Adverse events of upper GI endoscopy

Abstract

This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this document, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results of large series and reports from recognized experts. This document is based on a critical review of the available data and expert consensus at the time that the document was drafted. Further controlled clinical studies may be needed to clarify aspects of this document. This document may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This document is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This document is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient's condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from this document. Upper GI (UGI) endoscopy is commonly performed and carries a low risk of adverse events. Large series report adverse event rates of 1 in 200 to 1 in 10,000 and mortality rates ranging from none to 1 in 2000.1Silvis S.E. Nebel O. Rogers G. et al.Endoscopic complications Results of the 1974 American Society for Gastrointestinal Endoscopy Survey.JAMA. 1976; 235: 928-930Crossref PubMed Google Scholar, 2Froehlich F. Gonvers J.J. Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.Endoscopy. 1994; 26: 231-234Crossref PubMed Google Scholar, 3Quine M.A. Bell G.D. McCloy R.F. et al.Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.Gut. 1995; 36: 462-467Crossref PubMed Google Scholar, 4Sieg A. Hachmoeller-Eisenbach U. et al.Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.Gastrointest Endosc. 2001; 53: 620-627Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 5Wolfsen H.C. Hemminger L.L. Achem S.R. et al.Complications of endoscopy of the upper gastrointestinal tract: a single-center experience.Mayo Clin Proc. 2004; 79: 1264-1267Abstract Full Text Full Text PDF PubMed Google Scholar, 6Heuss L.T. Froehlich F. Beglinger C. Changing patterns of sedation and monitoring practice during endoscopy: results of a nationwide survey in Switzerland.Endoscopy. 2005; 37: 161-166Crossref PubMed Scopus (94) Google Scholar Data collected from the Clinical Outcomes Research Initiative database show a cardiopulmonary event rate of 1 in 170 and a mortality rate of 1 in 10,000 from among 140,000 UGI endoscopic procedures.7Sharma V.K. Nguyen C.C. Crowell M.D. et al.A national study of cardiopulmonary unplanned events after GI endoscopy.Gastrointest Endosc. 2007; 66: 27-34Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar The variability in rates of adverse events may be attributed to the method of data collection, patient populations, duration of follow-up, and definitions of adverse events. Some authors include minor incidents, such as transient hypoxemia or self-limited bleeding as adverse events, whereas others report only significant adverse events that prevent completion of the procedure or result in hospitalization.8Cotton P.B. Eisen G.M. Aabakken L. et al.A lexicon for endoscopic adverse events: report of an ASGE workshop.Gastrointest Endosc. 2010; 71: 446-454Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Additionally, the majority of publications rely on self-reporting, and most reported data collected only from the immediate periprocedure period, thus the rate of late adverse events and mortality may be underestimated.8Cotton P.B. Eisen G.M. Aabakken L. et al.A lexicon for endoscopic adverse events: report of an ASGE workshop.Gastrointest Endosc. 2010; 71: 446-454Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 9Zubarik R. Eisen G. Mastropietro C. et al.Prospective analysis of complications 30 days after outpatient upper endoscopy.Am J Gastroenterol. 1999; 94: 1539-1545PubMed Google Scholar Major adverse events related to diagnostic UGI endoscopy are rare and include cardiopulmonary adverse events, infection, perforation, and bleeding. Adverse events of ERCP and EUS are discussed in separate ASGE documents.10Mallery J.S. Baron T.H. Dominitz J.A. et al.Complications of ERCP.Gastrointest Endosc. 2003; 57: 633-638Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 11Adler D.G. Jacobson B.C. Davila R.E. et al.ASGE guideline: complications of EUS.Gastrointest Endosc. 2005; 61: 8-12Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar Most UGI procedures in the United States and Europe are performed with patients under sedation (moderate or deep).12Cohen L.B. Wecsler J.S. Gaetano J.N. et al.Endoscopic sedation in the United States: results from a nationwide survey.Am J Gastroenterol. 2006; 101: 967-974Crossref PubMed Google Scholar Cardiopulmonary adverse events related to sedation and analgesia account for as much as 60% of UGI endoscopy adverse events.1Silvis S.E. Nebel O. Rogers G. et al.Endoscopic complications Results of the 1974 American Society for Gastrointestinal Endoscopy Survey.JAMA. 1976; 235: 928-930Crossref PubMed Google Scholar, 2Froehlich F. Gonvers J.J. Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.Endoscopy. 1994; 26: 231-234Crossref PubMed Google Scholar, 3Quine M.A. Bell G.D. McCloy R.F. et al.Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.Gut. 1995; 36: 462-467Crossref PubMed Google Scholar, 4Sieg A. Hachmoeller-Eisenbach U. et al.Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.Gastrointest Endosc. 2001; 53: 620-627Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 7Sharma V.K. Nguyen C.C. Crowell M.D. et al.A national study of cardiopulmonary unplanned events after GI endoscopy.Gastrointest Endosc. 2007; 66: 27-34Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar The rate of cardiopulmonary adverse events in large, national studies is between 1 in 170 and 1 in 10,000.1Silvis S.E. Nebel O. Rogers G. et al.Endoscopic complications Results of the 1974 American Society for Gastrointestinal Endoscopy Survey.JAMA. 1976; 235: 928-930Crossref PubMed Google Scholar, 2Froehlich F. Gonvers J.J. Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: results of a nationwide survey in Switzerland.Endoscopy. 1994; 26: 231-234Crossref PubMed Google Scholar, 3Quine M.A. Bell G.D. McCloy R.F. et al.Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.Gut. 1995; 36: 462-467Crossref PubMed Google Scholar, 4Sieg A. Hachmoeller-Eisenbach U. et al.Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.Gastrointest Endosc. 2001; 53: 620-627Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 6Heuss L.T. Froehlich F. Beglinger C. Changing patterns of sedation and monitoring practice during endoscopy: results of a nationwide survey in Switzerland.Endoscopy. 2005; 37: 161-166Crossref PubMed Scopus (94) Google Scholar, 7Sharma V.K. Nguyen C.C. Crowell M.D. et al.A national study of cardiopulmonary unplanned events after GI endoscopy.Gastrointest Endosc. 2007; 66: 27-34Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar Reported adverse events range from minor incidents, such as changes in oxygen saturation or heart rate, to significant adverse events such as aspiration pneumonia, respiratory arrest, myocardial infarction, stroke, and shock. Patient-related risk factors for cardiopulmonary adverse events include preexisting cardiopulmonary disease, advanced age, American Society of Anesthesiologists class III or higher, and an increased modified Goldman score.13Gangi S. Saidi F. Patel K. et al.Cardiovascular complications after GI endoscopy: occurrence and risks in a large hospital system.Gastrointest Endosc. 2004; 60: 679-685Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 14Clarke G.A. Jacobson B.C. Hammett R.J. et al.The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort.Endoscopy. 2001; 33: 580-584Crossref PubMed Scopus (74) Google Scholar Procedure-related risk factors for hypoxemia include difficulty with intubating the esophagus, a prolonged procedure, and a patient in the prone position.7Sharma V.K. Nguyen C.C. Crowell M.D. et al.A national study of cardiopulmonary unplanned events after GI endoscopy.Gastrointest Endosc. 2007; 66: 27-34Abstract Full Text Full Text PDF PubMed Scopus (110) Google Scholar, 8Cotton P.B. Eisen G.M. Aabakken L. et al.A lexicon for endoscopic adverse events: report of an ASGE workshop.Gastrointest Endosc. 2010; 71: 446-454Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 15Bell G.D. Bown S. Morden A. et al.Prevention of hypoxaemia during upper-gastrointestinal endoscopy by means of oxygen via nasal cannulae.Lancet. 1987; 1: 1022-1024Abstract PubMed Scopus (0) Google Scholar, 16Griffin S.M. Chung S.C. Leung J.W. et al.Effect of intranasal oxygen on hypoxia and tachycardia during endoscopic cholangiopancreatography.BMJ. 1990; 300: 83-84Crossref PubMed Google Scholar For a detailed discussion and specific recommendations, the reader is referred to the ASGE document “Sedation and Anesthesia in GI Endoscopy”17Lichtenstein D.R. Jagannath S. Baron T.H. et al.Sedation and anesthesia in GI endoscopy.Gastrointest Endosc. 2008; 68: 815-826Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar and the “American Society of Anesthesiology Practice Guidelines for Sedation and Analgesia by Nonanesthesiologists.”18American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-AnesthesiologistsPractice guidelines for sedation and analgesia by non-anesthesiologists.Anesthesiology. 2002; 96: 1004-1017Crossref PubMed Scopus (689) Google Scholar Infectious adverse events of diagnostic UGI endoscopy can result from either the procedure itself or failure to follow guidelines for the reprocessing and use of endoscopic devices and accessories.19American Society for Gastrointestinal EndoscopyMulti-society guideline for reprocessing flexible gastrointestinal endoscopes.Gastrointest Endosc. 2003; 58: 1-8Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 20Banerjee S. Shen B. Baron T.H. et al.Antibiotic prophylaxis for GI endoscopy.Gastrointest Endosc. 2008; 67: 791-798Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar Transient bacteremia as a result of diagnostic UGI endoscopy has been reported at rates as high as 8%, but the frequency of infectious endocarditis and other clinical sequelae is extremely low.21Nelson D.B. Infectious disease complications of GI endoscopy: Part I, endogenous infections.Gastrointest Endosc. 2003; 57: 546-556Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 22Allison M.C. Sandoe J.A. Tighe R. et al.Antibiotic prophylaxis in gastrointestinal endoscopy.Gut. 2009; 58: 869-880Crossref PubMed Scopus (37) Google Scholar Current American Heart Association and ASGE guidelines do not recommend antibiotic prophylaxis with diagnostic UGI endoscopy solely to prevent infectious endocarditis.20Banerjee S. Shen B. Baron T.H. et al.Antibiotic prophylaxis for GI endoscopy.Gastrointest Endosc. 2008; 67: 791-798Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar, 23Wilson W. Taubert K.A. Gewitz M. et al.Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.Circulation. 2007; 116: 1736-1754Crossref PubMed Scopus (575) Google Scholar Prospective, multicenter registries report perforation rates of 1 in 2500 to 1 in 11,000.4Sieg A. Hachmoeller-Eisenbach U. et al.Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists.Gastrointest Endosc. 2001; 53: 620-627Abstract Full Text Full Text PDF PubMed Scopus (142) Google Scholar, 24Quine M.A. Bell G.D. McCloy R.F. et al.Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England.Br J Surg. 1995; 82: 530-533Crossref PubMed Scopus (68) Google Scholar Factors predisposing to perforation include the presence of anterior cervical osteophytes, Zenker's diverticulum, esophageal stricture, malignancies of the UGI tract, and duodenal diverticula.24Quine M.A. Bell G.D. McCloy R.F. et al.Prospective audit of perforation rates following upper gastrointestinal endoscopy in two regions of England.Br J Surg. 1995; 82: 530-533Crossref PubMed Scopus (68) Google Scholar, 25Schulze S. Móller Pedersen V. Hóier-Madsen K. Iatrogenic perforation of the esophagus Causes and management.Acta Chir Scand. 1982; 148: 679-682PubMed Google Scholar Perforation of the esophagus is associated with a mortality rate between 2% and 36%.26Pettersson G. Larsson S. Gatzinsky P. et al.Differentiated treatment of intrathoracic oesophageal perforations.Scand J Thorac Cardiovasc Surg. 1981; 15: 321-324Crossref PubMed Google Scholar, 27Vogel S.B. Rout W.R. Martin T.D. et al.Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality.Ann Surg. 2005; 241 (discussion 1021-3): 1016-1021Crossref PubMed Scopus (98) Google Scholar, 28Eroglu A. Turkyilmaz A. Aydin Y. et al.Current management of esophageal perforation: 20 years experience.Dis Esophagus. 2009; 22: 374-380Crossref PubMed Scopus (24) Google Scholar, 29Abbas G. Schuchert M.J. Pettiford B.L. et al.Contemporaneous management of esophageal perforation.Surgery. 2009; 146: 749-755Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Early identification and expeditious management of a perforation have been shown to decrease associated morbidity and mortality.29Abbas G. Schuchert M.J. Pettiford B.L. et al.Contemporaneous management of esophageal perforation.Surgery. 2009; 146: 749-755Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar, 30Lai C.H. Lau W.Y. Management of endoscopic retrograde cholangiopancreatography-related perforation.Surgeon. 2008; 6: 45-48Abstract Full Text PDF PubMed Google Scholar Clinically significant bleeding is a rare adverse event of diagnostic UGI endoscopy.31Anderson M.A. Ben-Menachem T. Gan S.I. et al.Management of antithrombotic agents for endoscopic procedures.Gastrointest Endosc. 2009; 70: 1060-1070Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Mallory-Weiss tears occur in less than 0.5% of diagnostic UGI endoscopic procedures and usually are not associated with significant bleeding.32Montalvo R.D. Lee M. Retrospective analysis of iatrogenic Mallory-Weiss tears occurring during upper gastrointestinal endoscopy.Hepatogastroenterology. 1996; 43: 174-177PubMed Google Scholar Bleeding may be more likely in individuals with thrombocytopenia and/or coagulopathy.1Silvis S.E. Nebel O. Rogers G. et al.Endoscopic complications Results of the 1974 American Society for Gastrointestinal Endoscopy Survey.JAMA. 1976; 235: 928-930Crossref PubMed Google Scholar The minimum threshold platelet count for the performance of diagnostic UGI endoscopy has not been established. UGI endoscopy with biopsy was shown to be safe in 1 study of adults with solid malignancies and platelet counts greater than 20,000/mL.33Chu D.Z. Shivshanker K. Stroehlein J.R. et al.Thrombocytopenia and gastrointestinal hemorrhage in the cancer patient: prevalence of unmasked lesions.Gastrointest Endosc. 1983; 29: 269-272Abstract Full Text PDF PubMed Google Scholar Two case series of UGI endoscopy with or without biopsies in children with platelet counts greater than 50,000/mL reported no bleeding adverse events.34Vishny M.L. Blades E.W. Creger R.J. et al.Role of upper endoscopy in evaluation of upper gastrointestinal symptoms in patients undergoing bone marrow transplantation.Cancer Invest. 1994; 12: 384-389Crossref PubMed Google Scholar, 35Chongsrisawat V. Suprajitporn V. Kittikalayawong Y. et al.Platelet count in predicting bleeding complication after elective endoscopy in children with portal hypertension and thrombocytopenia.Asian Biomed. 2009; 3: 731-734Google Scholar However, a larger study of 198 UGI endoscopies in children after stem cell transplantation demonstrated that the risk of bleeding requiring red blood cell transfusions after UGI endoscopic biopsies was 4% despite a minimum platelet count of 50,000/mL.36Khan K. Schwarzenberg S.J. Sharp H. et al.Diagnostic endoscopy in children after hematopoietic stem cell transplantation.Gastrointest Endosc. 2006; 64: 379-385Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Four of these 8 patients were found to have duodenal hematomas. Thus, some authors have concluded that diagnostic UGI endoscopy can be performed when the platelet level is 20,000/mL or greater and that a threshold of 50,000/mL should be considered before performing biopsies.37Van Os E.C. Kamath P.S. Gostout C.J. et al.Gastroenterological procedures among patients with disorders of hemostasis: evaluation and management recommendations.Gastrointest Endosc. 1999; 50: 536-543Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 38Rebulla P. Revisitation of the clinical indications for the transfusion of platelet concentrates.Rev Clin Exp Hematol. 2001; 5: 288-310Crossref PubMed Scopus (18) Google Scholar, 39Samama C.M. Djoudi R. Lecompte T. et al.Perioperative platelet transfusion: recommendations of the Agence Francaise de Securite Sanitaire des Produits de Sante (AFSSaPS) 2003.Can J Anaesth. 2005; 52: 30-37Crossref PubMed Google Scholar, 40British Society of GastroenterologyGuidelines on complications of gastrointestinal endoscopy.http://www.bsg.org.uk/clinical-guidelinesDate: 2006Google Scholar Data from randomized trials and large case series suggest that the overall rate of dilation adverse events is between 0.1% and 0.4%.1Silvis S.E. Nebel O. Rogers G. et al.Endoscopic complications Results of the 1974 American Society for Gastrointestinal Endoscopy Survey.JAMA. 1976; 235: 928-930Crossref PubMed Google Scholar, 41Cox J.G. Winter R.K. Maslin S.C. et al.Balloon or bougie for dilatation of benign esophageal stricture?.Dig Dis Sci. 1994; 39: 776-781Crossref PubMed Scopus (34) Google Scholar, 42Hernandez L.V. Jacobson J.W. Harris M.S. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures.Gastrointest Endosc. 2000; 51: 460-462Abstract Full Text Full Text PDF PubMed Google Scholar, 43Lew R.J. Kochman M.L. A review of endoscopic methods of esophageal dilation.J Clin Gastroenterol. 2002; 35: 117-126Crossref PubMed Scopus (67) Google Scholar, 44Scolapio J.S. Pasha T.M. Gostout C.J. et al.A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings.Gastrointest Endosc. 1999; 50: 13-17Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar The most common adverse events are perforation, hemorrhage, aspiration, and bacteremia. Most dilation-related bleeding is self-limited, but rare episodes of bleeding requiring endoscopic hemostasis and dissection into major blood vessels have been reported.45Lehmann K.G. Blair D.N. Siskind B.N. et al.Right atrial-esophageal fistula and hydropneumopericardium after esophageal dilation.J Am Coll Cardiol. 1987; 9: 969-972Abstract Full Text PDF PubMed Google Scholar, 46Piotet E. Escher A. Monnier P. Esophageal and pharyngeal strictures: report on 1,862 endoscopic dilatations using the Savary-Gilliard technique.Eur Arch Otorhinolaryngol. 2008; 265: 357-364Crossref PubMed Scopus (25) Google Scholar Patients with significant obstruction of the UGI tract may be at risk of aspiration of retained food and fluid. In these situations, measures to avoid aspiration should be considered (eg, nasogastric suction before sedation, reverse Trendelenburg position), and, when appropriate, placement of an endotracheal tube for airway protection. Although the incidence of bacteremia with UGI dilation ranges from 12% to 22%, infectious sequelae are rare.47Nelson D.B. Sanderson S.J. Azar M.M. Bacteremia with esophageal dilation.Gastrointest Endosc. 1998; 48: 563-567Abstract Full Text Full Text PDF PubMed Google Scholar Therefore, antibiotic prophylaxis is not recommended.20Banerjee S. Shen B. Baron T.H. et al.Antibiotic prophylaxis for GI endoscopy.Gastrointest Endosc. 2008; 67: 791-798Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar The most common adverse events of esophageal dilation are perforation and bleeding. Wire-guided bougie dilation or through-the-scope balloon dilation may have lower risks of adverse events than blind passage of dilators.42Hernandez L.V. Jacobson J.W. Harris M.S. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures.Gastrointest Endosc. 2000; 51: 460-462Abstract Full Text Full Text PDF PubMed Google Scholar Randomized trials suggest that wire-guided polyvinyl dilators and through-the-scope balloons have similar rates of both efficacy and adverse events.41Cox J.G. Winter R.K. Maslin S.C. et al.Balloon or bougie for dilatation of benign esophageal stricture?.Dig Dis Sci. 1994; 39: 776-781Crossref PubMed Scopus (34) Google Scholar, 44Scolapio J.S. Pasha T.M. Gostout C.J. et al.A randomized prospective study comparing rigid to balloon dilators for benign esophageal strictures and rings.Gastrointest Endosc. 1999; 50: 13-17Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 48Saeed Z.A. Winchester C.B. Ferro P.S. et al.Prospective randomized comparison of polyvinyl bougies and through-the-scope balloons for dilation of peptic strictures of the esophagus.Gastrointest Endosc. 1995; 41: 189-195Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 49Shemesh E. Czerniak A. Comparison between Savary-Gilliard and balloon dilatation of benign esophageal strictures.World J Surg. 1990; 14: 518-521Crossref PubMed Scopus (32) Google Scholar The rate of perforation after esophageal dilation for esophageal rings and simple peptic strictures is lower than that of certain high-risk lesions. Dilation of complex strictures (angulated, multiple, or long) with Maloney dilators may be associated with a 2% to 10% risk of perforation50Patterson D.J. Graham D.Y. Smith J.L. et al.Natural history of benign esophageal stricture treated by dilatation.Gastroenterology. 1983; 85: 346-350PubMed Google Scholar, 51McClave S.A. Brady P.G. Wright R.A. et al.Does fluoroscopic guidance for Maloney esophageal dilation impact on the clinical endpoint of therapy: relief of dysphagia and achievement of luminal patency.Gastrointest Endosc. 1996; 43: 93-97Abstract Full Text Full Text PDF PubMed Google Scholar so wire-guided or balloon dilation is likely a safer alternative.42Hernandez L.V. Jacobson J.W. Harris M.S. Comparison among the perforation rates of Maloney, balloon, and savary dilation of esophageal strictures.Gastrointest Endosc. 2000; 51: 460-462Abstract Full Text Full Text PDF PubMed Google Scholar Dilation of caustic strictures, which tend to be long and angulated, is associated with a higher rate of adverse events.52Broor S.L. Lahoti D. Bose P.P. et al.Benign esophageal strictures in children and adolescents: etiology, clinical profile, and results of endoscopic dilation.Gastrointest Endosc. 1996; 43: 474-477Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 53Karnak I. Tanyel F.C. Buyukpamukcu N. et al.Esophageal perforations encountered during the dilation of caustic esophageal strictures.J Cardiovasc Surg. 1998; 39: 373-377PubMed Google Scholar Dilation of eosinophilic esophagitis is associated with a high incidence of mucosal tears, but only 1 perforation was identified in a systematic review of 671 dilations for eosinophilic esophagitis.54Jacobs Jr, J.W. Spechler S.J. A systematic review of the risk of perforation during esophageal dilation for patients with eosinophilic esophagitis.Dig Dis Sci. 2010; 55: 1512-1515Crossref PubMed Scopus (27) Google Scholar The risk of perforation resulting from dilation of malignant strictures of the esophagus is approximately 10%55Anderson P.E. Cook A. Amery A.H. A review of the practice of fibreoptic endoscopic dilatation of oesophageal stricture.Ann R Coll Surg Engl. 1989; 71: 124-127PubMed Google Scholar, 56Van Dam J. Rice T.W. Catalano M.F. et al.High-grade malignant stricture is predictive of esophageal tumor stage Risks of endosonographic evaluation.Cancer. 1993; 71: 2910-2917Crossref PubMed Google Scholar and is associated with increasing dilator diameter.56Van Dam J. Rice T.W. Catalano M.F. et al.High-grade malignant stricture is predictive of esophageal tumor stage Risks of endosonographic evaluation.Cancer. 1993; 71: 2910-2917Crossref PubMed Google Scholar, 57Catalano M.F. Van Dam J. Sivak Jr, M.V. Malignant esophageal strictures: staging accuracy of endoscopic ultrasonography.Gastrointest Endosc. 1995; 41: 535-539Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 58Pfau P.R. Ginsberg G.G. Lew R.J. et al.Esophageal dilation for endosonographic evaluation of malignant esophageal strictures is safe and effective.Am J Gastroenterol. 2000; 95: 2813-2815Crossref PubMed Google Scholar, 59Wallace M.B. Hawes R.H. Sahai A.V. et al.Dilation of malignant esophageal stenosis to allow EUS guided fine-needle aspiration: safety and effect on patient management.Gastrointest Endosc. 2000; 51: 309-313Abstract Full Text Full Text PDF PubMed Google Scholar Radiation-induced strictures have also been reported to have a high rate of dilation-related adverse events,60Swaroop V.S. Desai D.C. Mohandas K.M. et al.Dilation of esophageal strictures induced by radiation therapy for cancer of the esophagus.Gastrointest Endosc. 1994; 40: 311-315Abstract Full Text Full Text PDF PubMed Google Scholar but this risk may be related to the presence of malignancy rather than the effect of radiation.61Ng T.M. Spencer G.M. Sargeant I.R. et al.Management of strictures after radiotherapy for esophageal cancer.Gastrointest Endosc. 1996; 43: 584-590Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Pain is the most common symptom related to perforation.25Schulze S. Móller Pedersen V. Hóier-Madsen K. Iatrogenic perforation of the esophagus Causes and management.Acta Chir Scand. 1982; 148: 679-682PubMed Google Scholar, 26Pettersson G. Larsson S. Gatzinsky P. et al.Differentiated treatment of intrathoracic oesophageal perforations.Scand J Thorac Cardiovasc Surg. 1981; 15: 321-324Crossref PubMed Google Scholar, 62Larsen K. Skov Jensen B. Axelsen F. Perforation and rupture of the esophagus.Scand J Thorac Cardiovasc Surg. 1983; 17: 311-316Crossref PubMed Google Scholar, 63Wychulis A.R. Fontana R.S. Payne W.S. Instrumental perforations of the esophagus.Dis Chest. 1969; 55: 184-189Crossref PubMed Google Scholar Fever, crepitus, pleuritic chest pain, leukocytosis, and pleural effusion may also be present. Perforation with associated air dissection may be diagnosed by plain radiography of the neck and/or chest, but such findings may be absent immediately after perforation.64Panzini L. Burrell M.I. Traube M. Instrumental esophageal perforation: chest film findings.Am J Gastroenterol. 1994; 89: 367-370PubMed Google Scholar If a perforation is suspected, contrast esophagography should be performed, usually beginning with water-soluble contrast.65Gimenez A. Franquet T. Erasmus J.J. et al.Thoracic complications of esophageal disorders.Radiographics. 2002; 22: S247-S258PubMed Google Scholar If the site of perforation cannot be determined but suspicion remains high, a barium esophagram or CT scan of the chest is indicated. A CT scan with oral contrast is sensitive for the site of perforation and for more subtle findings such as minute amounts of air or fluid.66Wu J.T. Mattox K.L. Wall Jr, M.J. Esophageal perforations: new perspectives and treatment paradigms.J Trauma. 2007; 63: 1173-1184Crossref PubMed Scopus (52) Google Scholar The approach to the patient with perforation depends on the state of health of the individual, the site of the perforation, and the overall prognosis. In selected patients, early recognition may allow nonoperative management with nasogastric suction, intravenous antibiotics, and parenteral nutrition.27Vogel S.B. Rout W.R. Martin T.D. et al.Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality.Ann Surg. 2005; 241 (discussion 1021-3): 1016-1021Crossref PubMed Scopus (98) Google Scholar Surgical consultation should be obtained, and surgical management i