Atlas of Colonoscopy

Transcription

1 Atls of Colonoscopy Techniques - Dignosis - Interventionl Procedures Bereitet von Mximilin Bittinger, Helmut Messmnn 1. Auflge Buch. 248 S. Hrdcover ISBN Formt (B x L): 23 x 31 cm Weitere Fchgeiete > Medizin > Klinische und Innere Medizin > Gstroenterologie, Proktologie Zu Inhltsverzeichnis schnell und portofrei erhältlich ei Die Online-Fchuchhndlung eck-shop.de ist spezilisiert uf Fchücher, insesondere Recht, Steuern und Wirtschft. Im Sortiment finden Sie lle Medien (Bücher, Zeitschriften, CDs, ebooks, etc.) ller Verlge. Ergänzt wird ds Progrmm durch Services wie Neuerscheinungsdienst oder Zusmmenstellungen von Büchern zu Sonderpreisen. Der Shop führt mehr ls 8 Millionen Produkte.

2 5 Inserting the Endoscope nd Advncing It in the Colon A. Prost Inspection nd Plption Inspection. The exmintion egins with n inspection of the perinl region. The ptient should e in the left lterl position with his knees ent nd pulled up. A simple inspection cn detect skin chnges, scrs, nl skin tgs, hemorrhoids, nl fissures, nl venous thromoses, fistul, injuries, or prolpse (nl or rectl prolpse). Any findings must e noted lter in the exmintion report. Figures 5.1, 5.2 show exmples of pthologies detected during inspection. The dignostic report should include exct locliztion: for exmple, distnce from the nus or description of loction s if the ptient were in the dorsl recument position (t the 12-o clock position ventrl to the nus). Plption. Following inspection, digitl exmintion of the nl cnl nd distl rectum must e completed efore the ctul endoscopic exmintion egins. Attention should e pid to plple endoluminl normlities (polyps, tumors, foreign ojects) s well s to extrluminl ppernces. Mle ptients cn lso undergo prostte check. An ssessment of sphincter tonus s well s ny noticele discomfort during the exmintion (inflmmtion, fissures) should e included in the plption findings. Ptients who hve een prepred for routine endoscopy will hve n empty rectl mpull. Emergency ptients re nother mtter, however. Especilly in the event of cute gstrointestinl leeding, in ddition to endoluminl inspection, chrcteriztion of stool contents cn provide importnt dditionl informtion (melen, fresh lood, cogulum, stool), helping to infer the source nd intensity of leeding nd mking the rest of the dignostic procedure esier. Figure 5.3 provides some exmples of endoscopic pthologicl findings tht cn e detected during digitl plption. Tle 5.1 provides summry of possile findings from inspection nd plption prior to endoscopy. Tle 5.1 Inspection Inspection nd plption prior to endoscopy Skin chnges (eczem, ulcers, condylom)? Signs of swelling (periproctic scess)? Injuries? Scrs (surgicl opertions)? Anl skin tgs? Hemorrhoids? Anl venous thromosis? Anl fissure? Fistul openings? Anl prolpse/rectl prolpse? Pssing the Anl Sphincter Plption Intestinl contents (stool, lood, cogulum)? Sphincter tonus? Pin (inflmmtion, nl fissures)? Endoluminl ostruction (polyps, tumors, hemorrhoids)? Impressions from n extrluminl spect? Prostte? Stenosis (pssge of finger or endoscope)? Anstomosis? After completing inspection nd plption nd, if necessry, dministering n nlgesic, the ctul endoscopic exmintion cn egin. A locl nesthetic luricting jelly, such s luricnt contining Lidocin, should e pplied lierlly. The endoscope tip is then inserted in the rectum nd guided digitlly without visuliztion. The exminer should explin to the ptient the steps eing tken nd inform the ptient tht he my experience the urge to evcute his owels. The endoscope tip is inserted in the direction indicted y preceding plption; s rough guide, the direction of the nl cnl runs in line etween the nus nd the nvel. After lindly inserting the endoscope 4 5 cm, 5 II Figure 5.1 Exmining the perinl region in the left lterl position: ptient with Crohn disese; reddened fistul opening t out the 6-o clock position. Fig. 5.2 Inspecting the perinl region. Totl rectl prolpse. Pronounced circulr nl skin tgs. 25 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg

3 Inserting the Endoscope nd Advncing It in the Colon Fig. 5.3 Endoluminlly plple ostructions. Soft, stlklike ostructions with smooth surfce in the nl cnl (hypertrophied nl ppill on the dentte line, endoscope inverted in rectum). Sessile, sumucosl ostruction with indenttion in the center, 6 cm ove the nus (histology: lymphom). c Lrge, endoluminl ostruction 5 cm ove the nus (luminl ostruction due to polyp; histologicl denom with severe intrepithelil neoplsi). d Hrdened semicirculr ostruction in distl rectum (rodsed growing crcinom with spontneous leeding). IINorml Exmintion Procedure c d Fig. 5.4 After lindly dvncing the endoscope in the rectum, the instrument is withdrwn. Direct view of the rectl wll. After withdrwl nd ir insuffltion the lumen cn e seen (lower right). Fig. 5.5 Centering the rectl lumen efore continuing colonoscopy. Fig. 5.6 Colostomy (ppositionl streks of lood due to cute lower gstrointestinl leeding). ir is insufflted nd the endoscope tip is pulled ck until the lumen of the distl rectum cn e seen (Fig. 5.4). The rectl lumen is then centered in the middle of the monitor screen (Fig. 5.5) nd the endoscope is dvnced under visuliztion of the lumen to the rectosigmoid junction. At this point in the exmintion there hs not yet een sufficient inspection of the distl rectum or nl cnl, which will e more closely exmined on withdrwl of the endoscope lter (possily lso using retroflexion of the endoscope in the rectum; see elow). Endoscope Insertion in Postopertive Ptients (Colostomy/Ileostomy) Exmintion options. If the ptient hs colostomy/ileostomy s result of n opertion with lost intestinl continuity, endoscopy of the colon vi the nus nd ileum is often impossile nd must e performed through the stom (Fig. 5.6). Before the exmintion, the exminer should know the extent of the opertion(s), the type of stom, nd its loction. In the cse of n end ileostomy, only the nstomosed smll intestine cn e exmined endoscopiclly; the remining colon, if there is ny, is not rechle vi the stom. If the ptient hs colostomy, the 26 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg

4 Advncing the Endoscope in the Sigmoid Colon (Sigmoidoscopy) proximl colon nd terminl ileum cn normlly e exmined without prolem. If the ptient hs doule-rreled ileostomy or colostomy, the intestinl segments proximl nd distl to the stom cn e exmined (Fig. 5.7). Inspection nd plption. Before the ctul endoscopy, thorough inspection of the re surrounding the stom nd digitl plption of the nstomosed intestinl segment should e performed. Specil ttention should e pid during inspection to signs of prolpse nd mucosl normlities involving the visile intestinl mucos s well s irregulrities on the surrounding skin. Along with detecting endoluminl irregulrities, the purpose of plption is to scertin the width of the lumen nd the direction of the nstomosed intestinl segment. Knowing the width of the stom nd insertion direction is essentil for inserting the endoscope nd choice of instrument used is determined in prt y the plpted dimeter of the lumen. c Inserting nd dvncing the endoscope. Insertion of the instrument is esed y the exminer s finger nd the use of ir insuffltion; it is inserted until the intestinl lumen comes into view. The lumen is then centered on the monitor screen efore further dvncing the endoscope. The rest of the exmintion ultimtely depends on remining intestine. Colonoscopy through the stom cn e mde more difficult y loss of originl intestine, incresed postopertive moility of the remining intestine, or ngultion s result of postopertive dhesions. Advncing the Endoscope in the Sigmoid Colon (Sigmoidoscopy) Norml procedure. After reching the rectosigmoid junction out c. 16 cm proximl to the nocutneous line, the endoscopy of the sigmoid colon egins. The sigmoid colon is situted intrperitonelly nd is highly vrile in length. The junction etween rectum nd sigmoid colon often ppers s n cute end in the lumen. The sigmoid colon cn lso e recognized y its prominent, circulr folds. Pssing the sigmoid colon with the ptient lying in the left lterl position is unprolemtic in simple cses where the sigmoid colon shortens itself, enling esier pssge through curves. Pssing the sigmoid-descending junction is often more difficult in this position, especilly for more slender ptients, s the sigmoid colon is forced into the left domen, nrrowing the ngle of the junction with the descending colon. Chnging position to the supine position or, especilly for slender ptients, to the right lterl position llows the sigmoid colon to fll more into the middle nd right Fig. 5.7 Schemtic illustrtion of vrious stoms. : end colostomy, : doule-rreled colostomy, c: end ileostomy. lower domen, therey strightening the ngle nd mking pssge of the endoscope tip into the descending colon significntly esier. Constnt visuliztion of the lumen is desirle for pssing the sigmoid colon. The instrument should e kept s stright s possile, without significnt owing or looping. However, individul differences in length nd course of the sigmoid colon cn mke viewing the lumen more difficult nd in some ptients, looping cnnot e voided. Blind dvncement of the endoscope nd chnging ptient position. If the view of the colonic lumen is ostructed or prevented y shrp ngling, the exminer cn ttempt to scertin luminl direction nd riefly point the instrument tip without visuliztion in the presumed direction of the lumen, using gentle pressure to dvnce the endoscope in this direction. The presumed direction of the lumen is often indicted y shdowing (Fig. 5.8). Such mneuvers, which re performed only in exceptionl cses, require experience, light touch, nd extreme concentrtion. The procedure must e stopped if mcroscopic chnges to the nery mucosl surfce (lnching, loodless- 5 II Fig. 5.8, Acute ngling of the lumen (exmple shown: sigmoid-descending junction). The direction of the lumen cnnot e seen either t out the 7-o clock position () or t the 12-o clock position (), ut it cn e presumed, in prt due to shdowing (rrows). In exceptionl situtions, the endoscope tip cn e very crefully dvnced in the presumed direction without visuliztion. 27 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg

5 Inserting the Endoscope nd Advncing It in the Colon IINorml Exmintion Procedure Fig. 5.9 Looping in the sigmoid colon. Strightening the loop y withdrwing the instrument nd desufflting ir (or suctioning insufflted ir). Strightening the loop using externl hnd pressure nd withdrwing the instrument. ness of mucosl vessels) re oserved, or if there is incresed resistnce to dvncement of the instrument nd discomfort to the ptient s these re signs of incresed dnger of perfortion. Shrp kinks of the lumen cn often e minimized or even eliminted y chnging the position of the ptient; the intrperitonel loction of the moile sigmoid colon mkes this esier. In ddition to the supine position, the right lterl position cn lso e helpful in some situtions. Chnging the ptient s position does not increse risk nd thus must lwys e ttempted first efore resorting to lind dvncement of the instrument. Bowing nd Looping. An dditionl prolem in pssing the flexile sigmoid colon is owing nd looping of the endoscope. Disprity etween the mount of colonoscope introduced into the rectum nd the mount of dvncement of the tip in the lumen is sign tht loop is forming. In extreme cses, the instrument tip no longer moves proximlly in the colon when dvnced or even moves prdoxiclly in the direction of the nus. Pronounced looping in the sigmoid colon cn result in the entire instrument eing used up efore reching the descending colon; it cn lso crete discomfort for the ptient nd increse risk of perfortion, nd, ultimtely, mke it impossile to complete the colonoscopy. To counterct looping, the exminer cn withdrw the instrument premturely, nd, if necessry, repetedly, to the eginning of the loop. This cn strighten the lredy intuted colon segment nd llow grdul dvncement proximlly. Suctioning ir when withdrwing the instrument cn lso e helpful (Fig. 5.9). If looping still cnnot e entirely prevented or countercted, nd is impeding the continution of the procedure, the use of externl hnd pressure cn e helpful in fixing or splinting the sigmoid colon (Fig. 5.9; see elow). Using externl compression preventively cn often counterct looping (prophylcticlly). The optiml locliztion for pplying pressure 28 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg

6 Advncing Further to the Heptic Flexure c d Fig Alph loop technique. Alph loop. d Strightening the loop y pulling the endoscope ck nd rotting the shft clockwise. cn e found y plption. In rre cses of pronounced or typicl looping, rief use of rdiogrphy my e necessry for orienttion. A further option for strightening the lumen nd mking it esier to pss the proximl sigmoid colon nd the sigmoid-descending junction is the so-clled lph-loop mneuver. Rotting the endoscope 180 counterclockwise in the sigmoid colon cretes loop (similr in shpe to the Greek letter lph; Fig ) which mkes further dvncement esier. The loop cn e strightened fter reching the descending colon or the splenic flexure (y rotting the colonoscope clockwise). The procedure is detiled schemticlly in Fig d. 5 II Advncing Further to the Heptic Flexure Sigmoid-descending junction. After pssing the sigmoid colon, the junction with the descending colon is reched. Shrp ngling of the lumen, due to the secondry retroperitonel position of the descending colon, cn mke it difficult to pss the sigmoid-descending junction. Unlike the flexile sigmoid colon, which is locted intrperitonelly, the descending colon is fixed on the posterior dominl wll. Looping or excess ir insuffltion in the sigmoid colon during preceding dvncement of the endoscope cn increse ngling. Thus, fter pssing the sigmoid-descending junction, it is recommended tht the sigmoid loops should e strightened y crefully withdrwing the instrument nd suctioning excess ir. This reduces the pull on the mesentery, which cn cuse discomfort to the ptient, nd lso mkes further dvncement of the instrument esier. In the cse of long nd highly flexile sigmoid colon, pplying externl hnd pressure or using the lph mneuver cn mke entering the descending colon esier (Fig. 5.10). The ctul eginning of the descending colon (corresponding to its distl endpoint) is usully evident when longer intestinl section with somewht ovl-shped lumen nd reltively stright pth ecomes visile (Fig. 5.11). A visile fold in the lumen on the other side of this segment often indictes the splenic flexure. Fig View into the descending colon. Reltively stright pth, ovl lumen, nd evenly spced hustrtions. Another leit less relile sign tht the splenic flexure hs een reched is the luish colortion of the spleen visile through the colon wll (Fig. 5.12). After successfully pssing the sigmoid-descending junction, dvncing the endoscope in the descending colon is generlly unprolemtic. Nonetheless, splinting the sigmoid colon cn still e helpful. Splenic flexure. At the proximl end of the descending colon the splenic flexure is reched, mrking the trnsition to the trnsverse colon. The trnsverse colon is locted intrpertionelly, running cross the upper domen to the heptic flexure. The splenic flexure is highly vrile with regrd to position nd degree of ngling. A high flexure, which is locted eneth the diphrgm, results in lrger ngle ( 90 ) etween the descending colon nd the trnsverse colon compred with more cudl loction ( 90 ). In extreme cses, the flexure cn e mde of n scending nd descending lim (Pyr disese), 29 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg

7 Inserting the Endoscope nd Advncing It in the Colon Fig spleen. Splenic flexure with luminl impression, shimmering of IINorml Exmintion Procedure Fig Vritions of the splenic flexure with different ngles etween the descending colon nd trnsverse colon. A high flexure, c Drooping flexure. Fig. 5.14, View into the trnsverse colon fter pssing the splenic flexure: typicl tringulr configurtion nd pronounced, evenly spced hustrtion. creting n ngle of 180 (Fig. 5.13). Pssge cn e especilly difficult if the splenic flexure is displced verticlly. In such cses, pushing up the endoscope in the more distl colon (especilly the sigmoid colon) followed y withdrwing the instrument cn dvnce the endoscope in the left side of the trnsverse colon. This is siclly the sme procedure s the lph mneuver descried ove, though insted of forming complete loop in the sigmoid colon, merely the eginning of end or n incomplete loop (comined with externl pressure if necessry) is sufficient (cf. Fig. 5.9, Fig. 5.10). Trnsverse colon. Recognizing tht the trnsverse colon hs een reched is usully simple, given its typicl tringulrshped lumen nd strong, evenly spced hustrtions (Fig. 5.14). Compred with the reltively uniform, stright pth of the descending colon, the position of the trnsverse colon is more vrile due to its intrperitonel position nd fixtion on mesocolon, which my vry in length. The fixtion on oth retroperitonel fixted colon flexures cuses it to end convexly nd ventrlly. The middle of the trnsverse colon, however, droops cudlly. The pth etween splenic nd heptic flexures cn vry gretly; t the one extreme, the trnsverse colon cn e nerly horizontl, while t the other it cn droop ll the wy down to the minor pelvis (Fig. 5.15). This results in ny numer of relted difficulties in pssge nd therefore lso dvncing the endoscope in the heptic flexure. Externl pressure cn lift drooping midtrnsverse colon crnilly nd enle the dvncement of the endoscope to continue (see elow). It is lso possile to push the endoscope up fter reching the most cudl point in the drooping trnsverse colon. If the instrument is then crefully withdrwn, crnil displcement of the midtrnsverse colon nd corresponding strightening of the trnsverse colon cn ese pssge nd retrieve used-up endoscope length. Pssge of the trnsverse 30 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg

8 Proximl Colon colon nd reching the heptic flexure is sometimes only possile using comintion of dvncing/withdrwing nd externl hnd pressure. Optiml coopertion etween exminer nd ssistnt is essentil. Pronounced ngling of the lumen towrd the scending colon is sign tht the endoscope is reching the heptic flexure (Fig. 5.16). Heptic flexure. The fixtion of the heptic flexure nd the scending colon to the posterior dominl wll comined with the moility of the intrperitonelly locted trnsverse colon cn result in shrp ngling t the heptic flexure. The sitution is similr to the trnsition descried ove from the intrperitonelly situted sigmoid colon to the retroperitonelly fixted descending colon; the difficulties pssing the heptic flexure re nlogous. If t this point the ptient is still in the left lterl position, it is strongly recommended tht he should chnge position if prolems pssing the heptic flexure re encountered; the ptient should e supine or even in the right lterl position. In some cses, simply chnging the position of the ptient results in visuliztion of the previously displced lumen of the scending colon nd cn enle the exminer to overcome the flexure without prolem. If pssge continues to e difficult, it is often necessry to push the endoscope up until the instrument tip is plced where the scending colon egins. This prt of colonoscopy often cuses discomfort to the ptient. As soon s the instrument tip is positioned in the scending colon, it should e strightened y pulling ck. This ssists further dvncement considerly nd often the endoscope tip moves further towrd the cecum s result. Applying externl pressure cn lso e significnt help with the heptic flexure. Splinting the sigmoid colon, drooping trnsverse colon, or oth cn help strighten the endoscope, preventing repeted looping which uses up endoscope length while helping to rech the scending colon successfully. If this does not work, dditionl externl hnd pressure on the right flnk with the flt of the hnd plced dorslly or slnted lterlly to pply pressure directly to the flexure cn e very helpful (see elow). Fig Schemtic illustrtion of vrious pths of the trnsverse colon. Drooping trnsverse colon. Nerly horizontl trnsverse colon. Proximl Colon After pssing the heptic flexure, the view opens up to the proximl segments of the lrge intestine. In ddition to the cpcious scending colon, the cecl pole nd ileocecl vlve re often visile t the end of the field of vision (Fig. 5.17). Often fter pssing the heptic flexure, there cn e certin unnecessry dvncement of the endoscope in the more distl colon segments. Thus, fter positioning the endoscope tip securely in the scending colon, it is recommended tht the endoscope e crefully withdrwn nd strightened. This lone cn often further dvnce the instrument, in some cses even reching the se of the cecum. If this does not succeed, ctive dvncement of the endoscope is necessry. For pssing the scending colon, 5 II Fig Heptic flexure from n endoscopic spect. Ascending colon towrd the 5-o clock position. Ascending colon towrd the 7-o clock position. 31 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg

9 Inserting the Endoscope nd Advncing It in the Colon IINorml Exmintion Procedure Fig View into the scending colon fter pssing the heptic flexure. The ileocecl vlve, seen s yellowish, thickened fold, is on the lower edge of the lumen (rrow) in the distnce. Fig View of the ileocecl vlve (thickened, yellowish semicirculr fold on the left) nd tilted cecum, oscured view into the cecum from this spect. Fig Trnsillumintion of the endoscope tip through the dominl wll of the lower right domen upon reching the cecum. Fig View of the se of the cecum. Convergence of the three teni originting t out the 3-o clock, 11-o clock, nd 6-o clock positions; ppendix orifice in the center of the imge. dvncing nd withdrwing to strighten it, pplying externl hnd pressure to prevent inefficient loss of instrument length in the flexile, more distl colon segments, or comintion of oth procedures cn e helpful. In some cses, the se of the cecum cn ultimtely e reched only y dditionlly repositioning the ptient; especilly for dvncement in the right hemicolon, positioning the ptient on his right side cn mke dvncement esier. Bse of the cecum. Identifying the se of the cecum is usully unprolemtic, given its chrcteristic morphology nd the proximity of the ileocecl vlve. The se of the cecum is chrcterized y folded pttern produced y the three converging teni; the ppendix vlve or invginted ppendicel orifice is locted t its center (Fig. 5.18). The ileocecl vlve is locted few centimeters distlly, nd usully ppers s yellowish, thickened fold, seprting the cecum from the scending colon (Fig. 5.19). Position nd flexiility of the cecum vry depending on its fixtion to the dorsl dominl wll. A rodly fixted cecum on the posterior wll of the dominl cvity (s continution of the fixtion of the scending colon) results in mostly immoile cecum. The rnge of norml ntomy encompsses ll possile vritions, including the complete lck of such fixtion, resulting in extreme cses in highly moile cecum nd possile inversion of the cecl pole or only the ppendix. This explins why the se of the cecum cn in some cses e completely visulized from the proximl scending colon, ut not in the cse of n inverted or tilted cecum, which requires precise dvncement in the cecum (Fig. 5.19). It is good ide to document the imges of the cecum (with or without the ileocecl vlve) s record of completion of colonoscopy. Along with the typicl endoluminl morphology, reching the cecum cn often lso e confirmed y visile trnsillumintion of the endoscope tip in the lower right domen (Fig. 5.20). 32 Messmnn, Atls of Colonoscopy (ISBN ) 2005 Georg Thieme Verlg