Indication for the EGD

For each upper endoscopy that is performed, it is important that there is an appropriate indication for the procedure. In a series assessing indications for EGD, approximately 15–20% of cases have been determined to be non‐indicated examinations [4]. Published data have shown that many patients undergo repeat EGDs for dyspepsia where the yield of a second EGD is very low, particularly in patients without alarm symptoms. Similarly, in patients with chronic GERD who have an initial normal EGD, the yield of repeated endoscopic examinations remains low; performance of an esophageal pH or motility study may yield more diagnostic information in patients who fail to respond to PPI therapy [5]. However, in patients with repeated hematemesis or ongoing melena, studies have demonstrated a miss rate of 15–20% for lesions in the upper GI tract, highlighting the importance of second‐look endoscopy in patients with ongoing acute or chronic GI bleeding [6].

Administration of moderate sedation

In addition to understanding the appropriate indications for upper endoscopy, another important cognitive aspect of EGD training is the administration of moderate sedation. Studies have demonstrated that the administration of moderate sedation increases the probability of a successful examination, patient satisfaction, and willingness to repeat the examination [7]. It is also important to train fellows that some patients may be able to undergo an EGD without the administration of conscious sedation and with topical anesthesia only. Patients who request to undergo endoscopy without sedation should be advised regarding symptoms that they might experience during the procedure. They should be provided with the opportunity to undergo a sedated procedure if they are unable to tolerate endoscopy without sedation. Prior studies have indicated that only a minority of patients in the United States would be willing to undergo an EGD without sedation [8]. Transnasal endoscopy without sedation has been shown to be acceptable to patients who are offered this examination and equally effective for screening and surveillance of Barrett’s esophagus (BE) [9].

In some patients, routine administration of moderate sedation may not be effective. This includes patients who consume moderate to large amounts of alcohol and who use benzodiazepines and/or narcotics. These patients should be advised that the administration of conscious sedation might not produce significant sedative effects. In such cases, utilization of propofol or general anesthesia may be required and has been shown to be associated with a higher probability of a complete examination [10].

Landmark and pathology recognition

It is important for the trainee to recognize important landmarks during an EGD and document these findings appropriately. The location of the gastroesophageal junction (GEJ) in centimeters from the endoscope insertion point should be noted. In order to characterize this landmark, trainees must be able to discern the top of the gastric folds, which can be accentuated by gentle suction or by identification of the distal end of the longitudinal palisade vessels commonly seen in normal esophageal mucosa. The appearance of the GEJ should be described as regular or irregular, and with or without findings to suggest esophagitis. A standard classification system (such as Los Angeles Classification, Figure 5.1) should be used for all examinations where erosive esophagitis is present [11].

It should also be noted if tongues or segments of salmon‐colored mucosa are present. The location of the Z‐line is required to determine the length of a segment of suspected or established BE. In the absence of BE, the Z‐line is located at the top of the gastric folds. If BE is found (Figure 5.2), the Prague classification system should be used to document the maximal and circumferential involvement of intestinal metaplasia [12]. If a hiatal hernia is present, the endoscopist should mark the proximal and distal end of the hernia sac and whether Cameron erosions are present.

Other important landmarks include the gastric body and antrum (Figure 5.3), gastric fundus and cardia during the retroflexed view (Figure 5.4), pylorus (see Figure 5.3), duodenal bulb (Figure 5.5), and first and second portions of the duodenum (Figure 5.6).

In addition to reflux esophagitis and BE, the fellow must also learn to recognize a number of commonly encountered pathological findings. These include inlet patches, esophageal candidiasis, features suggestive of eosinophilic esophagitis, rings, diverticula, esophageal varices, achalasia, hiatal hernia, fundic gland polyps, hyperplastic polyps, ulcers, gastric antral vascular ectasia (GAVE), features suggestive of H. pylori gastritis and NSAID‐associated gastropathy, atrophic gastritis, subepithelial lesions, Brunner’s gland hyperplasia, duodenal diverticula, duodenal and ampullary adenomas, findings suggestive of celiac disease, malignancy, among other findings that can occur in the upper digestive tract (Figure 5.7).

Technical aspects

The most important technical aspects for the trainee to master include successful esophageal intubation, retroflexion in the stomach, pyloric intubation, traversal of the duodenal sweep, thorough examination of the mucosa, and the ability to perform biopsies and therapeutic maneuvers such as those required for endoscopic hemostasis and removal of foreign bodies.

Patient positioning

Patient positioning is important to a successful examination. The patient should lie on his or her left side, which facilitates insertion of the endoscope and may reduce aspiration by allowing gastric contents to pool in the fundus. A small pillow may be used to support the patient’s head. One exception to the left lateral position is during placement of a PEG tube where the patient would be placed in the supine position. Vital signs should be obtained prior to initiation of moderate sedation, and nasal oxygen administered. A bite block, either with or without a neck strap, should be placed prior to the administration of moderate sedation. The patient should be instructed not to talk to the physician or staff after administration of sedation to allow the intended effects of sedation to occur and so that appropriate response to sedation can be monitored.

Handling of the endoscope (Video 5.1)

The trainee should be instructed not to point the endoscope tip at the patient until adequate sedation has been administered, as the light from the endoscope may distract the patient and result in the need for additional medications for moderate sedation. Some physicians place a washcloth over the patients’ eyes in order to prevent the distraction from visualization of the endoscopy equipment, especially if the patient is undergoing the procedure without sedation. When it is time to start the procedure, the endoscopist should stand acing the patient with the endoscope held directed toward the patient’s mouth. The patient’s head should be flexed with the chin toward the chest, to facilitate esophageal intubation.

The trainee should be instructed to hold the control head of the endoscope in his/her left hand, using the thumb and third or fourth finger to control the up/down and left/right angulation knobs (Figure 5.9). The forefinger and thirrd finger can be applied to the suction and air/water buttons as needed. The trainee should be encouraged to learn to use the left hand to control both knobs and buttons rather than taking the right hand away from the endoscope to help control the knobs, as this technique may lead to loss of endoscope position and increased loop formation particularly during colonoscopy.