GuidelineAdverse events associated with EGD and EGD-related techniques
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.
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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
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This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.
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Drs Coelho-Prabhu and Forbes contributed equally to this article.