S E C T I O N. Gastroenterology

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1 S E C T I O N V I I Gastroenterology

2 C h a p t e r 3 3 G.I. Endoscopy Sharad C Shah 1, Prasanna S Shah 2 1 Hon. Gastroenterologist: Jaslok Hospital, Breach Candy Hospital & Sir H.N. Hospital, Ex-Head, Dept. of Gastroenterology, Sir J.J. Hospital & Grant Medical College, 2 Consultant Gastroenterologist Introduction One of the wonders of the recent times, is G.I.Endoscopy, both for diagnostic as well as therapeutic purposes. It has gone a long way in the patient care to prevent morbidity and mortality. I would like to approach this topic in a different way. This starts with the evaluation of different G.I. symptoms. G.I. Symptoms Upper GI Colonoscopy ERCP Capsule endoscopy (OGD scopy) Dysphagia + Odynophagia + Heart burn + Dyspepsia Nausea & vomiting + + Diarrhoea + with D2 biopsy + + Gas problem (bloating of abdomen) Faecal incontinence + Constipation + G.I. Bleed Jaundice + + Contraindications to Endoscopy 1. Till 3 weeks after myocardial infarction 2. Pregnancy 3. Acute and severe inflammatory process, e.g. Ulcerative colitis 4. Large and deep ulcers of bowel wall. 5. Chronic stage of irradiation colitis 6. Acute diverticulitis 7. Marked abdominal tenderness 8. Peritonitis

3 9. Ascites 10. Patients on peritoneal dialysis 11. Heart valve replacement patients 12. Marasmic infants 13. Immunosuppressed or immunodepressed patients 14. Conscious adult patient refusing to Endoscopy. 15. Sick and moribund patient. Upper G.I. Endoscopy Diagnostic Indications 1. Haemetemesis 2. Malena 3. Suspected varices 4. Aortic graft 5. Rectal bleeding 6. Dysphagia 7. Upper abdominal discomfort 8. Motility disorder 9. Odynophagia 10. Vomiting 11. Heart burn 12. Regurgitation Therapeutic Upper Endoscopy 1. Management of benign and malignant oesophageal stricture by oesophageal dilatation. 2. Foreign bodies & polyps (i) food impaction (ii) true foreign bodies (iii) gastric bezoars 3. Bleeding varices by (a) Injection Sclerotherapy (b) Rubber banding 4. Actively bleeding ulcers. (i) Lasers (ii) Heat probe (iii) Injection (Adrenalin 1:10,000 dilution) most popular 5. Treatment of mucosal lesions. - angiomas and telangectasia 6. Feeding tubes and gastrostomy. Complications 1. Medication Reactions It may arise from idiosyncrasy or over dosage. Small doses of sedative may produce coma in patients with respiratory or hepatic insufficiency. 2. Pulmonary Problems Mild hypoxia may be prevented by use of oximeter and appropriate action (stimulation, oxygen and injection of antidotes). Aspiration pneumonia can occur in achalasia, patients with pyloric stenosis or in those with active bleeding, in the elderly and when gag reflex is suppressed by pharyngeal anesthesia or excessive sedation. 262 CME 2004

4 3. Perforation 1. Most common in pharynx and cervical oesophagus where endoscope is passed blindly but can also occur at the cardia and superior duodenal angle when these areas are distorted or diseased. 2. During therapeutic dilatation. 3. Perforation of an existing lesion due to excessive air insufflation. 4. Instrumental impaction Tip of endoscope can get impacted in hiatus hernia or the distal oesophagus. 5. Bleeding In patients with impaired coagulation or portal hypertension bleeding may occur. Bleeding is common while taking out biopsies and after therapeutic procedure. 6. Cardiac Dysarrythmias ECG monitoring and oximetry is advisable when Endoscopy is performed in patients with cardiac problems. 7. Transmission Of Infection Colonoscopy Indications 1. Bleeding PR 2. Anemia 3. Prolonged bowel frequency or diarrhoea 4. Any patient with the risk of cancer 5. Constipation 6. Pain in abdomen Therapeutic Colonoscopy 1. Polypectomy 2. Balloon dilatation of short colonic stricture 3. Tube placement (Drainage tube or recording device) 4. De-rotation of volvulus 5. Obliteration of angiodysplasia (electrocoagulation) 6. Tumour destruction (laser photocoagulation to vaporize inoperable or obstructing tumor tissue in the recto-sigmoid) Endoscopic Retrograde Cholangio-Pancreato Graphy (ERCP) Indications 1. Post Cholecystectomy 2. Unexplained pancreatitis 3. Obscure abdominal pain 4. Diagnosis and management of jaundice ERCP also allows specimen collection 1. Collection of pure bile and pancreatic juice 2. Duct Cytology 3. Biopsies at ERCP Complication of ERCP 1. Perforation 2. Bleeding G.I. Endoscopy 263

5 3. Pancreatitis 4. Infection (mainly cholangitis) Delayed Complication 1. Delayed bleeding 2. Gall stone ileus 3. Acute cholecystitis 4. Cholangitis / Pancreatitis. 5. Stenosis of orifice. 6. New stone formation. 7. Recurrent attacks of cholangitis. Small Intestinal Endoscopy Mucosal lesions of sprue or coeliac disease are equally prominent in second part of duodenum as in jejunum. Enteroscopy Examination of the small intestine beyond the ligament of Treitz is difficult. A sterilized colonoscope, preferably pediatric, is suitable for jejunoscopy as it is significantly more flexible than gastroscope. A sonde-type small intestinal endoscope is very long and a passive fibreoptic bundle without biopsy capability, with a distensible balloon at the tip to let intestinal peristalsis movements carry it down towards the ileum (in 4-8 hrs). The partial view and lack of biopsies makes this a rarely used approach. The best way for small intestinal endoscopy is by using a floppy or extra flexible pediatric colonoscope used in conjuction with special soft tellon (Gortex) 60cm long overtube that is passed with the instrument into the duodenum. This overtube has low friction characteristics, which allow the endoscope to pass down without intragastric looping. Total enteroscopy has been achieved with the use of a weighted Teflon string, which the patient swallows and eventually passes (after a few days). The string at the patients mouth is threaded back up the channel of an extra long double channelled instrument. The Endoscope is then advanced over the string, the two ends being pulled apart to straighten it. The whole of the small intestine and colon can be intubated by this means from mouth to anus with examination on withdrawal. It is expensive, discomfortable and occasionally hazardous. References 1. Habr-Gama, A; Waye, JD. Complications and hazards of gastrointestinal endoscopy. World Journal of Surgery 1989;13, Larson AW, Cohen H, Zweiban B, Chapman D, Gourdji M, Korula J and Weiner J. Acute oesophageal variceal sclerotherapy. Journal of the American Medical Association 1986;255, Sanowski RA, Waring JP. Endoscopic techniques and complications in variceal sclerotherapy. Journal of Clinical Gastroenterology 1987;9, Chung SCS, Leung JWC, Steele RJL, Crofts TS, Li AKC. Endoscopic injection of adrenaline for actively bleeding ulcers. A randomised controlled study; British Medical Journal 1988;296, Chung RS. Management of upper gastrointestinal bleeding. In Therapeutic Endoscopy and Gastrointestinal Surgery. 1987;pp. 5-38,Churchill Livingstone, Edinburgh. 6. Ponsky JL, Gauderer MWL. Percutaneous endoscopic gastrostomy: Indications, limitations, techniques and results: World Journal of Surgery 1989;13, Rankin GB. Indications, contraindications and complications of colonoscopy: in Gastroenterologic Endoscopy (ed. Sivak, M.V. Jr.) 1987;pp WB Saunders, Philadelphia. 8. Shinya H. Colonoscopy :Diagnosis and Treatment of Colonic Diseases 1982;Igaku-Shoin,Tokyo. 9. Ferguson DR, Sivak MV. Contraindications and complications of ERCP, in Gastroenterologic Endoscopy (ed. Sivak, M.A.) 1987;WB Saunders, Philadelphia. 10. Schapiro RH. ERCP in the diagnosis of pancreatic and biliary disease; in ERCP, Diagnostic and Therapeutic Applications (ed. Jacobson, I.M.), 1989;pp CME 2004

INVESTIGATIONS OF GASTROINTESTINAL DISEAS

INVESTIGATIONS OF GASTROINTESTINAL DISEAS Lecture 1 and 2 دز اسماعيل داود فرع الطب كلية طب الموصل Radiological tests of structure (imaging) Plain X-ray: May shows soft tissue outlines like liver, spleen,