Practical Gastrointestinal Endoscopy

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CHAPTER 3
during therapeutic procedures such as dilatation. This may be
dangerous in patients who are immunocompromised, and in
some with diseased heart valves and prostheses. Endoscopyinduced
endocarditis is extremely rare, but antibiotic prophylaxis
is advised in certain circumstances (see below).
ASSESSING AND REDUCING RISKS
Endoscopists are obliged to balance the potential risks against
the expected benefits before recommending procedures. Knowledge
of the risks determines the necessary precautions.
Certain comorbidities and medications clearly increase the
risk of endoscopic procedures. A checklist should be used to
ensure that all of the issues have been addressed. Some of this
information must be obtained when the procedure is scheduled,
since action is required days ahead of the procedure (e.g. adjusting
anticoagulants, stopping aspirin, etc.). Other aspects are
dealt with when the patient arrives in the preprocedure area.
• Cardiac and pulmonary disease. Patients with recent myocardial
infarction, unstable angina or hemodynamic instability are
obviously at risk from any intervention. Expert advice should
be sought from cardiologists. Endoscopy can be performed in
patients with pacemakers and artificial implantable defibrillators—but
the latter must be deactivated (with a supplied magnet)
if diathermy is performed. Anesthetic supervision is essential if
endoscopy is needed in such patients, and in others with respiratory
insufficiency.
• Coagulation disorders. Patients with a known bleeding diathesis
or coagulation disorder should have the situation normalized
as far as possible before endoscopy (particularly if biopsy or
polypectomy is likely). Anticoagulants can be stopped ahead
of time, and (if clinically necessary) replaced by heparin for the
period of the procedure, and early recovery. Certain antiplatelet
drugs may need to be stopped also. There is little evidence that
aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) increase
the risk of endoscopic procedures. However, it is common
practice to ask about these drugs, and to recommend that they be
discontinued for five days before endoscopic procedures.
• Sedation issues. Nervous patients and others who have had
prior problems with sedation can pose challenges for safe endoscopy.
If in doubt, use anesthesia.
• Endocarditis. The risk of developing endocarditis after upper
endoscopy procedures is extremely small, and there is no evidence
that antibiotic prophylaxis is beneficial. However, most
experts recommend prophylaxis for patients deemed to be at
increased risk for endocarditis (especially those with artificial
valves, previous proven endocarditis, recent vascular prostheses
and systemic–pulmonary shunts), particularly when they
are undergoing procedures known to provoke bacteremia (e.g.