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4 Complications of Endoscopy

       Julie E. Dechant DVM, MS, DACVS, DACVECC

       School of Veterinary Medicine, University of California–Davis, Davis, California

Overview

      Endoscopy is performed using a flexible video‐endoscope, although rigid endoscopes may be used for certain surgical applications. The upper respiratory tract, larger airways of the lower respiratory tract, proximal gastrointestinal tract (esophagus, stomach and proximal duodenum), caudal intestinal tract (rectum and distal small colon), lower urinary tract (urethra, bladder and occasionally ureters), and uterus are commonly examined using endoscopy. This chapter will review complications associated with endoscopic examination procedures, whereas surgical endoscopic procedures will be discussed separately. Similarly, complications associated with arthroscopy, tenoscopy, laparoscopy and thoracoscopy will be reviewed in their respective chapters. Complications can occur related to equipment damage, patient injury from the endoscope, and sequellae from insufflation.

List of Complications Associated with Endoscopy

       Epistaxis/mucosal trauma

       Equipment damage

       Insufflation‐related complications

       Air embolism

Epistaxis/Mucosal Trauma

       Definition

      Epistaxis is the presence of hemorrhage exiting the nares. Mucosal trauma includes bruising, abrasions, and lacerations which can occur during passage of the endoscopy into any hollow organ.

       Risk factors

       Small‐sized horses or foals

       Insufficient restraint

       Unsedated patients

       Restriction of the passageway to be scoped by luminal masses or extraluminal swelling

       Pathogenesis

      Similar to passage of a nasogastric tube, there is the potential risk of epistaxis or other mucosal trauma. The severity of this injury is typically much less than for nasogastric intubation, because passage of the endoscope is visually guided and directed and the endoscopes are generally narrower in diameter and more pliable than most nasogastric tubes. Sources of epistaxis would most likely include the nasal mucosa during endoscope advancement, because visualization would reduce the risk of traumatizing the nasal turbintate and ethmoid turbinates. However, further advancement of the endoscope into a more restricted space (guttural pouches, esophagus) could result in inadvertent flexing of the scope into the turbinates. Advancement of the endoscope into the urethra, ureters, uterus, or caudal intestinal tract could cause direct mucosal trauma in some cases.

       Prevention

      Use of intranasal phenylephrine, which causes vasoconstriction of mucosal vessels, and application of carbomethylcellulose lubricant, which reduces friction between the endoscope and the passageways, may reduce mucosal trauma and irritation in small patients or patients with restricted nasal passages.

       Treatment and expected outcome

      Most epistaxis and mucosal trauma complications associated with endoscopy are self‐limiting and do not need specific treatment. If severe epistaxis occurred, treatment could be applied similar to that described for epistaxis associated with nasogastric intubation (see Chapter 5: Complications of Nasogastric Intubation).

Equipment Damage

       Definition

      Crushing damage to the endoscope by mastication

       Risk factors

       Upper airway endoscopy or gastroscopy without endoscope protector

       Inexperience

       Oral endoscopy without a mouth speculum

       Pathogenesis

The most common damage is associated with endoscopy of the nasopharynx due to retroflexion of the endoscope into the oral cavity. Damage can occur at the end of the endoscope if the leading edge retroflexes into the oral cavity or it may occur in the body of the endoscope if the scope does not advance through the cranial esophageal sphincter and a loop of the endoscope retroflexes into the oral cavity (Figure 4.1). This would be most common when performing esophagoscopy and gastroscopy, because of the intentional induction of a swallowing reflex to enter the esophagus and the long length of the endoscope used for gastroscopy. Upper airway endoscopy is not immune to oral retroflexion, although the risk is much lower because the esophagus is not intentionally entered. Use of the endoscope to evaluate the oral cavity directly exposes the endoscopy to risk of damage by the teeth. The damage