Esophagogastroduodenoscopy EGD

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Esophagogastroduodenoscopy(EGD)

• Indications
• Contraindications
• Complications

Mark D. Goodwin, Lt Col, USAF, MC Program
Director, Family Medicine Residency 55 MDG
Director, Medical Education
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• The 3 Ws
• Who
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EGD vs. UGI?

• EGD Pros and Cons
• Pros Cons
• Direct visualization Motility not assessed
• Incr. Sens. 0.92 Cost
• Incr. Spec. 1.0 Bleeding
• Patient preference Perforation
• Able to Bx/Tx Aspiration
• Dx/o H. pylori Arrhythmia
• Hypoxia

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EGD vs. UGI?

• UGI Pros and Cons
• Pros Cons
• Cheaper Less Sens. 0.54
• No drug ADE less Spec. 0.9
• Evaluate motility No Bx available
• Less work! Radiation exposure
• Indirect visualization

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EGD vs. UGI?

• UGI indications
• Motility problems
• EGD unavailable
• Anesthesia concerns
• Patient preference

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EGD Indications

• Diagnostic vs. Therapeutic endoscope

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Indications Diagnostic EGD

• Common indications
• Abdominal pain- ulcer-like distress unresponsive
  to Treatment
• Any patient gt45 yrs with new-onset dyspepsia
• Heartburn (pyrosis)/refractory or persistent GERD
• Dysphagia/Odynophagia
• Hematemesis
• Melena
• Hematochezia (after lower intestinal bleeding
  excluded)

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Indications Diagnostic EGD

• Common indications
• Fecal occult blood/ Iron deficiency anemia (after
  nondiagnostic colonoscopy)
• Atypical chest pain (after cardiac disease
  excluded)
• Caustic ingestion
• Abnormal UGI (mass, stricture, ulcers etc.)
• Acute upper GI hemorrhage
• Locate site definitive Treatment

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EGD vs. UGI?

• Abnormal UGI

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Indications Diagnostic EGD

• Acute Upper GI bleeding
• Multiple etiologies
• Present with hematemesis or bloody NG aspirate
• Present with Melena

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Indications Diagnostic EGD

• Acute Upper GI bleeding
• Common causes
• Duodenal ulcers   
• Gastric ulcers   
• Gastritis   
• Duodenitis
• Esophagitis   
• Mallory-Weiss tear
• Angiodysplasia   

• Cirrhosis-associated lesions     
• Esophageal varices    
• Gastric varices    
• Portal gastropathy   
• Anastomotic (marginal) ulcer      
• Dieulafoy lesion

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Indications Diagnostic EGD

• Acute Upper GI bleeding
• Uncommon causes
• Duodenal Crohn's disease
• Leiomyoma
• Hemobilia
• Gastric polyps
• Aortoenteric fistula
• Postpolypectomy bleeding
• Gastric antral vascular ectasia
•   

• Malignancy
• Esophageal squamous cell cancer
• Esophageal adenocarcinoma
• Gastric adenocarcinoma
• Gastric lymphoma
• Gastric Kaposi's sarcoma

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Indications Diagnostic EGD

• Uncommon indications
• Intestinal malabsorption
• Regurgitation
• Unexplained nausea and vomiting
• Anorexia and involuntary weight loss
• Unexplained diarrhea in a patient with AIDS

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Indications Diagnostic EGD

• For surveillanceassociated lesion
• Barrett's esophagus- esophageal adenocarcinoma
• Prior partial gastric resection- gastric
  adenocarcinoma
• Pernicious anemia- gastric adenocarcinoma
• Atrophic gastritis- gastric adenocarcinoma
• Esophageal stricture from lye ingestion-esophageal
  cancer

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Indications Diagnostic EGD

• For surveillanceassociated lesion
• After antibiotic treatment for mucosal associated
  lymphoid tumor- tumor recurrence
• Achalasia at initial diagnosis- malignancy at
  gastroesophageal junction (pseudoachalasia)
• H pylori- gastric adenocarcinoma, lymphoma
• Gastric ulcers to follow until healing- gastric
  adenocarcinoma
• Familial polyposis coli- duodenal adenocarcinoma

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Indications Diagnostic EGD

• Review of Upper GI Tract Disorders
• What you might encounter as you advance the EGD
• Esophagus
• Stomach
• Duodenum

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Indications Diagnostic EGD

• Esophageal disorders
• Esophagitis
• Causes
• Complications
• Webs/rings/diverticuli
• Sources of bleeding
• Motility disorders

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Indications Diagnostic EGD

• Esophagitis
• Causes
• GERD
• Direct injury (NSAIDS)
• Infection

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Indications Diagnostic EGD

• Esophagitis

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Indications Diagnostic EGD

• GERD
• Epidemiology
• 3rd most common GI disorder in US
• 60 million adults monthly sxs, 25 million daily
  sxs 4,590,000 outpatient visits 96,000
  hospitalizations
• Causes
• Gastric secretions irritation
• Decreased LES tone
• Hiatal Hernia
• Pregnancy, obesity
• Scleroderma
• Smoking, ETOH, caffeine, meds

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Indications Diagnostic EGD

• GERD

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Indications Diagnostic EGD

• GERD
• Symptoms
• Typical- heartburn, reflux of gastric contents
• Atypical- Belching, hiccups, epigastric/chest
  pain, chronic cough, asthma, hoarseness, sore
  throat, chronic throat clearing
• Red Flags- dysphagia, odynophagia, bleeding,
  weight loss, anemia

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Indications Diagnostic EGD

• GERD

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Indications Diagnostic EGD

• GERD
• Who should undergo EGD
• Patients presenting with Red Flags
• Patients with chronic GERD after 5 or more years
• Patients gt 50 years
• Failure of standard therapy (?)
• gt50 will have normal mucosa non-erosive
  disease
• Sxs do not always correlate with the degree of
  underlying esophageal damage

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Indications Diagnostic EGD

• GERD

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Indications Diagnostic EGD

• GERD

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Indications Diagnostic EGD

• GERD

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Indications Diagnostic EGD

• NSAIDS
• Risk factors for NSAID complications
• Age gt65 yrs (3X incr. RR)
• Prior complications (i.e. ulcer)
• High dose, multiple NSAIDS
• Concomitant corticosteroid use (2X RR)
• Therapy duration lt 3mos RR declines after 90
  days

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Indications Diagnostic EGD

• NSAIDS
• 10 to 15 of older US patients use prescription
  NSAID daily OTC use possibly up to 7X greater
• Risk for NSAID-related GI symptoms and
  complications increases with age
• 40 of NSAID users develop dyspepsia erosive
  disease in approx. 30 ulceration up to 20
• NSAID-related erosion, ulceration, or hemorrhage,
  up to 60 have no warning s/sxs

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Indications Diagnostic EGD
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Indications Diagnostic EGD

• NSAIDS GI toxicity
• Salsalate 0.81 Tolmentin 2.02
• Ibuprofen 1.13 Piroxicam 2.03
• ASA 1.18 Fenoprofen 2.35
• Sulindac 1.68 Indomethicin 2.39
• Diclofenac 1.81 Ketoprofen 2.65
• Napoxen 1.91 Meclofenamate 3.91

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Indications Diagnostic EGD
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Indications Diagnostic EGD

• Infections
• Candidiasis- cheesy, shaggy, white patchy exudate
• Consider HIV, DM, Rx, cancer
• Herpes simplex- vesicles diffuse erythema with
  ulcerations (Bx margin)
• Consider HIV, immunocompromise
• CMV- large, geographic ulcers nonraised borders
  (Bx base)
• Consider HIV, immunocompromise

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Indications Diagnostic EGD

• Infections

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Indications Diagnostic EGD

• Infections

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Indications Diagnostic EGD

• Esophagitis
• Grading systems
• No widely accepted standard criteria multiple
  systems
• Likely best for research and treatment protocols
  vs. clinical applications
• Report by accurate description of findings,
  pictures location and extent as centimeters from
  incisors

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Indications Diagnostic EGD
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Indications Diagnostic EGD

• Esophagitis LA Modified Grading system
• Grade A- One (or more) mucosal break on longer
  than 5 mm that does not extend between the tops
  of two mucosal folds
• Grade B- One (or more) mucosal break more than
  5-mm long that does not extent between the tops
  of two mucosal folds
• Grade C- One (or more) mucosal break that is
  continuous between the tops of two or more
  mucosal folds but that involves less than 75 of
  the circumference
• Grade D- One (or more) mucosal break that
  involves at least 75 of the esophageal
  circumference

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Indications Diagnostic EGD
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Indications Diagnostic EGD

• Esophagitis
• Complications
• Strictures
• Ulcerations
• Barretts esophagitis
• Carcinoma

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Indications Diagnostic EGD

• Esophageal Strictures
• Caused by
• Prolonged reflux
• Ingestion of corrosive agents
• Bx/brushing required to exclude malignancy
• Characteristics
• Firm non-stretchable

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Indications Diagnostic EGD

• Esophageal Strictures

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Indications Diagnostic EGD

• Esophageal Ulcerations/Erosions
• Ulcerations- defects that extend through the
  muscularis mucosae into the submucosa
• Erosions- superficial necrotic defects that do
  not penetrate the muscularis mucosae
• Odynophagia is the Sx usually attributed to
  esophageal erosions/ulcerations
• Rarely can erode into blood vessels
• Treatment is with PPI or anti-reflux surgery

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Indications Diagnostic EGD

• Esophageal Ulcerations/Erosions

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Indications Diagnostic EGD

• Barretts Esophagitis
• Metaplasia of esophageal mucosa to specialized
  columnar mucosa
• 10 patients with GERD Sxs
• Lifetime risk of adenocarcinoma reported as high
  as 10
• Rate at which Barretts esophagus progresses to
  adenocarcinoma (0.5 percent per year)
• Dxd by Goblet cells on Bx above the Z-Line

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Indications Diagnostic EGD

• Barretts Esophagitis
• True incidence unknown estimated 700,000 in US
• The incidence of Barretts esophagus progressing
  to adenocarcinoma is estimated to be 0.5 per 100
  patient-years (i.e. one in 200 patients
  developing carcinoma per year)
• Risk of developing adenocarcinoma is 30 to 125
  times higher in persons with BE
• 25 present w/o GERD Sxs!

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Indications Diagnostic EGD

• Barretts Esophagitis
• Dxd by endoscopy and histology
• Bxs q2 cm four quadrant
• Z-line- columnar epithelium transitions to the
  squamous epithelium (i.e. the squamocolumnar
  junction)
• Normally, the Z-line corresponds to the
  gastroesophageal (GE) junction

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Indications Diagnostic EGD

• Barretts Esophagitis

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Indications Diagnostic EGD

• Barretts Esophagitis

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Indications Diagnostic EGD

• Barretts Esophagitis
• Extent of Columnar epithelium up the esophagus
• Long-segment Barretts esophagus
• Short-segment Barretts esophagus
• Specialized intestinal metaplasia
• Unknown whether natural course or pathogenesis
  varies between these two entities or whether
  short-segment progresses to long-segment disease

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Indications Diagnostic EGD

• Barretts Esophagitis

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Indications Diagnostic EGD

• Barretts Esophagitis
• Physically and financially impossible to screen
  all patients with GERD symptoms for the
  development of Barretts metaplasia
• Patients with alarm symptoms such as dysphagia,
  odynophagia, bleeding, or weight loss should be
  referred promptly for endoscopy
• Little evidence screening reduces mortality
• No evidence has shown that surveillance improves
  mortality rates

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Indications Diagnostic EGD

• Barretts Esophagitis

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Indications Diagnostic EGD

• Barretts Esophagitis
• ACG Surveillance Recommendations
• Patients with Barretts esophagus should undergo
  surveillance endoscopy with biopsies
• GERD should be treated before endoscopy to
  minimize inflammation, which can make
  interpretation more difficult
• Patients with two consecutive negative
  surveillance endoscopies showing no dysplasia may
  undergo subsequent surveillance every 3 (up to
  5?) years

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Indications Diagnostic EGD

• Barretts Esophagitis
• ACG Surveillance Recommendations
• Patients with dysplasia should have the diagnosis
  confirmed by another expert pathologist
• Patients with low-grade dysplasia- scope q6 mos
  for 1st year then annual endoscopy assuming no
  progression
• Patients with high-grade dysplasia can receive
  short-interval endoscopy (i.e., every 3 months)
  or intervention (i.e. esophagectomy), depending
  on the extent of the dysplasia

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Indications Diagnostic EGD

• Barretts Esophagitis
• Factors Associated with Adenocarcinoma
• GERD, especially of long duration
• Sxs gt 3X/wk gt20 yrs 40-fold increased risk
• White or Hispanic race
• Male sex
• Advancing age (plateau in the 60s)
• Smoking (2 fold increase)
• Obesity

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Indications Diagnostic EGD

• Esophageal Cancer
• Typically squamous cell
• Hx/o tobacco/ETOH abuse
• Achalasia
• Adenocarcinoma rate increasing
• gt33 and up to 50 in recent studies
• Presentation
• Dysphagia, odynophagia, anorexia, weight loss
• SCCA- upper/middle 1/3
• AdenoCa- distal 1/3, GE jxn

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Indications Diagnostic EGD

• Esophageal Cancer
• Epidemiology
• 14,250 Americans will be diagnosed with
  esophageal cancer each year, and 13,300 will die
  of this malignancy
• Of the new cases, 10,860 are likely to occur in
  men and 3,390 in women

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Indications Diagnostic EGD

• Esophageal Cancer
• Risk factors
• Age most persons are gt60 years
• Sex men gt women (31)
• Tobacco use Smoking cigarettes/smokeless tobacco
  (SCCA)
• Alcohol use Chronic/heavy use (SCCA)
• Barrett's esophagus (AdenoCa)
• Other types of irritation swallowing lye or
  other caustic substances
• Medical history other head/neck cancers have an
  increased chance of developing a second cancer
  (SCCA)

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Indications Diagnostic EGD

• Esophageal Cancer

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Indications Diagnostic EGD

• Esophageal Cancer

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Esophageal webs
• Thin flexible membrane nl mucosa upper 1/3
  congenital rarely encircle lumen presents with
  solid food dysphagia
• Assocd with Plummer-Vinson syndrome (IDA,
  dysphagia assocd with SCCA) celiac sprue
• Best seen on esophogram
• If symptomatic- treatment is dilation

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Indications Diagnostic EGD

• Esophageal webs

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Esophageal rings
• Stretchable muscular (A) or fibrous (B or
  Schatzkis)
• Schatzki ring seen in 6-14 patients undergoing
  routine UGI
• Congenital demarcates the squamocolumnar
  junction always assocd with HH
• Presents with solid food dysphagia/impaction
• Treated with dilation repeat 99 in 3yrs

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Indications Diagnostic EGD

• Esophageal rings

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Esophageal diverticuli
• Zenkers diverticuli- upper esophagus or
  hypopharyngeal
• 1 of esophograms 21 male to feamle
  predominantly present 7th to 8th decade of life
• Present with Dysphagia, Regurgitation, Cough,
  Aspiration pneumonia, Weight loss, Choking,
  Regurgitation of undigested material, Halitosis

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Esophageal diverticuli
• Mid-body and distal (epiphrenic) diverticuli
• Assocd with motility disorders i.e. diffuse
  esophageal spasm, hypertensive lower esophageal
  sphincter, achalasia
• Traction diverticuli assocd with TB or histo
• Present with dysphagia or regurge but most w/o
  sxs
• Avoid perforation! minimal insufflation

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Indications Diagnostic EGD

• Esophageal
• diverticuli

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Mallory-Weiss tear
• Longitudinal mucosal split at GE jxn
• Assocd with coughing, emesis, retching
• Heals rapidly may appear as superficial ulcer
• Varices
• Dilated submucosal veins most prominent at GE
  jxn extend proximally
• Assocd with incr. portal pressure
• Graded on size (1-4), extent, number, location
• DO NOT BIOPSY!

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Indications Diagnostic EGD

• Other Esophageal abnormalities

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Indications Diagnostic EGD

• Other Esophageal abnormalities

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Varices
• Develop in 50-60 of cirrhotic patients 30
  experience variceal hemorrhage within 2 yrs of
  the Dx
• Greatest risk of initial variceal bleed is within
  6- to 12-months after discovery
• Risk of rebleeding is 60 - 70 over 24-months
• Variceal hemorrhage is the most serious
  complication of portal hypertension accounts for
  1/5 to 1/3 of all deaths in cirrhotic patients
• Mortality rate after variceal bleed is 40 to
  70 average of approximately 50 within 6 weeks

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Glycogen Acanthosis
• Glycogenic Acanthosis are small discrete
  elevations in the
• esophageal mucosa
• Whiter color than the
• surrounding mucosa
• due to a high content
• of glycogen
• No clinical significance
• no need for Bx or Tx

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Indications Diagnostic EGD

• Motility disorders
• Achalasia
• Motor disorder hallmark of hypermotility means
  failure to relax cardinal feature poorly
  relaxing LES produces a functional esophageal
  obstruction
• Presents with solid/liquid dysphagia,
  regurgitation, chest discomfort, weight loss
• Annual incidence 1 2 per 200k M F onset
  usually in 3rd5th decades

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Indications Diagnostic EGD

• Motility disorders
• Achalasia
• Broad differential- malignancy (many),
  sarcoidosis, amyloidosis, etc.
• Risk factor for SCCA 2-7 prevalence
• A regular surveillance program presently is not
  the standard of practice

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Indications Diagnostic EGD

• Achalasia

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Motility disorders
• Nutcracker esophagus
• Diffuse esophageal spasm
• Both present with chest pain and
• dsyphagia
• Inlet Patch
• Congenital ectopic gastric mucosa in the
• upper 1/3 of the esophagus 2-5 of
• individuals acid secretions can produce
• localized inflammation and discomfort.

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Indications Diagnostic EGD

• Other Esophageal abnormalities
• Scleroderma
• Atrophy and motor dysfunction of esophageal
  smooth muscle
• Decreased peristalsis in distal 2/3 decreased
  LES pressure
• Presents with Raynauds phenomenon, dysphagia,
  GERD, severe esophagitis, strictures

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Indications Diagnostic EGD

• Gastric disorders
• Gastritis
• Gastric atrophy
• Gastric polyps
• Gastric ulcers
• Gastric cancer

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Indications Diagnostic EGD

• Gastritis
• Microscopic inflammation
• Characterized by increased erythema, friability,
  petechiae, hemorrhagic lesions
• Classifications
• Reactive (erosive gastritis)
• Chronic nonspecific
• Infectious

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Indications Diagnostic EGD

• Gastritis
• Classifications
• Granulomatous
• Distinctive forms
• Miscellaneous
• Hyperplastic

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Indications Diagnostic EGD

• Gastritis

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Indications Diagnostic EGD

• Gastritis

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Indications Diagnostic EGD

• Gastric atrophy
• Thin gastric mucosa prominent vessels
• Body predominant form assocd with B-12
  deficiency
• In some individuals, chronic superficial H.
  pylori gastritis progresses over time to atrophic
  gastritis
• Multifocal atrophic gastritis- intestinal
  metaplasia may occur increased risk of
  Intestinal-type gastric cancer
• EGD surveillance every 1 to 3 years should be
  considered

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Indications Diagnostic EGD

• Gastric atrophy

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Indications Diagnostic EGD

• Gastric polyps
• lt1 of population
• lt1 cm usually inflammatory hyperpalstic lt1
  chance for malignant transformation 90 of all
  gastric polyps
• 1-2 cm 20 chance carcinoma
• gt2 cm 50 chance of cancer
• Adenoma 11 develop CIS within 4 yrs
• Bx/snare/excision required

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Indications Diagnostic EGD

• Gastric polyps
• Adenomatous gastric polyps require annual
  endoscopic surveillance because of the risk of
  developing new polyps or cancer
• Surveillance is not recommended for patients with
  only hyperplastic or hamartomatous polyps

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Indications Diagnostic EGD

• Gastric polyps

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Indications Diagnostic EGD

• Gastric polyps

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Indications Diagnostic EGD

• Gastric submucosal polyps
• Overlying mucosa normal
• Leiomyomas
• Lipomas (cushion sign)
• Carcinoids
• Thickened gastric folds
• Menetriers Dz
• ZE syndrome
• Lymphoma
• Gastric varices

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Indications Diagnostic EGD

• Gastric submucosal polyps/Thickened gastric folds

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Indications Diagnostic EGD

• Gastric submucosal polyps/Thickened gastric folds

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Indications Diagnostic EGD

• Gastric ulcers
• PUD
• Most common cause of upper GI bleeding
• Cumulative lifetime prevalence of 8 - 14
  slightly more frequently in men (?) 1.8 US
• 70 patients are between the ages of 25 and 64
• Peak prevalence of complicated ulcer disease
  requiring hospitalization is 65- to 74-year-olds
• 4.5 million cases of PUD each year in the US, of
  which 500,000 are new
• Costs of PUD gt 9 billion dollars a year

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Indications Diagnostic EGD

• Gastric ulcers
• PUD
• H pylori 1 causative agent (32-61 in US)
• 90 duodenal ulcers 50 gastric ulcers
• NSAID 2 causative agent (15-20 chronic users)
• 60 unexplained PUD cases due to unrecognized
  NSAID use
• Other factors- advancing age, prior hx/o PUD,
  prior hx/o complicated ulcer dz, multiple NSAID
  use (including concomitant use of low-dose
  aspirin and NSAID), concurrent warfarin or
  corticosteroid use
• Tobacco and ETOH impact uncertain

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Indications Diagnostic EGD

• Gastric ulcers

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Indications Diagnostic EGD

• Gastric ulcers

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Indications Diagnostic EGD

• Gastric ulcers

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Indications Diagnostic EGD

• Gastric ulcers
• Present as dyspepsia occurring 5 to 15 minutes
  after eating and remaining until the stomach
  empties, which may be several hours
• Pain is generally absent during times of fasting
• Nausea/vomiting, which may occur anytime shortly
  after eating to several hours later
• Atypical presentations very common!

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Indications Diagnostic EGD

• Gastric ulcers
• Crater usually white coating, edematous red
  margin
• Deeper ulcers have yellow coating, thick margins
• Occur most commonly on lesser curvature
• Most authorities currently agree that gastric
  ulcer does not predispose to gastric cancer
• However, since gastric cancer can present as an
  ulceration (5), all gastric ulcers should be
  Bxd from the margins (not crater)

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Indications Diagnostic EGD

• Gastric ulcers

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Indications Diagnostic EGD

• Gastric ulcers

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Indications Diagnostic EGD

• Gastric ulcers
• Who/when to scope
• 6-8 wks after treatment for documentation of
  healing of ulcer
• American Gastroenterological Association and
  American College of Physicians have endorsed
  prompt endoscopy in any patient gt45 yrs with
  new-onset dyspepsia
• Red Flags
• Failed therapy for dyspepsia
• Atypical presentation

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Indications Diagnostic EGD

• Gastric ulcers

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Indications Diagnostic EGD

• Gastric cancer
• US- annual incidence of gastric cancer declined
  from more than 30 cases per 100,000 population in
  the 1930s to less than 10 cases per 100,000 in
  the 1990s
• 22,000 new cases and 14,000 deaths for 1999
• African, Hispanic, and Native Americans are 1.5
  to 2.5 times more likely to develop gastric
  cancer than whites

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Indications Diagnostic EGD

• Gastric cancer

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Indications Diagnostic EGD

• Gastric cancer
• Environmental factors, particularly diet, play a
  dominant role
• Chronic Helicobacter pylori infection, a
  causative agent of chronic antral gastritis and
  peptic ulcer disease (PUD), has also been
  implicated in the etiology of gastric cancer

108
Indications Diagnostic EGD

• Gastric cancer

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Indications Diagnostic EGD

• Gastric cancer
• Genetic factors
• Gastric cancer is one of the extracolonic
  malignancies associated with hereditary
  nonpolyposis colorectal cancer (HNPCC)
• First-degree relatives of patients with gastric
  cancer have a twofold to threefold increased risk
  of developing the disease
• Also increased among persons with blood group A

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Indications Diagnostic EGD

• Gastric cancer
• Predisposing conditions
• Chronic atrophic gastritis with intestinal
  metaplasia and achlorhydria is found in the
  majority of patients
• Pernicious anemia scope at Dx no surveillance
  indicated currently
• Prior gastric surgery for PUD associated with an
  increased risk of cancer in the gastric remnant
  15 to 20 years after the initial surgery
• Premalignant conditions- gastric adenomatous
  polyps Menetrier's disease Barrett's esophagus

111
Indications Diagnostic EGD

• Gastric cancer

112
Indications Diagnostic EGD

• Gastric cancer
• Persistent abdominal pain/weight loss- most
  common presenting symptoms, occult GI blood loss
  with or without iron deficiency anemia is common,
  gross hematemesis is rare
• Gastric cancer is also associated with a variety
  of paraneoplastic phenomena

113
Indications Diagnostic EGD

• Gastric cancer

114
Indications Diagnostic EGD

• Gastric disorders- other
• Dieulafoy lesion
• Abnormaly large submucosal artery within 6 cm of
  GE jxn lesser curvature often bleeds
  persistently/severely
• Pigmented protuberance minimal surrounding
  erosion w/o ulceration
• Treat with thermocoagulation, electrocoagulation
  or injection therapy
• Gastric antral vascular ectasia (GAVE)
• Occurs in women, elderly, assocd with cirrhosis,
  presents with IDA
• Watermelon stomach

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Indications Diagnostic EGD

• Gastric disorders- other

116
Indications Diagnostic EGD

• Gastric disorders- other

117
Indications Diagnostic EGD

• Duodenal disorders
• Duodenitis
• Duodenal ulcers
• Duodenal polyps
• Duodenal cancer

118
Indications Diagnostic EGD

• Duodenitis
• Rare cause of acute bleeding
• Risk factors for severe erosive duodenitis are
  similar to those found in patients with bleeding
  peptic ulcers
• Bleeding is usually self-limited and rarely
  requires intervention
• Appears as mucosal erythema, edema, petechiae,
  friability

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Indications Diagnostic EGD

• Duodenitis

120
Indications Diagnostic EGD

• Duodenal ulcers
• Present with burning or gnawing pain located in
  the epigastrium
• Occurs 2 to 3 hours after a meal, is relieved by
  the ingestion of food or antacids
• Most commonly in bulb, often mutiple, bulb
  scarring/deformity
• No Bxs needed nearly always benign!
• 80-90 caused by H pylori

121
Indications Diagnostic EGD

• Duodenal ulcers

122
Indications Diagnostic EGD

• Duodenal polyps
• Infrequent caused by chronic inflammation
  usually benign
• Bx required to confirm no malignancy
• Can be seen in familial polyposis or Gardner's
  syndrome

123
Indications Diagnostic EGD

• Duodenal polyps

124
Indications Diagnostic EGD

• Duodenal cancer
• Very uncommon
• Carcinoid, adenomas (FAP), gastrinomas
• Typically irregular shape, rough texture,
  friable, surrounding erythema
• Negative BX unreliable excision required

125
Indications Diagnostic EGD

• Duodenal cancer

126
Indications Therapeutic EGD

• Therapeutic EGD
• Foreign bodyremoval
• Stricturedilation
• Polypsnare polypectomy
• Esophageal varicesendoscopic band ligation,
  sclerotherapy
• Nonvariceal upper gastrointestinal bleeding
  lesionhemostasis (electrocautery,
  thermocoagulation, injection therapy, laser)

127
Indications Therapeutic EGD

• Therapeutic

128
Indications Therapeutic EGD

• Therapeutic EGD
• Nonbleeding lesion at high risk of rebleeding
  (eg, ulcer with visible vessel, Dieulafoy
  lesion)hemostasis
• Achalasiabotulinum toxin injection
• Disintegration of bezoars
• PEG placement

129
Indications Therapeutic EGD

• Therapeutic

130
Indications Therapeutic EGD

• Therapeutic

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Contraindications EGD

• Absolute
• Risks outweigh benefits
• Patient refusal
• Documented/suspected perforation
• Suspected or known peritonitis
• Severe coagulopathy (INRgt3.0) thrombocytopenia
  (lt30k)/neutropenia
• Severe respiratory distress/hypoxia

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Contraindications EGD

• Relative
• Zenkers diverticulum obstructing
  pharyngeal/laryngeal lesion
• Severe hypopharyngeal trauma
• Severe hypotension/shock/sepsis
• Severe electrolyte d/o
• Life threatening dysrhythmias/unstable angina
• Tense ascites/severe abdominal distension
  (pregnancy 2nd or 3rd trimester)
• Recent AMI/thoracic aortic aneurysm
• Recent upper GI surgery

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Contraindications EGD

• Generally not indicated in
• Sxs functional in origin (exceptions- an
  endoscopic examination may be done once to rule
  out organic disease, especially if symptoms are
  unresponsive to therapy)
• Metastatic adenocarcinoma of unknown primary site
  when the results will not alter management
• Radiographic findings of
• Asymptomatic/uncomplicated sliding hiatal hernia.
  
• Uncomplicated duodenal ulcer which has responded
  to therapy
• Deformed duodenal bulb when symptoms are absent
  or respond adequately to ulcer therapy

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Contraindications EGD

• Sequential or periodic EGD is generally not
  indicated for
• Surveillance for malignancy in patients with
  gastric atrophy, pernicious anemia, or prior
  gastric operations for benign disease
• Surveillance of healed benign disease such as
  esophagitis, gastric or duodenal ulcer
• Surveillance during repeated dilations of benign
  strictures unless there is a change in status

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EGD Complications

• Related to Medications
• Related to Procedure
• Overall complication risk
• 0.13
• Fatality risk
• 0.004

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EGD Complications

• Related to Medications
• Cardiopulmonary
• Generalized reactions
• Hypoxia/hypoventilation/apnea (70 desat 4.4
  need O2)
• Bradycardia/Hypotension (0.5 require
  intervention w/o adverse sequelae)
• 5.4/1000 cardiovascular complications
• Account for up to 40-46 of all complications
• Nearly all are readily reversible!

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EGD Complications
138
EGD Complications

• Related to Procedure
• Perforation
• 0.03-0.1 occurrence mortality rate 0.001
• Predisposing factors-
• Operator inexperience
• Anterior cervical osteophytes
• Zenkers diverticulum
• Esophageal strictures
• Malignancies

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EGD Complications

• Perforation
• Most commonly in pharynx, upper esophagus
• Esophageal perforations 25 mortality rate!
• Uncommonly assocd with forceps Bx
• Present with pain, fever, crepitance, pleurisy,
  leukocytosis, pleural effusion

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EGD Complications

• Perforation
• Diagnosis is by water-soluable contrast plain
  film CT if not seen on plain film
• Management-
• Surgical c/s! conservative approach may be
  appropriate depending upon site of perforation,
  overall health of patient etc.
• NEVER NEVER NEVER FORCE SCOPE!!

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EGD Complications

• Perforation pic

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EGD Complications

• Related to Procedure
• Bleeding
• Rare complication (lt0.1)
• Mallory-Weiss tear by EGD occurs lt0.1
• More common in setting of balloon dilation,
  polypectomy, sclerotherapy
• Treated by standard techniques of injection
  therapy or electrocautery

143
EGD Complications

• Related to Procedure- Rare
• Salivary hyperamylasemia
• Pancreatitis
• Endocarditis
• Ventral herniation
• CVA/AMI
• Seizures

144
EGD

• Summary

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EGD

• Summary
• Endoscopy is an invasive procedure with potential
  serious complications
• All providers who perform endoscopy should be
  mindful of the risks involved, apply good patient
  pre-selection criteria using the appropriate
  indications and understand the tenets of risk
  management utilizing adequate informed consent

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Questions??