Esophagogastroduodenoscopy EGD

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Esophagogastroduodenoscopy(EGD)

• Patient Preparation
• Antibiotic Prophylaxis
• Anticoagulation Management

Mark D. Goodwin, Lt Col, USAF, MC Program
Director, Family Medicine Residency 55 MDG
Director, Medical Education
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Or

• The 3 Ps
• Prep
• Protection from the Bugs
• Platelets

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EGD Patient Preparation
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EGD Patient Preparation

• Goal of preparation should be to make possible a
  safe, comfortable, accurate and complete
  examination

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EGD Patient Preparation

• Preprocedure assessment includes
• Indication for study/previous endoscopy
• PMHx- cardiac, pulmonary, endocrine etc.
• PSHx- intra-abdominal, oral, neck, chest
• Medications/drug allergies
• Bleeding disorders
• Targeted PE
• Selected preprocedure lab analysis

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EGD Patient Preparation

• Preprocedure assessment includes
• Routine screening tests not indicated
• INR/PT/PTT, BMP, CBC, EKG, CXR, TS
• Consider ßHCG in women of child-bearing age
• lt1 of all tests revealed abnormalities that
  would have influenced perioperative management
• No complications were noted to these identified
  (and frequently overlooked) abnormalities

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EGD Patient Preparation

• Preprocedure assessment includes
• Informed Consent
• Based upon ethical determinations of
  self-determination and autonomy
• Not merely the signing of a form
• Do it personally!
• Allow for questions/answers
• Witness the process
• Document the process (Informed consent form and
  in Op note)

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EGD Patient Preparation

• Informed Consent
• Crux is adequate disclosure
• Nature of proposed procedure
• Underlying reason why procedure is necessary and
  its goals
• Risks and complications and their possible
  treatments including relative incidence (include
  ADE)
• Reasonable alternatives to proposed procedure

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EGD Patient Preparation

• No bowel prep as in c-scope!
• No solids for at least 6 hours before the
  procedure
• No liquids (other than a sip of water for
  necessary medications) for at least 4 hours
  before the procedure
• Avoid pill medications immediately before
  procedure

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EGD Patient Preparation

• Topical anesthesia
• May diminish gag reflex/lessen discomfort
• 14 benzocaine or 2 tetracaine spray
• 5050 viscous lidocaine/water gargle
• Best in younger patients those with high anxiety
• Caution in elderly rare ADEs

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EGD Patient Preparation

• Medication management
• Antihypertensives- continued for procedure (BB
  can add to sedation induced bradycardia)
• Insulin/oral hypoglycemics- typically hold am SQ
  insulin or HS PO meds

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Anticoagulation/antiplatelet therapy
• Must consider the following
• Risk of complication of underlying GI disorder
  related to anticoagulant Tx
• Risk of bleeding related to endoscopic procedure
  carried out in setting of anticoagulation

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Must consider the following
• Risk of thromboembolic event related to
  interruption of anticoagulation
• Risk of event in patient with mechanical heart
  valve prosthesis w/o antithrombotic Tx is 4 per
  100 patient years c/t 2.2 with antiplatelet 1
  with Coumadin
• Risk in sustained AFIB w/o valvular dz is 5-7
  annually w/o anticoagulation Tx

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Anticoagulation therapy
• Procedure risks
• Condition risks

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Procedure risks
• Low risk procedure
• EGD /- biopsy
• High risk procedures
• Gastric polypectomy (4 risk of bleeding)
• Laser ablation/coagulation (lt6)
• Pneumatic or bougie dilation of benign or
  malignant strictures
• Varices tx

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Condition risks
• Low risk conditions- DVT, chronic or PAFIB w/o
  valvular dz, bioprosthetic valves, mechanical
  aortic valves
• High risk conditions- AFIB w valvular dz,
  mechanical mitral valves, mechanical valves in
  patients with hx/o prior thromboembolic event

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Recommendations
• Low risk procedures- No adjustments in Coumadin
  are indicated elective procedures should be
  avoided when anticoagulation gt therapeutic range
• High risk procedures in low risk
  conditions-Coumadin should be stopped 3-5 days
  before procedure

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Recommendations
• High risk procedure in high risk conditions-
  Coumadin should be stopped 3-5 days before
  procedure
• Decision to administer intravenous heparin once
  the INR falls below the therapeutic level should
  be individualized
• Preliminary experience suggests there may be a
  role for monitored reduction in the INR without
  the use of heparin

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Recommendations
• IV Heparin (or LMWH as per ACCP but to date no
  prospective significantly powered studies
  evaluating safety or efficacy) started once INR
  falls below target level and then stopped 4-6 hrs
  before and resumed 2-6 hrs after the procedure
  Warfarin may be resumed night of scope

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Antiplatelet therapy
• Aspirin/NSAIDS- inhibit platelet cycoloxygenase
  resulting in suppression of thromboxane
  A2-dependent platelet aggregation
• Ticlopidine/Clopidogrel- antagonists of platelet
  cell-surface adenosine diphosphate receptor (P2T)
• Eptifibatide/abciximab/tirofiban- antagonist of
  IIb/IIIa receptor

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EGD Management of Anticoagulation/Antiplatelet
Therapy

• Recommendations
• ASA/NSAIDs in standard doses do not increase risk
  of significant bleeding in any endoscopic
  procedure
• P2T and IIb/IIIa receptor blockers- inadequate
  data temporary discontinuation is desirable in
  high risk procedure- weighing risk for adverse
  coronary event

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EGD Antibiotic Prophylaxis

• Statistics-
• Bacteremia rates 0-8 (4.4 mean) transient (lt30
  min) no infectious complications
• Despite millions of procedures done, very few
  cases of SBE after endoscopy
• No study to date has demonstrated reduction in
  infectious complications using antibiotic
  prophylaxis in endoscopic procedures
• Antibiotic prophylaxis for infective endocarditis
  in patients undergoing GI endoscopic procedures
  is not always successful

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EGD Antibiotic Prophylaxis

• Procedure risks
• Condition risks

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EGD Antibiotic Prophylaxis

• Procedure risks
• Low risk procedure
• EGD /- biopsy or polypectomy
• High risk procedure
• Esophageal stricture dilation
• Sclerotherapy of esophageal varices
• Endoscopic variceal ligation (EVL)

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EGD Antibiotic Prophylaxis

• High risk procedures-
• Esophageal stricture dilation/bougie-
• 3 recent studies- bacteremia rate 12-22 19/24
  BCs S viridans BC increased in multiple
  passages vs. single and malignant strictures vs.
  benign no infectious complications noted
• Sclerotherapy of esophageal varices largely
  replaced by endoscopic variceal ligation (EVL)-
• 6 studies- bacteremia rates 1-25 (8.8) c/t
  earlier studies showing scleroTx with rate 31

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EGD Antibiotic Prophylaxis

• Condition risks
• Low risk conditions
• Previous CABG
• Pacemakers/implanted defibrillators,
• MVP/RHD w/o valvular dysfunction or regurgitation
• Isolated ASD
• Repaired ASD, VSD, PDA
• Innocent/functional murmurs
• Previous Kawasaki w/o valvular dysfunction

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EGD Antibiotic Prophylaxis

• Condition risks
• Intermediate/moderate risk conditions
• Most congenital cardiac malformations (excluding
  those in high risk)
• Acquired valvular dysfunction
• Hypertrophic cardiomyopathy
• MVP with regurgitation/thickened leaflets

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EGD Antibiotic Prophylaxis

• Condition risks
• High risk conditions
• Prosthetic heart valves
• Previous BE
• Surgically constructed systemic pulmonary shunts
  or conduits
• Complex cyanotic congenital heart disease (TOF,
  transposition, single ventricle)

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EGD Antibiotic Prophylaxis

• Recommendations
• For EGD /- biopsy, polypectomy
• Antibiotic prophylaxis is not recommended for
  patients with lesions at low or intermediate risk
  for the development of endocarditis
• For example, patients with mitral valve prolapse,
  with or without regurgitation, do not require
  prophylaxis for any of the above procedures.

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EGD Antibiotic Prophylaxis

• Recommendations
• For EGD /- biopsy, polypectomy
• Insufficient data to recommend routine
  prophylaxis for patients at high risk for
  infective endocarditis. Considered optional
• The endoscopist may consider prophylaxis on a
  case-by-case basis.

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EGD Antibiotic Prophylaxis

• Recommendations
• For EGD dilation/EVL or sclerotherapy
• Recommend prophylaxis for patients at high risk
  for infective endocarditis.
• Prophylaxis optional for those with moderate
  risk for BE
• Prophylaxis not recommended for low risk
  patients

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EGD Antibiotic Prophylaxis

• Regimens
• Std general prophylaxis
• Amoxicillin 2.0 g PO (adult) or 50 mg/kg by mouth
  (child), 1 hr before procedure
• Alternative is ampicillin 2.0 g IV/IM (adult) or
  50 mg/kg IV/IM (child), within 30 minutes before
  procedure

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EGD Antibiotic Prophylaxis

• Regimens
• Pcn-allergic patients
• Clindamycin 600 mg by PO (adult) or 20 mg/kg by
  mouth (child), 1 hr before procedure
• Alternatives cephalexin or cefadroxil 2.0 g PO
  (adult) or 50 mg/kg by mouth (child), 1 hour
  before the procedure azithromycin or
  clarithromycin 500 mg PO (adult) or 15 mg/kg
  (child), 1 hour before the procedure.

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EGD Antibiotic Prophylaxis

• Regimens
• Penicillin-allergic patients unable to take by
  mouth
• Clindamycin 600 mg IV (adult) or 20 mg/kg IV
  (child), within 30 minutes before the procedure
• Alternative cefazolin 1.0 g IV/IM (adult) or 25
  mg/kg IV/IM (child) within 30 minutes before the
  procedure vancomycin1.0 g IV (adult) or 1020
  mg/kg (child)

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EGD Antibiotic Prophylaxis

• Other conditions-
• Synthetic vascular graft
• Infection is devastating!
• Risk decreases with time
• Recommendations
• For up to the 1st year after grafting, antibiotic
  prophylaxis is needed in high risk procedures
• Insufficient data regarding low risk procedures-
  up to endoscopist

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EGD Antibiotic Prophylaxis

• Other conditions-
• Prosthetic joint/orthopedic prosthesis
• Infection extremely rare!
• Recommendations
• Insufficient data to recommend prophylaxis for
  these patients undergoing GI endoscopy
• ID PDs indicated prophylaxis not indicated at
  any time for these EGD procedures

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EGD Antibiotic Prophylaxis

• Other conditions-
• Cirrhotic, Immunocompromised, transplant patients
  on high dose steroids
• Increased susceptibility to transient bacteremia
• Recommendations
• All cirrhotics with GI bleeding should receive
  antibiotic prophylaxis
• Routine prophylaxis not recommended for low risk
  procedures
• Consider prophylaxis in those high risk
  procedures

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EGD Antibiotic Prophylaxis

• Summary- Antibiotic guidelines established for
  prophylaxis against infective endocarditis should
  be reserved for those patients with the highest
  risk for infection.
• Indiscriminate use of antibiotics in association
  with GI endoscopic procedures is to be
  discouraged, as it adds unnecessary cost and the
  potential for adverse reactions.

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Questions??