Conditions of Urgent Endoscopy - Causes, Symptoms, and Management

Introduction

An urgent endoscopy is an effective and life-saving technique. Urgent Endoscopy is done in an emergency setting using local anesthesia. Local anesthesia provides simple sedation, which helps the patient tolerate the procedure well. The period for an emergency procedure can range from 24 hours to 72 hours. An elective medical intervention is done in the gastrointestinal tract using an emergency endoscopy. Conditions of the gastrointestinal tract, including the stomach, duodenum, and esophagus, are easily diagnosed and treated by Endoscopy.

What Are the Conditions That Require an Urgent Endoscopy?

The three conditions which usually require urgent Endoscopy include acute biliary pancreatitis, acute cholangitis, and acute gastrointestinal bleeding.

What Is Acute Gastrointestinal Bleeding?

Acute upper gastrointestinal bleeding is the most common medical emergency in the gastrointestinal tract. Acute variceal bleeding occurs in patients with liver cirrhosis conditions and is a complication in liver cirrhosis patients. Nonvariceal upper gastrointestinal bleeding develops in the stomach, esophagus, and proximal duodenum.

What Are the Causes of Acute Gastrointestinal Bleeding?

A few causes of acute gastrointestinal bleeding are:

• Peptic Ulcer - Peptic ulcer is one of the most common reasons causing upper gastrointestinal tract bleeding. Peptic ulcers are sores that form in the lining of the upper area of the small intestine and the stomach. When stomach acids, either bacteria or the intake of anti-inflammatory drugs, damage the stomach lining, it leads to stomach ulcers or sores.

• Esophageal Varices - Large and abnormal veins form in the esophageal area of people with serious liver conditions. They are called esophageal varices.

• Gastric Varices - Gastric varices are dilated veins found in the stomach lining of patients with portal hypertension. The portal vein is the major vein that goes to the liver. Portal hypertension is mainly caused due to liver cirrhosis, and it refers to increased pressure in the portal vein and its branches.

What Are the Symptoms of Acute Gastrointestinal Bleeding?

Acute gastrointestinal bleeding is characterized by symptoms like vomiting of blood (hematemesis) and black-colored stools, which occurs due to bleeding of the gastrointestinal tract (melena). Patients may also experience dizziness, difficulty breathing, chest pain, hypovolemic shock, or syncope. Hypovolemic shock is a condition that occurs when severe blood loss in the body makes it difficult for the heart to pump enough blood into the body, causing the organs to shut down.

How Does Endoscopy Help in the Management of Acute Gastrointestinal Bleeding?

For patients with acute gastrointestinal bleeding, urgent Endoscopy is done immediately or within 24 hours after stabilizing the unstable patient.

• For bleeding ulcers, if active bleeding is noted or Endoscopy suggests chances of rebleeding, then endoscopic therapy is essential. Some high-risk features of bleeding ulcers include ulcers with an active growing vessel, active oozing or adherent clot (clot resistant to a forceful suction or irrigation), or a nonbleeding visible vessel (ulcer which already bled out but has a high chance of rebleeding).

• Endoscopic therapy combines adrenaline injection into the ulcer and a mechanical or thermal method. Mechanical involves using endoscopic clips (to close mucosal defects), and thermal involves using a heater probe or bipolar electrocoagulation. Bipolar electrocoagulation involves the application of electrodes to the bleeding vessels to stop bleeding (hemostasis) immediately. Both these methods together achieve hemostasis (stopping the blood flow).

After the first attempt of Endoscopy, if patients rebleed after achieving initial hemostasis, another attempt should be made with Endoscopy to control the bleeding.

• Immediate management is essential because if rebleeding occurs and there is a failure to achieve hemostasis, the chances of the patient's death are high.

• For esophageal varices, the first-line treatment is endoscopic band ligation. This technique places elastic bands around the enlarged veins to stop the bleeding. A balloon tamponade will also help in controlling esophageal variceal bleeding.

• A temporizing measure is a transjugular intrahepatic portosystemic shunt (TIPS). In the TIPS procedure, a stent is placed between the hepatic and portal veins to reduce hypertension.

• For gastric varices, the treatment is the intravesical injection of cyanoacrylate glue. When cyanoacrylate glue is injected into the bleeding site, the glue comes in contact with blood and becomes a hard substance closing the swollen blood vessel.

What Is Acute Biliary Pancreatitis?

Acute biliary pancreatitis is pancreatitis (inflammation of the pancreas) caused by gallstones. In this condition, gallstones block the pancreatic duct causing inflammation. Acute Biliary Pancreatitis is a complication of gallstone disease and can cause several complications and, in worse scenarios, even death.

What Are the Signs and Symptoms of Acute Biliary Pancreatitis?

A major symptom of acute biliary pancreatitis is severe abdominal pain on the upper left of the body, where the pancreas is located. The pain is usually sharp, and a squeezing feeling might occur. This pain can radiate to the shoulder, chest, or back area. Other symptoms include:

• Fever and chills.

• Nausea and vomiting.

• Jaundice.

• Dehydration.

• Swelling in the abdomen.

• Increased breathing.

• Shortness of breath.

• Increased heart rate.

• Low blood pressure.

• Low body temperature.

How Do Gallstones Cause Pancreatitis?

The common bile duct connects the pancreas and gallbladder. Bile mostly passes from the gallbladder to the common bile duct into the small intestine. When gallstones occur, they can travel and get stuck in narrow places. In acute biliary pancreatitis, gallstones travel into the pancreatic duct and can cause a blockage outside it. This blockage causes inflammation of the pancreas in two ways. First, when the gallstones block the common bile duct outside the pancreatic duct, it causes the bile to flow back to the pancreas. Since bile is highly corrosive, it irritates the pancreas, causing inflammation. Another way is when bile flows back into the pancreas; the pancreatic enzymes irritate it due to bile flow. These pancreatic enzymes are also highly corrosive as bile, as they are required to break down carbohydrates, fats, and proteins in the small intestine. Since the pancreas does not have a thick mucus lining, even small irritations could cause inflammation.

How Does Endoscopy Manage Acute Biliary Pancreatitis?

• Acute Biliary Pancreatitis is managed by emergency endoscopic retrograde cholangiopancreatography (ERCP) within 24 hours of the attack.

• ERCP is a technique that combines the use of both endoscopes and X-rays. An endoscope is a lighted tube with a camera at its end. The endoscope is usually inserted from the mouth. Since it is flexible, it slides down easily, reaching the gastrointestinal tract, where it creates images that will be shown on the operating room monitor. With the guided image, the blocked duct is then drained through ERCP.

What Is Acute Cholangitis?

Acute cholangitis is a swelling of the bile duct caused due to infections from the biliary tract and is characterized by symptoms like jaundice, abdominal pain, and fever. A biliary tract consists of bile ducts and organs (gallbladder and liver) that make bile and releases it to the small intestine. The severity of acute cholangitis can range from very mild to life-threatening.

What Causes Acute Cholangitis?

Acute cholangitis can be caused due to bacterial infection, blockage, gallstone, or tumor. Environmental factors causing acute cholangitis include smoking and chemicals.

How Does Endoscopy Help in the Management of Acute Cholangitis?

Depending on the severity of acute cholangitis, the treatment can vary from mild antibiotic therapy to emergency endoscopic biliary drainage.

• Antibiotics commonly given include Penicillin, Metronidazole, and Ciprofloxacin.

• Endoscopy is used for sphincterotomy or the placement of a stent. The sphincterotomy procedure cuts the muscle between the pancreatic and common bile duct. This will help remove the stones from the duct and help with drainage.

• Patients treated in the first 24 hours had a faster recovery rate, a very small duration of hospital stay, and less morbidity and mortality rate than patients who underwent medical intervention after 24 hours.

Conclusion

Conditions that require an urgent endoscopy include acute biliary pancreatitis, acute cholangitis, and acute gastrointestinal bleeding. The first-line treatment of both acute biliary pancreatitis and acute cholangitis is endoscopic retrograde cholangiopancreatography (ERCP). Acute gastrointestinal bleeding is managed by endoscopic therapy using an adrenaline injector and a mechanical method like a heater probe to control the bleeding. All these conditions have significant outcomes with urgent Endoscopy, but they must be managed within the first 24 hours for better outcomes.