Does having the flu increase the risk of complications during an Esophagogastroduodenoscopy (EGD) procedure?

Does Flu Increase Risks of Complications in EGD?

Yes, having active influenza increases the risk of complications during EGD, primarily through increased transmission risk to healthcare personnel and potential for respiratory decompensation in the patient, making it advisable to defer non-urgent procedures until recovery.

Risk Assessment Framework

The primary concern with performing EGD in patients with active flu relates to aerosol generation and viral transmission rather than direct procedural complications to the patient. Upper gastrointestinal endoscopy is classified as a high-risk aerosol-generating procedure that can spread respiratory viruses through respiratory and gastric secretions 1. During the 2009 H1N1 pandemic, obesity was identified as a major risk factor for mortality from influenza, with 91% of deaths occurring in patients with obesity 1.

Transmission Risk to Healthcare Personnel

• EGD infection rates for endoscopy personnel historically ranged from 3.0 per 1,000 procedures in the pre-pandemic era, which is higher than colonoscopy (1.1 per 1,000) 1
• Upper gastrointestinal endoscopy induces aerosol spreading through blowing air and suction through the nose and throat, creating high viral loads in respiratory and gastric secretions 1
• The procedure requires close proximity of healthcare workers to the patient's airway for extended periods 1

Patient-Specific Risks

• Patients undergoing major procedures are at increased risk of life-threatening inflammatory complications including viral infections, systemic inflammatory response syndrome, and sepsis 1
• Active respiratory infection increases the risk of hypoxia during sedation, which already occurs in 1.6% of routine EGD procedures 2
• Patients with chronic conditions (obesity, diabetes, chronic lung disease) face compounded risks when combining active flu with procedural sedation 1, 3

Clinical Decision Algorithm

Defer EGD if:

• Patient has active flu symptoms (fever >37.5°C, cough, myalgia, respiratory symptoms) AND the indication is non-urgent 1
• The procedure can safely wait 3-4 weeks for viral recovery without significant harm 1
• Non-invasive alternatives (imaging, biomarkers) can provide adequate clinical information 1

Proceed with EGD (with enhanced precautions) if:

• Life-threatening indications exist: acute gastrointestinal bleeding, suspected perforation, foreign body obstruction, or acute severe conditions requiring immediate endoscopic intervention 1
• The patient is clinically stable despite flu symptoms and the benefit clearly outweighs transmission risk 1
• Appropriate biosafety level 3 protection is available (N95 respirators, full PPE, negative pressure rooms) 1

Enhanced Safety Protocols When Proceeding

Pre-procedure Requirements:

• Screen patients 1 week before and 1-2 days before the scheduled procedure for fever, respiratory symptoms, and flu exposure 1
• Perform temperature checks at hospital entrance and endoscopy unit entrance 1
• Consider viral testing if available and clinical situation permits delay for results 1

Procedural Modifications:

• Use biosafety level 3 protection: N95 masks (not surgical masks), waterproof gowns, full face shields or goggles, gloves, caps, and shoe covers 1
• Perform procedure in negative-pressure room when available 1
• Minimize personnel in the room to only essential staff 1
• Keep room empty for at least 1 hour after procedure without negative pressure, or 30 minutes with negative pressure, due to aerosolization risk 1

Post-procedure Considerations:

• Enhanced monitoring for respiratory complications given baseline respiratory compromise from flu 3
• Standard endoscope disinfection is adequate as influenza virus is easily inactivated by common disinfectants 1

Critical Pitfalls to Avoid

• Do not use only surgical masks in the endoscopy room for patients with active respiratory infections—N95 or equivalent respirators are mandatory 1
• Do not proceed with elective or semi-urgent procedures during active flu infection when deferral for 3-4 weeks would not cause harm 1
• Avoid underestimating transmission risk in patients with mild flu symptoms—viral shedding can be significant even with minimal symptoms 1
• Do not perform procedures without adequate PPE availability, as this places healthcare workers at unacceptable risk 1

Special Populations

Patients with obesity or diabetes warrant particular caution, as they have augmented risk for severe complications from viral respiratory infections through mechanisms including chronic inflammation, reduced natural killer cell activity, and impaired immune responses 1. In these patients, the threshold for deferring non-urgent EGD should be lower 1.

Patients with chronic obstructive pulmonary disease can safely undergo EGD when stable, but active flu creates compounded respiratory risk requiring careful assessment of hypoxemia and consideration of endotracheal intubation for severe cases 3.