Preliminary training course on diagnostic upper gastrointestinal endoscopy

1
Preliminary training course on diagnostic upper
gastrointestinal endoscopy

• Raika Jamali M.D.
• Gastroenterologist
• Sina Hospital
• Tehran University of Medical Sciences

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After this course you would be able to

• Determine the indications and contraindications
  of upper gastrointestinal endoscopy (patient
  selection)
• Define the proper time for the procedure
• Prepare the patient for the procedure
• Handle the endoscopy team
• Perform the procedure
• Check for the possible complications
• Write an endoscopy report

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Patient selection

• Patient with upper gastrointestinal discomfort
  with the alarming signs
• Age gt 50
• Weight loss
• Anemia
• Vomiting
• Family history of upper gastrointestinal
  malignancy
• Those refractory to therapy
• Surveillance for Barrett's esophagus
• Long standing reflux symptoms

4
Contraindications

• Hemodynamic unstable patient that need
  resuscitation before endoscopy
• Hopoxia
• Cardiac arrhythmia
• Esophageal perforation

5
Precaution

• Patients with unstable airway or respiratory
  failure need tracheal intubation before endoscopy
• Check for hypoxia during the procedure and
  titrate the supplemental oxygen to avoid hypoxia
• Patients with massive bleeding with risk of
  aspiration need tracheal intubation before
  endoscopy

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Precaution

• Patients with cardiac instability need proper
  management before endoscopy
• Check for arrhythmia during the procedure and
  terminate the procedure immediately if
  significant tachy or brady arrhythmias arise
• Patients suspected for esophageal perforation
  (with foreign body swallowing or corrosive
  esophagitis) need CXR and contrast radiography
  for detection of possible perforation before
  endoscopy

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Timing of endoscopy

• Emergent endoscopy is preferred in patients with
  ongoing (active) severe bleeding
• Fresh blood on gastric washing
• Orthostatic hypotension in spite of proper
  resuscitation
• Melena perse or coffee ground in gastric washing
  is not a sign of active bleeding
• Elective endoscopy is preferred when no sign of
  ongoing bleeding exist

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Preparing the patient

• The risks and benefits of the procedure should be
  offered to the patient and written informed
  consent should be taken before the procedure
• The patient should be examined before the
  procedure for the evaluation of
• Vital signs
• Existence of wheezing in lungs that need
  bronchodilator before the procedure
• Signs of esophageal perforation (pnumothorax and
  subcutaneous emphysema)

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Preparing the patient

• Check for hypoxia by pulse oximetery
• Use supplemental nasal oxygen for patient with O2
  saturation lt 90
• Check for false teeth or any foreign body in
  mouth and remove them before the procedure
• Secretions in mouth should be suctioned and loose
  teeth should be removed to reduce the risk of
  aspiration
• Insert appropriate airway device

10
Preparing the patient

• Check for the I.V. lines
• Position the patient on left lateral decubitus
• Sedate the patient with midazolame infusion

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Checking the endoscopy unit

• Check the light source of scope
• Perform white balance for getting the optimal
  light
• Check for the air pump for appropriate air
  insufflation
• Check the water tank and appropriate water spray
• Check for the power of suction

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Endoscopy procedure

• Check for the locks on endoscope and ensure that
  the tip of scope can move freely
• Lubricate the end of scope with appropriate gel
  to facilitate the passage of scope through the
  pharynx
• To reduce the risk of aspiration of the gel, the
  amount of gel should not be too much to suspense
  from the tip of scope
• Do not insert gel near to the end of scope to
  avoid covering the lens

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Endoscopy procedure

• Insert the scope in the mouth and move it toward
  the uvula watching the palate
• Find the pyriform recess and insert the scope
  carefully to the esophagus
• Do not use the blind approach to reduce the risk
  of perforation
• Move the scope down and air insufflate to open
  the esophagus

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Endoscopy procedure

• Mention to any mucosal abnormality or strictures
  and obtain biopsy for the evaluation of
  malignancy
• Identify glycogenic acanthosis and inlet patch
  that do not have risk of malignancy
• Watch for white plaques that indicate candidiasis
• The possible web or ring in esophagus should be
  mentioned
• Check for the possible esophageal varices in
  distal part
• Describe the size
• Notice to the signs of bleeding tendency (red
  wale sign)

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Endoscopy procedure

• Observe the Z line in distal esophagus
• Pay special attention to the possible mucosal
  breaks in distal esophagus before entering the
  stomach, since traumatizing the mucosa by the
  scope might cause false breaks
• Observe for the length of salmon color appearance
  in distal esophagus
• The salmon color appearance in distal esophagus
  is indicative of columnar epithelium
• If the length of salmon color appearing part is gt
  3 cm, obtain 4 quadrant biopsies from it for the
  detection of possible Barrett's esophagus

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Endoscopy procedure

• Move the scope upward and right to reach the
  pylorus
• Insufflate air to inflate the stomach and watch
  for mucosal abnormalities carefully
• To observe the cardia and the lesser curvature,
  retroflex the scope and withdraw the scope to
  reach the cardia
• Check for the hiatal hernia in retroflexion
  maneuver

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Endoscopy procedure

• Check for any evidence of mucosal edema (snake
  skin appearance, cobble stoning) in stomach
• Check for the erosions and ulcers
• Define the location
• Define the size
• Stigmata of bleeding
• Check for submucosal lesions and polyps
• Check for any evidence of vascular malformations
  suspicious as a source of bleeding

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Endoscopy procedure

• It is better to approach from the base of antrum
  for passing through the pylorus and entering the
  duodenum
• Check the bulb for the signs of duodenitis (snake
  skin appearance) or ulcer
• The scope should move upward and right for
  reaching to the second part of duodenum
• Check for any signs of malabsorption in D2
  (scalloping)
• Obtain biopsy from any suspicious lesion in D2
  for evaluation of malabsorption
• If the mucosa seemed normal, Obtain 4 quadrant
  biopsy for evaluation of malabsorption
• Check for Periampullary diverticula
• Check for Hemobilia

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Check for the possible complications

• Check for chest pain, diaphoresis, and fatigue
  after the procedure that might indicate ischemic
  heart disease
• In case of dyspnea, examine the lungs to check
  for aspiration
• Check for chest pain, subcutaneous, emphysema and
  respiratory distress after the procedure that
  might indicate perforation

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Endoscopy report

• Report should include
• Patient identification
• Date of endoscopy
• The reason for endoscopy
• Sedation details
• Endoscopic findings
• Name of the endoscopist and the endoscopy team

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Endoscopy report

• The abnormalities in larynx and vocal cords
  should be mentioned (vocal cord nodule,
  laryngitis, vocal cord paralysis)
• The description of mucosal, submucosal, vascular
  abnormalities, and extrinsic compression in the
  esophagus should be reported.

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Endoscopy report

• The description of mucosal abnormality consists
  of
• Size
• Location
• Stigmata of bleeding (active bleeding, cloth, or
  visible vessel)
• Shape (depressed, elevated, or flat)
• Causing obstruction (could the scope pass through
  or not)
• An easy way to define the size of lesion, you
  should compare the size of the lesion with the
  tip of biopsy forceps
• To localize the lesions in esophagus, the
  distance of the lesion is reported from the
  incisor teeth

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Endoscopy report

• The description of submucosal abnormality
  consists of
• Size
• Location
• Stigmata of bleeding (active bleeding, cloth, or
  visible vessel)
• Causing obstruction (could the scope pass through
  or not)
• The description of extrinsic compression consists
  of
• Size
• Location
• Causing obstruction (could the scope pass through
  or not)

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Endoscopy report

• Vascular abnormalities in esophagus consist of
• Varices
• Arteriovenous malformation
• Angiodysplasia
• Hemangioma
• The description of vascular abnormality consists
  of
• Size
• Location
• Stigmata of bleeding (active bleeding, clot, or
  visible vessel)

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Z line and salmon color appearance mucosa in
distal esophagus
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Submucosal lesion
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ESOPHAGEAL STRICTURE
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Endoscopy report

• Describe the mucosal breaks in distal esophagus
  according to Los angles classification
• If the mucosal break is lt 5 mm (GERD A)
• If the mucosal break is gt 5 mm (GERD B)
• If the mucosal break is gt 5 mm and invading more
  than 75 of the esophageal circumference (GERD C)
• If ulcer exists (GERD D)
• Describe the length of salmon color appearance
  part in distal esophagus
• Report that biopsy was taken if the length of
  salmon color appearance part in distal esophagus
  was gt 3 cm

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GERD
GERD A
GERD B
GERD C
GERD D
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Endoscopy report

• Report the size of hiatal hernia
• Small size hiatal hernia exists if there is free
  space between the scope and esophagogastric
  junction with inspiration and disappearance of
  the free space with expiration
• Medium size hiatal hernia exists if there is
  fixed free space between the scope and
  esophagogastric junction that do not change with
  respiration
• large size hiatal hernia exists if there is
  fixed free space between the scope and
  esophagogastric junction that do not change with
  respiration and the scope can freely enter the
  esophagus by withdrawing the scope in
  retroversion maneuver

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Hiatal hernia
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Large size hiatal hernia with cameron ulcer
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Endoscopy report

• The description of mucosal, submucosal, vascular
  abnormalities, and extrinsic compression in the
  stomach should be reported with the details
  mentioned previously.
• Report the mucosal edema or nodularity in stomach
• Check for the erosions and ulcers
• Define the location
• Define the size
• Stigmata of bleeding

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Nodularity (above)Snake skin appearance (below)
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Erosions (active bleeding in right and without
bleeding in left)
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Stigmata of rebleeding in ulcer
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Gastric polyp
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Gastric tumor
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Submucosal lesion
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Submucosal lesion in stomach
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Angiodysplasia
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Blue rubber nevus syndrome
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Varice in fundus
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Watermelon stomach
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Hypertrophied gastric folds
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Endoscopy report

• To localize the lesions in stomach you should
  find the incisura angularis as an important
  marker.
• If the lesions are between the incisura angularis
  and pylorus they are located in antrum.
• If the lesions are above the incisura angularis
  they are located in body.
• The area about 2-3 cm around the esophagogastric
  junction is cardia.
• The fundus is considered as the portion of the
  stomach that lies above the cardiac notch.

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Endoscopy report

• The description of mucosal, submucosal, vascular
  abnormalities, and extrinsic compression in the
  duodenum should be reported with the details
  mentioned previously.
• Report the mucosal edema
• Check for the erosions and ulcers
• Define the location
• Define the size
• Stigmata of bleeding

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Submucoal lesion in second part of duodenum
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Scalloping in second part of duodenum
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hemobilia