You are in: eMedicine Specialties > Gastroenterology > Systemic Disease EsophagogastroduodenoscopyArticle Last Updated: Aug 2, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Tony E Yusuf, MD, Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, The University of Texas - Houston Medical School Tony E Yusuf is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Medical Association, American Society for Gastrointestinal Endoscopy, Louisiana State Medical Society, Medical Society of the State of New York, and Minnesota Medical Association Coauthor(s): Scott A Wofford, MD, Fellow, Department of Gastroenterology, Hepatology and Nutrition, University of Florida; Manoop S Bhutani, MD, FACG, FACP, Professor, Department of Medicine, Division of Gastroenterology, Director, Center for Endoscopic Ultrasound, Co-Director, Center for Endoscopic Research, Training and Innovation, University of Texas Medical Branch at Galveston Editors: Maurice A Cerulli, MD, FACG, Chief, Division of Gastroenterology and Hepatology, Associate Professor of Clinical Medicine, Department of Internal Medicine, Division of Gastroenterology, New York Methodist Hospital, Cornell University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Douglas M Heuman, MD, FACP, Director of Hepatology, McGuire Veterans Affairs Medical Center, Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine; Alex J Mechaber, MD, FACP, Assistant Dean for Medical Curriculum, Associate Professor of Medicine, Division of General Internal Medicine, University of Miami Miller School of Medicine; Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania Author and Editor Disclosure Synonyms and related keywords: EGD, gastroscopy, upper gastrointestinal endoscopy, GI endoscopy, upper GI endoscopy, endoscope INTRODUCTIONSection 2 of 11
  Esophagogastroduodenoscopy (EGD) is a procedure during which a small flexible endoscope is introduced through the mouth (or with smaller caliber endoscopes, through the nose) and advanced through the pharynx, esophagus, stomach, and duodenum. An enteroscope, a longer endoscope, can be introduced beyond the ligament of Treitz into the jejunum. EGD is used for both diagnostic procedures and therapeutic procedures. Most modern endoscopes now use a video chip (charged coupled device) for better imaging, as opposed to the older endoscopes, in which fiber optics are used for image transmission. PREPARATIONSection 3 of 11
General Ideally, the patient should have nothing by mouth (ie, NPO) for at least 6 hours prior to the procedure to allow for adequate gastric emptying. If conscious sedation is used, intravenous access and standard monitoring are also needed. Informed consent should be obtained from the patient (or their legal representative if the patient is unable to give informed consent) prior to the procedure. A patient history should be obtained, and a physical examination should be performed to determine if performing the procedure is appropriate. Patient assessment A complete history should be obtained, and a physical examination should be performed. Findings should be documented in the patient's medical record. Special attention is directed to certain illnesses that might bear a direct effect on endoscopy, such as cardiovascular and pulmonary diseases. History of drug allergies and previous abdominal surgeries should also be obtained. Preprocedure testing in selected cases might include, but is not limited to, a complete blood cell count, blood crossmatching, coagulation studies, a chemistry panel, urinalysis, pregnancy testing, electrocardiogram, and chest radiographs. No data support routine laboratory testing prior to elective outpatient endoscopy. Preprocedure tests should be individualized and based on information obtained from the patient's history and physical examination and the indication for the procedure. Informed consent Obtaining informed consent prior to each endoscopic procedure is extremely important and is the responsibility of the endoscopist. The indications, nature, and relevant details of the procedure should be explained to the patient. Risks, benefits, alternatives, and complications should also be presented to the patient. The consent form should be signed and dated by the patient and endoscopist and must be witnessed by other personnel and placed in the patient record. Antibiotic prophylaxis Transient bacteremia may occur during most endoscopic procedures, but the risk of infectious complications (including endocarditis) is low. Antibiotic prophylaxis is clearly recommended when patients with an underlying high-risk condition for infectious complications (eg, prosthetic heart valve, history of endocarditis) undergo a high-risk endoscopic procedure, such as stricture dilation, sclerotherapy of varices, and ERCP, in the presence of an obstructed biliary tree. All patients undergoing percutaneous endoscopic gastrostomy placement should receive antibiotic prophylaxis against soft tissue infections; the regimen usually includes cefazolin (1 g IV). The patient's condition and the nature of the procedure should be reviewed carefully, and the decision to administer antibiotic prophylaxis is individualized. An acceptable prophylaxis regimen is parenteral ampicillin at 2 g and gentamicin at 1.5 mg/kg (up to 80 mg) 30 minutes prior to the procedure. Vancomycin (1 g IV) is substituted for penicillin in patients who are allergic to penicillin. Specific recommendations for antibiotic prophylaxis based on the type of the endoscopic procedure that is being contemplated and the underlying patient condition are available from the American Society for Gastrointestinal Endoscopy (ASGE). Anticoagulants and esophagogastroduodenoscopy Diagnostic EGD is considered a low-risk procedure for bleeding in patients on anticoagulants and, therefore, can be performed without adjustment of anticoagulants prior to the procedure. However, if polypectomy is contemplated or conceivable, then the patient's coagulation profile should be normalized. A risk of retropharyngeal hematoma also may be present in patients with severe coagulation abnormalities. Certain therapeutic procedures (ie, dilations, percutaneous gastrostomy, polypectomy, endoscopic sphincterotomy, EUS-guided fine-needle aspiration, laser ablation, coagulation) are considered high-risk procedures for bleeding, and adjustment of anticoagulation may be necessary. INDICATIONSSection 4 of 11
CONTRAINDICATIONS AND RELATIVE CONTRAINDICATIONSSection 5 of 11
Contraindications include possible perforation, medically unstable patients, or unwilling patients. Relative contraindications include anticoagulation, pharyngeal diverticulum, or head and neck surgery. COMPLICATIONSSection 6 of 11
The major complications of EGD are bleeding, infection, perforation, and cardiopulmonary problems. Approximately 1 complication occurs for every 1000 procedures. The mortality rate is estimated to be 0.5-3 deaths for every 10,000 procedures. Cardiopulmonary events comprise 50% of all major complications, and most of these events result from the medications used for conscious sedation. EQUIPMENTSection 7 of 11
Endoscopes are available from several different manufacturers (eg, Flexible ultrathin fiberoptic and video endoscopes that can be used without sedation are also available for EGD. These endoscopes are inserted transnasally or perorally and have a working length of 925-1050 mm, an external diameter of 5.3-6 mm, and a working channel diameter of 2 mm. Multiple instruments can be introduced through the working channel of the endoscope. These instruments include biopsy forceps, snares, sclerotherapy needles, heater probes, electrocautery probes, balloon-dilation devices, nets, and baskets. Guidewires can be placed, and, when the endoscope is withdrawn, wire-guided bougie dilators can be passed. Devices can also be placed onto the end of the endoscope for banding of esophageal varices and endoscopic mucosal resection. Some of the newer endoscopes provide high resolution and magnifying endoscopy and are used for the evaluation of certain upper gastrointestinal diseases. The upper endoscope is also used to guide endoscopic treatment of gastroesophageal reflux disease (GERD), such as with the Bard EndoCinch endoscopic suturing device and the NDO full-thickness plicator. One of the recent advances in video endoscopy is narrow band imaging (NBI). NBI uses optical filters and high relative intensity of blue light for imaging and characterization of mucosal morphology, such as mucosal and superficial vascular patterns. NBI has been studied in patients with Barrett esophagus, early gastric tumors, and colorectal lesions and has had promising results. THE PROCEDURESection 8 of 11
The patient is usually placed in the left lateral position. Topical and/or intravenous sedation is administered to minimize gagging and to facilitate the procedure. A bite block is placed to prevent damage to the endoscope and to ease its passage through the mouth. The endoscope is then passed under direct vision through the pharynx, esophagus, and stomach and into the duodenum, with careful inspection upon both insertion and slow withdrawal. Air is insufflated to distend the lumen to aid in viewing. Liquid and particulate matter can be aspirated through the suction channel. The procedure and findings can be documented with pictures or a video system. Biopsy specimens can be obtained by passing forceps and taking small mucosal samples for histology studies. A number of therapeutic procedures can be performed during the endoscopy. The procedure may last from 5-30 minutes or longer, depending on which diagnostic or therapeutic maneuvers are used. After completion of a procedure performed under conscious sedation, the patient is transferred to a recovery room for further monitoring by an endoscopy nurse. Once alert and mobile (after approximately 1 h), the patient is allowed to leave the recovery room with an escort and is given postprocedure instructions (eg, diet, activity) and advised to observe for signs and symptoms of GI bleeding, fever, and abdominal pain. A follow-up appointment with the primary care physician and/or the endoscopist is usually arranged prior to patient's discharge from the endoscopy unit. SEDATION AND MISCELLANEOUS PROTOCOLSSection 9 of 11
SedationIn the When conscious sedation is being administered, the patient must be monitored throughout the procedure. Pulse oximetry, heart rate, and blood pressure are commonly monitored. Electrocardiographic monitoring is recommended in patients with cardiopulmonary disease, in elderly patients, and during a prolonged procedure. Pharmacology of commonly used sedatives, analgesics, and reversal agents
Infection control during gastrointestinal endoscopyDespite the large number of endoscopic procedures performed each day, the incidence of infection transmission via endoscopes remains very rare. Methods of reprocessing endoscopes include mechanical cleaning, high-level disinfection, rinsing, and drying. Proper and diligent care during reprocessing of endoscopes, with attention to quality control, cannot be overstated for minimizing the risk of spreading infection via endoscopic procedures. Establishment of gastrointestinal endoscopy areasEndoscopy units are specific areas in a hospital (or physician's office) in which all endoscopic procedures are performed. For this unit to be functional and effective, the ASGE recommends that certain conditions must be met. These conditions include a properly trained endoscopist and nursing staff, functioning and adequately maintained equipment, an endoscope cleaning area, personnel trained to perform cardiopulmonary resuscitation, and a quality improvement program. Open access endoscopyOpen access endoscopy is a system designed to offset the cost of endoscopy in stable patients without significant comorbidities who have clear indications for upper endoscopy. The responsibilities of the referring physician are complete understanding of the patient's condition and the accepted indications for endoscopy. If the patient is on anticoagulation or if antibiotic prophylaxis is required, these issues must be addressed via proper communication between the referring physician and the endoscopist. Training and certification requirements for endoscopistsThe ASGE recommends that training in upper endoscopy include an understanding of indications, limitations, contraindications, alternatives, principles of conscious sedation, and correct interpretation of endoscopic findings. A minimum of 100 upper endoscopic procedures is recommended for trainees to become competent in diagnostic upper endoscopy. Therapeutic upper endoscopy requires further training and experience to gain competency. The recommendations of the ASGE for the number of procedures required to gain competency in various therapeutic upper endoscopic procedures are available through the society Web site (see American Society for Gastrointestinal Endoscopy). MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Esophagogastroduodenoscopy excerpt Article Last Updated: Aug 2, 2007 | |||||||||||||||||||||||||||||||
