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Iatrogenic Complications in Five Patients with Upper Gastrointestinal Bleeding due to Ambient Air: Case Series and Literature Review.

Manser CN, Bauerfeind P, Gubler C - Case Rep Gastroenterol (2012)

Bottom Line: Two rumenocenteses and consecutively three laparotomies had to be performed in three patients.In the other two, gastroscopies had to be stopped for an emergency computed tomography.All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air.

View Article: PubMed Central - PubMed

Affiliation: Clinic of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital, Zurich, Switzerland.

ABSTRACT
Despite the increasing use of carbon dioxide for endoscopies during the last years, ambient air is still used. The amount of air depends on several factors such as examination time, presumable diameter of the endoscope channel and of course active use of air by the operator. Although endoscopic complications due to ambient air in the gastrointestinal (GI) tract are a rare observation and mostly described in the colon, we report five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer. Due to insufflation of inadequate amounts of air through the endoscope channel, all patients deteriorated in circulation and ventilation. Two rumenocenteses and consecutively three laparotomies had to be performed in three patients. In the other two, gastroscopies had to be stopped for an emergency computed tomography. All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air. Therefore in emergency situations, endoscopies should be performed with either submersion, low air flow pumps or even better by the use of carbon dioxide.

No MeSH data available.


Related in: MedlinePlus

Endoscopic images of patient 4 show: a A large duodenal ulcer with hematin (asterisks) in the first endoscopy. b Major papilla with larger amounts of blood in the second endoscopy. c Clip in situ on one of the ulcers, coagula in the second endoscopy.
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Figure 3: Endoscopic images of patient 4 show: a A large duodenal ulcer with hematin (asterisks) in the first endoscopy. b Major papilla with larger amounts of blood in the second endoscopy. c Clip in situ on one of the ulcers, coagula in the second endoscopy.

Mentions: A 78-year-old patient, who was hospitalized due to tachycardic atrial fibrillation and aortocoronary bypass surgery, developed upper GI bleeding on hospital day 9. Two large duodenal ulcers were diagnosed (fig. 3a). Despite ulcer treatment with endoclips as well as proton pump inhibitor therapy, the patient again developed a bleeding leading to another upper endoscopy 6 days after the first endoscopy. Despite revealing an in situ present clip on one of the duodenal ulcers, the endoscopy showed large amounts of blood and coagula in the duodenum (fig. 3b, c). The site of bleeding, however, could not be located. Within a few minutes, increasing difficulties in the patient's mechanical ventilation occurred, and increasing norepinephrine requirement from 10 to 50 μg/kg/min made an emergency treatment by rumenocentesis necessary. The immediately performed emergency surgery revealed a massive distension with several serosal disruptions of stomach, small intestine and colon. A resection of the antrum and pars I duodeni with Billroth II reconstruction had to be done due to perforation into the omentum majus. Three days later a hemicolectomy was necessary due to persisting colon distension and serosal disruptions. Due to chronic renal insufficiency recovery was delayed and the patient was dismissed 2 months later.


Iatrogenic Complications in Five Patients with Upper Gastrointestinal Bleeding due to Ambient Air: Case Series and Literature Review.

Manser CN, Bauerfeind P, Gubler C - Case Rep Gastroenterol (2012)

Endoscopic images of patient 4 show: a A large duodenal ulcer with hematin (asterisks) in the first endoscopy. b Major papilla with larger amounts of blood in the second endoscopy. c Clip in situ on one of the ulcers, coagula in the second endoscopy.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC3362206&req=5

Figure 3: Endoscopic images of patient 4 show: a A large duodenal ulcer with hematin (asterisks) in the first endoscopy. b Major papilla with larger amounts of blood in the second endoscopy. c Clip in situ on one of the ulcers, coagula in the second endoscopy.
Mentions: A 78-year-old patient, who was hospitalized due to tachycardic atrial fibrillation and aortocoronary bypass surgery, developed upper GI bleeding on hospital day 9. Two large duodenal ulcers were diagnosed (fig. 3a). Despite ulcer treatment with endoclips as well as proton pump inhibitor therapy, the patient again developed a bleeding leading to another upper endoscopy 6 days after the first endoscopy. Despite revealing an in situ present clip on one of the duodenal ulcers, the endoscopy showed large amounts of blood and coagula in the duodenum (fig. 3b, c). The site of bleeding, however, could not be located. Within a few minutes, increasing difficulties in the patient's mechanical ventilation occurred, and increasing norepinephrine requirement from 10 to 50 μg/kg/min made an emergency treatment by rumenocentesis necessary. The immediately performed emergency surgery revealed a massive distension with several serosal disruptions of stomach, small intestine and colon. A resection of the antrum and pars I duodeni with Billroth II reconstruction had to be done due to perforation into the omentum majus. Three days later a hemicolectomy was necessary due to persisting colon distension and serosal disruptions. Due to chronic renal insufficiency recovery was delayed and the patient was dismissed 2 months later.

Bottom Line: Two rumenocenteses and consecutively three laparotomies had to be performed in three patients.In the other two, gastroscopies had to be stopped for an emergency computed tomography.All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air.

View Article: PubMed Central - PubMed

Affiliation: Clinic of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital, Zurich, Switzerland.

ABSTRACT
Despite the increasing use of carbon dioxide for endoscopies during the last years, ambient air is still used. The amount of air depends on several factors such as examination time, presumable diameter of the endoscope channel and of course active use of air by the operator. Although endoscopic complications due to ambient air in the gastrointestinal (GI) tract are a rare observation and mostly described in the colon, we report five cases in the upper GI tract due to insufflating large amounts of air through the endoscopes. All 5 patients needed an emergency upper endoscopy for acute presumed upper GI bleeding. In two cases both esophageal variceal bleeding and ulcer bleeding were detected; the fifth case presented with a bleeding due to gastric cancer. Due to insufflation of inadequate amounts of air through the endoscope channel, all patients deteriorated in circulation and ventilation. Two rumenocenteses and consecutively three laparotomies had to be performed in three patients. In the other two, gastroscopies had to be stopped for an emergency computed tomography. All critical incidents were believed to be a consequence of a long-lasting examination with use of too much air. Therefore in emergency situations, endoscopies should be performed with either submersion, low air flow pumps or even better by the use of carbon dioxide.

No MeSH data available.


Related in: MedlinePlus