Esophagogastroduodenoscopy

Arpan H. Patel, MD

Upper gastrointestinal (GI) endoscopy provides a means for accurate diagnosis and therapy of upper GI diseases. The purpose of this chapter is to provide an overview of upper GI endoscopy, its clinical indications, contraindications, the procedure itself, and a summary of known adverse events. It is not intended to be a comprehensive source of instruction. Endoscopic technique and interpretation are best taught by an experienced endoscopist, supplemented by a review of recent inclusive texts¹,²,³,⁴ that outline technique and pathology in detail. Training guidelines have been established by professional societies.⁵

INDICATIONS

Diagnostic

1. To establish the site of upper GI bleeding
2. To visually define and/or biopsy abnormalities seen on radiological studies (ulcers, filling defects, and cancers)
3. To evaluate healing of medically treated gastric ulcers
4. To evaluate dysphagia, dyspepsia, abdominal pain, gastric outlet obstruction, chest pain after negative cardiac evaluation, and iron deficiency anemia after negative colonoscopy
5. To evaluate odynophagia
6. To determine the extent of damage after a caustic ingestion
7. To sample for infection (e.g., cytomegalovirus, Helicobacter pylori) or disease (e.g., graft vs. host disease, eosinophilic esophagitis)

Therapeutic

1. Esophageal, gastric, and duodenal polypectomy
2. Removal of foreign bodies
3. Disintegration of bezoars and food impactions
4. Treatment of bleeding lesions with directed thermal or injection therapy
5. Treatment of esophageal varices (banding and/or sclerotherapy)
6. Placement of guidewires or balloons for esophageal and gastric dilation
7. Placement of small-intestinal feeding tubes and percutaneous gastrostomy tubes
8. Treatment of Barrett esophagus with tissue vaporization
9. Palliation of esophageal, gastric, or duodenal tumors with stent placement
10. Facilitation of pancreatic necrosectomy after creation of a cyst gastrostomy
11. Bariatric endoscopy with suturing including outlet revision, endoscopic sleeve gastroplasty

CONTRAINDICATIONS

Absolute

1. Shock (unless used as a preoperative to guide emergent surgical therapy)
2. Acute myocardial infarction
3. Severe dyspnea with hypoxemia
4. Coma (unless patient is intubated)
5. Seizures
6. Acutely perforated ulcer or perforated esophagus
7. Atlantoaxial subluxation

Relative

1. Uncooperative patient
2. Coagulopathy (relative contraindication is with the use of thermal therapy)
- a. Prothrombin time 3 seconds over control
- b. Partial thromboplastin time (PTT) 20 seconds over control
- c. Bleeding time >10 minutes
- d. Platelet count <50,000/mm³
3. Myocardial ischemia
4. Thoracic aortic aneurysm

PREPARATION

1. The patient should have nothing by mouth for 6 hours prior to the procedure. If this is not possible due to the need for emergent esophagogastroduodenoscopy (EGD), the stomach should be evacuated by means of an orogastric or nasogastric lavage. Intubation for airway protection should be considered in patients who are having vigorous upper GI bleeding in
which it is not possible to completely evacuate the stomach, such as in variceal bleeding and in patients with decreased consciousness.
2. Review the patient’s chart, including x-rays and coagulation studies.
3. See the patient prior to the procedure. Be certain the study is indicated and that the patient understands the risks and benefits and agrees to the procedure. Obtain written informed consent from the patient or his or her legal proxy.
4. Write a preprocedure note that documents cardiovascular and airway assessment, comorbidities, and informed consent.
5. Start an intravenous (IV) line; anesthetize the patient’s throat with a topical agent such as lidocaine spray, and attach the pulse oximeter. Oxygen saturation, blood pressure, and pulse rate are routinely monitored during procedures requiring conscious sedation.
6. Administer a short-acting narcotic such as fentanyl through the IV line. There should be at least a 2-minute pause in between doses given slight delay in medication effect and risk of respiratory depression with escalating narcotic dosage.
7. If needed, slowly administer midazolam (0.75 to 2 mg) intravenously until an appropriate level of sedation is reached. Watch the patient carefully for respiratory depression and give preoperative medication cautiously in elderly or malnourished patients.