Paediatric gastrointestinal endoscopy
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1 Skillslab 2018, Maribor, Slovenia Paediatric gastrointestinal endoscopy Assist. Prof. Jernej Dolinšek, MD, PhD
2 Bacground and History Endoscopy (biopsy) devices Endoscopy protocol Indications Nonindications Contraindications Case report Basic endoscope handling Hands-on training TAKING COOPERATION FORWARD 2
3 PAEDIATRIC GASTROINTESTINAL ENDOSCOPY TAKING COOPERATION FORWARD 3
4 TAKING COOPERATION FORWARD 4
5 History of gastrointestinal endoscopy Kussmaul is generally credited with the first gastroscopy in The first approach to the tortuosity of the gut was an instrument with articulated lenses and prisms, as proposed by Hoffmann in Semi flexible gastroscope, the work of Wolf, a fabricator of medical instruments, and Schindler, a physician in Hopkins built a model of a flexible fibre imaging device. 1958: the flexible fibreoptic endoscope of Larry Curtiss, then a graduate student in physics, and Basil Hirschowitz, a trainee in gastroenterology. TAKING COOPERATION FORWARD 5
6 History of gastrointestinal endoscopy Highlights from the golden era ( ) of gastrointestinal endoscopy 1968 Endoscopic retrograde pancreatography 1969 Colonoscopic polypectomy 1970 Endoscopic retrograde cholangiography 1974 Endoscopic sphincterotomy (w/bile duct stone extraction) 1979 Percutaneous endoscopic gastrostomy 1980 Endoscopic injection sclerotherapy (reinvented) 1980 Endoscopic ultrasonography 1983 Electronic (charge coupled device) endoscope 1985 Endoscopic control of upper gastrointestinal bleeding 1990 Endoscopic variceal ligation TAKING COOPERATION FORWARD 6
7 INTESTINAL BIOPSY Margot Shinner device London TAKING COOPERATION FORWARD 7
8 INTESTINAL BIOPSY Suction biopsy device Maribor TAKING COOPERATION FORWARD 8
9 MODERN ENDOSCOPY Modern flexible endoscopes TAKING COOPERATION FORWARD 9
10 OESOPHAGOGASTRODUODENOSCOPY PROTOCOL (OEGDS) 2. Explain the purpose and the course of the procedure. 6. Hold the control panel of the endoscope in the left hand. 7. Check the suction channel (first button - left index finger). 8. Check the air/water channel (second button left indexfinger). 9. Check the control knobs (R/L, U/D). 10. Slowly insert the endoscope - avoid the intubation of the trachea! 14. Slowly push the endoscope toward the antrum and to the duodenal bulb. 17. The hallmark of second portion of the duodenum is the papilla of Vater (usually 9 o clock). 18. Start the withdrawal phase of the endoscopy and carefully observe all the parts of the duodenum. 19. Take biopsy specimens on the way back. 21. For the inspection of the gastric cardia and fundus perform the U-turn manoeuvre - retroflexion. 28. Explain your findings to the patient. TAKING COOPERATION FORWARD 10
11 OEGDS Diagnostic and therapeutic indications, nonindications and contraindications. DIAGNOSTIC INDICATIONS THERAPEUTIC INDICATIONS NONINDICATIONS CONTRAINDICATIONS Weight loss, failure to thrive Percutaneous endoscopic gastrostomy (re)placement Uncomplicated gastroesophageal To diagnose perforation Unexplained anaemia Duodenal tube placement reflux disease Abdominal pain with suspicion of an organic disease Dysphagia and odynophagia Caustic ingestion Recurrent vomiting with unknown cause Hematemesis Hematochezia Unexplained chronic diarrhoea Suspicion of graft-versus-host disease Gastrointestinal allergy Chronic gastroesophageal efflux disease to exclude other diseases or surveillance of Barrett oesophagus Foreign body removal Food impaction Hemostasis Percutaneous jejunostomy placement Oesophageal varices Dilatation of oesophageal or upper gastrointestinal strictures Perforation closure if this occurs during endoscopy itself Achalasia pneumodilation of occasionay botulinum injection Percutaneous endoscopuc gastrojejunostomy tube insertion Cystogastrostomy for drainage of pancreatic pseudocyst (preferably with endoultrasound guidance) Polipectomy, endomucosal resection Functional gastrointestinal disorders TAKING COOPERATION FORWARD 11
12 ILEOCOLONOSCOPY PROTOCOL 2. Explain the purpose and the course of the procedure. 6. Hold the control panel of the endoscope in the left hand. 7. Check the suction channel (first button - left index finger). 8. Check the air/water channel (second button left index finger). 9. Check the control knobs (R/L, U/D). 10. Perform digital rectal examination. 11. Hold the shaft of the endoscope cm from the tip. The distal 20 cm of the shaft is lubricated. Slowly insert the endoscope into the rectum. Bend the tip slightly to the anterior abdominal wall, and rotate the shaft clockwise. 12. Avoid aspiration of the semi-formed stool to prevent clogging of the suction channel. 13. Intubation of the sigmoid colon creates clusters of sharply angled and bent segments. Avoid forming larger loops. 14. If you do not see the lumen, pull back. 15. In case of sharp angle of sigmoid-descending colon angle, put the patient in the supine position and apply the hand pressure to the abdominal wall. 16. The lumen of descending colon is more oval. 17. Splenic flexure is marked by bluish discoloration (spleen). 18. Transverse colon has more triangular lumen. 19. Observe the bluish discoloration of mucosa acquired from the adjacent liver. 21. Visualise the appendix orifice. 22. Successful exploration of the terminal ileum is manifested by the change in colour and texture of the mucosa: it is light pink or yellowish, velvet, with multiple small (< 3mm) lymphoid follicles. 23. After reaching terminal ileum, start withdrawing the endoscope and carefully observe mucosa of all the parts of the colon. Take multiple biopsy specimen from all the parts. 24. Reaching the rectum, do the U-turn maneuverer to inspect the anal sphincter. 27. Explain your findings to the patient. TAKING COOPERATION FORWARD 12
13 ILEOCOLONOSCOPY Diagnostic and therapeutic indications, nonindications. DIAGNOSTIC INDICATIONS THERAPEUTIC INDICATIONS NONINDICATIONS CONTRAINDICATIONS Unexplained anaemia Unexplained chronic diarrhoea Perianal lesions (fistula, abscess) Rectal blood loss Polipectomy, endomucosal resection or extended submucosal dissection, and removal of sessile polyps Dilatation of ileocolonic or colonic stenosis Functional gastrointestinal disorders Constipation with normal faecal calprotectin Toxic megacolon Recent colonic perforation Recent intestinal resection (<7 days) Unexplained failure to thrive Treatment of bleeding lesions Initial work up for inflammatory bowel disease Foreign body removal Suspicion of graft-versus-host disease Reduction of sigmoidal volvulus Rejection or complications after intestinal transplantation Cecostomy or sigmoidostomy Radiological suspicion of ileocolonic stenosis/stricture Polyposis syndromes Orofacial granulomatosis when Crohn disease is suspected TAKING COOPERATION FORWARD 13
14 BIOPSY Indication and site of tissue sampling during endoscopy. INDICATION TISSUE SAMPLES SITES AND NUMBERS Eosinophilic oesophagitis At least 3 biopsy sites should be targeted with 1 2 biopsies from proximal, middle, and distal oesophagus, regardless of the endoscopic appearance of the oesophagus. Helicobacter pyori infection Six biopsies (2 from antrum and 2 from corpus for Sydney classification; 2 for specific H. pylori diagnosis: CLO and culture). Coeliac disease At least 1 biopsy from the duodenal bulb and at least 4 biopsies from the second or third portion of the duodenum. Inflammatory bowel disease (Multiple biopsies (2 or more per section) from all sections of the visualized GI tract, even in the absence of macroscopic lesions. TAKING COOPERATION FORWARD 14
15 BIOPSY COELIAC DISEASE TAKING COOPERATION FORWARD 15
16 BIOPSY COELIAC DISEASE TAKING COOPERATION FORWARD 16
17 Case presentation
18 CASE REPORT 26m, male history while reading (with mother) accidentally swallowed a coin salivation/vomiting moderate/severe discomfort mid thoracic pain no other signs TAKING COOPERATION FORWARD 18
19 CASE REPORT 26m, male rtg (upper abdomen) metal detector (before rtg read-out) strong signal over the entire upper abdomen TAKING COOPERATION FORWARD 19
20 CASE REPORT 26m, male rtg pc+abdomen TAKING COOPERATION FORWARD 20
21 CASE REPORT 26m, male refferal to ORL for urgent removal rigid oesophagoscopy general anaesthesia visualisation of 1 in distal oesophagus coin slips into the stomach TAKING COOPERATION FORWARD 21
22 CASE REPORT observation post anaesthesia rtg day after discharged careful parental observation of stools TAKING COOPERATION FORWARD 22
23 CASE REPORT control rtg two days afterwards parents work at Court of law coin in distal jejunum TAKING COOPERATION FORWARD 23
24 CASE REPORT after 5 days spontaneous defecation TAKING COOPERATION FORWARD 24
25 CASE REPORT after 5 days spontaneous defecation employed at Bank of Slovenia strong possibility to send him to Brussels TAKING COOPERATION FORWARD 25
26 CASE REPORT TAKING COOPERATION FORWARD 26
27 Endoscope handling
28 BASIC ENDOSCOPE HANDLING UP/DOWN WHEEL LEFT/RIGHT WHEEL BIOPSY CHANNEL TAKING COOPERATION FORWARD 28
29 BASIC ENDOSCOPE HANDLING BIOPSIY CHANNEL CAMERA LENS LIGHT SOURCE AIR/WATTER CHANNEL TAKING COOPERATION FORWARD 29
30 BASIC ENDOSCOPE HANDLING SUCTION KNOB AIR (LIGHT TOUCH) WATTER (HARD PRESS) KNOB TAKING COOPERATION FORWARD 30
31 NEUTRAL POSITION L U alignment TAKING COOPERATION FORWARD 31
32 LOOKING UP TAKING COOPERATION FORWARD 32
33 LOOKING DOWN TAKING COOPERATION FORWARD 33
34 INSERTING BIOPSY FORCEPS TAKING COOPERATION FORWARD 34
35 FOREIGN BODY REMOVAL DEVICES TAKING COOPERATION FORWARD 35
36 SIMULATOR TRAINING Hands-on Lets go TAKING COOPERATION FORWARD 36
37 WP T1 ASSESSMENT OF CD MANAGEMENT PRACTICES TAKING COOPERATION FORWARD 37
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