrointestinal haemorrhage has a double objective. It is difficult and to be optimal, it must be conducted at the right time and in the best technical conditions as possible. Depending on the etiology, identification of the cause of bleeding precedes the choice of the haemostatic method to be used, preferentially injections of adrenaline in the case of bleeding ulcers and elastic ligature in the case of ruptured oesophageal varicose veins. In general the aim of endoscopic treatment is to stop the haemorrhage and to reduce as far as possible the risk of recurrent haemorrhage, which represents a factor of high deathrate.     

Perforation of the organs of the upper gastrointestinal tract during fiber endoscopy

The work deals with problems of urgent surgical aid to patients with perforation of hollow organs during fiber endoscopy. Two of four patients were subjected to surgery, the other two with covered perforation of the hollow organ were treated conservatively. All the patients recovered.     

Sedation with intravenous midazolam during upper gastrointestinal endoscopy--changes in hemodynamics, oxygen saturation and memory

BACKGROUND: Cardiorespiratory adverse effects are often observed in patients undergoing upper gastrointestinal endoscopy with sedation. In this study, we examined hemodynamics, oxygen saturation and memory during upper gastrointestinal endoscopy under sedation with intravenous midazolam. METHODS: Eight healthy outpatients without any obvious complications received intravenous midazolam 5 mg for sedation for upper gastrointestinal endoscopy. Blood pressure, heart rate and percutaneous arterial oxygen saturation (SpO2) were measured before, during and after endoscopy. After the arousal by intravenous flumazenil, we inquired the patients about the level of memory during the endoscopy. RESULTS: Blood pressure decreased significantly two minutes after midazolam administration, but increased significantly after the insertion of an endoscope which was not different from the control value. Heart rate increased significantly one and three minutes after the insertion of the endoscope. SpO2 decreased significantly after midazolam administration and stayed at around 95%. No patients remembered the procedure. CONCLUSIONS: Sedation with intravenous midazolam during upper gastrointestinal endoscopy is useful to control the cardiovascular responses, and to obtain amnesia. However, a decrease in SpO2 should be watched carefully.     

Effect of pethidine and esmolol on the cardiovascular changes occurring during upper gastrointestinal endoscopy

The cardiovascular effects of patients undergoing upper GI endoscopy when sedated with midazolam and pethidine, or midazolam and esmolol have been compared. A significant rise in heart rate (P < 0.006), systolic blood pressure (P < 0.001) and rate pressure product (systolic blood pressure × heart rate) (P < 0.001) occurred in both the patients receiving midazolam alone and those receiving pethidine in addition to midazolam. There were no significant differences in the peak rises in heart rate, blood pressure and, thus, rate pressure product between these two groups of patients. Those patients receiving a bolus dose of esmolol just prior to oesophagoscopy demonstrated a significantly smaller rate pressure response to oesophageal intubation than those in the first two groups.     

Diagnostic failures in endoscopy for acute upper gastrointestinal haemorrhage

BACKGROUND: Oesophagogastroduodenoscopy (OGD) is the diagnostic tool of choice in acute upper gastrointestinal haemorrhage. However, the factors causing diagnostic failure are not well documented or discussed. METHODS: OGDs performed by a single surgeon for acute upper gastrointestinal haemorrhage were reviewed retrospectively for 'missed' diagnosis. RESULTS: There were nine cases (1.4 per cent) of 'missed' diagnosis in 638 OGDs performed over a 3-year period. Incomplete examination caused by a fundal pool precluded three examinations in which two Dieulafoy's lesions and one chronic gastric ulcer were later found. Other difficult examination sites were the cardia/high lesser curve (three cases), the stomal line of a gastrojejunostomy anastomosis (two) and at the junction of the first and second part of the duodenum (one). Four of the overlooked diagnoses were Dieulafoy's lesions. CONCLUSION: OGD was able to diagnose the cause of bleeding in 98.6 per cent of patients with acute upper gastrointestinal haemorrhage. The factors that caused diagnostic failure were a difficult examination site and failure to recognize lesions (Dieulafoy's).     

The role of intraoperative carbon dioxide insufflating upper gastrointestinal endoscopy during laparoscopic surgery

Background

Intraoperative endoscopy (IOE) is a useful adjunct during laparoscopic gastrointestinal (GI) surgery. However, one potential hazard of IOE is a prolonged bowel distension due to insufflated air, which may cause obstructed surgical exposure and increased postoperative abdominal pain. Recently, carbon dioxide (CO₂), with its rapid absorptive nature, has been proven effective to minimize prolonged bowel distension in ambulatory/intraoperative colonoscopy. The objectives were to assess the feasibility, safety, and efficacy of CO₂-insufflating upper GI IOE during laparoscopic surgery.

Methods

A historical comparison study was performed on the initial ten consecutive patients who underwent CO₂-insufflating upper GI IOE (CO₂-IOE) during laparoscopic surgery. The control group consisted of the past 12 consecutive patients who underwent conventional air-insufflating upper GI IOE (air-IOE) during laparoscopic surgery. The following parameters were compared between the two groups: (1) patient demographics; (2) feasibility (% completion of IOE); (3) safety (complications related to IOE, impacts on cardiopulmonary status, including systemic blood pressure, heart rate, and end-tidal CO₂); (4) efficacy (postoperative residual intestinal gas, time to resume oral intake, and bowel movement). The amounts of post-IOE residual intestinal gas were evaluated and classified on the immediate postoperative abdominal radiographs in a blinded manner.

Results

Patient demographics were comparable between the two groups. IOE was completed in both groups without complications. Adverse effects on cardiopulmonary status were not observed during simultaneous intraperitoneal and intraluminal CO₂ insufflation. In the air-IOE group, one patient was converted to open surgery because of inadequate surgical exposure from prolonged distension of the downstream bowel. The patients in the CO₂-IOE group had significantly lower grade of postoperative bowel distension than the control group. Postoperative oral intake was resumed earlier in the CO₂-IOE group.

Conclusion

CO₂-insufflating upper GI IOE during laparoscopic surgery is feasible, safe, and has a practical advantage in minimizing post-IOE bowel distension compared with conventional air-insufflating upper GI IOE.     

Indications and techniques of upper gastrointestinal endoscopy in infants and children

Review of 98 endoscopies done over a 4-year period demonstrated that these procedures aided in the diagnosis and management of infants and children with upper gastrointestinal disorders. Endoscopic indications included evaluation of the esophagus in gastroesophageal reflux, achlasia, and lye ingestion; and evaluation of biliary and pancreatic diseases. Other indications included diagnosis of the site of upper gastrointestinal bleeding and treatment of esophageal varices with sclerotherapy, esophageal strictures with steroid injection and removal of foreign bodies. The majority of the procedures were done under sedation. There were no complications.     

Optimal propofol plasma concentration during upper gastrointestinal endoscopy in young, middle-aged, and elderly patients

BACKGROUND: Suitable propofol plasma concentrations during gastroscopy have not been determined for suppressing somatic and hemodynamic responses in different age groups. METHODS: Propofol sedation at target plasma concentrations from 0.5 to 4.0 microgram/ml were performed randomly in three groups of patients (23 per group) who were undergoing elective outpatient gastroscopy: ages 17-49 yr (group 1), 50-69 yr (group 2), and 70-89 yr (group 3). Plasma propofol concentration in which 50% of patients do not respond to these different stimuli were determined by logistic regression: verbal command (Cp50ls), somatic response to gastroscopy (Cp50endo), and gag response to gastroscopy (Cp50gag). Hemodynamic responses were also investigated in the different age groups. RESULTS: Cp50ls concentrations were 2.23 microgram/ml (group 1), 1.75 microgram/ml (group 2), and 1.40 microgram/ml (group 3). The Cp50endo values in groups 1 and 2 were 2.87 and 2.34 microgram/ml, respectively, which were significantly higher than their respective Cp50ls values. Cp50endo value in group 3 was 1.64 microgram/ml, which was close to its Cp50ls value. Because of a high degree of interpatient variability, Cp50gag could not be defined. Systolic blood pressure response decreased with increasing propofol concentrations. CONCLUSIONS: The authors determined the propofol concentration necessary for gastroscopy and showed that increasing age reduces it. Propofol concentration that suppresses somatic response induces loss of consciousness in almost all young patients.     

Pediatric upper gastrointestinal endoscopy: a 13-year experience

This report describes a series of 553 flexible upper gastrointestinal (GI) endoscopies performed on 382 children in two surgical centers between 1975 and 1987. Indications included abdominal pain (180), reassessment of known disease (149), upper GI bleeding (99), foreign body ingestion (77), vomiting (14), dysphagia (10), and miscellaneous (24). Findings were chronic peptic ulcer (47), gastritis/duodenitis (63), healing disease (92), nonhealing disease (22), recurrent disease (32), foreign body impaction (22), stricture (9), esophagitis (7), varices (7), mass (6 [3 polyp, 1 lymphoma, 1 fungus ball, 1 inflammation]), normal (209), and miscellaneous (37). Endoscopic diagnosis was uniformly correct except on two occasions, when the presence of recurrent tracheoesophageal fistula in small infants was missed due to use of an inadequate instrument. A pathologic lesion is likely to be identifiable in GI bleeding (84.8%). Endoscopic surveillance for progress of known disease was found to be valuable, particularly in peptic ulcer management, as both incomplete healing after standard therapy as well as recurrence are frequent. The recent practice of routine antral biopsy in children with severe "nonspecific abdominable pain" enabled four cases of Campylobacter pylori colonization in the stomach to be diagnosed, thus allowing appropriate treatment. Endoscopy was therapeutic on 61 occasions: injection sclerotherapy (32), foreign body removal (20), polypectomy (3), and stricture dilatation (6). Endoscopy-guided bougienage, in particular, represents a recent major advance. There was no morbidity or mortality in the entire series. It is concluded that pediatric upper GI endoscopy performed by experienced surgeons is safe and effective. As a result of better understanding and technological advances, a changing trend of wider and more rational applications of the procedure is now evident.     

Fiberoptic endoscopy: Precise definition of upper gastrointestinal disease

When properly employed, endoscopic examination of the upper gastrointestinal tract with the flexible maneuverable-tip fiberoptic instruments is the most accurate method of diagnosing any upper gastrointestinal tract disease. Two hundred consecutive endoscopic procedures in the upper gastrointestinal tract were performed without significant morbidity or mortality; the results were reviewed to ascertain the overall diagnostic value of this modality. Although the overall numbers in each subgroup are still small, the experience indicates that: (1) thorough endoscopic examination of the upper gastrointestinal tract can be carried out expeditiously in most patients without morbidity; (2) upper gastrointestinal tract disease can be precisely defined in the majority of patients; and (3) endoscopic examination frequently alters the initial clinical diagnosis. The precise cause of upper gastrointestinal tract hemorrhage can be diagnosed in at least three of four cases. Some unnecessary operations can be avoided and proper therapy for specific sources of bleeding can be initiated promptly.