INTRODUCTION TO DIAGNOSTIC ENDOSCOPY

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1 INTRODUCTION TO DIAGNOSTIC ENDOSCOPY EGD & Colonoscopy Procedure Kolegium Ilmu Bedah Indonesia B. Parish Budiono Sub Bagian Bedah Digestif FK UNDIP/RSUP Dr. Kariadi Semarang

2 GI Endoscopy GI Endoscopy is defined as the direct visual examination of the lumen of the gastrointestinal tract A flexible end-viewing or side-view endoscope An anoscope A proctosigmoidoscope or rectosigmoidoscope A flexible sigmoidoscope A colonoscope

3 COLONOSCOPY : Indications Blood in the stool Preventive colonoscopy / screening Periodic colonoscopy is desirable over the age of 50 to detect polyps, history of CRC Polyp found on X-ray studies Persistent diarrhea or constipation Imaging studies (barium enema, CT scan, MRI) suggestive of an abnormality Therapeutic : ESD Evaluation of response to treatment

4 Contraindications An unwilling patient Intestinal Obstruction (Total) Peritonitis Acute or chronic obstructive airway disease Recent myocardial infarction (6 weeks) Toxic megacolon Fulminant Ulcerative Colitis/Chron s disease Acute severe diverticulitis Massive Colonic bleeding Acute surgical abdomen / fresh anastomosis Shock, Septicaemia

5 EGD : Indications Gastrointestinal bleeding Unexplained iron deficiency anaemia Positive occult blood test Dysphagia (food sticking) Odynophagia (painful swallowing) Upper abdominal pain Moderate, long standing upper abdominal pain Recurrent vomiting Unexplained weight loss Severe heart burn Suspicious barium meal result Gastric ulcer Check gastric ulcer for healing Achalasia

6 EGD Contraindications : Suspected perforated viscus Shock Seizures Recent M.I. Severe cardiac decompensation Respiratory compromise

7 Preparation Patients Equipment Monitoring Medication After care

8 Preparation Explanation to patient about indication, preparation, procedure & potential of complications. Take a proper consent. The colon must be completely cleaned liquid diet the day before the test / no fiber diet laxatives to clean the bowel Most medications may be continued Aspirin products, arthritis medications, anticoagulants), insulin and iodine products may interfere cleansing antibiotics prior to the procedures (+/-)

9 Preparation Day before No fibre diet Dulcolax 2 tab after dinner Day of procedure : 4 hours before Fleet (phosphosoda)/ MgSO 4 30 gr in 200 cc plain water, continue with 2 liter of water Need fasting for 3-4 hours if use sedation

10 Conscious Sedation The use of mood altering, amnestic, and analgesic medication before and during procedure to improve patient tolerance and satisfication Reduction of anxiety and pain Induction of amnesia Improvement in patients cooperation Close monitoring Risk of cardiopulmonary complications

11 Conscious Sedation Upper Endoscopy Short procedure Less than 10 minutes Great anxiety Discomfort : Gagging Retching Distention of upper gut Larger scopes : therapeutic endoscopes Colonoscopy Discomfort : Distention of the colon Stretching of the large bowel Longer procedure (30 minutes or more)

equipment : IV supplies, infusion, suplemental O2, oral suctioning equipment, nasal

12 Monitoring and Ancillary equipment Monitoring equipment : Automated blood pressure and heart rate monitoring Pulmonary ventilation Pulse oxymetry ECG monitoring Ancillary equipment : IV supplies, infusion, suplemental O2, oral suctioning equipment, nasal cannulae, facemask and oral airway Resuscitation equipment Intubation equipment GI assisstant Medication

13 Medication

14 Choice of Sedation Midazolam vs. Diazepam Short acting, amnesic effect Fentanyl vs. Pethidine Less nausea and vomiting Short acting drugs Faster recovery, less demand on recovery, earlier discharge Reversal Flumazenil, Naloxone

15 Procedure Colonoscopy is usually done under sedation. Some discomfort, such as a feeling of pressure, bloating or cramping, or pain may be encountered at times The patient lies on the left side or sometimes on the back / right side during the procedure The colonoscope is slowly inserted into the rectum and slowly advanced through the colon while the physician removes any residual material missed by the preparation and observes the wall of the bowel. As the colonoscope is slowly withdrawn, the lining is again carefully examined.

16 Procedure The procedure takes about 30 minutes. If an area of the bowel wall needs to be evaluated in greater detail, a forceps instrument is passed through the colonoscope to obtain a biopsy. If sites of bleeding or a potential bleeding site is found, the bleeding may be controlled by injecting certain medications or by coagulation with electricity, heat or laser; also with hemoclips

17 Colonoscopy The objective is to reach the Caecum as quickly and safely as possible then to meticulously inspect the colon during withdrawal. This is the time to perform therapeutic procedures such as polypectomy, dilatation, biopsy, etc. Major complications occur in less than 1% of patients undergoing colonoscopy. The 2 most common complications, perforation and hemorrhage, most likely occur during or after polypectomy.

18 Normal anatomy Valv Bauhini Caecum Appendix Ileum

19 Normal anatomy Colon desc Colon transv Sigmoid Rectum

20 COLONOSCOPY REPORT

21 EGD REPORT

22 Colorectal Pathology Colorectal cancer Polyps Diverticulosis Inflammatory bowel disease Crohn s disease, ulcerative colitis, ischemic colitis Internal hemorrhoids Vascular abnormalities Radiation proctitis

23 Colorectal Pathology Colorectal Cancer

24 Colorectal Pathology Colorectal polyp

25 Colorectal Pathology Diverticular disease

26 Colorectal Pathology Ulcerative colitis

27 Colorectal Pathology Crohn s disease : Cobble stone appearance

28 Colorectal pathology Radiation proctitis

29 Colorectal pathology Internal hemorrhoids

30 Staining technique Lymphoid follicel as small papules

31 Staining technique Lymphoid hyperplasia

32 Staining technique Lymphoid plaque

33 Staining technique Advantage of Chromoscopy for mucosal neoplasia

34 Hot biopsy polypectomy

35 Cold biopsy polypectomy

36 Piecemeal polypectomy

37 After Care After the test, patients are monitored in the recovery area for minutes, until the effects of sedation have worn off. No driving or working is allowed (until the next day). There may be some cramping or bloating because of the air introduced into the colon during the examination. This disappears with the passage of flatus (gas)

38 After Care Generally the patient should be able to eat after the endoscopy, but the physician may restrict the diet or activities, especially, after extensive endoscopic work (i.e. large polypectomy, control of bleeding, etc). The doctor will discuss with the patient or designated companion any further instructions or need for follow up

39 Thank you

Why Choose Wudassie Diagnostic Center for GI service? Ease of Use: One Location: Reduced Cross-Infection: Focus on the Patient: Reduced Cost:

Why Choose Wudassie Diagnostic Center for GI service? In our center, patients find that the process much more convenient, as well as more personal. Our center offers a relaxed environment with medical