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
Early endoscopes 1805: Bozzini Lichtleiter 1853: Desormeux Cystoscope
1957: Hirschowitz Fiberoptic Endoscope
Current generation gastroscopes
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
Indications for Diagnostic EGD Dyspepsia w/ alarm symptoms or age > 45 Unresponsive to therapy Dysphagia Odynophagia New onset GERD in older adults Refractory GERD
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
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?
NOT an indication for EGD Distress which is chronic, nonprogressive, atypical for known organic disease, and is considered functional
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
Insertion of the Endoscope Direct Visualization Examination of the hypopharynx UES Vocal cords and piriform sinuses Level of the thyroid cartilage 15-18 cm from incisors Special considerations Zenker s diverticulum Esophageal strictures
Diagnostic EGD
Epiglottis
Epiglottis Aryepiglottic fold False vocal cord Vocal cord Arytenoid Piriform sinus Cricopharyngeus
Caveats : Oropharyngeal Cancer
Caveats : Zenker s Diverticulum Black arrow shows lumen!
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
Be aware of the DEATH grip!
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
Normal GE Junction
Reflux Esophagitis
Infectious Esophagitis HSV CMV Candida
Partial Schatzki s Ring
Barrett s Esophagus
Esophageal Cancer
Esophageal Varices
Eosinophilic Esophagitis
Hiatal Hernia
Entering the Stomach
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
Moving Through the Stomach
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
Pylorus and Antrum Your Month 1 nemesis!
Erosions and Ulcers
Gastric Cancer/Malignant Ulcers
Bleeding Lesions
Unexpected Findings
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
Moving Through the Duodenum Right rotation of the insertion tube as well as full upward and right tip deflection
Straightening in the Duodenum
Normal Villous Pattern
Celiac Disease
Ampulla
Duodenal Ulcers
Angiodysplasia
Duodenal Carcinoma
Aortoenteric Fistula BEWARE: The elderly patient with a suspected UGI bleed and a long midline abdominal scar Abernethy and Sekijima NEJM 1997;336:27
Return to the Stomach Angulus (incisura angularis) 2/3 down the lesser curve Common site for gastric ulcers Take time to examine completely
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
Retroflexed View: Incisura/Angularis and Body
Hiatal Hernia
Cameron Erosions
Gastric Varices Do not biopsy!
Mallory-Weiss Tear
Surgical Fundoplication
Biopsy technique
Complications of EGD Discomfort Sore throat, Bloating Bleeding Rare in diagnostic EGD Infection Aspiration pneumonia Medication Reaction Perforation 1:5000 1:10,000
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!