What are contraindications to surgery for upper gastrointestinal bleeding (UGIB)?

Updated: Sep 01, 2021
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

Contraindications to upper endoscopy include an uncooperative or obtunded patient, severe cardiac decompensation, acute myocardial infarction (unless active, life-threatening hemorrhage is present), and perforated viscus (eg, esophagus, stomach, intestine). Expert subspecialty consultation may be beneficial to optimize the patient and establish a best “window of opportunity” should endoscopy proceed.

Contraindications to emergency surgery include impaired cardiopulmonary status and bleeding diathesis.

Esophagogastroduodenoscopy (EGD) may be more difficult or impossible if the patient has had previous oropharyngeal surgery or radiation therapy to the oropharynx. Altered upper GI tract anatomy from previous surgery (eg, Roux-en-Y gastric bypass) may pose unique challenges to endoscopic management of bleeding.

The presence of a Zenker diverticulum can make intubation of the esophagus more difficult.

Patients with Down syndrome are more sensitive to conscious sedation and, when possible, should be monitored by an anesthesiologist and/or intubated prophylactically prior to the procedure. Monitored anesthesia care has been increasingly used in more challenging and sometimes prolonged cases such as EGD for active UGIB.

Hypotension may be exacerbated by sedation; therefore, patients who are clinically unstable should be carefully sedated. Continuous monitoring in the ICU is warranted and monitored anesthesia care by an anesthesia provider may improve the safety of endoscopy, particularly if there is decompensation or compromise of the airway.

Patients with massive bleeding should be considered for intubation to reduce the increased risk of aspiration. Such patients should be treated in an intensive care setting. As suggested, subspecialty consultation with a pulmonologist or an intensivist may be prudent, and sedation might be best managed with the subspecialists in attendance. Anesthesia assistance should be considered even with intubated patients depending on patients' comorbidities and overall stability.

Ideally, the patient should be stabilized prior to endoscopy and abnormalities in coagulation should be corrected. When this is not possible, the judgment of an experienced endoscopist is vital. The merits of the multidisciplinary team approach in critically ill patients cannot be overemphasized.


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