Imaging Complications of Gastrointestinal and

Biliopancreatic Endoscopy Procedures

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Massimo Tonolini
Editor

Imaging Complications
of Gastrointestinal
and Biliopancreatic
Endoscopy Procedures
Editor
Massimo Tonolini
Department of Radiology
Luigi Sacco University Hospital
Milan
Italy

ISBN 978-3-319-31209-5 ISBN 978-3-319-31211-8 (eBook)

DOI 10.1007/978-3-319-31211-8

Library of Congress Control Number: 2016941181

© Springer International Publishing Switzerland 2016

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To Kumsa
who made me a father
Foreword

During the last decades, digestive endoscopy significantly developed not only
as a diagnostic technique but also in its operative-therapeutic applications.
Endoscopy increasingly has replaced surgery and previous radiological
approaches in a variety of conditions, which up to some years ago required a
surgical approach, such as endoscopic submucosal dissection of intramucosal
tumors or endoscopic drainage of pseudocysts. In the diagnostic field, for
instance, fine needle aspiration (FNA) of pancreatic masses is currently per-
formed under echoendoscopy (EUS), whereas until a few years ago it required
CT or ultrasound guide.
Over time some endoscopic methods, such as endoscopic retrograde chol-
angiopancreatography (ERCP), acquired an almost exclusive therapeutic role
since the diagnosis increasingly relied on other modalities including CT,
magnetic resonance imaging (MRI), and EUS.
This evolution has surely contributed to increase the risks related to endo-
scopic procedures.
In this scenario, the relationship between endoscopists and radiologists
has become increasingly close in the past 20 years. Indeed, the accurate
knowledge of the potential risks of operative endoscopic techniques requires
collaboration between endoscopists and radiologists for two main reasons.
First, advanced endoscopy increases the potential risk of perforation: when
iatrogenic perforation is suspected, the contribution of the radiologist
becomes essential both to make the diagnosis and to guide the treatment strat-
egy. Second, with operative endoscopic procedures, the risk is not limited to
perforation but encompasses other complications such as post-ERCP pancre-
atitis (where contrast-enhanced CT is crucial to assess the severity) and dis-
location of metallic or plastic gastrointestinal or biliopancreatic stents. For
instance, in my personal experience, a plastic stent placed in the common bile
duct may dislodge, ulcerate, and penetrate the contralateral wall to the papilla
of Vater, an occurrence which requires dedicated attention by the radiologist
to reach a comprehensive diagnosis.
Therefore, when a complication occurs, a radiologist with appropriate
knowledge on possible endoscopy-related injuries and with experience in
interventional radiology is indispensable in treatment decision-making and
sometimes in treating the complication itself, such as to drain intra-abdominal
abscesses.
The therapeutic choice certainly requires not only support from the radi-
ologist but also consultation with the surgeon, which allows to solve some

vii
viii Foreword

challenging occurrences; this means that an interdisciplinary consultation

before any complicated procedure is indispensable.
Besides the technical expertise, the endoscopist should possess a thorough
clinical knowledge in order to better accomplish the procedure, to prevent
risks related to it, and also to face them appropriately when they occur. The
skilled endoscopist is always ready to approach any occasional and unfore-
seeable situation, even when they are not so simple. Thorough preparation
and experience allow the endoscopist both to take the necessary precautions
to reduce and prevent iatrogenic injuries and to adequately face the complica-
tions; as a result, the related morbidity and mortality will diminish over time.
With this in mind, not only is the the endoscopist manually performing a
procedure, but also his/her work relies on accurate experience and knowledge
in many areas: medical, oncological, surgical, and radiological. This expanded
knowledge in multiple fields allows the endoscopist to face possible adverse
outcomes and to plan an effective therapy.
In the future, digestive endoscopy will continue to be performed in the
operative-therapeutic field, and emerging methods such as EUS will allow
further applications of endoscopic procedures in different fields.
This could possibly lead to an increase of complications related to diges-
tive endoscopy. The role of the endoscopist will be to prevent and reduce the
related risks and that of the radiologist to recognize them and guide the
endoscopist in his/her work so that the procedures can find wide application
in clinical practice.
This book has clear radiological images and provides a comprehensive
coverage of possible complications of endoscopy, which can help the opera-
tor in his/her “delicate” work.

Milan, Italy Pietro Gambitta, MD

Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Massimo Tonolini

Part I Complications of Upper Digestive Endoscopy

2 Complications of Upper Digestive Endoscopy . . . . . . . . . . . . . . . . 7
Alessandra Dell’Era
3 Imaging Techniques, Normal Post-procedural
Findings and Complications After Upper
Gastrointestinal Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Massimo Tonolini
4 Imaging of Complications of Oesophageal
and Gastroduodenal Stents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Brice Malgras, Athur Berger, Paul Bazeries,
Christophe Aubé, and Philippe Soyer

Part II Complications of Percutaneous Endoscopic

Gastrostomy
5 Complications of Percutaneous Endoscopic
Gastrostomy (PEG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Alessandra Dell’Era
6 Imaging of Percutaneous Endoscopic Gastrostomy
(PEG)-Related Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Massimo Tonolini

Part III Complications of Endoscopic Retrograde

Cholangiopancreatography and Endoscopic
Biliopancreatic Interventions
7 Complications of Endoscopic Retrograde
Cholangiopancreatography (ERCP) . . . . . . . . . . . . . . . . . . . . . . . 69
Emilia Bareggi
8 Imaging Techniques, Expected and Reactive
Appearances After Endoscopic Retrograde
Cholangiopancreatography (ERCP) . . . . . . . . . . . . . . . . . . . . . . . 77
Massimo Tonolini

ix
x Contents

9 Imaging Findings of Complications After Endoscopic

Retrograde Cholangiopancreatography (ERCP)
and Biliary Stenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Massimo Tonolini and Alessandra Pagani

Part IV Complications of Colonoscopy and Colorectal

Interventional Procedures
10 Complications of Lower Digestive Endoscopy . . . . . . . . . . . . . . 113
Emilia Bareggi and Alessandra Dell’Era
11 Imaging Techniques and Expected Post-colonoscopy
Appearances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Anna Ravelli, Alessandro Campari, and Massimo Tonolini
12 Imaging Appearances of Post-colonoscopy Complications . . . . 127
Alessandro Campari, Anna Ravelli, and Massimo Tonolini
13 Endoscopic Perforation in Inflammatory Bowel Diseases . . . . 135
Massimo Tonolini
14 Imaging of Complications of Colonic Stents . . . . . . . . . . . . . . . 141
Brice Malgras, Athur Berger, Paul Bazeries,
Christophe Aubé, Mourad Boudiaf, and Philippe Soyer
15 Imaging Complications of Anorectal Endoscopic
Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Massimo Tonolini

Part V Miscellanous Topics

16 Complications of Small Bowel Capsule Endoscopy . . . . . . . . . . 159
Massimo Tonolini
17 Interventional Radiology in the Treatment
of Complications After Digestive and Biliopancreatic
Endoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Anna Maria Ierardi, Josè Urbano, Ejona Duka,
Natalie Lucchina, and Gianpaolo Carrafiello
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
 Introduction
1
Massimo Tonolini

1.1 Background difference between these groups. The mean time

of ED presentation after the procedure was 6 days
Nowadays, gastrointestinal (GI) endoscopy is (median 5.5 days) after upper GI endoscopy and
extensively used worldwide for diagnosis, screen- 5.2 days (median 3.5 days) for colonoscopy. The
ing, treatment and surveillance of a wide spec- commonest complaints were abdominal pain
trum of alimentary tract symptoms and disorders. (47 %), digestive tract bleeding (12 %) and chest
An estimate of 15–20 million endoscopies are pain (11 %), followed by pneumonia and fever.
performed annually in the United States. Although The impressive range of reported adverse events
generally considered safe techniques with limited included fall, exacerbation of congestive heart
contraindications, digestive endoscopic proce- failure, dehydration, bowel perforation, syncope,
dures are associated with a non-negligible mor- atrial fibrillation, vomiting, back or neck pain, diar-
bidity and occasional mortality. However, the true rhoea, transient ischaemic attack or cerebrovascu-
range and incidence of post-GI endoscopy adverse lar stroke, acute appendicitis, urinary retention,
events are much greater than typically appreci- myocardial infarction, asthma, hepatic encepha-
ated. In the past decade, hospitalisation rates of lopathy, hypoglycaemia, small bowel obstruction,
1.1 % and 0.5 % were reported after upper GI cardiac arrest, deep venous thrombosis, acute pan-
endoscopy and colonoscopy, respectively [1, 2]. creatitis and adynamic ileus. Approximately one-
By reviewing more than 18,000 outpatient third of all ED visits were considered related to
digestive endoscopies, a recent study disclosed the recent endoscopic procedure, and more than
that one out of 127 patients sought medical atten- half (56.7 %) of these resulted in hospitalisation.
tion at emergency department (ED) within 2 weeks Interestingly, only one death was considered pro-
from the procedure. Hospital visit rates reached cedure related [3].
0.79 % (95 % confidence interval 0.63–0.88 %), Firstly, the range, risk and severity of post-GI
1.07 % (CI 0.84–1.35 %), 0.84 % (CI 0.69–1.03 %) endoscopy complications significantly widened
and 0.95 % (CI 0.75–1.19 %) for all endoscopies, with the expansion of minimally invasive thera-
upper GI, colonoscopies and screening colonosco- peutic interventions such as foreign body
pies, respectively, without statistically significant retrieval, stricture or anastomotic dilatation, posi-
tioning of gastroesophageal, duodenal or colonic
stents, endoluminal haemostasis and variceal
M. Tonolini
sclerotherapy, ablation of mucosal lesions,
Radiology Department, “Luigi Sacco” University
Hospital, Via G.B. Grassi 74, Milan 20157, Italy polypectomy, endoscopic mucosal resection and
e-mail: [email protected] submucosal dissection [4–6].

© Springer International Publishing Switzerland 2016 1

M. Tonolini (ed.), Imaging Complications of Gastrointestinal and Biliopancreatic Endoscopy
Procedures, DOI 10.1007/978-3-319-31211-8_1
2 M. Tonolini

Secondly, percutaneous endoscopic gastrostomy increasingly faced with suspected iatrogenic

(PEG) has become established as the preferred min- complications, which represent a major cause of
imally invasive technique to provide long-term concern and often have unspecific clinical and
nutrition support and prevent lung aspiration in laboratory manifestations [1–6, 9, 15]. Among
patients with dysphagia or impaired swallowing post-endoscopy complications, medication-
and to palliate inoperable upper aerodigestive related cardiorespiratory and systemic events
tumours. Despite the growing operators’ experi- include oversedation, flushing, respiratory
ence, due to the steady increase in referrals, PEG- depression, aspiration, arrhythmias, hyperten-
related complications are commonly encountered in sion, hypotension and vasovagal fainting, angina,
most general hospitals and may occur during or myocardial infarction and stroke in descending
shortly after insertion or result from devices left in order or frequency. With the increased use of
place for a long time. The overall post-PEG compli- operative techniques, PEG-related, specific GI
cation rate approaches 21 %. Major occurrences are endoscopy and post-ERCP complications such as
reported in approximately 3–4 % of patients but perforation, bleeding, luminal obstruction and
often need urgent surgery and are associated with a infections are increasingly encountered, particu-
significant (17 %) mortality [7, 8]. larly in elderly patients or with comorbidities
Thirdly, due to the widespread availability of [4–6, 9, 14, 15].
non-invasive imaging techniques such as mag- According to the guidelines issued by the
netic resonance cholangiopancreatography American and European Societies for
(MRCP) and multidetector computed tomogra- Gastrointestinal Endoscopy and by the World
phy (CT), during the last decade, endoscopic ret- Society of Emergency Surgery (WSES), diagno-
rograde cholangiopancreatography (ERCP) sis and management of post-endoscopy compli-
transitioned from a diagnostic tool towards a pri- cations should rely upon a combination of
marily therapeutic procedure. Currently indis- physical, laboratory and imaging data. Early
pensable in surgical practice, ERCP is widely diagnosis is essential in optimising management
used to treat several biliopancreatic (BP) diseases and outcome of post-endoscopy complications,
and often allows obviating surgery. However, particularly to triage those occurrences that
despite improvements in periprocedural care, require prolonged hospitalisation and to choose
ERCP has a non-negligible post-procedural mor- the most appropriate therapeutic approach
bidity (estimated in the range 4–10 % overall) between conservative treatment, surgery and
and mortality (0.5–1.4 %). The incidence of endoscopic, percutaneous or endovascular inter-
ERCP-specific complications largely varies ventions [6, 16].
according to the underlying disease, patients’ age Aimed at gastroenterologists, general sur-
and comorbidities, complexity of the procedure geons and radiologists, this practical volume dis-
and operator’s experience. In particular, the risk cusses the incidence, mechanisms, patient- and
is significantly increased by operative techniques procedure-related risk factors, clinical features
such as use of balloons and dilating catheters, tis- and treatment options (including endoscopic hae-
sue sampling, mechanical lithotripsy and wire mostasis, perforation closure, transarterial
baskets for stone extraction and positioning of embolisation, percutaneous drainage and sur-
plastic and metallic biliary stents [9–14]. gery) of post-endoscopy complications. The
radiologic chapters review and illustrate with
several case examples the imaging appearances
1.2 Approach to Post-endoscopy of the commonest and unusual occurrences after
Complications upper GI endoscopy, ERCP (including sphincter-
otomy and positioning of biliary endoprosthesis),
Due to the large number of diagnostic and thera- PEG positioning, colonoscopy, stricture dilata-
peutic GI and BP endoscopic procedures cur- tion and anorectal procedures. Since clinical
rently performed, clinicians and radiologists are assessment of severely ill patients is usually
1 Introduction 3

difficult, emphasis is placed on the pivotal role of Available at: http://www.bsg.org.uk/pdf_word_docs/

complications.pdf. Accessed July 4th, 2015
CT to allow prompt efficient triage of endoscopy-
6. Paspatis GA, Dumonceau JM, Barthet M et al (2014)
specific complications. According to published Diagnosis and management of iatrogenic endoscopic
guidelines and to our experience, multidetector perforations: European Society of Gastrointestinal
CT represents the ideal imaging modality to Endoscopy (ESGE) position statement. Endoscopy
46:693–711
identify intraluminal or extravisceral haemor-
7. Gomes CA Jr, Lustosa SA, Matos D et al (2012)
rhage; signs of mediastinal, peritoneal or retro- Percutaneous endoscopic gastrostomy versus naso-
peritoneal perforation; acute pancreatitis; and gastric tube feeding for adults with swallowing distur-
infections [14, 16–19]. bances. Cochrane Database Syst Rev (3):CD008096
8. Jain R, Maple JT, Anderson MA et al (2011) The role
Specific attention is devoted to complications
of endoscopy in enteral feeding. Gastrointest Endosc
related to oesophageal, gastroduodenal and 74:7–12
colorectal stents, to the issue of video capsule 9. Anderson MA, Fisher L, Jain R et al (2012)
retention during small bowel capsule endoscopy Complications of ERCP. Gastrointest Endosc 75:
467–473
and to iatrogenic colonoscopy perforations in
10. Kapral C, Duller C, Wewalka F et al (2008) Case vol-
patients with Crohn’s disease and ulcerative coli- ume and outcome of endoscopic retrograde cholangi-
tis. Finally, a dedicated chapter discusses the role opancreatography: results of a nationwide Austrian
and possibilities of interventional radiology in benchmarking project. Endoscopy 40:625–630
11. Silviera ML, Seamon MJ, Porshinsky B et al (2009)
the treatment of complications after digestive and
Complications related to endoscopic retrograde chol-
biliopancreatic endoscopy. angiopancreatography: a comprehensive clinical
By providing an increased familiarity with review. J Gastrointest Liver Dis 18:73–82
clinical and imaging manifestations of endoscopy- 12. Stapfer M, Selby RR, Stain SC et al (2000)
Management of duodenal perforation after endo-
related complications, this book aims to enable
scopic retrograde cholangiopancreatography and
radiologists and clinicians to diagnose and treat sphincterotomy. Ann Surg 232:191–198
them in a timely fashion. The widespread use of 13. Glomsaker T, Hoff G, Kvaloy JT et al (2013) Patterns
CT will increasingly allow early diagnosis of and predictive factors of complications after endo-
scopic retrograde cholangiopancreatography. Br
post-endoscopy complications, thus preventing
J Surg 100:373–380
harmful delays and ultimately decreasing the iat- 14. Tonolini M, Pagani A, Bianco R (2015) Cross-sectional
rogenic morbidity and costs [6, 16]. imaging of common and unusual complications after
endoscopic retrograde cholangiopancreatography.
Insights Imag 6:323–338
15. Cotton PB (2006) Analysis of 59 ERCP lawsuits;
References mainly about indications. Gastrointest Endosc
63:378–382; quiz 464
1. Zubarik R, Fleischer DE, Mastropietro C et al (1999) 16. Sartelli M, Viale P, Catena F et al (2013) 2013 WSES
Prospective analysis of complications 30 days after guidelines for management of intra-abdominal infec-
outpatient colonoscopy. Gastrointest Endosc tions. World J Emerg Surg 8:3
50:322–328 17. Catalano O, De Bellis M, Sandomenico F et al (2012)
2. Zubarik R, Eisen G, Mastropietro C et al (1999) Complications of biliary and gastrointestinal stents:
Prospective analysis of complications 30 days after MDCT of the cancer patient. AJR Am J Roentgenol
outpatient upper endoscopy. Am J Gastroenterol 199:W187–W196
94:1539–1545 18. Pannu HK, Fishman EK (2001) Complications of
3. Leffler DA, Kheraj R, Garud S et al (2010) The incidence endoscopic retrograde cholangiopancreatography:
and cost of unexpected hospital use after scheduled out- spectrum of abnormalities demonstrated with
patient endoscopy. Arch Intern Med 170:1752–1757 CT. Radiographics 21:1441–1453
4. Ben-Menachem T, Decker GA, Early DS et al (2012) 19. Wax BN, Katz DS, Badler RL et al (2006)
Adverse events of upper GI endoscopy. Gastrointest Complications of abdominal and pelvic procedures:
Endosc 76:707–718 computed tomographic diagnosis. Curr Probl Diagn
5. Green J (2006) Complications of gastrointestinal endos- Radiol 35:171–187
copy. British Society of Gastroenterology, London.
 Part I
Complications of Upper
Digestive Endoscopy