Variceal and nonvariceal upper gastrointestinal bleeding (VUGIB and NVUGIB, respectively) require prompt intervention. Existing studies offer limited insight into the impact of interhospital transfers on patients with VUGIB and NVUGIB.

We conducted a retrospective study using the US National Inpatient Sample database from 2017 to 2020. The outcomes included in-hospital mortality, incidence of complications, procedural performance, and resource utilization.

A total of 28,275 VUGIB and 781,370 NVUGIB adult patients were included. Transferred VUGIB and NVUGIB patients, when compared to nontransferred ones, demonstrated higher inpatient mortality (adjusted odds ratio [AOR] 1.49 and 1.86, P < 0.05). Patients with VUGIB and NVUGIB had a higher likelihood of acute kidney injury requiring dialysis (AOR 3.79 and 1.76, respectively, P = 0.01), vasopressor requirement (AOR 2.13 and 2.37, respectively, P < 0.01), need for mechanical ventilation (AOR 1.73 and 2.02, respectively, P < 0.01), and intensive care unit admission (AOR 1.76 and 2.01, respectively, P < 0.01). Compared to their nontransferred counterparts, transferred VUGIB patients had a higher rate of undergoing transjugular intrahepatic portosystemic shunt (AOR 3.26, 95% CI 1.92-5.54, P < 0.01), while transferred NVUGIB patients had a higher rate of interventional radiology-guided embolization (AOR 2.01, 95% CI 1.73-2.34, P < 0.01) and endoscopic hemostasis (AOR 1.10, 95% CI 1.05-1.15, P < 0.01).

Interhospital transfer is associated with worse clinical outcomes and higher resource utilization for VUGIB and NVUGIB patients.

Background and study aims The utility of esophagogastroduodenoscopy (EGD) in the left lateral semi-recumbent position in the setting of acute upper gastrointestinal bleeding (UGIB) with a persistent fundal pool of blood for adequate visualization and effective endotherapy has not been studied. This study aimed to evaluate the feasibility, efficacy, and safety of this position in such settings. Patients and methods A prospective study of patients presenting with acute UGIB with an uncleared fundal pool of blood was conducted. All underwent EGD in the left lateral decubitus and secondary left lateral semi-recumbent positions. Outcomes in secondary position in terms of adequate visualization of the fundus, identification of new or additional sources of bleeding, and effectiveness of endotherapy were studied. Results We screened 860 patients and included 44 patients (5.11%) with a persistent fundal pool of blood. Endoscopy in the primary position revealed the source of bleeding in 37 of 44 patients (84%). The source of the bleeding was not identified in seven of 44 patients (16%). Endoscopy in the secondary position showed clearance of fundal pool in all 44 patients (100%). A new source of bleeding was identified in all seven patients (100%) and an additional source could be identified in another five patients (13.6%). Endotherapy was performed in the secondary position for all 44 patients with 100% technical success and 94% clinical success. Conclusions These data show that endotherapy in the left lateral semi-recumbent position is feasible, safe, and effective. It should be done when endoscopy in the left lateral decubitus position reveals a pool of blood in the fundus and there is inadequate visualization of the fundus.

Acute gastrointestinal bleeding (GIB) is associated with morbidity and mortality. There can be a low threshold for practitioners to assess for active GIB and computed tomography angiography (CTA) examinations are performed frequently, even for stable patients and those who are therapeutically anticoagulated. We aimed to assess the predictive value of CTA for acute GIB and the influence of CTA on treatment.

Retrospective single-centre study over a 2-year period.

A total of 227 patients with mean age 67.7 years (SD 17.86), 58.6% male. 84.4% were for lower GIB. 49 patients were on therapeutic anticoagulation (21.6%). 45 CTAs were positive (19.8%). 22 patients received embolisation, and 15 received acute endoscopic treatment. CTA sensitivity was 68.6% and specificity 89.1%. The PPV was 53.3% and NPV 93.9%. The odds ratio of a positive CTA requiring treatment for patients on therapeutic anticoagulation was 1.1 (P = 0.932) compared with the odds of patients not taking therapeutic anticoagulation 21.5 (P < 0.001). The risk ratio for requiring treatment if not taking anticoagulation was 6.2. A total of 19 patients (9.1%) met the definition of CI-AKI as a result of the CTA. A pre-existing eGFR of less than 20 was associated with significantly increased odds of developing CI-AKI (OR 3.95, P = 0.031, 95%CI 1.135-13.782).

The presence of anticoagulation has a significant impact on the decision not to perform interventional treatments on patients with acute GIB when CTA is positive. Anticoagulant reversal and volume resuscitation are important front-line measures, and CTA may have a role for those anticoagulated who are haemodynamically unstable after resuscitation.

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Chest pain experienced by patients with coronary artery disease can be partly due to gastroesophageal reflux-induced chest pain (GERP). Empirical proton pump inhibitor (PPI) therapy has been recommended as an initial clinical approach for treating GERP. However, PPI use may lead to some health problems. The Gastroesophageal Reflux Disease Questionnaire (GerdQ) may represent a noninvasive and cost-effective approach for avoiding PPI misuse and for identifying the appropriate patients for the PPI trial test. The aim of this pilot study was to prospectively evaluate the association between GerdQ scores and PPI response in patients with coronary artery disease (CAD) and GERP to determine whether the GerdQ predicts the PPI response in patients with CAD and GERP and to further validate the clinical application value of the GerdQ. A total of 154 consecutive patients with potential GERP were recruited to complete a GerdQ with subsequent PPI therapy. Based on the PPI trial result, patients were divided into a PPI-positive response group and a PPI-negative response group. The difference in the GerdQ scores between the two groups was assessed. The receiver operating characteristic (ROC) curve of GerdQ score was drawn according to the PPI response as the gold standard. The ability of GerdQ to predict the PPI response was assessed. A total of 96 patients completed the entire study; 62 patients (64.6%) were assigned to the PPI-positive response group, and 34 patients (35.4%) to the PPI-negative response group. The GerdQ score of the PPI-positive response group (8.11 ± 3.315) was significantly higher than that of the PPI-negative response group (4.41 ± 2.743), and the difference was statistically significant (t = 5.863, P = 0.000). The ROC curve was drawn according to a PPI response assessment result with a score above 2 as the gold standard. The area under curve was 0.806. When the critical value of GerdQ score was 7.5, Youden index was up to 0.514, the diagnostic sensitivity was 0.661, and the diagnostic specificity was 0.853. A GerdQ score greater than 7.5 better predicts the response to the PPI trial therapy. There is a strong association between the GerdQ score and the response to PPI therapy. Higher GerdQ scores were predictive of a positive PPI response in CAD patients with GERP. The GerdQ may be a reasonable screening tool for GERP in patients with CAD who are prepared to accept PPI therapy.

To compare the effect of endoscopic variceal ligation (EVL) with that of endoscopic injection sclerotherapy (EIS) in the treatment of patients with esophageal variceal bleeding.

We performed a systematic literature search of multiple online electronic databases. Meta-analysis was conducted to evaluate risk ratio (RR) and 95% confidence interval (CI) of combined studies for the treatment of patients with esophageal variceal bleeding between EVL and EIS.

Fourteen studies comprising 1236 patients were included in the meta-analysis. The rebleeding rate in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR=0.68, 95%CI: 0.57-0.81). The variceal eradication rate in actively bleeding varices patients in the EVL group was significantly higher than that in the EIS group (RR=1.06, 95%CI: 1.01-1.12). There was no significant difference about mortality rate between the EVL group and EIS group (RR=0.95, 95%CI: 0.77-1.17). The rate of complications in actively bleeding varices patients in the EVL group was significantly lower than that in the EIS group (RR=0.28, 95%CI: 0.13-0.58).

Our meta-analysis has found that EVL is better than EIS in terms of the lower rates of rebleeding, complications, and the higher rate of variceal eradication. Therefore, EVL is the first choice for esophageal variceal bleeding.

An 80-year-old woman was referred to our hospital for the treatment of advanced gastric cancer which extended from the antrum to the bulbus of the duodenum. Although the patient did not struggle or retch during endoscopy, multiple mucosal lacerations were observed in the proximal stomach by Mallory-Weiss tears. No evidence of perforation was identified at the sites. The day after endoscopy, computed tomography revealed free air close to the gastric cardia, but the patient did not complain of any symptoms; she was able to consume a normal diet and did not require any treatment.

The management of patients with acute myocardial infarction (AMI) and upper gastrointestinal bleeding (UGIB) can present a challenge. The utility of upper endoscopy (esophagogastroduodenoscopy, EGD) and endoscopic therapy must be weighed against safety considerations.

To assess the utility and safety of EGD in patients with UGIB and AMI.

Using decision analysis, patients with UGIB and AMI were assigned to one of two strategies: (1) EGD prior to cardiac catheterization (EGD strategy) and (2) cardiac catheterization without EGD (CATH strategy).

In patients with overt UGIB, the EGD strategy resulted in 97 deaths per 10,000 patients, compared with 600 deaths in the CATH strategy. The EGD strategy resulted in fewer non-fatal complications (1,271 vs. 6,000 per 10,000 patients). In patients with occult blood loss, the EGD strategy resulted in more deaths (59 vs. 16 per 10,000) and more non-fatal complications (888 vs. 160 per 10,000) than the CATH strategy.

Our analysis supports EGD prior to cardiac catheterization in patients with AMI and overt UGIB. This strategy results in fewer deaths and complications compared with a strategy of proceeding directly to catheterization. Our analysis does not support routine EGD prior to cardiac catheterization in patients with fecal occult blood.

Routine endoscopic mucosal biopsies are generally considered safe. However, the outcomes of performing large numbers of biopsies in subjects enrolled in research protocols have not been reported.

Our purpose was to assess the safety of taking numerous mucosal biopsy specimens during endoscopic procedures (eg, >20/endoscopic procedure) in research subjects.

Single-center retrospective chart review.

Research hospital: National Institutes of Health (NIH) Clinical Center.

Volunteers who underwent research protocol endoscopies with large numbers of biopsies during 2001 to 2008 at the NIH.

Charts were reviewed for the occurrence of procedure-related major/minor complications.

A total of 253 research endoscopies were performed on 133 patients: 169 colonoscopies, 64 sigmoidoscopies, and 20 upper endoscopies. A total of 9,661 biopsy specimens were obtained for research and histopathologic examination (mean 38.2 +/- 15.6 per procedure). No major complications were identified. Minor complications occurred with 13 (5.1%) lower endoscopic procedures and included self-limited bleeding (4), pain (5), or both (4). There was no statistically significant association between the number of biopsies, type of procedure, location of research biopsies, operator, polypectomy, or the use of nonsteroidal anti-inflammatory drugs and the risk of complications.

Retrospective design, modest sample size.

This is the first report on the safety of performing large numbers of endoscopic biopsies in research subjects. This practice is well tolerated and appears to have no more than minimal risk without appreciably increasing the risk of otherwise routine endoscopy.

Gastrointestinal bleeding affects a substantial number of elderly people and is a frequent indication for hospitalization. Bleeding can originate from either the upper or lower gastrointestinal tract, and patients with gastrointestinal bleeding present with a range of symptoms. In the elderly, the nature, severity, and outcome of bleeding are influenced by the presence of medical comorbidities and the use of antiplatelet medication. This Review discusses trends in the epidemiology and outcome of gastrointestinal bleeding in elderly patients. Specific causes of upper and lower gastrointestinal bleeding are discussed, and recommendations for approaches to endoscopic diagnosis and therapy are given.

Variceal hemorrhage (VH) is a lethal complication of portal hypertension. Aspiration occurring during endoscopic intervention for acute VH is a concern; however, few data exist regarding the efficacy of prophylactic intubation to prevent aspiration pneumonia. We reviewed all endoscopic procedures for acute VH from January 1995 to December 2002; only patients with the absence of hepatic encephalopathy greater than stage II and normal chest x-ray at admission were included. The use of prophylactic intubation, post-procedure chest x-ray, and mortality were recorded. Sixty-two patients (69 bleeding episodes) were identified. Elective intubation was performed in 42 patients (47 episodes); pulmonary infiltrates developed in 7 of 42 (17%), with an overall mortality rate of 9 of 42 (21%). Twenty patients (22 episodes) were not intubated. None developed pulmonary infiltrates, and the overall mortality rate was 1 in 20 (5%). We conclude that in patients with suspected variceal bleeding, elective intubation is associated with a substantial risk of aspiration pneumonia.

Pulmonary aspiration is a life-threatening complication of upper gastrointestinal endoscopy, the incidence of which has not been determined. Endoscopy-related aspiration has not been studied in procedures in which patients swallow a radiolabelled potential aspirate immediately before endoscopy and undergo nuclear scanning postprocedure.

A pilot study was conducted in which 200 MBq of nonabsorbable technetium-99m phytate in 10 mL of water was administered orally to 50 patients who were about to undergo endoscopy. Gamma camera images were obtained to ensure that there had been no aspiration before endoscopy. After endoscopy, a repeat scan was performed. Fluid aspirated through the endoscope was also collected and analyzed for radioactivity using a hand-held radiation monitor.

No evidence of pulmonary aspiration was found in any of the patients studied. The mean estimated percentage of the initially administered radioactivity aspirated through the endoscope was 2.66% (range 0% to 10.3%).

The present pilot study confirms earlier observations that clinically significant aspiration in the context of upper gastrointestinal endoscopy is uncommon. The incidence of aspiration may, however, be different in acutely bleeding patients undergoing endoscopy. For logistic reasons, this group could not be studied.

The demand for information on quality in health care has risen sharply over the past decade. Endoscopic outcomes, including complication rates, need to be accurately measured and reported. Such documentation continues to be problematic because of the lack of a widely accepted classification system for endoscopic complications. Such a system should (1) include unequivocal definitions for the various types of negative outcomes and categories of complications; (2) define what negative outcomes are to be classified as complications, and (3) standardize the stratification of complications by severity. Establishing such a standardized classification of endoscopic complications could facilitate clinical research, improve the position of gastroenterologists vis-à-vis pay-for-performance programs, and result in better and more meaningful quality improvement programs, ultimately improving the care provided to patients.

Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal risks from endoscopy. Before endoscopy, the gastroenterologist or anesthesiologist should evaluate the potential fetal risks of sedation and analgesia, identify any contraindications to endoscopy, stabilize the maternal medical status as necessary, and correct maternal hypoxia or hypotension. The mother should be informed about the potential teratogenic risks of endoscopic medications during pregnancy. Patients who receive sedation and analgesia should be monitored during endoscopy by continuous electrocardiography, continuous pulse oximetry, and intermittent sphygmomanometry, as well as by the pulse and respiratory rate. General principles of sedation and analgesia during pregnancy include use of the minimal effective dose, avoidance of unnecessary medications, and preferable use of Food and Drug Administration category B medications.

More than 12,000 pregnant patients in the United States per annum have conditions that are normally evaluated by EGD. More than 6000 pregnant patients in the United States per annum have conditions that are normally evaluated by sigmoidoscopy or colonoscopy. About one thousand more have symptomatic choledocholithiasis during pregnancy, which is a strong indication for endoscopic sphincterotomy in nonpregnant patients. Endoscopy during pregnancy raises the unique issue of fetal safety. Endoscopic medications comprise a significant component of fetal endoscopic risks. Safety of EGD during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and 28 case reports. Safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 46 patients, a mailed survey of 13 patients, and 10 case reports. Safety of therapeutic ERCP during pregnancy has been analyzed in studies of 23, 10, 6, and 5 patients, and in 32 case reports. These studies suggested that EGD, sigmoidoscopy, and ERCP should be performed when strongly indicated: EGD for significant upper gastrointestinal bleeding, sigmoidoscopy for nonhemorrhoidal rectal bleeding, and ERCP for symptomatic choledocholithiasis when sphincterotomy is contemplated. PEG and colonoscopy are currently considered experimental during pregnancy because of insufficient data on fetal safety. Several cases of PEG and colonoscopy were successfully performed during pregnancy. Performance of endoscopy during pregnancy should increase with further technical refinements, and greater awareness of procedure safety.

Aspiration of blood may cause significant morbidity during emergent endoscopy for severe upper GI bleeding. Endotracheal intubation is widely performed for airway protection in this setting, but there are few data regarding its efficacy.

Outcomes were compared for intensive care unit patients with upper GI bleeding for 1 year (1988) during which prophylactic endotracheal intubation was seldom performed before endoscopy, with outcomes during a subsequent year (1992) in which endotracheal intubation was routine for airway protection before or during EGD when there was hematemesis, altered mentation, unstable cardiopulmonary status, or large amounts of blood in the proximal GI tract, or before endoscopic treatment of lesions at high risk for bleeding.

Background variables were similar for intensive care unit patients in 1988 (n = 101) and 1992 (n = 119) with respect to number of patients who had shock (respectively, 66.3% vs. 67.2%), cirrhosis (34.7% vs. 38.6%), variceal/portal hypertensive bleeding (22.8% vs. 33.6%), and endoscopic therapy (37.6% vs. 42.0%). Although use of endotracheal intubation specifically for EGD increased significantly between 1988 and 1992 (3.0% vs. 15.1%; p < 0.05), there were no significant changes in endotracheal intubation at any time during hospitalization (24.8% vs. 28.6%), in all EGD-related cardiopulmonary complications (5.0% vs. 3.4%), in new pulmonary infiltrates after EGD (12.9% vs. 15.1%), in mean number of intensive care unit days (7.1 vs. 6.4), or in mortality (15.9% vs. 11.8%). New infiltrates developed in 10 (48%) of 21 patients after EGD despite endotracheal intubation specifically for airway protection. However, in 1992 there were no fatal episodes of aspiration during EGD (2.0% vs. 0%; p = 0.21), no emergent post-EGD endotracheal intubation (6.0% vs. 0%; p < 0.05), and fewer in-hospital cardiopulmonary arrests (12.9% vs. 5.0%; p < 0.05).

Frequent use of endotracheal intubation for airway protection during EGD for upper GI bleeding requiring intensive care unit admission did not significantly change the relatively high frequency of acquired pneumonia or cardiopulmonary events, but may have prevented the rare fatal episode of massive aspiration. Endotracheal intubation may benefit selected patients with upper GI bleeding, but its specific role remains unclear, and alternative methods of airway protection should be investigated.

Esophagogastroduodenoscopy has revolutionized the clinical management of upper gastrointestinal diseases. Millions of EGDs are performed annually in the United States for many indications, such as gastrointestinal bleeding, abdominal pain, dysphagia, or surveillance of premalignant lesions. Esophagogastroduodenoscopy is very safe, with a low risk of serious complications such as perforation, cardiopulmonary arrest, or aspiration pneumonia. It is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Esophagogastroduodenoscopy is increasingly being used therapeutically to avoid surgery. New endoscopic technology such as endosonography, endoscopic sewing, and the endoscopic videocapsule will undoubtedly extend the frontiers and increase the indications for endoscopy.

The prognosis of GI bleeding depends upon many factors. Patients should be evaluated carefully for risk factors. To avoid complications from GI bleeding, triage should be performed promptly after patient presentation. The history and physical examination should emphasize analysis of risk factors for severe GI bleeding and mortality. Factors that increase the morbidity and mortality include: age greater than 60 years; underlying comorbidity such as pulmonary diseases, liver diseases, renal diseases, encephalopathy, or cancer; physiologic stress from major surgery, trauma, or sepsis; coexisting disease in three organ systems; low hematocrit; melena or hematochezia; and prolonged prothrombin time. Hospitalized patients who require more than five units of packed erythrocytes transfusion or who develop hypotension or hypovolemic shock are more likely to need surgery. Patients with a high APACHE II score, the presence of esophageal varices, active bleeding, or other endoscopic stigmata of recent hemorrhage are more likely to rebleed and undergo surgery. The proliferation of multivariable prognostic scales, as described herein, provides ample evidence that the goal of developing a single comprehensive multivariable scale to accurately assess severity of disease and to determine prognosis of GI bleeding is still not achieved. Yet significant progress has occurred in this field, leading to the hope of developing a universally applicable multivariable scale.

Therapeutic gastrointestinal endoscopy has a much greater risk of inducing gastrointestinal hemorrhage than diagnostic endoscopy. For example, colonoscopic polypectomy has a risk of approximately 1.6% of inducing bleeding, compared with a risk of approximately 0.02% for diagnostic colonoscopy. Higher-risk procedures include colonoscopic polypectomy, endoscopic biliary sphincterotomy, endoscopic dilatation, endoscopic variceal therapy, percutaneous endoscopic gastrostomy, and endoscopic sharp foreign body retrieval. The risk of inducing hemorrhage is decreased by meticulous endoscopic technique. Hemorrhage from endoscopy may be immediate or delayed. Immediate hemorrhage should be immediately treated by endoscopic hemostatic therapy, including injection therapy, thermocoagulation, or electrocoagulation. Delayed hemorrhage generally requires repeat endoscopy for diagnosis and for therapy, using the same hemostatic techniques.

To analyze the risks versus benefits of esophagogastroduodenoscopy performed soon after myocardial infarction.

We studied 200 patients who underwent endoscopy within 30 days after myocardial infarction with 200 controls matched for age, sex, and endoscopic indication who underwent endoscopy without a history of myocardial infarction within the prior 6 months. Odds ratios (OR) and 95% confidence intervals (CI) are reported.

The indications for endoscopy included hematemesis in 88, melena in 43, fecal occult blood and anemia in 33, red blood per rectum in 13, abdominal pain in 13, and other indications in 10. Endoscopy was performed a mean (+/- SD) of 9.1 +/- 8.9 days after myocardial infarction, was diagnostic in 85% of all the patients, and was more frequently diagnostic when performed for hematemesis or melena than when performed for other indications (92% vs 71%, P <0.0003). Common diagnoses included duodenal ulcer, gastric ulcer, gastritis, and esophagitis. Fifteen post-myocardial infarction patients (7.5%) suffered endoscopic complications, including fatal ventricular tachycardia (n = 1), near respiratory arrest (n = 1), mild hypotension (n = 11), and moderate hypoxemia (n = 2), compared with three patients (1.5%) in the control group (OR = 5.3, CI = 1.5 to 19). Patients who had endoscopic complications after myocardial infarction had a significantly higher APACHE II score than those who did not (mean score of 17.3 +/- 5.8 vs 11.7 +/- 5.7, P <0.001). Endoscopic complications occurred in 21% (12 of 58) of post-myocardial infarction patients who were very ill (APACHE II score > or = 16) but in only 2% (3 of 142) of those whose condition was relatively stable (APACHE II score < or = 15, OR = 12; CI = 3.3 to 45). Hypotension before endoscopy and a high APACHE II score were independent risk factors for complications in post-myocardial infarction patients.

Relatively stable patients with upper gastrointestinal bleeding and recent myocardial infarction can and should undergo esophagogastroduodenoscopy. Most endoscopic complications in these patients are cardiopulmonary, and they generally occur in very ill patients.

The effectiveness of upper endoscopy in unselected patients with upper gastrointestinal hemorrhage has not been well studied. This study was undertaken to identify factors associated with the performance of early endoscopy (ie, within 1 day of hospitalization) and, after adjusting for these factors, to determine associations between early endoscopy and in-hospital mortality, length of stay, and performance of surgery.

Subjects in this observational cohort study were 3,801 consecutive admissions with upper gastrointestinal hemorrhage to 30 hospitals in a large metropolitan region. Demographic and clinical data were abstracted from hospital records. A multivariable model based on factors that potentially could relate to the decision to perform endoscopy was developed to determine the propensity (0 to 100%) for early endoscopy in each patient.

Early endoscopy was performed in 2,240 patients (59%), and although it was not associated with mortality after adjusting for severity of illness among all patients, it was associated with a higher risk of death for patients in the lowest propensity group. Early endoscopy was associated with a lower likelihood of upper gastrointestinal surgery in all patients and in the two highest propensity groups and with a shorter length of stay in the entire cohort and in all subgroups.

In the absence of specific contraindications, early endoscopy should be considered because of associated reductions in length of stay and surgical intervention. Further studies are needed to identify subgroups in whom the procedure may be associated with adverse effects on survival.

More than 12,000 pregnant patients in the United States per year have conditions normally evaluated by esophagogastroduodenoscopy (EGD). More than 6000 pregnant patient in the United States per year have conditions normally evaluated by sigmoidoscopy or colonoscopy. Endoscopy during pregnancy raises the unique issue of fetal safety, and endoscopic medications comprise a significant component of fetal risks from endoscopy. This article analyzes the safety of endoscopic medications during pregnancy, reviews the literature on the safety of gastrointestinal endoscopy during pregnancy, proposes guidelines for endoscopic indications during pregnancy, and describes modifications of gastrointestinal endoscopy during pregnancy to increase fetal and maternal safety.

Every available means to insure the safety of patients during endoscopic procedures is mandatory. This begins with a fully trained and knowledgeable endoscopist, thorough preparation of the unit to handle endoscopic procedures and potential adverse outcomes, appropriate patient preparation, skilled assistants, and monitoring of the patient's well-being before, during and after the procedure. The relative risks involved can be estimated from patient and procedural factors and should be determined for each procedure. The level and type of monitoring during endoscopic procedures is dependent upon a thorough understanding and assessment of the risk to the patient. Monitoring of patients undergoing endoscopic procedures is mandatory and prudent. The ultimate responsibility for protecting patients lies with the endoscopist and cannot be assigned to an assistant or electronic monitoring device. However, both may greatly improve the ability to detect patient distress at a time when intervention will prevent an otherwise adverse outcome.

The risks versus benefits of flexible sigmoidoscopy and colonoscopy performed within three weeks of myocardial infarction were studied in nine consecutive patients who underwent sigmoidoscopy and in nine consecutive patients who underwent colonoscopy at two university hospitals. Indications for sigmoidoscopy were red blood per rectum in seven and occult blood in the stools in two. Sigmoidoscopy provided the diagnosis in three, including colon cancer in two and bleeding internal hemorrhoids in one, and provided helpful information in three. Sigmoidoscopy led to colon cancer surgery in two patients, and polypectomy of a 1-cm adenoma in one. Of two highly unstable patients before sigmoidoscopy, one developed second-degree heart block and frequent premature ventricular contractions 3 hr after sigmoidoscopy. No sigmoidoscopic complications occurred in the seven relatively clinically stable patients. Indications for colonoscopy included red blood per rectum in five, occult blood in the stools in three, and melena in one. Colonoscopy provided the diagnosis in five, including one each with colon cancer, internal hemorrhoids, large adenoma, ischemic colitis, and angiodysplasia. Colonoscopy resulted in colon cancer surgery in one patient and endoscopic polypectomies in three patients. Of two moderately unstable patients before colonoscopy, one developed asymptomatic bradycardia during colonoscopy. No colonoscopic complications occurred in the seven clinically stable patients. This study suggests that recent myocardial infarction is not an absolute contraindication to sigmoidoscopy or colonoscopy, that sigmoidoscopy is beneficial in medically stable patients with significant gastrointestinal bleeding, and that colonoscopy may be beneficial in selected, highly stable patients with significant gastrointestinal bleeding.(ABSTRACT TRUNCATED AT 250 WORDS)

About 30% to 35% of patients with portal hypertension bleed from gastroesophageal varices and mortality remains high reflecting the challenges of effectively dealing with the bleeding event itself and the problems of underlying liver disease. Careful resuscitation and control of risk of complications is the most essential element of medical therapy (Fig. 2). Use of newer, more effective drug combinations with vasopressin or somatostatin permit control of hemorrhage in the majority of patients with fewer drug-induced complications. Endoscopic sclerotherapy and, more recently, banding therapy provide immediate control of hemorrhage and eradication of varices and rebleeding in up to 90% of patients. Persistent, recurrent bleeding in the small number of remaining patients can be effectively managed by "portacaval shunt rescue" or orthotopic liver transplantation in selected cases with acceptable surgical morbidity and mortality. The contribution and role of the TIPS procedure is unknown but very promising; at least as a bridge procedure in patients awaiting transplantation. Until appropriate prospective, comparative trials are performed, the role of TIPS as a long-term alternative to portacaval shunt surgery or other endoscopic or surgical options remains unknown.

We investigated 610 endoscopy-associated and 486 gastroenterology-associated malpractice claim files of the Physicians Insurers Association of America data-sharing project. We determined the relative malpractice claim risk for each of the major types of endoscopic procedures by comparing claim frequencies with Medicare performance frequencies. Relative malpractice risks were 1.0 for sigmoidoscopy, 1.2 for esophagogastroduodenoscopy, 1.6 for endoscopic retrograde cholangiopancreatography, and 1.7 for colonoscopy. "Improper performance" was alleged in 54% of claims and "diagnosis error" in 24% of claims. Of 121 claim files alleging a diagnostic error, 74 (61%) pertained to missed malignancies, of which 69% were colorectal. Of 147 claims alleging iatrogenic injury, 140 (95%) involved perforation or similar direct injury to the gastrointestinal tract. Problems with consent were alleged in 44% of 158 endoscopy-related claim files alleging additional associated issues.

Endoscopic esophageal variceal sclerotherapy (EVS) is often used in the treatment of upper gastrointestinal hemorrhage due to esophageal varices. We retrospectively reviewed the Mayo Clinic experience with EVS between 1980 and 1989 to determine the incidence of thoracic manifestations and chest roentgenographic abnormalities associated with this procedure. The study population consisted of 223 patients who underwent 390 EVS procedures. In all patients, chest roentgenography was done before and after EVS. Ethanolamine oleate or tetradecyl sulfate was used as the sclerosant. Fever, chest pain, and odynophagia were frequent findings after EVS and tended to be short-lived. Local complications at the site of injection, such as esophageal perforation (in 1% of EVS procedures) and abscess (in 0.3%), were infrequent but associated with substantial mortality. Esophageal stricture was noted as a late complication in less than 10% of patients, and clinically recognized aspiration pneumonitis was rare. Respiratory insufficiency developed after 14 EVS procedures. Chest roentgenographic abnormalities, which were commonly detected (after 85% of EVS procedures) but were rarely of clinical significance, included retrocardiac or mediastinal widening or densities (in 35%), pleural effusions (in 27%), atelectasis (in 12%), and pulmonary infiltrates (in 9%). Most thoracic manifestations after EVS are likely due to a local inflammatory response to the sclerosant.

Endoscopic variceal sclerotherapy (EVS) is an effective means of controlling variceal hemorrhage, which develops as a consequence of portal hypertension. While esophageal perforation, ulceration, strictures, and mediastinitis are potential complications associated with this procedure, it is not clear whether isolated pleuropulmonary events such as pleuritis, pneumonitis, and adult respiratory distress syndrome are causally related to the EVS. Endoscopy and sedation with the attendant risk of aspiration, particularly in the background of hepatic encephalopathy, may account for some of these events. Recent controlled studies of respiratory function demonstrate that EVS as such results in minor changes in gas exchange, lung volumes, and pulmonary and systemic hemodynamics. Most pulmonary complications have been reported with the use of sodium morrhuate sclerosant. Comparative studies among different sclerosants are necessary to evaluate relative safety. Finally, there have been rare reports of myocardial ischemia and pericarditis reported in association with EVS, but these are of a transient nature. Chest symptoms, roentgenographic pleuropulmonary changes, pulmonary hemodynamics, and cardiac perturbations are transient and should not preclude offering EVS to patients with variceal hemorrhage.

Arterial blood oxygen desaturation and abnormal electrocardiographic changes have been reported in adults undergoing upper gastrointestinal endoscopy. We studied 32 infants and children less than 12 years of age using pulse oximetry and continuous electrocardiography before, during, and after upper gastrointestinal endoscopy performed under intravenous sedation. Sinus tachycardia was the most common electrocardiographic change, and no clinically significant electrocardiographic abnormalities were induced by the procedure. Desaturation to less than or equal to 90% was found in 37.5% of the patients and was most commonly noted during the endoscopy procedure and in patients with cardiopulmonary disease. The desaturation was unpredictable because there was no correlation between desaturation and medication, tolerance to the procedure, weight, or age of the child. Some patients who subjectively appeared to tolerate the procedure well had significant desaturation. The use of pulse oximetry should be considered for all children undergoing upper gastrointestinal endoscopy.

Considerable progress has been made in endoscopic hemostasis. Several methods are available. Sclerotherapy of esophageal varices is the procedure of choice for the control of active variceal hemorrhage and for the prevention of recurrent bleeding. For endoscopic treatment of nonvariceal gastrointestinal bleeding, the nonerosive contact probes (heater probes and BICAP) and injection sclerotherapy are preferred. Several hemostatic modalities should be available and applied depending on the anatomic location and type of bleeding lesions. Advanced endoscopic hemostatic techniques seem to be decreasing the mortality rates in patients with upper gastrointestinal bleeding.

Various strategies can be used in the diagnosis of upper gastrointestinal tract bleeding. This study investigates the relevance of anamnestic and clinical findings for the diagnosis of the bleeding source. The authors introduced a computer-aided diagnostic system using Bayes' theorem and compared it with clinicians' predictions using anamnestic and clinical findings only. There was no difference in the overall accuracy rates, but a difference was observed in the diagnostic behaviors of the two "systems." In addition, the discriminatory ability of the computer-aided system, the sharpness of the predictions obtained, and the reliability of the posterior probabilities were analyzed. It is concluded that the clinician and the computer-aided system are not able to discriminate well between the disease categories. Derived classification matrices and probability-based measures show the reasons for the inadequacy of diagnostic information obtainable from the clinical history and physical findings.