Scoping our practice
The benefits of endoscopy have increased enormously as it has matured from a purely diagnostic tool to become a therapeutic subspecialty, but so too has the potential for causing harm. Endoscopic haemostasis for varices and ulcers, relief of biliary obstruction from stones or tumours, and alleviation of luminal obstruction using balloons, bougies and stents improve quality of life and may obviate the need for operative surgery, but all risk serious complications. The risks of endoscopy are worth taking only when the procedure is worth doing and when the benefits outweigh the risks. Complications are unacceptable if endoscopy is not indicated; pancreatitis after diagnostic endoscopic retrograde cholangiopancreatography (ERCP) and colonoscopic perforation done during follow-up of a single rectosigmoid polyp are examples. The risk:benefit ratio is dictated by the disease process and by the underlying health of the patient—thus (to rehearse an old chestnut), the complications of endoscopic bile duct clearance are probably fewer and better tolerated than those of surgical exploration in the elderly and frail and are therefore acceptable; the same may not be true for younger and fitter patients for whom surgery has a lower complication rate than ERCP. Relatively high-risk endoscopic procedures can be justified to palliate symptoms in patients with terminal diseases, whereas the risks become unacceptable when the same procedure is done to a patient with surgically respectable disease.
These issues received considerable airing in the National Confidential Enquiry into Patient Outcome …
Of 279 patients admitted to a specialist unit with acute pancreatitis, 210 were admitted directly and 69 were transferred for treatment of local or systemic complications. Outcome was assessed in terms of mortality and morbidity and in relation to aetiology, predicted severity of disease (modified Glasgow score), organ failure (modified Goris multiple organ failure score), and need for surgical intervention. The death rate was 1.9% in patients admitted directly but was 18.8% in those transferred from other units. Mortality in gall stone related pancreatitis was 3% compared with 15% (p = 0.03) in pancreatitis of unknown aetiology and 27% (p = 0.01) in post-endoscopic retrograde cholangiopancreatography pancreatitis. Mortality was related to age (mortality > 55 years old 11% v 2%; p = 0.003) and Goris score (score 0, mortality 0% v score 5-9, mortality 67%; p = 0.001). In patients transferred from other units, mortality was 11% in those transferred within a week of diagnosis and 35% when transfer was delayed (p = 0.04). Thirty six patients had pancreatic necrosis on dynamic computed tomography of whom 29 underwent pancreatic necrosectomy with a 34% mortality. Mortality was related to the modified Goris score (median score 2 in survivors v 6 in non-survivors; p = 0.005) and was higher when necrosectomy was performed within the first two weeks of admission (100% vs 21%; p = 0.004). In conclusion, mortality in acute pancreatitis is influenced by age, aetiology of the disease, and presence of organ failure. Patients transferred for specialist care have a 10-fold greater mortality than those admitted directly and mortality is greatest when transfer is delayed. Early necrosectomy carries a prohibitively high mortality.
Endoscopic retrograde pancreatograms have been examined in patients presenting with cholestasis caused by either primary sclerosing cholangitis (13 subjects), or high cholangiocarcinomata (15 subjects), and in normal individuals (13 subjects). Pancreatograms were reported by two independent observers who had no knowledge of the diagnosis in any case and abnormalities were graded using a conventional scoring system. Pancreatograms were abnormal in 77% of cases of primary sclerosing cholangitis and in 60% of cholangiocarcinoma patients. These abnormalities usually consisted of side branch irregularities, although in five patients with primary sclerosing cholangitis and in two with cholangiocarcinoma, the main pancreatic duct was also markedly irregular.
Acute gastrointestinal haemorrhage is a common medical emergency that has a hospital mortality of approximately 10%. Peptic ulcer bleeding, complicating non-steroidal anti-inflammatory drugs, aspirin or Helicobacter pylori infection is the most common cause of major bleeding. Gastro-oesophageal varices are less common but managing the underlying liver disease and the severity of bleeding may be demanding. The prognosis of patients presenting with acute bleeding is dictated by the presence of medical co-morbidities and by the severity of liver disease in patients with varices. Validated prognostic scoring systems, based upon the severity of bleeding, diagnosis, endoscopic findings and extent of co-morbidities, predict mortality and have clinical utility. The treatment of non-variceal bleeding is based upon cardiovascular resuscitation followed by endoscopic therapy in patients with active bleeding or major stigmata of recent haemorrhage. Proton pump inhibitor drugs reduce the risk of re-bleeding but have little effect on mortality. Emergency surgery is undertaken for uncontrolled bleeding or re-bleeding that cannot be controlled by further endoscopic therapy. Oesophageal varices are managed by fluid resuscitation, antibiotics and endoscopic band ligation. Vasoactive drugs may stop active bleeding but have no effect upon mortality. Management of the complications of the underlying liver disease and complete variceal ablation in a banding programme are essential. Gastric varices are treated by injection with tissue adhesives or transjugular intrahepatic porto-systemic shunt (TIPSS) insertion. Surgical intervention has little role in the management of varices and patients who do not respond to endoscopic therapies are best treated by TIPSS.
Acute upper gastrointestinal bleeding is the commonest medical emergency managed by gastroenterologists in the United Kingdom. The most frequently identified source of bleeding is peptic ulcer disease, but other important causes exist, particularly oesophageal or gastric varices, which are classically associated with more severe bleeding. A large audit in the UK in 20071 indicated that the rate of mortality from acute upper gastrointestinal bleeding (about 7%) has not changed much over the past 50 years, and that service provision varies considerably across the UK. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of acute upper gastrointestinal bleeding.2
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.
### Risk assessment
At presentation with acute upper gastrointestinal bleeding, assess for risk of serious adverse events or need for intervention. To do this use the following formal risk assessment scoring systems for all patients with acute gastrointestinal bleeding: the Blatchford scoring system3 at first assessment and the full Rockall scoring system4 after endoscopy (tables 1⇓ and 2⇓). [ Based on low to very low quality evidence from prospective and retrospective case reviews ]
View this table:
Table 1
The Blatchford scoring system.3 For a patient with acute upper gastrointestinal bleeding, add up scores in the right hand column for each risk marker (if no value applies for a particular marker, score 0) to derive a total score*
View this table:
Table 2
The full (post-endoscopy) Rockall scoring system.4 For a patient with acute upper gastrointestinal bleeding, add up scores at the top of the …
Abstract We report four cases of collagenous colitis. These show the variable course of the disease and emphasise the difficulties that this involves in assessing therapy.
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