Complications after outpatient upper GI endoscopy in children: 30-day follow-up

OBJECTIVE: Upper GI endoscopy (UGE) is a common procedure performed for evaluation and treatment of various upper GI tract disorders in children. Limited comprehensive data are available on the complications of UGE in adults and particularly in children. The goals of this study were to identify complications and adverse events reported by patients and their parents after outpatient UGE under general anesthesia (GA). METHODS: Pediatric patients who underwent outpatient UGE under GA between April, 2000 and April, 2001 at the James Whitcomb Hospital for Children were identified. The interviewer obtained verbal consent and performed standardized telephone interviews 30 days after the outpatient UGE. RESULTS: A total of 393 patients participated in this survey. Of the patients, 165 (42%) had one or more complications or adverse events. The most common ones reported by patients or parents 30 days after the UGE under GA were sore throat or hoarseness (34.6%), fatigue (6.6%), cough (4.1%), headache (3.3%), excessive gas or burping (2.8%), nausea (2.5%), emesis (2.3%), abdominal pain (2%), fever (2%), behavior problems (1.8%), upper respiratory symptoms (1.3%), excessive drowsiness (0.5%), nosebleed (0.3%), perioral rash (0.3%), and chest pain (0.3%). Ten of 165 patients with complications or adverse events after UGE sought medical assistance. CONCLUSIONS: Approximately one third of pediatric patients complained of sore throat or hoarseness after UGE under GA. All other reported complications or adverse events were infrequent. We conclude that UGE under GA is safe and well tolerated in pediatric patients.     

A prospective study of endoscopy in HIV-associated diarrhea

OBJECTIVE: Diarrhea commonly occurs in persons with human immunodeficiency virus (HIV) infection. The optimal use of endoscopic procedures remains poorly studied for patients with HIV-related diarrhea. The purpose of this study is to compare the diagnostic yield of a complete endoscopic work-up including an esophagogastroduodenoscopy and colonoscopy to a more limited approach of biopsies obtainable by flexible sigmoidoscopy. METHODS: A prospective study of 79 patients with HIV-related diarrhea. Upper endoscopy and colonoscopy were performed with tissue biopsies labelled according to location within the colon or small intestine. RESULTS: A new infection was diagnosed in 22 of 79 patients (28%). Biopsy of the left colon yielded an enteric pathogen in 17 of 22 patients (sensitivity: 77%) and in 15 of 15 patients with cytomegalovirus colitis (sensitivity: 100%). Combined left and right colonic biopsies had a sensitivity of 82%. Combined colonic and terminal ileum biopsies missed no pathogens. Duodenal biopsies yielded no additional pathogens beyond those identified by colonoscopy and terminal ileal biopsy. Patients with a new pathogen diagnosed had significantly lower CD4 lymphocyte counts as compared to patients without a new pathogen (p = 0.001). CONCLUSIONS: For patients with CD4 counts < 100/mm3 and unexplained AIDS-related diarrhea, flexible sigmoidoscopy with biopsy is a sufficiently thorough endoscopic evaluation.     

A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses

BACKGROUND: The purpose of this study is to prospectively evaluate the performance characteristics of endoscopy and EUS in the diagnosis of GI subepithelial masses. METHODS: A total of 100 consecutive patients referred for the evaluation of a suspected GI subepithelial lesion were prospectively studied with endoscopy followed by EUS. Size, color, mobility, location (intramural or extramural), consistency (solid, cystic, or vascular), and presumptive diagnosis were recorded at the time of endoscopy. EUS then was performed, and size, echogenicity, location, and presumptive diagnosis were determined. RESULTS: A total of 100 subepithelial lesions were evaluated. Endoscopy had 98% sensitivity and 64% specificity in identifying intramural lesions. Size measurement by endoscopy correlated with size measurement by EUS (r = 0.88). Histology was obtained in 23 cases, with the presumptive EUS diagnosis correct in only 48% of cases. Most incorrect EUS diagnoses occurred with hypoechoic 3rd and 4th layer masses. CONCLUSIONS: Endoscopy has high sensitivity but low specificity in identifying the location (intramural or extramural) of subepithelial lesions. In addition, EUS imaging alone is insufficient to accurately diagnose 3rd and 4th layer hypoechoic masses, and histologic confirmation should be obtained whenever possible.     

Ensure preparation and capsule endoscopy:A two-center prospective study

AIM:To compare small bowel(SB) cleanliness and capsule endoscopy(CE) image quality following Ensure,polyethylene glycol(PEG) and standard preparations.METHODS:A preparation protocol for CE that is both efficacious and acceptable to patients remains elusive.Considering the physiological function of the SB as a site for the digestion and absorption of food and not as a stool reservoir,preparation consisting of a liquid,fiber-free formula ingested one day before a CE study might have an advantage over other kinds of preparations.We conducted a prospective,blind-topreparation,two-center study that compared four types of preparations.The participants’ demographic and clinical data were collected.Gastric and SB transit times were calculated.The presence of bile in the duodenum was scored by a single,blinded-to-preparation gastroenterologist expert in CE,as was cleanliness within the proximal,middle and distal part of the SB.A four-point scale was used(grade 1 = no bile or residue,grade 4 ≥ 90% of lumen full of bile or residual material).RESULTS:The 198 consecutive patients who were referred to CE studies due to routine medical reasons were divided into four groups.They all observed a 12-h overnight fast before undergoing CE.Throughout the 24 h preceding the fast,control group 1(n = 45 patients) ate light unrestricted meals,control group 2(n = 81) also ate light meals but free of fruits and vegetables,the PEG group(n = 50) ate unrestricted light meals and ingested the PEG preparation,and the Ensure group(n = 22) ingested only the Ensure formula.Preparation with Ensure improved the visualization of duodenal mucosa(a score of 1.76) by decreasing the bile content compared to preparation with PEG(a score of 2.9)(P = 0.053).Overall,as expected,there was less residue and stool in the proximal part of the SB than in the middle and distal parts in all groups.The total score of cleanliness throughout the length of the SB showed some benefit for Ensure(a score of 1.8) over control group 2(a score of 2)(P = 0.06).The cleanlin     

A prospective study of complications of endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in an ambulatory endoscopy center.

BACKGROUND AND AIMS: Our aim was to assess the safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in an ambulatory endoscopy center (AEC). METHODS: Complications occurring in consecutive patients undergoing ERCP or EUS from March 2003 to February 2004 at our AEC were recorded prospectively. Comprehensive complications were defined as consensus criteria plus other adverse events: use of reversal agents, unplanned hospital admission, hospitalization beyond planned 23-hour observation, unplanned emergency department or primary care provider visit, and 30-day mortality. RESULTS: A total of 497 patients (median age, 57 y; 82% American Society of Anesthesiologists class II or III) underwent 685 procedures. Monitored or general anesthesia was used in 25% of EUS and 50% of ERCP procedures. ERCP interventions were as follows: biliary or pancreatic stenting (N = 168), stone extraction (N = 70), sphincterotomy (N = 62), sphincter of Oddi manometry (N = 53), other (N = 66). EUS indications were as follows: known or suspected pancreatic mass (N = 103), upper-gastrointestinal mass/submucosal lesion (N = 71), luminal malignancy staging (N = 40), other (N = 96); 52% had EUS fine-needle aspiration. There was follow-up evaluation in 94% of the patients. There were 43 comprehensive ERCP complications (12.9%), 18 (5.4%) of these fit consensus criteria: pancreatitis (N = 14), cholangitis (N = 2), and perforation (N = 2). There were 9 comprehensive EUS complications (2.9%), 2 (.7%) of these fit consensus criteria: pancreatitis (N = 1) and bleeding (N = 1). Other adverse events for ERCP and EUS were as follows: prolongation of 23-hour observation (N = 14), emergency room visits (N = 3), primary care physician visits (N = 6), use of reversal agents (N = 3), unplanned admissions (N = 2), infection (N = 3), and death (N = 1). CONCLUSIONS: ERCP and EUS can be performed in an AEC, provided mechanisms for admission and anesthesia support are in place. The assessment of comprehensive complications is more reflective of adverse events related to ERCP and EUS than consensus criteria alone.     

Infective complications of plasma exchange: a prospective study

We examined the incidence and types of infective complications which occurred in 41 patients whose medical management included plasma exchange (PX) by intermittent cannulation; femoral, subclavian, or internal jugular catheter; or arteriovenous shunt. A high incidence of positive cultures from vascular access catheters was demonstrated. Of 23 patients for whom data were available, 13 had positive cultures, and results on 3 of these showed greater than 1 species. Gram-positive cocci were typically found. Of the 34 patients who received drug immunosuppression with PX, 1 patient developed severe shunt-site infection, and an additional 4 developed bacteremia. Seven patients were given PX alone, and none of these developed clinically significant infection; however, this difference in infection rate did not reach statistical significance. Clinically significant access-related infection remains an infrequent but potentially important hazard of therapeutic PX.     

Primary stenting in acute myocardial infarction: A 30-day follow up study

Primary coronary stenting is being increasingly used in patients undergoing primary coronary angioplasty for acute myocardial infarction. In this prospective study we evaluated our experience of direct angioplasty in 68 patients with acute myocardial infarction of whom 57 received intracoronary stents using high-pressure deployment (≥12 atmospheres) with adjunct aspirin and ticlopidine therapy without coumadin. All patients underwent pre-discharge follow-up angiography. Stent implantation was successful in all patients. Stent thrombosis was not seen in any patient. However, TIMI grade 3 flow was obtained in only 51 patients (89.6%) with evidence of slow flow present in remaining six patients. Follow-up angiograms showed no stent thrombosis but five out of the six patients (83%) with slow-flow phenomenon persisted to have slow flow. These patients had lower left ventricular ejection fraction as compared to patients with TIMI 3 flow at follow-up angiography (27.5 ± 10.2% vs. 42.1 ± 15.2%, P < .001) and a high mortality (two out of six) within 30 days. Primary stenting is safe and feasible in the majority of patients with good short-term outcomes, but persistent slow-flow phenomenon with adverse clinical outcome is seen in a small but significant number of patients. Cathet. Cardiovasc. Intervent. 46:4–10, 1999. © 1999 Wiley-Liss, Inc.     

Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists

BACKGROUND: Although most diagnostic GI endoscopic procedures in Germany are performed on an outpatient basis, there is no large-scale prospective evaluation of complication rates. METHODS: Ninety-four gastroenterologists and internists from all regions of Germany recorded the number of EGD, colonoscopies, and polypectomies performed over a period of 1 year. All serious complications occurring in relation to the procedure, including the use of medication, were recorded in a structured protocol. RESULTS: A total of 110,469 EGDs, 82,416 colonoscopies, and 14,249 polypectomies were evaluated. The "reach-the-cecum-rate" was 97% (median). The overall complication rates for EGD, colonoscopy, and polypectomy were low compared with published data (0.009%, 0.02%, and 0.36%, respectively). The perforation rates were 0.0009%, 0.005%, and 0.06%, respectively, the rates of significant hemorrhage 0.002%, 0.001%, and 0.26%, respectively, and the mortality rates 0.0009%, 0.001%, and 0.007%, respectively. The rates of cardiorespiratory complications associated with EGD and colonoscopy were 0.005% and 0.01%, respectively. The overall complication rate for all procedures (diagnostic and therapeutic) was lower for gastroenterologists (1 per 5155 procedures) than internists (1 per 1539 procedures). Most of the adverse events associated with diagnostic endoscopy were attributable to use of medication. The severity score ranged from 2 to 5 for most of the adverse events occurring as a result of diagnostic procedures and 2 to 50 for polypectomy. The severity sum score per 10,000 procedures was 26 for EGD, 67 for colonoscopy, and 1185 for polypectomy. CONCLUSIONS: Outpatient endoscopy performed in practice settings by German gastroenterologists and internists is safe. The low complication rates may partly be explained by the high degree of experience resulting from the larger numbers of procedures performed relative to the numbers performed by gastroenterologists in hospitals and in other countries.     

Vascular complications in systemic sclerosis: a prospective cohort study

Clinical Rheumatology - Two major complications in scleroderma patients that cause substantial morbidity and mortality are ischemic digital lesions (DL) and pulmonary hypertension (PH). The...     

Troponin T levels and risk of 30-day outcomes in patients with the acute coronary syndrome: prospective verification in the GUSTO-IV trial

BACKGROUND: A third-generation troponin T assay with improved precision and a lower detection limit has been developed. However, the appropriate cutoff for identifying patients with the acute coronary syndrome who are at low risk of subsequent mortality has not been established. METHODS: A retrospective evaluation of data from the Fragmin and fast Revascularization during InStability in Coronary artery disease II (FRISC-II) trial suggested that a cutoff below 0.1 microg/L for troponin T levels might be more useful in risk stratification. A prospective validation of two cutoff levels (0.03 microg/L and 0.01 microg/L) was performed in 7115 patients with non-ST-elevation acute coronary syndrome from the Global Utilization of Strategies To open Occluded arteries IV (GUSTO-IV) trial. RESULTS: Patients with troponin T levels >0.1 microg/L had greater 30-day mortality (5.5% [201/3679]) than did those with levels 相似文献   

A prospective study of same day bi-directional endoscopy in the evaluation of patients with occult gastrointestinal bleeding

OBJECTIVE: Previous studies show conflicting results in the diagnostic yield of oesophagogastroduodenoscopy (OGD) and colonoscopy (bi-directional) in identifying potential bleeding sources (PBS) in patients investigated for occult gastrointestinal bleeding (OGIB). The aims of this study were to evaluate the diagnostic yield of bi-directional endoscopy in patients presenting with OGIB and to assess the factors predictive of a positive yield. MATERIAL AND METHODS: Patients with OGIB referred to the gastroenterology unit were prospectively included in the study. Colonoscopy was immediately followed by OGD. Predetermined criteria for the diagnosis of a PBS were used. Potential clinical factors predictive of positive yield were assessed. RESULTS: Of the 219 patients (mean age 65 years, 34% M), 110 (50%) had at least one PBS. Colonoscopy revealed 87 PBS in 73 patients (33%), the most common being adenoma. OGD detected 49 PBS in 48 patients (22%), gastric ulcer being the most common. Of the patients with PBS at OGD, 23% also had a PBS at colonoscopy, including 3 patients with colonic cancers. Patients presenting with either a positive faecal occult blood test (FOBT) or iron-deficiency anaemia (IDA) only had a significantly lower yield for PBS than patients with combined positive FOBT and IDA. The percentages of patients with a PBS increased substantially with age. CONCLUSIONS: A PBS was found in only 50% of the patients. Colonoscopy had a slightly higher diagnostic yield, and as expected, resulted in a significantly higher cancer detection rate than OGD. In older patients, colonoscopy should be done irrespective of the findings at OGD. Gastrointestinal-specific symptoms and the use of ASA/NSAIDs were not predictive in finding or localizing PBS.     

A prospective study of same day bi-directional endoscopy in the evaluation of patients with occult gastrointestinal bleeding

Objective. Previous studies show conflicting results in the diagnostic yield of oesophagogastroduodenoscopy (OGD) and colonoscopy (bi-directional) in identifying potential bleeding sources (PBS) in patients investigated for occult gastrointestinal bleeding (OGIB). The aims of this study were to evaluate the diagnostic yield of bi-directional endoscopy in patients presenting with OGIB and to assess the factors predictive of a positive yield. Material and methods. Patients with OGIB referred to the gastroenterology unit were prospectively included in the study. Colonoscopy was immediately followed by OGD. Predetermined criteria for the diagnosis of a PBS were used. Potential clinical factors predictive of positive yield were assessed. Results. Of the 219 patients (mean age 65 years, 34% M), 110 (50%) had at least one PBS. Colonoscopy revealed 87 PBS in 73 patients (33%), the most common being adenoma. OGD detected 49 PBS in 48 patients (22%), gastric ulcer being the most common. Of the patients with PBS at OGD, 23% also had a PBS at colonoscopy, including 3 patients with colonic cancers. Patients presenting with either a positive faecal occult blood test (FOBT) or iron-deficiency anaemia (IDA) only had a significantly lower yield for PBS than patients with combined positive FOBT and IDA. The percentages of patients with a PBS increased substantially with age. Conclusions. A PBS was found in only 50% of the patients. Colonoscopy had a slightly higher diagnostic yield, and as expected, resulted in a significantly higher cancer detection rate than OGD. In older patients, colonoscopy should be done irrespective of the findings at OGD. Gastrointestinal-specific symptoms and the use of ASA/NSAIDs were not predictive in finding or localizing PBS.