Esophageal Perforation

Patients with significant pain, fever or leukocytosis should be examined for esophageal perforation. An esophagram may display extravasation of contrast into the mediastinum or a chest radiograph may show air in the mediastinum. Patients with mild symptoms and minimal extravasation of contrast into the mediastinum may be treated conserv atively with antibiotics, parenteral nutrition (PN), and nasogastric suction. Patients with free perforation and leakage of contrast into the mediastinum, pleural space or abdomen must undergo surgery in addition to receiving antibiotics and PN. In patients who are septic and are poor surgical candidates, an esophageal stent may be temporarily placed to seal the perforation site.

Bacteremia

Trauma to a strictured, damaged esophagus during esophageal dilatation may lead to bacteremia. Rates of bacteremia detected by postdilatation blood cultures is 22% by some recent studies in contrast to studies performed in the 1980s that showed rates of 50% or higher (Botoman and Surawicz, 1986). The majority of isolated organisms prove to be Streptococcus viridans, refuting earlier beliefs that the source of the bacteremia was the result of incompletely sterilized dilators (Zuccaro et al, 1998). Factors that may predispose to bacteremia during esophageal dilatation include multiple passes with dilators, the use of bougie dilators instead of balloons, and dilatation of malignant strictures or tight strictures that are not easily traversed by the endoscope (Nelson et al, 1998). Bacteremia is highest during the first few minutes following the procedure and drops from 22 to 5% 30 minutes after the procedure. Antibiotic prophalaxis prior to esophageal dilatation remains controversial. Current practice is to administer preprocedure antibiotics to patients at high risk. It is still debatable if patients with moderate risk should receive antibiotics. Currently, the American Heart Association advises prophylaxis for patients undergoing esophageal dilatation, whereas the American Society for Gastrointestinal Endoscopy has remained neutral on the issue (Dajani et al, 1997). Recommendations are diverse since case reports of bacterial endocarditis or abscess formation as a result of esophageal dilatation are rare. The lack of evidence has led some experts to believe that providing antibiotic prophylaxis is not warranted and lends itself to adverse drug reactions and antimicrobial resistance (Meyer, 1998). There is a separate chapter on endoscopic disinfection (see Chapter 4, "Endoscopic Disinfection").

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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