Gastrointestinal endoscopy in the cirrhotic patient

Abstract

As advances in liver disease continue, including the increasing use of liver transplantation, the endoscopist needs to be familiar with the standards of care and potential complications in the management of the cirrhotic population. This includes both elective endoscopic procedures, such as screening colonoscopies and variceal banding, as well as the acutely bleeding cirrhotic patient. Peri-procedural management and standards of care for acute gastrointestinal hemorrhaging of cirrhotic patients will be emphasized. This article will focus on the plethora of data available to highlight the benefits of endoscopic intervention in the care of patients with liver disease and outline the areas of future emphasis.

Gastrointestinal endoscopy in cirrhotic patient: Issues on the table

“…Characteristics of most used drugs for sedation in endoscopy are reported in Table 1 . Although it is widely considered that any endoscopic examination can be more effectively conducted under sedation[ 5 , 11 ], not all endoscopists consider it mandatory in every situation. In fact cardio-vascular or respiratory complications may occur also for low-grade sedation and according to baseline patient conditions or type of endoscopic procedure, as extensively reported by some reviews on this issue[ 12 , 13 ].…”

“…In this setting, however, the binary classification into compensated or decompensated cirrhosis remains too broad, thus requiring specific scoring systems, such as Child-Turcotte-Pugh[ 3 ] or model for end stage liver disease (MELD)[ 4 ] score to properly delimit the condition of the individual patient[ 5 ].…”

“…The British Society of Gastroenterology guidelines recommend screening with slight modification: On an every 3 year basis if no varices were present and annual screening for small varices[ 6 ]. Despite the proposal of alternative tests to rule out the presence of varices (such measuring the degree of hepatic stiffness by elastography), the lack of reliability of these techniques still supports the need of upper endoscopy for a definitive diagnosis in the majority of patients[ 5 , 9 ]. Nonetheless, the general use of GI endoscopy has been expanded to also include the cirrhotic population for colon cancer screening, for the advent of ultrasound endoscopy and for the treatment of benign or malignant diseases of the biliary tract.…”

Effect of dexmedetomidine in the prophylactic endoscopic injection sclerotherapy for oesophageal varices: a study protocol for prospective interventional study

“…[1][2][3][4] However, anxiety, pain, fear and adverse gastrointestinal reactions may cause subjects to be less cooperative during endoscopic procedures, and may even cause harmful cardiovascular adverse events. [5][6][7] Thus, the role of sedation in endoscopy is therefore very important, with various sedative agents commonly used during endoscopic procedures. [5][6][7] Midazolam (MDZ, Dormicum; Astellas Pharma, Tokyo, Japan), the most common agent used for sedation, is a benzodiazepine with a rapid onset of action and short duration of sedative effect.…”

“…[5][6][7] Thus, the role of sedation in endoscopy is therefore very important, with various sedative agents commonly used during endoscopic procedures. [5][6][7] Midazolam (MDZ, Dormicum; Astellas Pharma, Tokyo, Japan), the most common agent used for sedation, is a benzodiazepine with a rapid onset of action and short duration of sedative effect. 8 9 However, it has several unfavourable side effects, including delayed recovery of memory, long-term behavioural changes such as long-term cognitive dysfunction, and respiratory suppression.…”