Endoscopy: Transoral (Upper) Endoscopy – Complications

Complications

Esophageal Perforation

  • Upper Endoscopy is the Most Common Cause of Esophageal Perforation
  • Risk:
    • Pneumatic Dilation for Achalasia: 2-6% (Highest Risk)
    • Stricture Dilation: 0.09-2.2%
    • Sclerotherapy: < 1%
    • Diagnostic Endoscopy with a Rigid Endoscope: 0.11%
    • Diagnostic Endoscopy with a Flexible Endoscope: 0.03%
  • Diagnosis/Treatment:

Bleeding

  • Risks:
    • Sphincterotomy
    • Endoscopic Mucosal Resection
    • Esophageal Dilation
    • Percutaneous Endoscopic Gastrostomy (PEG) Placement
  • Severity:
    • Mild: Clinical Evidence (Not Just Endoscopic) with Hgb Drop < 3 g/dL without Transfusion
    • Moderate: Transfusion ≤ 4 Units without Any Angiographic or Surgical Intervention
    • Severe: Transfusion ≥ 5 Units or Requiring Angiographic or Surgical Intervention
  • ERCP Bleeding Prevention:
    • Use Blended Mode for Sphincterotomy (Compared to Pure-Cut)
    • Prophylactic Injection of Hypertonic Saline-Epinephrine Proximal to the Papilla
    • Consider Endoscopic Papillary Large-Balloon Dilation (EPLBD) without Sphincterotomy for Coagulopathic Patients at Increased Risk
  • Treatment:
    • Initial: Endoscopic Therapy
      • Dilute Epinephrine Injection
      • Electrocautery
      • Endoscopic Clips
      • Balloon Tamponade
    • If Refractory: Angiographic Embolization or Surgery
      • Equally Effective – Angiography Generally Preferred if Available

Infection

  • Cholangitis
  • Cholecystitis
  • Rarely Hepatitis B & Hepatitis C Have Been Seen Due to Breaches in Disinfection Protocol

Post-ERCP Pancreatitis (PEP)

  • Risk: 9.7% – Most Common Complication After ERCP
  • Risk Factors:
    • Patient-Related:
      • History of Post-ERCP Pancreatitis
      • Female Sex
      • History of Recurrent Pancreatitis
      • Suspected Sphincter of Oddi Dysfunction
      • Younger Age (< 40 Years)
      • Absence of Chronic Pancreatitis
      • Normal Serum Bilirubin
    • Procedure-Related:
      • Difficult Cannulation (> 10 Attempts)
      • Repetitive Pancreatic Guidewire Cannulation
      • Pancreatic Injection
      • Pancreatic Sphincterotomy
      • Endoscopic Papillary Large-0Balloon Dilation of an Intact Sphincter
    • Diagnostic Procedure (vs Therapeutic)
  • Prevention:
    • Pancreatic Duct Stenting
      • Decreases Risk but Requires Later Removal After 1-2 Weeks
      • Generally Used Only in High-Risk/Difficult Cases (Not Routinely)
    • Rectal NSAID’s (Indomethacin)
      • Decreases Risk of PEP
      • Oral NSAID’s Have Not Demonstrated the Same Effect
  • Treatment: Supportive Management