Urgent Endoscopy Research Articles

3105 Zenker's Diverticulum: Unusual Cause of Acute Oesophageal Impaction

INTRODUCTION: Dysphagia amongst the elderly results from increasing dysfunction of the upper esophageal sphincter (UES), which is vulnerable to effects of aging. Prevalence of dysphagia in geriatric population, especially above 80 is higher than overall prevalence in the general population. Zenker's diverticulum (ZD) is the hallmark pathology for UES dysfunction. These false diverticula are herniation of mucosa and submucosa through the Killian's Triangle. Albeit progressive dysphagia is the most common presentation, symptoms can range from globus sensation to obstruction. ZD may rarely present as complete esophageal obstruction. CASE DESCRIPTION/METHODS: An 89 years old female with hypertension, osteoarthritis and polycythemia vera presented with complaint of “having a pill stuck in my throat.” Unable to tolerate her breakfast and spitting up sputum. Similar symptoms in the past for which she changed her diet to soft bread. Initially, it worked however dysphagia gradually worsened to the extent of having to butter her pills to ease swallowing. Denies GERD. Vital signs within normal limits, physical exam revealed enlarged multinodular goiter with retropharyngeal extension however negative Pemberton's sign. Boyce sign was positive on sipping some water. Euthyroid and no other abnormalities. Urgent upper endoscopy was recommended however patient refused but agreed the next day. Endoscopy was remarkable for pill lodged in upper esophagus, upper esophageal ring and impacted food in ZD compressing esophagus. The ring was split using the endoscope and pill pushed down which was then propelled by peristalsis to the stomach. Content of ZD was retrieved with Roth net. Remaining endoscopy exam was unremarkable. ENT evaluation was recommended for ZD and goiter however patient declined intervention. DISCUSSION: ZD often presents as solid food and pill dysphagia, rarely as acute esophageal obstruction as seen in this case. A number of factors in addition to external esophageal compression by the enlarging ZD likely contributed to her presentation, including pressure from enlarged thyroid. ZD compounds the pharyngeal weakness that leads to its development, trapping the patient in a vicious cycle of worsening dysphagia that eventually results in obstruction. Furthermore, an association between esophageal webs and ZD has been demonstrated. Combination of these factors resulted in the complete obstruction in our patient. Dysphagia in old age, always have ZD in mind.

1720 A Case of Sunitinib-Induced Necrotizing Esophagitis

INTRODUCTION: Acute esophageal necrosis (AEN), also known as “black esophagus” or “acute necrotizing esophagitis”, is a rare entity thought to be caused by a known ischemic insult from a low perfusion state. Etiologies include multi-organ dysfunction, hypoperfusion, vasculopathy, sepsis, among others. Sunitinib, a chemotherapeutic agent for renal cell cancer and gastrointestinal stromal tumors, has common gastrointestinal (GI) side effects of diarrhea and vomiting but severe GI side effects are rare. We present a unique case of Sunitinib-induced AEN. CASE DESCRIPTION/METHODS: A 72-year-old man presented to the hospital for a two days history of epigastric abdominal pain, bilious vomiting, and multiple episodes of non-bloody diarrhea. His medical history was significant for metastatic papillary renal cell carcinoma on Sunitinib. On presentation, his blood pressure was 74/52 mm Hg and heart rate 107 beats per minute. He exhibited generalized abdominal tenderness without rebound or guarding. His hemoglobin was 15 g/dL. He was admitted to the ICU for hypovolemic shock thought to be secondary to severe gastroenteritis requiring the use of vasopressors. He later developed ongoing melena and his hemoglobin decreased to 10.8 g/dl requiring urgent Endoscopy. The examination revealed circumferential, black, necrotic mucosa in the lower one-half of the esophagus with a sharp demarcation of healthy mucosa at the level of gastroesophageal junction without any active bleeding. Findings were consistent with AEN. The patient remained hypotensive despite aggressive resuscitation and the use of vasopressors. Unfortunately, the patient died several days later. DISCUSSION: AEN is characterized by the classic endoscopic image of diffuse, circumferential, black-appearing necrotic mucosa. The exact etiology leading to the hypoperfusion state in our case is unclear and could be attributed to Sunitinib. The most common adverse GI reactions to Sunitinib include diarrhea (53%), nausea (44%), and vomiting (24%) which were intractable in the above case. This medication has also been linked to severe GI hemorrhage. Sunitinib inhibits platelet-derived growth factors and vascular endothelial growth factors which play a major role in angiogenesis and apoptosis. We believe that by inhibiting these cellular processes, the patient was predisposed to development of AEN which was potentiated by the patient’s hypovolemic state.

3086 “Knot” Your Average Nasogastric Tube

INTRODUCTION: A nasogastric tube (NGT) is commonly used for gastric decompression or enteral nutrition. Placement is usually safely performed blindly with positioning confirmed on plain x-rays. NGT self-knotting is a rare complication that requires awareness as management may necessitate urgent endoscopy. CASE DESCRIPTION/METHODS: An 88-year-old man presented with nausea and vomiting, and was found to have a small bowel obstruction. He was managed conservatively with NGT placement for decompression. Due to low output, the tube required manipulation and repositioning. Upper GI series with small bowel follow was obtained for further evaluation with fluoroscopy images revealing a knotted NGT with the tip in the mid esophagus. Attempts were made at removal, but it could not be withdrawn or advanced due to patient discomfort. The patient underwent EGD which confirmed that the knotted NGT was lodged at the upper esophageal sphincter. The NGT was advanced under direct visualization to the stomach where the knotted end was snared. After cutting the proximal end exiting the nare, the knotted NGT was withdrawn endoscopically via the mouth. The patient eventually had resolution of his small bowel obstruction and was discharged. DISCUSSION: Though generally considered safe, NGTs are associated with a variety of complications occurring at a rate of 0.3% to 8%. These include aspiration, pneumothorax, tracheal misplacement, esophageal perforation, epistaxis, mediastinitis, and sinusitis. NGT function may be compromised by kinking, malpositioning, and occlusion of the tube. With the literature limited to few case reports and series, the true incidence of NGT self-knotting is unknown. NGT knotting increases risk for further complications such as respiratory difficulty and trauma to the nasopharynx, larynx, and esophagus, including tracheoesophageal perforation or fistulization. NGT knotting may occur from faulty insertion, altered anatomy, repetitive manipulation, narrow bore design, excessive length of tubing in the stomach, prolonged duration of placement, violent peristalsis, and softening of the tube at body temperature. NGT knotting should be considered in patients with any resistance upon attempts at removal. Plain radiographs or fluoroscopy can detect knotting. Various methods for removal of knotted NGTs have been described, generally involving cutting and removing the knotted part through the mouth with the help of direct laryngoscopy or EGD, as illustrated by this case. Watch the video: http://bit.ly/32EOwHS

2517 Isn't Herpes Esophagitis Enough?

INTRODUCTION: Herpes simplex (HSV) esophagitis, typically found in immunocompromised hosts, is increasingly being seen in immunocompetent hosts. A PubMed search covering the last 10 years yielded 8 publications of HSV esophagitis in the immunocompetent pediatric population, 3 of which were associated with eosinophilic esophagitis. No literature was found regarding HSV esophagitis associated with H. pylori infection. This is not surprising as the incidence of H. pylori is <10% in developed countries. To our knowledge, this is the first case report of co-infection of HSV esophagitis and H. pylori gastritis. CASE DESCRIPTION/METHODS: A healthy 16 year old male presented with 7 days of fever, severe odynophagia, and epigastric pain with no oral ulcers. He had a one year history of heartburn and dysphagia. Family history positive for H. pylori in paternal grandmother. He was seen at multiple facilities prior to transfer with prior diagnosis of costochondritis, pericarditis, pneumonia, and cholecystitis. Work up showed a normal KUB, abdominal ultrasound and upper GI series. WBC was 12.7 × 103/µL with left shift and elevated CRP at 86 mg/L. He was unresponsive to 24 hours of IV acid suppression therapy. Urgent endoscopy revealed extensive shallow ulcerations with exudate of the mid and distal esophagus and mild nodularity of the antrum. Empiric IV acyclovir was started with rapid symptom improvement within 24 hours. Biopsies showed ulcerated squamous esophageal mucosa with acute inflammation and exudate without eosinophilia. Adjacent reactive epithelium included binucleated to multinucleated cells with eosinophil nuclear structures suggestive of Cowdry type A inclusion bodies. A single cell showed a Cowdry type B inclusion but without the presence of classic multinucleated cells with molded nuclei. Immunohistochemistry confirmed the presence of HSV and was negative for CMV. Gastric biopsy showed mild, diffuse chronic gastritis with scant acute inflammation. CLO test was negative, but Diff-Quik and immunohistochemistry stains confirmed H. pylori. Triple therapy for H. pylori and a 10 day acyclovir course were completed. Currently his immune work-up is still pending. DISCUSSION: Since herpes esophagitis is a rare diagnosis in pediatrics, it is easy to ignore the possibility of co-infection. The importance of considering a co-infection in acute herpes esophagitis important to consider as the acute symptoms did not explain the patient's chronic peptic symptoms.

Incidence and risk factors for adverse events during monitored anaesthesia care for gastrointestinal endoscopy in children: A prospective observational study.

Better understanding of risk factors for adverse events during monitored anaesthesia care (MAC) for paediatric gastrointestinal endoscopy may improve outcome in children. To identify the prevalence and predictors of adverse events during MAC for paediatric endoscopy. An observational study. Tertiary university hospital, single-centre cohort, from January 2010 to August 2016. The prospectively collected electronic anaesthetic records of 3435 children aged up to 16 years who underwent diagnostic gastrointestinal endoscopy under MAC were analysed retrospectively. Children with an American Society of Anesthesiologists' physical status at least 4, and those requiring mechanical ventilation and therapeutic or urgent endoscopy were excluded. The prevalence and predictors of adverse events during MAC for paediatric gastrointestinal endoscopy, with particular reference to the use of different anaesthetic or sedative agents. Mean ± SD age of the children was 8.5 ± 4.4 years. The incidences of adverse events and adverse respiratory events were 3.4 and 3.3%, respectively. Multivariate analysis identified 12 independent predictors: age [odds ratio (OR) 0.92, P = 0.002], children's size for example underweight (OR 1.78, P = 0.039), overweight (OR 2.20, P = 0.039), (morbid) obesity (OR 4.25, P = 0.006), presence of respiratory comorbidities (OR 8.18, P < 0.001), recent respiratory infection (OR 23.55, P < 0.001) or both (OR 17.46, P < 0.001), neurological comorbidities (OR 2.18, P = 0.007), upper gastrointestinal endoscopy (OR 5.66, P < 0.001), propofol co-administration with ketamine (OR 10.34, P < 0. 001) or after sevoflurane induction (OR 44.95, P < 0.001), and propofol induction dose (OR 18.97, P < 0.001). Posthoc secondary analyses revealed a significantly higher risk of adverse events (OR 3.9, P < 0.0001) and also significantly more respiratory comorbidities and respiratory infections (P < 0.0001) in children aged less than 2 years when compared with children aged at least 2 years. No cardiovascular events were observed and outcome was uneventful. The present cohort demonstrated the feasibility and safety of MAC for paediatric gastrointestinal endoscopy by an experienced team. Although adverse events occurred rarely, their predictive factors were clinically identifiable. Applying this information in risk assessment and modifying anaesthetic management accordingly could improve outcome. ISRCTN70362666.

DOZ047.123: Choose typology: oral communication multiple congenital bronchogenic cysts and thyroglossal duct remnant, case report

Abstract Background Thyroglossal duct remnants, most frequently presenting as cysts, are the most common congenital anomalies of the neck. Bronchogenic cysts are rare congenital anomalies of the primitive foregut and are a subtype of foregut supplication cysts. Those cysts are the most common cystic lesions of the mediastinum. They can present in other areas such as the neck. Such cystic lesions are usually seen in pediatric population and symptomology depends on the location, size and degree of compression to the surrounding structures. The synchronous presence of both lesions in one patient is rare. To the best of our knowledge, such presentation has not been reported in the literature. We present a case of multiple lesions in the neck and mediastinum including precricoid, paraglotttic and paratracheal regions. Case Presentation A full-term male newborn presented in day 1 post normal vaginal delivery with progressive stridor and decreased feeding. Urgent airway endoscopy revealed a left supraglottic cyst and proximal non pulsatile tracheal wall compression by another cystic lesion. Aspiration of the supraglottic cyst was done and one month later, he developed stridor again for which he had endoscopic marsupialization of right supraglottic cyst and internal aspiration of paratracheal cyst. MRI showed right paratracheal cystic lesion with evidence of a tubular tract and an infected cyst inferiorly. Decision was made to explore the neck for definite removal of the cysts. Three lesions were identified: a precricoid mass, and paraglottic and paratracheal cysts. Cervical lesions were carefully dissected and excised. For the paratracheal cyst which extended to the mediastinum, incision and drainage was done and part of cyst wall was excised, and a drain inserted into the cyst. Histopathology confirmed the precrcoid lesion to be a thyroglossal duct remnant, the paraglottic cyst in keeping with bronchogenic cyst and the paratracheal cyst wall showed granulation tissue. Discussion The fact that the embryological basis for development of thyroglossal duct cyst and bronchogenic cyst is different makes diagnosis of both lesions is challenging and such presentation is unique. Definite diagnosis depends on accurate history, imaging particularly MRI and histopathology. Surgery is the treatment of choice for symptomatic cases.

The evolution of treatment and complications of esophageal food impaction.

Esophageal food impaction is relatively common and increasing over time. Treatment ranges from medications to invasive endoscopic therapies. The endoscopic push technique has been advised against in favor of endoscopic retrieval for safety concerns. We sought to assess use patterns and safety of treatments for food impaction in a population-based retrospective review. A database of recorded esophageal food impactions in Olmsted County, MN, USA, from 1975-2011 was reviewed for patient demographics, treatment, and complications. A total of 645 impactions occurred, with increasing incidence over time, peaking at 23.2 per year (2000-2004). Medications (almost exclusively glucagon) were successful in relieving impactions 34.5% of the time when trialed. Urgent endoscopy was common (74.0%), as was the need for endoscopic therapy (67.1%). Endoscopic therapy increased over time, with the endoscopic push technique becoming most common. Esophageal complications (deep mucosal injury or perforation) increased over time but remained rare (peak 11%). There was no difference in complications between push and retrieval techniques. The endoscopic push technique is safe in comparison to endoscopic retrieval in esophageal food impactions. While complications surrounding impaction have increased, they remain rare. Medication trials are reasonable, as long as they do not delay endoscopy, and may prevent the need for emergent endoscopy in one-third of cases.

Mo1281 – The Impact of Urgent Upper Endoscopy on Clinical Outcomes in Patients with Acute Upper Gastrointestinal Bleeding

Mo1281 – The Impact of Urgent Upper Endoscopy on Clinical Outcomes in Patients with Acute Upper Gastrointestinal Bleeding

03:27 PM Abstract No. 241 Effects of time to visceral angiography for gastrointestinal bleeding on angiographic success

Gastrointestinal bleeding (GIB) is a complex problem with a multitude of etiologies requiring a multidisciplinary approach to treatment. There is varying data regarding the role of urgent endoscopy (EGD), colonoscopy, CT, nuclear medicine tests, or conventional angiogram in the acute setting. This retrospective review was conducted to evaluate the effect of time to angiogram on angiographic outcomes. The RRSB at University of Rochester approved this retrospective cohort study. Visceral angiograms performed from Jan 2012 to Dec 2015 were evaluated. Index angiograms for GIB were identified. Exclusion criteria included recent abdominal surgery (30 days), empiric embolization, or incomplete arteriograms. Multiple factors were included in the analysis, age, gender, angiogram time, EGD, colonoscopy, anti platelet use, anticoagulant use, INR, CT, and Tc99m RBC scan (RBC Scan), among others. 118 angiograms were included in the final analysis. 44 angiograms resulted in identification and embolization of a bleed. (average age 67.4 yrs, 65% male) 74 angiograms failed to identify a bleed. 74 (average age 70.6yrs, 52% male) In cases with a positive RBC scan in the preceding 24 hours, successful identification and embolization was significantly statistically correlated with a shorter time to angiogram 4.6 hrs compared to 9.6 hrs for unsuccessful angiograms (p=.026). Patients with a bleed identified on EGD or colonoscopy prior to successful angiogram had a shorter time to angiogram 9.1 vs 10 hours for non-diagnostic angiograms, although not significant. CTA examinations were excluded due to low sample size. 92% of active bleeds seen on RBC scan and 93% of directly visualized bleeds corresponded to the embolized location. Visceral arteriography is a key tool in the identification and treatment of acute GI bleeding. Successful angiograms had a, statically significant, shorter time to angiogram from positive RBC scan compared to inconclusive angiograms. Angiography should be performed as soon as possible after a positive RBC scan. Successful embolization after EGD did not have a strong time dependence, likely owing to several factors.

Azithromycin Versus Erythromycin Infusions in Upper Gastrointestinal Bleeding

Background: Intravenous erythromycin prior to endoscopy for upper gastrointestinal bleeding (GIB) improves outcomes but requires immediate preparation delaying administration in emergency cases. Azithromycin is readily available and does not require prolonged preparation. The aim of the study was to assess the effect of azithromycin in improving the quality of endoscopic visualization in upper GIB compared to erythromycin. Methods: Patients admitted with upper GIB who received erythromycin or azithromycin before urgent endoscopy were included. Primary outcome of the quality of visualization was assessed by two gastroenterologists, blinded to the choice of infusion, using a scoring system ranging from 0 to 8, with a maximum of 2 points assigned to the fundus, body, antrum and bulb. Results: Sixty-six patients were included; 25 received azithromycin and 41 received erythromycin. Mean total visualization score was significantly higher with azithromycin compared to that with erythromycin (6.8 ± 1.4 vs 5.5 ± 2.2, respectively; P=0.01) and remained significant after adjusting for confounders (Diff: 0.01, 1.88; P=0.05). Secondary outcomes analyses showed a shorter LOS when given azithromycin compared to erythromycin {6 (3-9) vs 8 (7-16) days, respectively, CI: 1.03, 3.89; P = 0.04}. Time between initiating the infusion and endoscopy was longer with azithromycin (Diff = 40.64 min; 95% CI: 7.23, 74.05; P=0.02). Need for second look endoscopy, procedure time, blood transfusion requirements and procedure-related complications did not differ between the groups. Conclusions: Azithromycin infusion before endoscopy for upper GIB was associated with better visualization than that of erythromycin. Randomized trials are needed to validate these findings. Funding: None. Declaration of Interest: All authors report no conflict of interest in relation to this study. Ethical Approval: The study protocol was approved by the Institutional Review Board of Virginia Commonwealth University.

Optimal endoscopy timing according to the severity of underlying liver disease in patients with acute variceal bleeding

BackgroundCurrent guidelines recommend endoscopic therapy to be performed within 12 h for acute variceal bleeding (AVB). However, the optimal timing of endoscopic therapy for AVB remains unclear. AimsTo examine the relationship between the endoscopy timing and clinical outcomes in AVB, with emphasis on liver function and endoscopy timing. MethodsFrom January 2010 to June 2017, cirrhotic patients with AVB confirmed by endoscopy were evaluated. The primary outcome was a composite of 6-week rebleeding and mortality. We stratified patients according to the MELD score. ResultsIn 411 patients, the overall composite outcome rate was 30.9% (n = 127) at 6 week. Patients who underwent urgent endoscopy (≤12 h) had a significantly higher composite outcome than patients who underwent non-urgent endoscopy (>12 h) (34.4% vs. 19.1%; P = 0.005). Low-risk patients who underwent urgent endoscopy were more likely to reach the composite outcome (adjusted OR, 0.84 per 4 h; 95% CI, 0.73–0.98; P = 0.027). These findings persisted even after adjustment for baseline characteristics between the urgent and non-urgent groups. ConclusionsUrgent endoscopy is significantly associated with a poorer outcome in patients with AVB, especially in low-risk patients. Our result provides a treatment strategy according to the severity of underlying liver disease in patients with AVB.

Comparison of computed tomography findings with clinical risks factors for endoscopic therapy in upper gastrointestinal bleeding cases.

Several risk scoring systems exist for acute upper gastrointestinal bleeding (UGIB). The clinical Rockall score (clinical RS) and the Glasgow-Blatchford score (GBS) are major risk scores that consider only clinical data. Computed tomography (CT) findings are equivocal in non-variceal UGIB. We compared CT findings with clinical data to predict mortality, rebleeding and need for endoscopic therapy in non-variceal UGIB patients. This retrospective, single-center study included 386 patients admitted to our emergency department with diagnosis of non-variceal UGIB by urgent endoscopy between January 2009 and March 2015. Multivariable logistic regression analysis was used to investigate CT findings and risk factors derived from clinical data. CT findings could not significantly predict mortality and rebleeding in non-variceal UGIB patients. However, upper gastrointestinal hemorrhage in CT findings better predicted the need for endoscopic therapy than clinical data. The adjusted odds ratios were 10.10 (95% CI 5.01-20.40) for clinical RS and 10.70 (95% CI 5.08-22.70) for the GBS. UGI hemorrhage in CT findings could predict the need for endoscopic therapy in non-variceal UGIB patients in our emergency department. CT findings as well as risk score systems may be useful for predicting the need for endoscopic therapy.

Ingestion of Dental Prosthesis of A Patient with an LMA Under General Anesthesia: A case report

60-year-old male presented for outpatient cystoscopy under General Anesthesia with a Laryngeal Mask Airway (LMA). The patient denied dental prosthesis during assessment. In recovery, a family member noticed a missing dental bridge which prompted a workup that revealed the ingested dental bridge in the stomach. The patient underwent a second anesthetic for upper endoscopy to retrieve the foreign body. This case report highlights the need for vigilance during the entire perioperative period. Early interventions in this setting should include chest and abdominal x-rays and possibly an urgent endoscopy to prevent severe damage to the Gastrointestinal tract.

Associations between general practice characteristics with use of urgent referrals for suspected cancer and endoscopies: a cross-sectional ecological study

BackgroundLarge variation in measures of diagnostic activity has been described previously between English general practices, but related predictors remain understudied.ObjectiveTo examine associations between general practice population and characteristics, with the use of urgent referrals for suspected cancer, and use of endoscopy.MethodsCross-sectional observational study of English general practices. We examined practice-level use (/1000 patients/year) of urgent referrals for suspected cancer, gastroscopy, flexible sigmoidoscopy and colonoscopy. We used mixed-effects Poisson regression to examine associations with the sociodemographic profile of practice populations and other practice attributes, including the average age, sex and country of qualification of practice doctors.ResultsThe sociodemographic characteristics of registered patients explained much of the between-practice variance in use of urgent referrals (32%) and endoscopic investigations (18–25%), all being higher in practices with older and more socioeconomically deprived patients. Practice-level attributes explained a substantial amount of between-practice variance in urgent referral (19%) but little of the variance in endoscopy (3%-4%). Adjusted urgent referral rates were higher in training practices and those with younger GPs. Practices with mean doctor ages of 41 and 57 years (at the 10th/90th centiles of the national distribution) would have urgent referral rates of 24.1 and 19.1/1000 registered patients, P < 0.001.ConclusionMost between-practice variation in use of urgent referrals and endoscopies seems to reflect health need. Some practice characteristics, such as the mean age of GPs, are associated with appreciable variation in use of urgent referrals, though these associations do not seem strong enough to justify targeted interventions.

Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding.

AIMTo examine the association between the timing of endoscopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.METHODSThis retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting (IPW) method. The primary outcome was the mortality of patients within 6 wk.RESULTSA total of 173 patients received urgent endoscopy (i.e., ≤ 12 h after admission), and 101 patients received non-urgent endoscopy (> 12 h after admission). The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before (P = 0.266) and after IPW (P = 0.639). The length of hospital stay was statistically different between the urgent group and non-urgent group (P = 0.033); however, there was no significant difference in the in-hospital mortality rate between the two groups (8.1% vs 7.9%, P = 0.960). In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality (hazard ratio, 1.297; 95% confidence interval, 0.806-2.089; P = 0.284).CONCLUSIONIn cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.

Svetimkūnių iš viršutinės virškinimo trakto dalies endoskopinis šalinimas Respublikinėje Vilniaus universitetinėje ligoninėje: 25 metų patirtis

[straipsnis ir santrauka lietuvių kalba; santrauka anglų kalba]&#x0D; Nurytas svetimkūnis ar maistas, įstrigę viršutinėje virškinimo trakto dalyje, yra dažna klinikinė situacija skubios pagalbos skyriuose visame pasaulyje. Didžioji dauguma svetimkūnių pereina per virškinimo traktą ir natūraliai pasišalina su išmatomis, tačiau apie 1/5 ligonių prireikia svetimkūnius šalinti. Viršutinėje virškinimo trakto dalyje įstrigęs svetimkūnis yra antra pagal dažnumą (po kraujavimo) skubios endoskopijos priežastis.Atlikto retrospektyvaus aprašomojo tyrimo tikslas yra apžvelgti Respublikinės Vilniaus universitetinės ligoninės (RVUL) gydytojų ketvirčio amžiaus (25 metų) patirtį lanksčiu endoskopu šalinant svetimkūnius iš viršutinio virškinimo trakto. Galima teigti, kad kvalifikuoto specialisto atliekamas endoskopinis svetimkūnių šalinimas naudojant endoskopą su priedais: kilpa, krepšeliu ir žnyplėmis, yra efektyvus ir saugus būdas, lemiantis didelę procedūros sėkmę, ženkliai sumažinantis hospitalizacijos laiką ir chirurgijos (operacinio gydymo) poreikį.

Prospective analysis of the complications, efficacy, and satisfaction level on the sedation performed by anaesthetists in gastrointestinal endoscopy

Abstract Objective To describe the anaesthesia/sedation complications during gastrointestinal endoscopy, as well as comparing scheduled procedures versus urgent procedures. Methods A protocol was developed to define the anaesthesia/sedation in gastrointestinal endoscopy, where the anaesthetist should always be present. These include ASA 3 and 4 patients, complex tests such as polypectomies, endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound, deep sedation, or patients with probable difficult airway management. An analysis was made of the safety based on the complications recorded from the data directly collected automatically from the monitors, both during the sedation and in the recovery unit. An analysis was also performed on the risk factors associated with cardiorespiratory complications, the effectiveness based on the completed tests and the overall level of satisfaction through an interview using a satisfaction scale. Results The study included a total of 3746 patients over a 7 year-period. The incidence of major complications was low, especially haemodynamic and respiratory complications. An incidence of hypoxaemia of 3% was found in scheduled endoscopy versus 5.7% in urgent endoscopy (p Conclusion The participation of the anaesthetist in sedation for gastrointestinal endoscopy has shown excellent results in this study, in terms of safety and efficacy, mainly in the most serious patients and complex tests, as well as a high level of satisfaction.

Endoscopy Timing in Patients with Acute Upper Gastrointestinal Bleeding.

Background/AimsThe role of very early (≤12 hours) endoscopy in nonvariceal upper gastrointestinal bleeding is controversial. We aimed to compare results of very early and early (12–24 hours) endoscopy in patients with upper gastrointestinal bleeding demonstrating low-risk versus high-risk features and nonvariceal versus variceal bleeding. MethodsThis retrospective study included patients with nonvariceal and variceal upper gastrointestinal bleeding. The primary outcome was a composite of inpatient death, rebleeding, or need for surgery or intensive care unit admission. Endoscopy timing was defined as very early and early. We performed the analysis in two subgroups: (1) high-risk vs. low-risk patients and (2) variceal vs. nonvariceal bleeding.ResultsA total of 102 patients were included, of whom 59.8% underwent urgent endoscopy. Patients who underwent very early endoscopy received endoscopic therapy more frequently (p=0.001), but there was no improvement in other clinical outcomes. Furthermore, patients at low risk and with nonvariceal bleeding who underwent very early endoscopy had a higher risk of the composite outcome. ConclusionsVery early endoscopy does not seem to be associated with improved clinical outcomes and may lead to poorer outcomes in specific populations with upper gastrointestinal bleeding. The actual benefit of very early endoscopy remains controversial and should be further clarified.

Endoscopic Removal of Gastric Perforating Fish Bone

Introduction: A foreign body ingestion in adults is usually diagnosed by medical history. In most cases, the foreign body passes through the gastrointestinal tract uneventfully. Complications such as perforation are rare and usually occur in areas of angulation or narrowing such as the gastric antrum. We present a case of an unintentional perforating fish bone ingestion that was found incidentally on cross-sectional imaging and was managed endoscopically. Case description: A 51-year-old woman presented to the hospital for subacute upper abdominal pain. The patient described the pain as crampy, accompanied by waxing-waning nausea and dry heaves. She had melena 2 weeks prior, for which she underwent a colonoscopy and an EGD which revealed polyps that were removed endoscopically. Her prior surgical history included open nephrectomy for a right kidney swelling. On examination, the patient was afebrile, hemodynamically stable and in no apparent distress. Her abdomen was soft, non-distended with mild epigastric tenderness, and no guarding or rebound tenderness. Lab tests revealed a white cell count of 12,600/mm3 and hemoglobin of 13.1 g/dl. A CT scan of the abdomen revealed a 3.2 cm intramural curvilinear foreign body within the gastric antrum, with an associated thickened antrum and pylorus and no evidence of extra-luminal air or bowel obstruction. After further questioning, the patient reported having eaten fish 3 weeks ago and had a fish bone stuck in her throat, which she was able to cough out. An urgent upper endoscopy was performed - revealing a large fish bone perforating through the gastric incisura. An overtube was placed and the fish bone was removed using a rat tooth forceps. The defect was closed with an over-the-scope clip. The patient post-endoscopy course was uneventful and she was discharged home. Discussion: Since foreign body ingestion is usually uneventful, conservative treatment is warranted in the majority of cases. Complications are more likely with foreign bodies that are sharp such as fish bones. CT is the most sensitive in locating the causal fish bone, most often appearing as a high-density linear structure within inflamed tissue. In our case, the foreign body finding on abdominal CT and the history of ingested fish bone, raised a high index of suspicion for a perforating fish bone, indicating urgent endoscopic intervention. Fish bone migrating into solid organs or intraperitoneal areas would require surgical intervention.1865_A Figure 1. Abdominal CT1865_B Figure 2. No Caption available.1865_C Figure 3. Endoscopic clip

Glucagon Use During Endoscopy to Assist Push Technique in Food Impactions

Introduction: Esophageal food impactions are a common indication for urgent upper endoscopy. Preprocedural glucagon, given to relax esophageal smooth muscle, increase spontaneous bolus passage, and thus avoid the need for endoscopy, has been shown to have limited efficacy. Endoscopic therapies, including push and extraction techniques, are often challenging, prolonged, and associated with increased risk of complications. We aim to investigate the effectiveness of perioperative glucagon administration on the success rate of bolus advancement with simple push technique and its impact on procedural duration. Methods: A retrospective, single center, chart review was performed utilizing an electronic medical record over a three-year period selecting for patients age 18 or older with an ICD-9 code of 935.1 (foreign body in esophagus) who underwent an EGD. The measured outcomes were success rate, defined as advancement of food bolus into the stomach with gentle pressure without reduction of bolus size or retrograde extraction, and procedural time between two groups, with and without use of periprocedural glucagon. Results: 150 total patient encounters were identified, 53 of which were excluded due to spontaneous bolus passage, presence of a nonfood foreign body, missing data, suspected underlying dysmotility, or patient refusal of procedure. 97 patients remained in the study; 11 received perioperative glucagon based on physician preference. Glucagon use was associated with a higher success rate (73%) than without (67%), however this was not statistically significant (p=0.579) when controlled for age and gender. Mean procedure time was shorter in the glucagon group at 7.54 min vs 14.93 min in the control group, but did not reach statistical significance (p=0.077). All procedure related complications occurred in the non-glucagon group, but the small sample size precluded it reaching statistical significance. Conclusion: The use of perioperative glucagon trended with an increased success rate of esophageal food bolus advancement into the stomach, decreased procedural duration and lower procedural complications. Though these results were not found to be statistically significant in our small sample size, we feel they hold promise to support further research.498_A Figure 1 No Caption available.498_B Figure 2 No Caption available.498_C Figure 3 No Caption available.