Elsevier

Gastrointestinal Endoscopy

Volume 96, Issue 3, September 2022, Pages 389-401.e1
Gastrointestinal Endoscopy

Guideline
Adverse events associated with EGD and EGD-related techniques

https://doi.org/10.1016/j.gie.2022.04.024Get rights and content

Section snippets

Methods

A comprehensive electronic database search was executed with the help of an expert medical librarian. The search was designed to capture AEs associated with diagnostic EGD with or without biopsy sampling, EGD with management of foreign body impaction, EGD with dilation and/or stent placement, EGD with hemostasis, and EGD with placement of percutaneous gastric or enteral access. Other therapeutic maneuvers including EMR, endoscopic submucosal dissection,4 radiofrequency ablation,5 endoscopic

Results

The electronic search yielded 4623 initial citations after removal of duplicates. A review of the evidence for each major AE type is provided below, with a summary of AE rates provided in Table 1. Predictors of AEs were also synthesized and reported wherever possible.

Bleeding

Clinically significant bleeding according to the ASGE lexicon (defined as a hemoglobin drop >2 g/dL and/or evidence of hematemesis, melena, or hematochezia)8 is rare after diagnostic EGD either with or without biopsy sampling. In a 2021 nationwide retrospective claims data analysis of over 380,000 patients who underwent diagnostic EGD, bleeding requiring emergency department visit or inpatient stay occurred at a rate of 80 in 100,000 patients within 30 days of the index procedure.9

A potential

Overview

GI foreign bodies and/or impactions frequently require urgent or emergent EGD.39 Given that obstructions and impactions occur most often at sites of angulation or narrowing,39 mucosal tears, ulcerations, and/or full-thickness perforations resulting from the ingested foreign body itself are all possible. They are, in fact, more common than AEs attributable to the performance of EGD, occurring in up to 15% of cases.40,41 Aspiration and respiratory compromise are also possible. Therefore, a

Esophageal stent placement

Palliative stent placement for advanced esophageal malignancy has been shown to have a relatively higher risk of bleeding. In a multicenter cohort study of self-expanding metal stent (SEMS) insertion for inoperable malignant esophageal strictures, bleeding occurred in 3.7% of patients.77 In a separate study of 442 patients who underwent SEMS placement for similar indications, bleeding occurred in 1.3% of patients.78 In a 2020 meta-analysis of 231 patients that compared fully covered to

Hemostasis for active nonvariceal upper GI bleeding

AEs associated with hemostasis of nonvariceal bleeding are heterogeneously defined and inconsistently reported in the literature and are therefore difficult to categorize and synthesize. A network meta-analysis of endoscopic therapies for high-risk bleeding peptic ulcers demonstrated that both epinephrine plus mechanical therapy and epinephrine plus thermal therapy demonstrated better AE profiles compared with epinephrine monotherapy or sclerosant injection, while significantly decreasing the

Bleeding

Clinically significant bleeding after PEG tube placement has been reported to occur in between .6% and 1.2% of cases112 and is of variable clinical significance, almost always minor and self-limited in nature. A 2020 meta-analysis of 320 PEG patients demonstrated a .9% rate of minor bleeding associated with PEG tube insertion.113 Similar rates of bleeding have been reported for percutaneous endoscopic jejunostomy (PEJ) procedures, with a reported rate of 2.4% in a single-center 10-year cohort

Future Directions

This document highlights several important areas within the field of EGD for which further high-quality research is needed to improve the strength of recommendations for future EGD-related guidelines. Below is a brief outline of these specific areas.

  • Predictors of AEs. Limited evidence is available regarding patient- and procedure-level predictors of AEs for routine EGD as well as more advanced EGD-guided techniques (Table 1). Dedicated efforts to reliably elucidate these independent predictors

Conclusion

Routine EGD with or without biopsy sampling is well established as a safe and effective procedure. Although several AEs are associated with routine EGD, their overall incidence is low. Additional interventional EGD-guided techniques are increasingly used as alternatives to surgical, radiologic, and other endoscopic approaches to managing GI disease and may be associated with higher AE rates compared with routine EGD. Endoscopists performing EGD-guided procedures should be aware of associated AE

Disclosure

The following authors disclosed financial relationships: N. Coelho-Prabhu is a consultant for Boston Scientific Corporation. N. Forbes is a consultant for Boston Scientific Corporation, Pentax of America, Inc, and Pendopharm Inc; is on the speaker bureau for Pentax of America, Inc and Boston Scientific Corporation; and has received research support from Pentax of America, Inc. N. Thosani is a consultant for and has received travel compensation and food and beverage from Boston Scientific

Acknowledgments

We acknowledge and are grateful for the contribution of Robyn Rosasco, who helped design and perform the electronic search strategies for this document, as well as Dr Jonathan Cohen, Dr Jenifer Lightdale, Dr Felix Leung, Dr Jean Chalhoub, Dr Madhav Desai, Dr Jorge Machicado, Dr Neil Marya, Dr Wenly Ruan, and Dr Sunil Sheth for their review of this document.

This document was funded exclusively by the American Society for Gastrointestinal Endoscopy; no outside funding was received to support the

References (126)

  • D.B. Nelson et al.

    Technology status evaluation report. Transmission of infection by gastrointestinal endoscopy

    Gastrointest Endosc

    (2001)
  • V. Chandrasekhara et al.

    Adverse events associated with ERCP

    Gastrointest Endosc

    (2017)
  • B.K. Enestvedt et al.

    Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?

    Gastrointest Endosc

    (2013)
  • S.H. Kim et al.

    The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis

    Ther Clin Risk Manag

    (2018)
  • S.O. Ikenberry et al.

    Management of ingested foreign bodies and food impactions

    Gastrointest Endosc

    (2011)
  • S.H. Sung et al.

    Factors predictive of risk for complications in patients with oesophageal foreign bodies

    Dig Liver Dis

    (2011)
  • E.S. Dellon

    Epidemiology of eosinophilic esophagitis

    Gastroenterol Clin North Am

    (2014)
  • V.O. Brunaldi et al.

    Isolated sleeve gastrectomy stricture: a systematic review on reporting, workup, and treatment

    Surg Obes Relat Dis

    (2020)
  • R. Kochhar et al.

    Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction

    Gastrointest Endosc

    (2018)
  • E.G.H. de Moura et al.

    Factors associated with complications or failure of endoscopic balloon dilation of anastomotic stricture secondary to Roux-en-Y gastric bypass surgery

    Surg Obes Relat Dis

    (2016)
  • A. Repici et al.

    Management of inoperable malignant oesophageal strictures with fully covered WallFlex(®) stent: a multicentre prospective study

    Dig Liver Dis

    (2014)
  • C. Wang et al.

    Comparison of fully-covered vs partially covered self-expanding metallic stents for palliative treatment of inoperable esophageal malignancy: a systematic review and meta-analysis

    BMC Cancer

    (2020)
  • G. Costamagna et al.

    Treatment of malignant gastroduodenal obstruction with a nitinol self-expanding metal stent: an international prospective multicentre registry

    Dig Liver Dis

    (2012)
  • J.P. Ratone et al.

    Outcomes of duodenal stenting: experience in a French tertiary center with 220 cases

    Dig Liver Dis

    (2020)
  • P. Pescatore et al.

    Epinephrine versus epinephrine plus fibrin glue injection in peptic ulcer bleeding: a prospective randomized trial

    Gastrointest Endosc

    (2002)
  • C. Zhong et al.

    Clinical outcomes of over-the-scope-clip system for the treatment of acute upper non-variceal gastrointestinal bleeding: a systematic review and meta-analysis

    BMC Gastroenterol

    (2019)
  • S. Wani et al.

    Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer

    Gastrointest Endosc

    (2018)
  • M.A. Khashab et al.

    ASGE guideline on the management of achalasia

    Gastrointest Endosc

    (2020)
  • H.I. Kim et al.

    Gastrointestinal and nongastrointestinal complications of esophagogastroduodenoscopy and colonoscopy in the real world: a nationwide standard cohort using the common data model database

    Gut Liver

    (2021)
  • R.D. Montalvo et al.

    Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy

    Hepatogastroenterology

    (1996)
  • K. Yabe et al.

    Risk of gastrointestinal endoscopic procedure-related bleeding in patients with or without continued antithrombotic therapy

    Dig Dis Sci

    (2021)
  • M. Fujita et al.

    Safety of gastrointestinal endoscopic biopsy in patients taking antithrombotics

    Dig Endosc

    (2015)
  • H. Bozkurt et al.

    The safety of upper gastrointestinal endoscopic biopsy in patients receiving antithrombic drugs. A single-centre prospective observational study

    Prz Gastroenterol

    (2020)
  • V. Heublein et al.

    Gastrointestinal endoscopy in patients receiving novel direct oral anticoagulants: results from the prospective Dresden NOAC registry

    J Gastroenterol

    (2018)
  • N. Ara et al.

    Prospective analysis of risk for bleeding after endoscopic biopsy without cessation of antithrombotics in Japan

    Dig Endosc

    (2015)
  • Y. Kono et al.

    Multicenter prospective study on the safety of upper gastrointestinal endoscopic procedures in antithrombotic drug users

    Dig Dis Sci

    (2017)
  • B. Johnson et al.

    Absence of complications after endoscopic mucosal biopsy

    Dig Dis

    (2018)
  • M.A. Quine et al.

    Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England

    Br J Surg

    (1995)
  • P. Wang et al.

    Rates of infection after colonoscopy and osophagogastroduodenoscopy in ambulatory surgery centres in the USA

    Gut

    (2018)
  • N. Forbes et al.

    Infection control in endoscopic retrograde cholangiopancreatography: a human factors perspective

    Clin Transl Gastroenterol

    (2020)
  • A.W. Rauwers et al.

    Nationwide risk analysis of duodenoscope and linear echoendoscope contamination

    Gastrointest Endosc

    (2020)
  • B. Goudra et al.

    Association between type of sedation and the adverse events associated with gastrointestinal endoscopy: an analysis of 5 years' data from a tertiary center in the USA

    Clin Endosc

    (2017)
  • J. Jun et al.

    Adverse events of conscious sedation using midazolam for gastrointestinal endoscopy

    Anesth Pain Med

    (2019)
  • F. Alshamsi et al.

    Prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy: a systematic review and meta-analysis

    Saudi J Med Med Sci

    (2017)
  • B. Olaiya et al.

    Air embolism secondary to endoscopy in hospitalized patients: results from the National Inpatient Sample (1998-2013)

    Ann Gastroenterol

    (2019)
  • S. Donepudi et al.

    Air embolism complicating gastrointestinal endoscopy: a systematic review

    World J Gastrointest Endosc

    (2013)
  • M. Benson et al.

    Safety and efficacy of moderate sedation in super obese patients undergoing lower and upper GI endoscopy: a case-control study

    Obes Surg

    (2020)
  • Y. Long et al.

    Pre-existing diseases of patients increase susceptibility to hypoxemia during gastrointestinal endoscopy

    PLoS One

    (2012)
  • M. Cena et al.

    Safety of endoscopic procedures after acute myocardial infarction: a systematic review

    Cardiol J

    (2012)
  • C.M. Andrade et al.

    Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea

    World J Gastrointest Endosc

    (2017)
  • Cited by (7)

    View all citing articles on Scopus

    This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

    Drs Coelho-Prabhu and Forbes contributed equally to this article.

    View full text