Sedation in digestive endoscopy: the Athens international position statements.

BACKGROUND: Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field. AIM: To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy. METHODS: Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll. RESULTS: The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures. CONCLUSIONS: While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.

Risk factors for post-ERCP pancreatitis: a prospective, multicenter study.

BACKGROUND: Post-ERCP pancreatitis is poorly understood. The goal of this study was to comprehensively evaluate potential procedure- and patient-related risk factors for post-ERCP pancreatitis over a wide spectrum of centers. METHODS: Consecutive ERCP procedures were prospectively studied at 11 centers (6 private, 5 university). Complications were assessed at 30 days by using established consensus criteria. RESULTS: Pancreatitis occurred after 131 (6.7%) of 1963 consecutive ERCP procedures (mild 70, moderate 55, severe 6). By univariate analysis, 23 of 32 investigated variables were significant. Multivariate risk factors with adjusted odds ratios (OR) were prior ERCP-induced pancreatitis (OR 5.4), suspected sphincter of Oddi dysfunction (OR 2.6), female gender (OR 2.5), normal serum bilirubin (OR 1.9), absence of chronic pancreatitis (OR 1.9), biliary sphincter balloon dilation (OR 4.5), difficult cannulation (OR 3.4), pancreatic sphincterotomy (OR 3.1), and 1 or more injections of contrast into the pancreatic duct (OR 2.7). Small bile duct diameter, sphincter of Oddi manometry, biliary sphincterotomy, and lower ERCP case volume were not multivariate risk factors for pancreatitis, although endoscopists performing on average more than 2 ERCPs per week had significantly greater success at bile duct cannulation (96.5% versus 91.5%, p = 0.0001). Combinations of patient characteristics including female gender, normal serum bilirubin, recurrent abdominal pain, and previous post-ERCP pancreatitis placed patients at increasingly higher risk of pancreatitis, regardless of whether ERCP was diagnostic, manometric, or therapeutic. CONCLUSIONS: Patient-related factors are as important as procedure-related factors in determining risk for post-ERCP pancreatitis. These data emphasize the importance of careful patient selection as well as choice of technique in the avoidance of post-ERCP pancreatitis.

Community issues in gastroesophageal reflux disease: what we know and what we do not know.

GERD is one of the most common disorders seen by physicians. Despite its wide prevalence, the impact of this disorder on patients and the community remains unclear. A more precise understanding of the impact of GERD on the community will require vigorous studies to determine if aggressive diagnosis and therapy improve clinical outcomes and decrease the cost of the disease to the community. In addition, the issue of screening and surveillance endoscopy for patients with long-standing GERD or Barrett's esophagus must be evaluated in terms of the ability to decrease esophageal cancer mortality and costs. Comparisons with similar diseases, such as asthma and breast cancer, may provide clues to the answers to these questions but are not a substitute for rigorous clinical trials.

One hundred years of NSAID gastropathy: are coxibs the answer?

One hundred years after the introduction of aspirin, greater understanding of the mechanism of action of NSAIDs has led to the development of selective COX-2 inhibitors. These have been shown to reduce pain and inflammation with reduced risk of GI complications. However, questions remain regarding such issues as restriction of their use to patients at high risk for complications, cost-effectiveness, effectiveness compared with prostaglandin replacement or acid reduction therapy, and safety in patients also taking aspirin for platelet inhibition.

KTP laser therapy for bleeding from chronic radiation proctopathy.

BACKGROUND: Endoscopic laser photocoagulation is commonly used to treat bleeding from the neovascular lesions of chronic radiation proctopathy. The KTP laser is an Nd/YAG-driven unit that emits light with a wavelength of 532 nm. This wavelength of energy is absorbed by hemoglobin and penetrates tissue to a depth of only 1 to 2 mm. METHODS: Twenty-three patients were treated with KTP laser and followed for a median of 29 months (range 5 to 51 months); 21 had received radiation for prostate cancer and 2 for uterine cancer. The median age was 77 years (range 68 to 87 years). A median of 2 sessions (range 1 to 5 sessions) was performed using 4 to 10 Watts of power and a median energy of 816 Joules per session (range 204 to 2430 Joules). RESULTS: After treatment there was a significant reduction in the frequency (p = 0.0005) of bleeding, increase in hematocrit level (p < 0.0001), improvement in activities of daily life (p = 0.01), and a reduction in use of health care resources (p < 0.0001). There was a trend toward decreased use of iron supplements (11 to 4 patients) and transfusions (4 to 0 patients). Two patients (9%) developed rectal ulcers after treatment. CONCLUSIONS: KTP laser photocoagulation is a safe and effective therapy for bleeding from chronic radiation proctopathy that improves activities of daily living and reduces use of health care resources.

Current status of nonsteroidal anti-inflammatory drug (NSAID) use in the United States: risk factors and frequency of complications.

Gastrointestinal (GI) toxicity is a major limiting factor in the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Because of the widespread use of these medications, the morbidity and costs associated with GI complications of NSAID use are significant. On the other hand, the costs of providing prophylactic cotherapy to all patients to prevent NSAID-induced ulcers and bleeding are prohibitive. The presence of specific risk factors (advanced age, prior peptic ulcer disease and bleeding, high NSAID doses and concomitant therapy with corticosteroids or anticoagulants) identifies patients who are most likely to have a GI complication. The recognition of these risks in specific patients may influence therapeutic decisions that could decrease the morbidity and costs of NSAID therapy.

The effect of aspirin and nonsteroidal anti-inflammatory drugs on prostaglandins.

Cyclic prostanoids play important physiologic roles in inflammation and maintaining normal function of several organ systems. Prostaglandin production requires the conversion of arachidonate to the intermediate prostaglandin H2, by the 2-step cyclo-oxygenation and peroxidation catalyzed by the enzyme cyclo-oxygenase (also called prostaglandin H synthase). Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) block the production of cyclic prostanoids by binding in different ways to this enzyme and blocking the active site. This results in decreased inflammation, but it can also produce side effects in the gastrointestinal tract, kidney, and platelets. Recent data demonstrate that there are 2 isoforms of the cyclo-oxygenase enzyme, called COX-1 and COX-2. These isoforms are similar in size, substrate specificity, and kinetics, but vary in their expression and distribution. Normal physiologic functions appear to be maintained by COX-1, while COX-2 appears to mediate the inflammatory response. Nonsteroidal drugs with selective inhibitory activity on the COX-2 isoform should theoretically decrease inflammation while maintaining normal physiologic prostaglandin levels. Current NSAIDs are not selective enough to confirm this, but newer, more selective inhibitors of COX-2 may answer this important question.

Generalized essential telangiectasia in the presence of gastrointestinal bleeding.

Generalized essential telangiectasia was well defined more than 30 years ago. There have been no reported cases of associated gastrointestinal (GI) bleeding. Recurrent hemorrhage in the setting of telangiectases, including GI bleeding, is more typically associated with hereditary hemorrhagic telangiectasia. We report a unique case of a woman with generalized essential telangiectasia and GI bleeding from a watermelon stomach. We include a brief review of the literature of watermelon stomach, generalized essential telangiectasia, and hereditary hemorrhagic telangiectasia.

Nonsteroidal anti-inflammatory drug-induced gastrointestinal injury.

Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, are the most commonly used medications worldwide. They are effective analgesic and anti-inflammatory agents. A major drawback to their use is a high frequency of adverse gastrointestinal (GI) effects that cause significant morbidity, occasional mortality, and substantial increases in cost of therapy. In this review, mechanisms of NSAID-induced GI injury are presented, and a clinical approach to diagnosis, treatment, and prevention of these adverse GI effects is provided.

Non-nonsteroidal anti-inflammatory drug, nonmalignant gastric ulcers.

The vast majority of gastric ulcers are owing to H. pylori infection or NSAID use. There are, however, uncommon causes of gastric ulceration that should be considered in the absence of these factors. Careful endoscopic evaluation of the ulcer associated with adequate biopsy specimens can provide the diagnosis in the vast majority of patients. All gastric ulcers should be evaluated by endoscopy and biopsy to rule out a possible malignancy. When adequate tissue samples are obtained the accuracy for diagnosis of gastric cancer is 99%. The prior recommendation of routine endoscopic follow up for gastric ulcers does not appear to be necessary. Repeat endoscopy should be reserved for patients whose initial endoscopic evaluation was inadequate or suspicious for malignancy, and those with refractory ulcers.

Postsurgical bile leaks: endoscopic obliteration of the transpapillary pressure gradient is enough.

OBJECTIVES: Bile leaks are a well documented complication of biliary surgery, occurring more frequently with laparoscopic procedures. Endoscopic therapy with a long biliary endoprosthesis traversing the site of the leak is effective. We have evaluated the hypothesis that equalizing biliary and duodenal pressures with a short transpapillary stent is an equally effective therapy for bile leaks. METHODS: Thirty one consecutive patients presenting over a 52-month period with postsurgical bile leaks were evaluated. Patients had been treated with long endoprostheses (stents or nasobiliary tubes), sphincterotomy, or short transpapillary stents. The success, complication rate, need for additional therapy, and hospitalization time of each therapeutic approach were determined. RESULTS: Endoscopic therapy was successful in all 25 patients in whom a bile leak could be documented. The clinical success, need for radiological drainage, length of hospitalization, and incidence of pancreatitis were similar for all methods of treatment. CONCLUSIONS: These results confirm that endoscopic therapy is highly successful in the treatment of postoperative bile leaks and suggest that the mechanism of healing is the equalization of bile duct and duodenal pressures, allowing flow of bile into the duodenum. The endoscopic placement of short transpapillary stents without sphincterotomy is a temporary, effective, and technically simple method of pressure equalization. This should be considered as the primary therapy for most postoperative bile leaks.

Nonsteroidal anti-inflammatory drugs and gastrointestinal disease: pathophysiology, treatment and prevention.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a common cause of gastrointestinal ulceration. Chronic NSAID use increases the risk of ulcer bleeding or perforation 3- to 4-fold. NSAID-induced injury results from both local effects and systemic prostaglandin inhibition. New evidence suggests that the systemic effects on prostaglandin production may vary between NSAIDs. The majority of NSAID-induced ulcers are asymptomatic. They may be treated by discontinuing the NSAID and using standard ulcer therapy. Patients taking NSAIDs who are at a high risk for a GI complication should also receive therapy to decrease their risk for ulceration. In this review the epidemiology, pathogenesis, risks, treatment and prophylaxis of NSAID-induced gastrointestinal complications are discussed.

A rational approach to giving antibiotic prophylaxis before endoscopy. Who needs it? Which procedures pose the greatest risk?

Although transient bacteremia occasionally occurs after many GI endoscopic procedures, the incidence of actual infection is low. However, in addition to endocarditis, peritonitis, abscesses, meningitis, portacaval anastomotic infection, and sepsis have been reported. Prophylaxis may reduce the risk of infection; whether it is needed depends on two factors: Is the procedure to be performed associated with an increased likelihood of infection? Does the patient have an underlying condition (such as valvular heart disease or immune system incompetence) that increases the risk of such an infection? Antibiotics that are frequently used for prophylaxis include amoxicillin or gentamicin and ampicillin.