Gastroenterology and Hepatology

Risk of Scopes post ACS

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There is always a dilemma of proceeding with endoscopic evaluation in a patient who is at an increased risk of procedural complications such as recent ACS.

The decision is always influenced by hemodynamic instability, coagulopathy, overt hematemesis, patient's decision, monitoring during procedure and whether urgent catheterization is planned.

Few things to note are:
  1. In 1% to 3% of patients admitted with an ACS, GIB will be present or will develop.
  2. IF GIB develops in ACS there is a 4- to 7-fold increased risk of mortality over patients with ACS but no GIB.
  3. In patients who presented with UGIB leading to acute MI are more likely to require endoscopy than patients in whom GIB developed after being treated for acute MI
  4. Endoscopy before cardiac catheterization was beneficial in patients who presented with overt GIB in ACS, reducing overall deaths from 600 to 97 per 10,000 patients, but was not beneficial in patients who presented with occult GIB and acute MI. Those who were not planned for cardiac catheterization subgroup were not analyzed and possibly had no benefit.

The Important thing to realize is that there are no good studies with enough blinding, randomization or numbers to guide us in our decisions, the % mentioned are arbitrary:

  1. The rate of complications can be as high as 12% in patients who undergo endoscopy on the same day (Day 0) of their ACS, but when the percentage is dragged over 30 days post MI, the overall rate of complications is only 1% to 2%
  2. 135 patients (over 48 months) who had OGDS within 30 day of ACS (no control group) had a 2% risk of major cardiopulmonary event (Spier, Bret J. MD,Journal of Clinical Gastroenterology: May/June 2007 - Volume 41 - Issue 5 - pp 462-467)
  3. 100 colonoscopies done within 30 day of ACS vs a risk free 100 colonoscopies in non ACS group shows 9 vs 1 colonoscopic complications (Mitchell S. Cappell, GIE, Volume 60, Issue 6 , Pages 901-909, December 2004)
  4. 3 of 34 OGDS had complications and none in 9 sigmoidoscopies within 3 weeks of ACS (Capell MS, Digestive Diseases 1996, Vol. 14, No. 4)


So in summary, it is multifactorial and individual based. But if the patient is actively bleeding or has an urgent cardiac catheterization planned, the gastro and cardio team needs to discuss on what needs to be done and if the patient understands the risk, endoscopy can be performed.