Tools of the Gastroenterologist: Introduction to GI Endoscopy

Tools of the Gastroenterologist: Introduction to GI Endoscopy

Objectives Endoscopy Upper endoscopy Colonoscopy Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic ultrasound (EUS) Endoscopic accessories and tools

Endoscopy

Upper Endoscopy Endoscopic examination of the upper GI tract Esophagus Stomach Duodenum aka EGD or esophagogastroduodenoscopy duodenum esophagus stomach

Indications Upper abdominal pain or discomfort Gastroesophageal reflux disease Dysphagia Iron deficiency anemia Esophageal varices Foreign body removal / food impaction Suspected small intestinal disease Feeding tube placement

Direct visualization Hypopharynx Epiglottis Vocal cords Piriform sinuses Insertion Upper esophageal sphincter

Gastroesophageal Junction Located at 35-40 cm from the incisors Squamocolumnar junction = Z-line Esophagus stratified squamous mucosa Stomach columnar mucosa Top of gastric folds Marks the beginning of stomach

Lower Esophagus Esophagus Stomach

Upper Stomach Lesser Curvature Greater Curvature

Body of Stomach Anterior Lesser Curvature Greater Curvature Posterior

Antrum Pylorus

Duodenal Bulb Anterior Posterior

2 nd Portion of Duodenum Major Papilla

Retroflexion in Stomach

Colonoscopy Endoscopic examination of colon Can also evaluate terminal ileum Last portion the small intestine where it connects to the colon Preparation required to clean colon Liquid diet Laxatives

Indications Colorectal cancer Screening Asymptomatic and high risk individuals Surveillance Periodic examinations when disease has been found

Indications - Diagnostic Unexplained GI signs and symptoms Rectal bleeding Iron deficiency anemia Inflammatory bowel disease Diarrhea Abnormal imaging

Indications - Therapeutic Polypectomy Bleeding site localization and hemostasis Colonic stent placement Decompression Volvulus reduction Foreign body removal

Large Intestine

ERCP Endoscopic Retrograde Cholangiopancreatography Endoscopic examination of Bile ducts Pancreas Also uses x-rays

Gallstone disease Stricture dilation Stent placement Biopsy of mucosa Indications

ERCP Scope Upper Endoscope Instrument channel Light Camera Air Light ERCP Scope Elevator Instrument channel Forward-viewing Side-viewing

Biliary Cannulation gallbladder side-viewing scope accessing ampulla ERCP intrahepatic bile ducts duodenum common bile duct (CBD) cholangiogram ampulla CBD intrahepatic bile ducts

ERCP Pancreatic Cannulation common bile duct (CBD) CBD stomach PD pancreas side-viewing scope accessing ampulla pancreatic duct (PD) ampulla pancreatogram

Endoscopic Ultrasound EUS Combines endoscopy with ultrasound capability Examination of Upper GI tract Bile ducts and pancreas Rectum

Staging of cancer Indications Esophageal / Gastric / Pancreatic / Rectal Fine needle aspiration of tissue and cysts Evaluation of submucosal lesions Gallstone disease Drainage of pancreatic pseudocysts

EUS Scopes Scans in plane perpendicular to axis of scope Radial Transducer Linear Scans in plane parallel to axis of scope Instrument channel Plane of imaging

Radial EUS Radial Esophagus

Linear EUS Linear Stomach

Accessories and Tools

Accessories and Tools Biopsy forceps Polypectomy snares Retrieval baskets and nets Injection needles Clips Electrocautery probes Band ligators

Biopsy Forceps Purpose Obtain mucosal tissue biopsies Remove small polyps Various sizes Spiked and non-spiked

Polypectomy Snares Purpose Remove large polyps Various shapes and sizes Special features Rotatable Spiral Barbed

Polypectomy Snares Technique Snare passed over polyp around the stalk Loop tightened to grip polyp stalk Polyp pulled away from the wall of colon 2 Methods Cold stalk cut to remove polyp Hot electric current passed through snare loop to cut stalk while providing electrocautery

Hot Snare Polypectomy

Retrieval Baskets and Nets Purpose Pick up and remove objects: Large polyps Food Foreign bodies

Polyp Retrieval

Injection Needles Purpose Inject medication, dye, or saline into submucosa Specifications 22-25 gauge needles Protrudes 5mm from end of the catheter

Common indications Injection Needles Hemostasis Epinephrine ulcers Ethanolamine varices Lift polypectomy Endoscopic musocal resection Tattoo Botulinum toxin (Botox)

Lift Polypectomy

Hemoclips Purpose Treat focal areas of bleeding Peptic ulcer disease Post-polypectomy bleeding Dieulafoy s lesion Close mucosal defects Various sizes

Electrocautery Probes Purpose Hemostasis of bleeding lesions Technique Generate heat by passage of electric current through probe Cauterize tissue to create hemostatic bond and stop bleeding

Argon Plasma Coagulation Purpose Treat superficial bleeding lesions Angiodysplasias Gastic antral vascular ectasia Radiation proctitis Technique Electric current passed through a jet of ionized argon gas Coagulates bleeding lesion without physical contact

Purpose Band Ligation Banding of esophageal varices Endoscopic musosal resection Technique Suction mucosa into plastic cap Place rubber band at base of mucosa

Banding of Esophageal Varices

Conclusions Introduction to GI endoscopy Basic understanding of Upper endoscopy Colonoscopy ERCP EUS Accessories and Tools used in endoscopy