The decision to continue or discontinue anticoagulant or antiplatelet therapy in patients undergoing endoscopic procedures has to be made on an individual basis. It should be based on the risk of postprocedural bleeding and on the risk of thromboembolic events. Therefore, interdisciplinary agreement is essential. For procedures with a low risk of bleeding (such as colonoscopy with or without biopsy) anticoagulant and antiplatelet therapy can be continued. However, antithrombotics except for aspirin should be discontinued promptly before any endoscopic procedure with a high risk of bleeding (such as large polypectomy) and a bridging therapy should be carried out in patients with a high risk of thromboembolic events. Special caution is required in patients on dual antiplatelet therapy early after coronary stenting.

This updated guideline (as in the original version in 2008) is published by the Endoscopy Section of the German Society for Gastroenterology, Digestive and Metabolic Diseases (Deutsche Gesellschaft fur Gastroenterologie, Verdauungs-und Stoffwechselerkrankungen, DGVS), which also has ultimate responsibility for them. Co-publishers are the professional associations and organizations that participated in the preparation of this guideline:.German Association of Gastroenterologists in Private Practice (Berufsverband Niedergelassener Gastroenterologen Deuschlands e.V., bng).Surgical Task Force for Endoscopy and Sonography of the German Society for General and Visceral Surgery (Chirurgische Arbeitsgemein-schaft fur Endoskopie und Sonographie der Deutschen Gesellschaft fur Allgemein- und Viszeralchirurgie; DGAV).German Crohn's Disease/ Ulcerative Colitis Association (Deutsche Morbus Crohn / Colitis ulcerosa Vereinigung e.V.; DCCV).German Society for Endoscopy Assisting Personnel (Deutsche Gesellschaft fur Endoskopiefachberufe; DEGEA).German Society for Anesthesiology and Intensive Care Medicine (Deutsche Gesellschaft fur Anasthesiologie und Intensivmedizin e.V.; DGAI).Society for Legislation and Politics in Health Care (Gesellschaft fur Recht und Politik im Gesundheitswesen; GPRG)Coordination and guidance: T. Wehrmann, A. Riphaus, I. Kopp

Die Entscheidung, eine Antikoagulation oder Thrombozytenaggregationshemmung vor einer Endoskopie abzusetzen, ist unter Abwägung der Blutungs- und Thromboembolierisiken in jedem Einzelfall individuell zu treffen. Wichtig ist eine Absprache mit den anderen beteiligten Fachdisziplinen. Bei Eingriffen mit niedrigem Blutungsrisiko (z. B. Koloskopie, auch mit Biopsie) können Antikoagulanzien und Thrombozytenaggregationshemmer i. d. R. weiter gegeben werden. Bei Eingriffen mit höherem Blutungsrisiko (z. B. Polypektomie größerer Polypen, Dilatation) sollten Antithrombotika mit Ausnahme von Acetylsalizylsäure rechtzeitig vor der Endoskopie abgesetzt werden, bei höherem Thromboembolierisiko ggf. mit einer Bridgingtherapie. Besondere Vorsicht ist bei der dualen Thrombozytenaggregationshemmung in der ersten Zeit nach Implantation von Koronarstents erforderlich.

Einleitung: Die Injektion von Botulinus-Toxin (BTX) in die Papille führt zu einer deutlichen Druckreduktion am Sphinkter Oddi (SO) und in prospektiven Studien konnte belegt werden, dass solche Patienten mit manometrisch verifizierter SO-Dysfunktion (SOD), die von einer BTX-Injektion ≥ 3 Mon. profitieren, durch eine nachfolgende Papillotomie langfristige Beschwerdefreiheit erzielen. Es wurde daher vorgeschlagen, den Effekt einer probatorischen BTX-Injektion auch ohne vorherige SO-Manometrie als Indikation zur Papillotomie zu verwenden.

Schlüsselwörter Sedierung - Analgesie - Endoskopie - Propofol - Midazolam - Pethidin - Monitoring

Prof. Dr. Till Wehrmann Fachbereich Gastroenterologie, DKD Helios Klinik Wiesbaden GmbH Aukammallee 33 65193 Wiesbaden Tel.: ++ 49/6 11/577212 Fax: ++ 49/6 11/577460 Herausgeber dieses Leitlinie-Updates ist, wie in der Erstfassung von 2008, die Sektion Endoskopie im Auftrag der Deutschen Gesellschaft für Gastroenterologie, Verdauungsund Stoffwechselerkrankungen e. V. (DGVS), die auch die federführende Fachgesellschaft ist. Mitherausgeber sind die an der Leitlinienentwicklung beteiligten Fachgesellschaften und Organisationen: ▶ Berufsverband Niedergelassener Gastroenterologen Deutschlands e.V. (bng) ▶ Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonografie der Deutschen Gesellschaft für Allgemeinund Viszeralchirurgie (DGAV) ▶ Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung e.V. (DCCV) ▶ Deutsche Gesellschaft für Endoskopiefachberufe (DEGEA) ▶ Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V. (DGAI) ▶ Gesellschaft für Recht und Politik im Gesundheitswesen (GPRG) Unter der koordinierenden Leitung von: T. Wehrmann, A. Riphaus, I. Kopp

Prof. Dr. Till Wehrmann Fachbereich Gastroenterologie, DKD Helios Klinik Wiesbaden GmbH Aukammallee 33 65193 Wiesbaden Tel.: ++ 49/6 11/577212 Fax: ++ 49/6 11/577460 Herausgeber dieses Leitlinie-Updates ist, wie in der Erstfassung von 2008, die Sektion Endoskopie im Auftrag der Deutschen Gesellschaft für Gastroenterologie, Verdauungsund Stoffwechselerkrankungen e. V. (DGVS), die auch die federführende Fachgesellschaft ist. Mitherausgeber sind die an der Leitlinienentwicklung beteiligten Fachgesellschaften und Organisationen: ▶ Berufsverband Niedergelassener Gastroenterologen Deutschlands e.V. (bng) ▶ Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonografie der Deutschen Gesellschaft für Allgemeinund Viszeralchirurgie (DGAV) ▶ Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung e.V. (DCCV) ▶ Deutsche Gesellschaft für Endoskopiefachberufe (DEGEA) ▶ Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V. (DGAI) ▶ Gesellschaft für Recht und Politik im Gesundheitswesen (GPRG) Unter der koordinierenden Leitung von: T. Wehrmann, A. Riphaus, I. Kopp

Introduction[nl]1 Indications/goals/known risks/patients/quality goals[nl]1.1 Recommendation on sedation choices[nl]1.2 Recommendation on indications for sedation[nl]1.3 Recommendation on examination quality[nl]1.4 Recommendation on risk assessment and structure quality[nl]1.4.1 General[nl]1.5 Recommendation on anesthesia/intubation[nl]1.6 Recommendation on protective intubation[nl]1.7 Recommendation on patient positioning[nl]2 Sedatives/analgesics/drugs acting on the autonomic nervous system/combination therapy/methods of administration[nl]2.1 Acceptance by the patient and the endoscopist[nl]2.1.1 Patient acceptance/satisfaction[nl]2.1.2 Endoscopist satisfaction[nl]2.2 Monotherapies[nl]2.2.1 Propofol[nl]2.2.2 Benzodiazepines[nl]2.2.3 Propofol versus midazolam[nl]2.2.4 Other drugs as monotherapeutics[nl]2.3 Combination therapies[nl]2.3.1 General[nl]2.3.2 Specific combinations[nl]2.3.3 Side effects of combination therapy[nl]2.3.4 Monitoring/structure quality[nl]2.4 Effect of co-morbidity[nl]2.4.1 General[nl]2.4.2 High-risk patients[nl]2.4.3 Substance type[nl]2.5 Music during endoscopy[nl]3 Structure quality: personal/personnel/equipment requirements[nl]Introduction[nl]3.1 Personal requirements[nl]3.2 Education and training courses[nl]3.3 Personnel requirements[nl]3.3.1 Education requirements[nl]3.3.2 Sedation monitoring[nl]3.3.3 Carrying out the sedation[nl]3.3.4 Monitoring after the endoscopic procedure[nl]3.4 Facilities requirements[nl]3.5 Equipment[nl]3.5.1 Clinical monitoring/standard monitoring[nl]3.5.2 Extended monitoring[nl]4 Informed consent/prerequisites for performance of sedation/preservation of vital functions/clinical monitoring/emergency management[nl]4.1 Informed consent of the patient[nl]4.1.1 General and legal aspects[nl]4.1.2 Informing person[nl]4.1.3 Informed consent procedure[nl]4.1.4 Content of the patient information interview[nl]4.1.5 Safety information (patient do’s and don’t’s after endoscopic sedation)[nl]4.2 Requirements for carrying out sedation[nl]4.3 Protection of vital functions[nl]4.4 Management of sedation-related emergencies[nl]4.4.1 Hypoxemia[nl]4.4.2 Cardiac arrhythmias[nl]4.4.3 Arterial hypotension[nl]4.4.4 Myocardial ischemia[nl]4.4.5 Rare events during sedation[nl]5 Quality goals: internal quality assurance/discharge criteria/fitness for road traffic/ability to work/documentation/benchmarking[nl]5.1 Internal quality assurance[nl]5.2 Discharge criteria[nl]5.2.1 Patient instructions[nl]5.2.2 Minimum criteria for discharge[nl]5.2.3 Use of score systems for discharge[nl]5.3 Fitness for road traffic[nl]5.4 Documentation[nl]5.4.1 General[nl]5.4.2 Inability to work[nl]5.5 Benchmarking

Da zu dem Themenkomplex der Strukturqualität derzeit keine prospektiven Studien existieren, wurden für die Empfehlungen fast ausnahmslos die bereits vorhandenen Leitlinien und Empfehlungen herangezogen.

With the advent of flexible, high-frequency catheter probes that can be introduced through the working channel of any endoscope, EUS became available as an additional and very powerful diagnostic tool during routine endoscopic procedures. Miniprobes as a supplement to echoendoscopes with radial or longitudinal scanners provide detailed images with a penetration depth of about 20mm using frequencies of around 20 MHz. Not only structures of the intestinal wall but also a considerable volume of the surrounding organs can be visualised. In the intestine sonographic coupling is best accomplished using bare miniprobes with water filling of the lumen. Out of 1007 miniprobe examinations carried out in the author's clinic, the most frequent indications involved the distal bile and pancreatic ducts (36%), carcinoma of the oesophagus or the cardia (18%), submucosal tumours and GIST (14%), and others (32%). For evaluating the distal common bile duct, extraductal EUS (EDUS) allows the visualisation of small pathological lesions, especially intraductal stones without ductal dilatation with a sensitivity of 97% and a specificity of 98%. For the staging of early cancers, miniprobe EUS has its significance mainly in showing a preserved submucosal layer, thereby excluding an endoscopically non-resectable T2 lesion, as was successfully done in all of our cases. Suspicious prominent structures were easily assigned to the correct layer of the wall or identified as external impressions.

Introduction: Penicillin-induced segmental haemorrhagic colitis (SHC) is a characteristic and striking but rarely diagnosed clinical entity. Bloody diarrhoe and abdominal cramps start a few days after the intake of oral penicillin derivatives. We report the ultrasonographic and clinical findings in nine patients with SHC and compare the results with the findings in ten patients with antibiotic-related pseudomembranous colitis (PMC).Methods: Nine consecutive patients with SHC (age: 32 +/- 70 years; five males, four females) with PMC-negative proctoscopic findings, stool cultures and negative clostridium difficile toxin and ten patients with PMC (age: 50 +/- 18 years; six males, four-females) with positive proctoscopy and Clostridium difficile toxin were clinically evaluated and examined by high resolution ultrasonography. The sonographic findings of the colonic and small bowel walls as well as the clinical course of the diseases were documented.Results: In all nine patients with SHC the wall of the ascending colon was asymmetrically thickened with loss of layer structure. Neither the small bowel nor the cecum were involved in patients with SHC. In all cases a distinct border between involved and uninvolved colon wall was found. During follow-up all patients recovered soon after stopping antibiotic treatment and symptomatic care. In seven of ten patients with PMC pancolitis and in three of ten with left-sided colitis were found at ultrasonography. In all patients with PMC the bowel wall was symmetrically thickened with the layers remaining distinct.Discussion: The knowledge of the clinical characteristics and sonographic findings of penicillin-induced segmental haemorrhagic colitis may reduce the need for invasive endoscopic and radiological investigations in diagnosis and follow-up. The age of patients, clinical course and sonographic findings may be helpful in differentiating patients with SHC and PMC.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

There is a general consensus that infected peripancreatic necrosis following acute pancreatitis requires interventional therapy. Endoscopic transgastric retroperitoneal debridement is a less traumatic alternative to open surgical procedures. Sufficiently wide fenestrations of the posterior gastric wall to the retroperitoneal space are created under endosonographic control. Using this access, even extended necrotic and putrid lesions can be cleaned and flushed. The first results are encouraging. In 150 patients treated in five German hospitals, the mortality rate was 8%. It must be emphasized that endo-scopic retroperitoneal necrosectomy should always be combined with the transpapillary reconstruction of the pancreatic duct ensuring the physiological flow of pancreatic secretion. "Endoscopic surgery" by gaining access through adequately wide gastric wall fenestrations seems possible with minimal tissue trauma and few intervention-related complications.

Bei infizierten Nekrosen als Folge einer akuten Pankreatitis sind therapeutische Interventionen indiziert. Das transgastrale/transduodenale endoskopische retroperitoneale Débridement ist eine im Vergleich zum offenen chirurgischen Vorgehen weniger traumatische Alternative. Unter sonographischer Steuerung werden ausreichend große Fenster der Magenhinterwand zum Retroperitoneum angelegt, über die auch ausgedehnte Nekrosen und putride Prozesse ausgeräumt und gespült werden können. Die ersten Ergebnisse deutscher Zentren sind ermutigend: Bei 150 Patienten aus 7 Zentren betrug die Letalität 8%. Das transgastrale Débridement sollte immer mit der transpapillären endoskopischen Rekonstruktion eines möglichst intakten Pankreasganges mit physiologischem Sekretfluss kombiniert werden. Es scheint erwiesen, dass das sog. endoskopische Operieren durch angemessen große Fenster der Magenwand auch bei komplexer Anatomie mit minimalem Gewebstrauma und ohne große eingriffsbezogene Komplikationen möglich ist.

In einer Pilotstudie (Endoscopy 1998; 30:702–7) konnte belegt werden, das die Ansprechrate der endoskopischen Papillotomie (EPT) bei Patienten mit manometrisch verifizierter biliärer SOD Typ III (hier üblicherweise Benefit nach EPT nur in ca. 2/3d. F.) durch eine Vorselektionierung mittels probatorischer BTX-Injektion deutlich gesteigert werden kann.

BACKGROUND:This prospective study evaluated whether extraductal catheter probe EUS as an adjunct to endoscopic retrograde cholangiography can detect or rule out choledocholithiasis and other pathologic conditions of the distal common bile duct.METHODS:A total of 119 patients referred because of suspected choledocholithiasis or other bile flow obstruction for endoscopic retrograde cholangiography and papillotomy were included in this prospective study. Extraductal EUS of the distal common bile duct with a radial-scanning catheter probe was followed immediately by endoscopic retrograde cholangiography and papillotomy by a second examiner who was blinded to the EUS findings. Extraductal EUS and endoscopic retrograde cholangiography findings were compared.RESULTS:Extraductal EUS detected 33/34 bile duct stones and all papillary adenomas (16 patients). In 8/34 patients, stones were missed on cholangiography but were seen after papillotomy and stone extraction. Extraductal EUS missed 10 peripheral lesions, one pancreatic tumor, and two distal bile duct stenoses. Overall, the sensitivity of EDUS was 78% and specificity was 98%.CONCLUSIONS:Extraductal EUS accurately detects abnormalities involving the distal common bile duct, especially small stones. The use of catheter probe EUS imaging during interventional endoscopy can help to avoid unnecessary papillotomy and can influence therapeutic strategy.

Frontiers and Transitions between Interventional Endoscopy and Abdominal Surgery More interesting than the boundaries are the transitions. The transgression of interventional endoscopy beyond the boundaries of surgery as well as the step of surgery into the realm of sophisticated sonographic, endosonographic and functional diagnostics do not originate in expansive attempts but in special expertise and technical skills (e. g. the interventional gastrointestinal endoscopy) – or in specific demands not accounted for by the other disciplines (e. g. pHmetry or manometry or rectal ultrasound carried out preoperatively). It is evident that in technically demanding medical interventions the physician is the most important variable influencing outcome. Therefore, the limits defining medical disciplines seem of merely political interest. The endoscopist''s or the surgeon''s limits should be defined by their expertise rather than by their professional board. The fact that in both disciplines expertise is based on theoretical knowledge grown over years of practical application automatically results in some limitations for the single specialist. In order to perform clinical work as well as teaching with high responsibility, he needs to focus on a defined field of competence. Endoscopic and surgical specialists meet with very similar considerations regarding diagnostic and therapeutic problems. Refinement of surgical procedures to minimally invasive techniques and the requirement of more and more diagnostic information for individualized surgical strategies is paralleled by the increasingly sophisticated endoscopic interventions becoming more invasive. The transitional zone between surgery and gastroenterology has the attraction not of repelling intruders but of ignoring boundaries while cooperatively discovering new diagnostic and therapeutic options. Most advanced endoscopic interventions always carry a risk of serious complications and can only be justified with the backing of a skilled visceral surgeon. Surgery needs to take into account gastroenterological diagnostic standards and less invasive therapeutic options. Perspectives and limits of modern interventional endoscopy are illustrated by the examples of endoscopic mucosectomy and ablation of Barrett''s epithelium as well as by endoscopic retroperitoneal necrosectomy in postpancreatitic necrosis.

Background: The "buried bumper syndrome," caused by migration of the internal bumper into the gastric walls, is a rare complication of PEG. The internal bumper becomes completely overgrown by gastric mucosa. Localization of internal bumpers in relation to the layers of the gastric wall was investigated with catheter probe US to define the optimal therapeutic strategy for PEG removal. Methods: Eleven patients with the buried bumper syndrome were encountered within 40 months. The internal bumper was localized endosonographically within the gastric and abdominal layers with a 20 MHz catheter US probe. In case of intramural localization, endoscopic extraction was attempted; extramurally located bumpers were removed surgically. Observations: In 8 patients with an intramural internal bumper, endoscopic PEG removal was achieved without major complication. Mild bleeding after needle knife incision in one case was successfully treated by clip application. In the 3 remaining patients with extragastric localization of the bumper, the PEG was surgically removed. Conclusion: The position of the internal bumper within the layers of the gastric and abdominal wall can be determined by EUS with high-resolution catheter probes, thereby indicating the appropriate therapeutic approach.