EGD. John M. Wo, M.D. University of Louisville July 3, 2008

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1 EGD John M. Wo, M.D. University of Louisville July 3, 2008

2 Different Ways to do an EGD Which scope? Pediatric, regular, jumbo EGD endoscope or pediatric colonoscope Transnasal vs. transoral insertion Sedation vs. no sedation Looking going down vs. looking coming back

3 Spraying for skunk!

5 Methemoglobinemia (MHb) Elevated oxidized hemoglobin that cannot bind and transport oxygen Benzocaine Oxidizing agent Cases of cyanosis and life-threatening complications 818,439 cases of SAE reported to FDA cases of definite or probable MHb 93 % was Benzocaine spray 2 deaths (1.5%) Health professionals should be aware of MHb Just say no Treatment: IV methylene blue at 1 to 2 mg/kg of

6 oore et al. Arch Intern Med 2004;164: Age Distribution of Methemoglobinemia Cases with Benzocaine Mean age: 54 years (75% from age years) 49% female N=132 (definitive or probable cases reported to FDA between )

7 ewcomer et al. Gastrointest Endosc Clin N Am 1994;4: ubarik et al. Am J Gastroenterol 1999;94: Complications of EGD Complications Sedation complication, perforation Sore throat (9.5%) Abdominal discomfort (5.3%) Reported serious complication rates Diagnostic EGD ( %) Therapeutic EGD Dilation (0.25%) Achalasia pneumatic dilation (3.3%) Prosthesis placement (7-15%) respectively

8 Indications for EGD GERD Alarm symptoms Persistent symptoms despite therapy Screening for Barrett s esophagus Dysphagia Persistent epigastric pain and dyspepsia UGI bleeding Screening for varices Etc.

9 Normal EGD

10 Starting EGD

11 Arytenoid medial wall Arytenoid Hypopharynx Anterior True vocal cord Ventricular space False vocal cord Right Left Pyriform sinus Posterior pharyngeal wall Posterior Interarytenoid space

12 Normal Esophagus

13 Low Road High Road

14 EGD blind spots

15 Retroflex

16 Hypopharynx and Larynx

17 Epiglottis Edema

18 Interarytenoid Edema

19 Vocal Cord Granuloma

20 Vocal Cord Granuloma

21 Ventricular Obliteration

22 Sarcoidosis

23 Resistance at the UES: Don t push too hard Zenker s Diverticulum

24 Zenker s Diverticulum

25 Zenker s Diverticulum

26 Zenker s Diverticulum

27 EGD for GERD

28 EE = erosive esophagitis; NERD = non-erosive reflux disease. Venables et al. Scand J Gastroenterol. 1997;32: Heartburn Severity Does Not Predict Presence of Erosive Esophagitis Heartburn Grade Mild Moderate Severe 32% EE (n = 316) 68% NERD (n = 677) Prevalence of Erosive Esophagitis

29 Diagnostic Testing for GERD Sensitivity (%) Specificity (%) Empiric Trial With a PPI Endoscopy Esophageal ph Monitoring Barium Swallow Esophageal Manometry

bridging the tops of folds but involving <75% of the circumference LA Grade D

30 LA Classification of Erosive Esophagitis LA Grade A Isolated mucosal breaks 5 mm long LA Grade B Isolated mucosal breaks >5 mm long A Grade C Mucosal breaks bridging the tops of folds but involving <75% of the circumference LA Grade D Mucosal breaks bridging the tops of folds and involving >75% of the circumference A = Los Angeles.

31 LA Grade A Esophagitis

32 LA Class C Esophagitis

33 LA Class D Esophagitis

34 Esophageal Scaring

35 Mucosal Sloughing (Esophagitis Dissecans Superficialis)

36 GERD: Mucosal Sloughing (Esophagitis Dissecans Superficialis)

37 o et al. Am J Gastroenterol 2004:99; EGD Improving the Management of GERD % of Subjects *p< p=0.03 #p= At least one management improved * # # * Alarm Symptoms (n=124) Medical therapy altered Dilated for esophageal stricture BE surveillance initiated Esophagitis grade 3 or 4 New diagnosis of cancer Persistent Heartburn (n=82)

38 Barrett s Esophagus

39 Barrett s Esophagus

40 Barrett s Esophagus with Erosion

41 Barrett s Esophagus with Stricture

42 Barrett s Esophagus with Nodule

43 Barrett s Esophagus with Nodular Surface

44 Barrett s Esophagus with Nodular Surface

45 Esophageal Inflammatory Diseases

46 25 yr old WM with recurrent intermittent food impaction

47 Inflammation along entire esophagus Granularity Loss of vascular pattern Linear furrow ( vertical lines ) Whitish papules Strictures anywhere in the esophagus Circumferential rings Proximal strictures GEJ stricture Long-segment strictures (small caliber esophagus) Can be normal Endoscopic Features of Eosinophilic Esophagitis are Variable

48 Eosinophilic Esophagitis: Circumferential Rings

49 Eosinophilic Esophagitis

50 Eosinophilic Esophagitis: Granularity

51 Eosinophilic Esophagitis: Loss of Vascular Pattern

52 Eosinophilic Esophagitis: Loss of Vascular Pattern

53 Eosinophilic Esophagitis: Linear Furrows

54 Eosinophilic Esophagitis: White Papules

55 Eosinophilic Esophagitis

56 Eosinophilic Esophagitis: Ulceration

57 Eosinophilic Esophagitis after dilation

58 Eosinophilic Esophagitis: Persistent Dysphagia Before Dilation After Dilation

59 36 yr old female with dysphagia, patient of Dryden but he is out of town Crohns of the esophagus

60 42 yr old female with dysphagia with h/o AIDS Pseudo-diverticulum from past CMV esophagitis

61 37 yr female with progressive odynophagia and dysphagia Mucosal Sloughing (Esophagitis Dissecans Superficialis)

62 Mucosal Sloughing (Esophagitis Dissecans Superficialis)

63 Pill esophagitis from doxycycline 21 yr old nursing student with acute odynophagia

64 EGD for Dysphagia

65 Esophageal Stricture

66 GEJ Peptic Stricture

67 50 yr old doctor with dysphagia attending a drug dinner Ruth Chris s Steak House Schatzki s Ring (Peptic Stricture)

68 42 yr old policeman with dysphagia Esophageal stricture and scarring from chronic GERD

69 82 yr old male with chronic intermittent dysphagia and chest pain Cork screw esophagus or type III achalasia or esophageal spasm

70 Esophageal Spasm

71 Mid Esophageal Diverticulum

72 Esophageal Diverticulum

73 60 yr old male with dysphagia to liquids and solids Achalasia

74 Achalasia: Esophageal Stasis

75 Achalasia with Esophageal Stasis

76 Extrinsic Compression

77 Hiatal Hernias

78 Wo JM et al. Am J Gastroenterol 1996;91: Types of Hiatal Hernias Type 1: Sliding Type 2: True Paraesophageal Type 3: Mixed Paraesophageal

79 Type 1: Sliding Hiatal Hernia Type 1: Sliding

80 Type 1: Sliding Hiatal Hernia Type 1: Sliding

81 Type 2: True Paraesophageal Hernia Type 2: True Paraesophageal

82 Type 3 Mixed Paraesophageal Hernia Type 3: Mixed Paraesophageal

83 Type 3 Mixed Paraesophageal Hernia 65 yr old female with acute vomiting and postprandial chest pain

84 50 yr old male with nocturnal choking Prolapsing paraesophageal hernia

85 Paraesophageal Hernia

86 EGD for Dyspepsia Scope and sign off OR Patient needs a doctor, not an endoscopist

87 Uninvestigated dyspepsia vs. Investigated dyspepsia (functional, non-ulcer or endoscopy-negative dyspepsia)

88 alley et al Practice guideline for dyspepsia, ACG

89 alley and Vakil. ACG Guidelines for dyspepsia. Am J Gastroenterol 2005;100:2324. Alarm Features of Dyspepsia New onset at age >55 years Unexplained weight loss >10% Progressive dysphagia Gastrointestinal bleeding Iron deficiency anemia Persistent vomiting Previous esophagogastric cancer Previous documented peptic ulcer Family history of gastrointestinal cancer Lymphadenopathy or abdominal mass on exam

90 alley et al. Gastroenterology. 1998;114:582. Non-Ulcer ( Functional ) Dyspepsia is Very Common Peptic Ulcer 15%- 25% Functional Dyspepsia 60% GERD 5%- 15% Malignancy <2%

91 EGD: Summary What is the indication and what are you looking for? GERD, dysphagia, dyspepsia, others Pick the right scope EGD is an Art

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