What are the risks associated with performing an endoscopic procedure in a patient taking oral corticosteroids?

Risk of Endoscopy in Patients on Oral Corticosteroids

Patients on oral corticosteroids can safely undergo diagnostic endoscopy with standard precautions, but face significantly increased risks if therapeutic endoscopic procedures (such as dilatation) or surgery are required, particularly those on ≥20 mg/day prednisolone or who have been on steroids for >4 weeks. 1, 2

Diagnostic Endoscopy Risk Profile

Diagnostic endoscopy (including flexible sigmoidoscopy) is safe in patients on oral steroids and should not be delayed or avoided. 1

• Flexible sigmoidoscopy can be performed with care even in patients with acute severe ulcerative colitis on intravenous steroids, providing critical information about disease severity without increased perforation risk 1
• Standard endoscopic examination carries no additional procedural risk related to steroid use alone 1

Therapeutic Endoscopy: Increased Bleeding and Perforation Concerns

For therapeutic procedures like endoscopic dilatation, patients on steroids face no higher perforation risk than other benign conditions, but require careful attention to wound healing and infection prevention. 1

Dilatation Safety Data

• Perforation risk during dilatation of eosinophilic esophagitis strictures is 0.38% in patients (many on topical steroids), comparable to other benign esophageal conditions 1
• Deep mucosal tears occur in 9% of dilatations and are associated with post-procedure pain, but are not specifically increased by steroid use 1
• Pain during and after therapeutic procedures is common and patients should be counseled accordingly 1

Critical Risk Factors to Assess

• Active inflammatory bowel disease with penetrating or stricturing disease significantly increases perforation risk 3
• Any new abdominal discomfort in steroid-treated patients requires immediate aggressive diagnostic workup with CT imaging preferred over plain radiographs 3

Dose-Specific Risk Stratification

The magnitude of risk correlates directly with steroid dose and duration:

High-Risk Category (≥20-40 mg/day prednisolone)

• Patients on ≥40 mg prednisolone have the greatest risk of postoperative infectious complications and anastomotic leaks 1, 3
• Those on ≥20 mg prednisolone undergoing proctocolectomy face increased complication rates 1, 3
• Meta-analyses show odds ratio of 1.68 (95% CI 1.24-2.28) for postoperative infectious complications, with adjusted pooled OR of 1.7 (95% CI 1.38-2.09) 1, 4

Moderate-Risk Category (≥15-20 mg/day)

• Significantly elevated risk of surgical site infections and wound complications 4
• CDC defines immunosuppression threshold at ≥20 mg/day for ≥2 weeks 2, 4

Lower-Risk Category (<15 mg/day)

• Lower but still present infection and wound healing risks 4
• Chronic use (≥30 days) may increase wound complication rates 2-5 times compared to non-steroid users 5

Duration of Steroid Use Matters

Patients on steroids for >4 weeks face distinct perioperative management requirements:

• Require equivalent intravenous hydrocortisone during nil-by-mouth periods to prevent adrenal crisis 1, 2
• Conversion: prednisolone 5 mg = hydrocortisone 20 mg = methylprednisolone 4 mg 1, 2
• Do NOT use stress-dose or supraphysiologic steroids—continue only the usual daily dose 2, 3
• Hypothalamic-pituitary-adrenal axis suppression may persist 9-12 months after withdrawal if supraphysiological doses used >2 weeks 6

Wound Healing Considerations

Chronic systemic steroids impair wound healing through multiple mechanisms:

• High-dose corticosteroids for <10 days have no clinically important effect on wound healing 5
• Chronic steroids (≥30 days preoperatively) may increase wound complication rates 2-5 times 5
• Animal studies show 30% reduction in wound tensile strength with perioperative steroids at 15-40 mg/kg/day 5
• Enhanced anti-inflammatory activity is not dissociated from catabolic actions on skin, muscle, and connective tissues 6

Infection Risk Mechanisms

Steroids increase infection susceptibility through:

• Impaired immune response and increased susceptibility to infections 1
• Reactivation of latent infections (such as tuberculosis) 6
• Unmasking of occult infections that require aggressive workup 3

Practical Management Algorithm

For Elective Procedures:

1. Attempt to stop or minimize steroids preoperatively 1, 2, 4
2. Target <20 mg/day prednisolone if cessation impossible 2, 4, 3
3. Wait 3-4 weeks post-procedure before additional interventions due to wound healing concerns 2

For Urgent/Emergency Procedures:

1. Proceed with endoscopy without delay—do not wait for steroid optimization 1
2. Continue usual steroid dose perioperatively (IV equivalent if NPO) 2, 3
3. Provide VTE prophylaxis with subcutaneous low molecular weight heparin 1
4. Monitor closely for wound healing problems, infections, and adrenal insufficiency signs 2

Common Pitfalls to Avoid

• Do not delay diagnostic endoscopy for steroid optimization—the diagnostic information outweighs theoretical risks 1
• Do not administer unnecessary stress-dose steroids—this increases infection risk without hemodynamic benefit 2, 3
• Do not assume all steroid-exposed patients have equal risk—dose and duration determine risk magnitude 2, 4
• Do not overlook VTE prophylaxis—risk is 2-3 fold higher in IBD patients on steroids 1
• Do not miss signs of perforation—maintain high clinical suspicion for any new abdominal symptoms and obtain CT imaging promptly 3