Upper Gastrointestinal Endoscopy (UGIE) in Patients with Gross Ascites
Patients with gross ascites can safely undergo upper gastrointestinal endoscopy with appropriate precautions, but require prophylactic broad-spectrum antibiotics to prevent infectious complications. 1
Pre-Procedure Assessment and Preparation
Risk Assessment
- Assess patient's fitness to undergo diagnostic UGIE as per standard practice 2
- Complete a comprehensive safety checklist before starting the procedure 2
- Allocate an appropriate time slot (minimum 20 minutes for standard diagnostic endoscopy) 2
- Consider the increased risk of bacterial translocation and spontaneous bacterial peritonitis in patients with ascites
Antibiotic Prophylaxis
- A prolonged course of prophylactic broad-spectrum antibiotics is strongly recommended for patients with ascites undergoing therapeutic EUS procedures 1
- This recommendation extends to diagnostic UGIE in patients with gross ascites due to similar risk of bacterial translocation
Informed Consent
- Obtain written informed consent before performing UGIE 2
- Discuss specific risks related to ascites:
- Higher risk of infection
- Potential for hemodynamic compromise
- Possible need for ascitic fluid drainage if respiratory compromise is present
Procedural Considerations
Sedation and Positioning
- Use intravenous sedation and local anesthetic throat spray with caution due to increased risk of aspiration 2
- Consider the following modifications:
- Position patient with head elevated to reduce pressure on the diaphragm
- Have suction readily available
- Monitor oxygen saturation closely
Technical Approach
- Ensure high-definition video endoscopy systems are used 2
- Maintain adequate mucosal visualization through proper air insufflation, aspiration, and mucosal cleansing techniques 2
- Document quality of mucosal visualization in the procedure report 2
- Take appropriate photo-documentation of relevant anatomical landmarks and any detected lesions 2
Special Considerations
- If varices are identified (common in patients with ascites due to portal hypertension), describe them according to standardized classification 2
- For any ulcers identified, follow standard biopsy protocols with appropriate follow-up 2
- If therapeutic intervention is needed, consider the increased bleeding risk in patients with coagulopathy secondary to liver disease
Post-Procedure Management
Monitoring
- Complete a post-procedure checklist before the patient leaves the endoscopy room 2
- Monitor for signs of infection, bleeding, or perforation
- Maintain vigilance for development of spontaneous bacterial peritonitis
Follow-up
- Schedule appropriate follow-up based on endoscopic findings
- Continue antibiotic prophylaxis as indicated
Potential Complications and Their Management
Infection
- Monitor for fever, increasing abdominal pain, or worsening ascites
- Low threshold for diagnostic paracentesis if infection is suspected
- Initiate broad-spectrum antibiotics promptly if infection is suspected
Bleeding
- Higher risk in patients with coagulopathy related to liver disease
- Follow standard protocols for management of non-variceal upper GI bleeding 3, 4
- Consider restrictive transfusion strategy (target hemoglobin 7-9 g/dL) 5, 4
Respiratory Compromise
- Patients with tense ascites may experience respiratory distress following sedation
- Consider therapeutic paracentesis before the procedure if respiratory function is compromised
Common Pitfalls and How to Avoid Them
- Failure to provide antibiotic prophylaxis: Always administer prophylactic antibiotics in patients with ascites undergoing UGIE
- Inadequate sedation management: Carefully titrate sedation due to altered drug metabolism in patients with liver disease
- Overlooking coagulopathy: Check and correct coagulation parameters before invasive procedures
- Neglecting post-procedure monitoring: Maintain vigilance for delayed complications, particularly infection
By following these guidelines, UGIE can be performed safely and effectively in patients with gross ascites, providing valuable diagnostic and therapeutic information while minimizing risks.