Endoscopic Sedation of the Patient With Cirrhosis

Choosing an appropriate sedative in the setting of endoscopy in patients with cirrhosis is challenging for many reasons. Providers must take into account the severity of liver disease, underlying causative factor, medication metabolism and interactions, baseline hemodynamics, and history of opioid, benzodiazepine, or alcohol dependence. A reduction in hepatic blood flow, increased portosystemic shunting, and decreased function and number of hepatocytes have all been implicated in impaired drug metabolism. Evidence of decompensated liver disease, such as the presence of edema, ascites, hepatic encephalopathy, and hepatorenal syndrome, further influence pharmacokinetics of most medications used for sedation. Endoscopy in patients with cirrhosis is usually well tolerated, and several prospective controlled trials have confirmed acceptable safety profiles in upper and lower endoscopy as well as endoscopic retrograde cholangiopancreatography (ERCP). However, controversy exists regarding which is safer—MAC or moderate sedation—and recent data from a retrospective study at our institution suggest that moderate sedation may be safer than MAC.