Hospital visits to deal with complications following gastrointestinal (GI) endoscopy, where a surgeon looks inside a patient's digestive tract using a tube-like instrument, may be more common in the US than previously estimated, suggested researchers who recommended changes to current standard reporting be made to ensure relevant emergency department visits and unexpected hospital admissions after endoscopies are not overlooked.

You can read how Dr Daniel A. Leffler and colleagues at Beth Israel Deaconess Medical Center, Boston, arrived at the conclusion that complications following GI endoscopy procedures may be two or even three times more common than current estimates suggest, in a study published online in the 25 October issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Millions of Americans every year undergo gastrointestinal (GI) endoscopic procedures, where a doctor inserts a tube-like instrument into the digestive tract, for instance to examine the anus, rectum, various parts of the the intestines, the pharynx/throat, esophagus or stomach, to look for signs of cancer, ulcers, and other symptoms.

GI endoscopy includes a range of procedures, for example esophagogastroduodenoscopy (to examine the esophagus, stomach and duodenum), colonoscopy (colon), sigmoidoscopy (sigmoid colon and rectum), and pharyngoscopy (pharynx: part of the throat).

However, the authors wrote that data on the safety of these procedures is limited and mostly rely on reports from doctors, reviews of medical records and follow-up interviews, which may not capture all complications that may arise afterwards.

For the study, Leffler and colleagues developed a system that looked at electronic medical records and automatically noted admissions to the emergency department (ED) within 14 days of patients undergoing endoscopy at Beth Israel Deaconess Medical Center.

They then had qualified doctors, equipped with a predetermined set of inclusion criteria, review the electronic records' reported cases and evaluate ED visits that were related to a prior outpatient endoscopy.

Altogether, they evaluated 18 015 GI procedures comprising "6383 esophagogastroduodenoscopies (EGDs) and 11 632 colonoscopies (7392 for screening and surveillance)".

The researchers found that:
  • Among the procedures they evaluated, 419 ED visits and 266 hospitalizations occurred within 14 days of the procedure.

  • 134 (32%) of the ED vistis and 76 (26%) of the hospitalizations were related to the prior recent GI procedure.

  • This compared to only 31 complications recorded by standard physician reporting (P<.001).

  • Procedure-related hospital visits occurred in 1.07% of all EGDs, 0.84% of all colonoscopies, and 0.95% of all screening colonoscopies.

  • Using Medicare standardized rates, the mean costs of these complications came to $1403 per ED visit and $10123 per hospitalization.

  • Across the overall screening and surveillance program, these adverse events added a cost of $48 to each exam.

  • The most common reasons for ED visits were abdominal pain (47%), gastrointestinal tract bleeding (12%) and chest pain (11%).
The researchers concluded that, based on their new system of searching the electronic medical records, they observed "a 1% incidence of related hospital visits within 14 days of outpatient endoscopy, 2- to 3-fold higher than recent estimates".

"Although the overall rate of severe complications, including perforation, myocardial infarction [heart attack] and death remained low, the true range of adverse events is much greater than typically appreciated," they added, remarking that an "overall rate of one in 127 patients visiting the hospital due to an outpatient endoscopic procedure is a cause for concern, especially in the setting of screening and surveillance when otherwise healthy individuals are subjected to procedural risks".

They noted that "most events were not captured by standard reporting", and suggested that new ways of automatically relating relevant adverse events back to recent GI procedures should be developed.

They also commented that the costs of unexpected emergency treatment following an endoscopy may be significant and should be taken into account when calculating the cost of a screening or surveillance program.

"The Incidence and Cost of Unexpected Hospital Use After Scheduled Outpatient Endoscopy."
Daniel A. Leffler; Rakhi Kheraj; Sagar Garud; Naama Neeman; Larry A. Nathanson; Ciaran P. Kelly; Mandeep Sawhney; Bruce Landon; Richard Doyle; Stanley Rosenberg; Mark Aronson.
Arch Intern Med. Vol 170, No 19, pp 1752-1757, 25 October 2010.
DOI:10.1001/archinternmed.2010.373

Sources: JAMA and Archives Journals.

Written by: Catharine Paddock, PhD