INTRODUCTION TO UPPER ENDOSCOPY
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1 INTRODUCTION TO UPPER ENDOSCOPY Satish Nagula, MD Associate Professor of Medicine Icahn School of Medicine at Mount Sinai NYSGE First Year Fellows Course July 14, 2018
2
3 Early endoscopes 1805: Bozzini Lichtleiter 1853: Desormeux Cystoscope
4 1957: Hirschowitz Fiberoptic Endoscope
5 Current generation gastroscopes
6 Learning to Perform Upper Endoscopy The good news Learning curve for EGD at 100 cases Competency Both technical and cognitive skills Keep track of your progress You can always get better Advanced endoscopic procedures build on fundamental skills learned with diagnostic EGD
7 Indications for Diagnostic EGD Dyspepsia w/ alarm symptoms or age > 45 Unresponsive to therapy Dysphagia Odynophagia New onset GERD in older adults Refractory GERD
8 Indications for Diagnostic EGD Persistent vomiting of unknown cause FAP Abnormal UGI tract x-ray GI bleeding Iron deficiency anemia (normal colonoscopy) Sampling of small bowel fluid Portal HTN: Document or treat esophageal varices After caustic ingestion
9 Indications for Diagnostic EGD Basically any indication where the findings will change management! New onset GERD in 25 year old EGD or empiric PPI? Acute gastroenteritis with nausea/vomiting? Abdominal pain, weight loss, early satiety?
10 NOT an indication for EGD Distress which is chronic, nonprogressive, atypical for known organic disease, and is considered functional
11 Setting the Scene Left lateral position Mouth guard/bite block Consider topical anesthesia, esp if conscious sedation Check the scope for proper function Air, Water, Dials
12 Insertion of the Endoscope Direct Visualization Examination of the hypopharynx UES Vocal cords and piriform sinuses Level of the thyroid cartilage cm from incisors Special considerations Zenker s diverticulum Esophageal strictures
13 Diagnostic EGD
14 Epiglottis
15 Epiglottis Aryepiglottic fold False vocal cord Vocal cord Arytenoid Piriform sinus Cricopharyngeus
16 Caveats : Oropharyngeal Cancer
17 Caveats : Zenker s Diverticulum Black arrow shows lumen!
18 What if the Endoscope Won t Go Down? Apply GENTLE pressure Try the opposite piriform sinus Try blind passage (encourages swallow reflex) Consult a more experienced endoscopist Consider a pediatric scope Obtain a radiologic contrast study
19 Be aware of the DEATH grip!
20 Examining the Esophagus GE junction usually around 40 cm from incisors Look for the top of the gastric folds Squamocolumnar junction / z-line Hiatal hernia Sliding Paraesophageal
21 Normal GE Junction
22 Reflux Esophagitis
23 Infectious Esophagitis HSV CMV Candida
24 Partial Schatzki s Ring
25 Barrett s Esophagus
26 Esophageal Cancer
27 Esophageal Varices
28 Eosinophilic Esophagitis
29 Hiatal Hernia
30 Entering the Stomach
31 Examining the Stomach Avoid full insufflation upon entering the stomach Often induces retching or belching Remove fundic pool of fluid Avoid suction artifacts Head for the pylorus first / listen to your attending. But keep your eyes open for pathology prior to endoscope trauma
32 Moving Through the Stomach
33 Examining the Pylorus Follow antral peristalsis if pylorus hard to find Use small, coordinated movements If pylorus is stenosed, consider balloon dilation Irregular shape may indicate prior ulcer Usually easier to examine upon withdrawal
34 Pylorus and Antrum Your Month 1 nemesis!
35 Erosions and Ulcers
36 Gastric Cancer/Malignant Ulcers
37 Bleeding Lesions
38 Unexpected Findings
39 Examining the Duodenum Bulb:First portion of the duodenum Turn right (posteriorly) Turn further right (inferiorly/caudally) Descending duodenum Valvulae conniventes (circular rings) Paradoxical motion upon withdrawal (gastric looping!) Multiple duodenal intubations may be required
40 Moving Through the Duodenum Right rotation of the insertion tube as well as full upward and right tip deflection
41 Straightening in the Duodenum
42
43
44 Normal Villous Pattern
45 Celiac Disease
46 Ampulla
47 Duodenal Ulcers
48 Angiodysplasia
49 Duodenal Carcinoma
50 Aortoenteric Fistula BEWARE: The elderly patient with a suspected UGI bleed and a long midline abdominal scar Abernethy and Sekijima NEJM 1997;336:27
51 Return to the Stomach Angulus (incisura angularis) 2/3 down the lesser curve Common site for gastric ulcers Take time to examine completely
52 Retroflexion Requires gastric distension Begin in the antrum Consider locking the wheels Withdraw to advance Rotate to obtain 360o view Biopsy may be difficult due to tip deflection Avoid getting stuck in hernia or esophagus
53 Retroflexed View: Incisura/Angularis and Body
54 Hiatal Hernia
55 Cameron Erosions
56 Gastric Varices Do not biopsy!
57 Mallory-Weiss Tear
58 Surgical Fundoplication
59 Biopsy technique
60 Complications of EGD Discomfort Sore throat, Bloating Bleeding Rare in diagnostic EGD Infection Aspiration pneumonia Medication Reaction Perforation 1:5000 1:10,000
61 Summary Respect the EGD simple, yet needs time and practice! Mindful of proper indications for EGD Be familiar with all the therapeutic tools Visual exam on the way in AND on the way out! Have fun!
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Last Revised: September 15 Last Reviewed: September EOSINOPHILIC ESOPHAGITIS (EOE)/PPI-RESPONSIVE ESOPHAGEAL EOSINOPHILIA (PPI-REE)
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Case Scenario year-old white male presented to personal physician with dyspepsia with reflux.
Case Scenario 1 57-year-old white male presented to personal physician with dyspepsia with reflux. 7/12 EGD: In the gastroesophageal junction we found an exophytic tumor. The tumor occupies approximately
Upper Gastrointestinal Manifestations in Chronic Renal Failure Through Upper Gastrointestinal Endoscopy
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What Is an Endoscopic Ultrasound (EUS)?
ENDOSCOPIC ULTRASOUND (EUS) What Is an Endoscopic Ultrasound (EUS)? An endoscopic ultrasound (EUS) is a specialized procedure that blends: Endoscopy use of a scope to look at the inside lining of the gastrointestinal