Preliminary training course on
diagnostic upper gastrointestinal
endoscopy
Raika Jamali M.D.
Gastroenterologist
Sina Hospital
Tehran University of Medical Sciences
After this course you would be able to
• Determine the indications and contraindications
of upper gastrointestinal endoscopy (patient
selection)
• Define the proper time for the procedure
• Prepare the patient for the procedure
• Handle the endoscopy team
• Perform the procedure
• Check for the possible complications
• Write an endoscopy report
Patient selection
• Patient with upper gastrointestinal discomfort
with the alarming signs:
–
–
–
–
–
Age > 50
Weight loss
Anemia
Vomiting
Family history of upper gastrointestinal malignancy
• Those refractory to therapy
• Surveillance for Barrett's esophagus
• Long standing reflux symptoms
Contraindications
• Hemodynamic unstable patient that need
resuscitation before endoscopy
• Hopoxia
• Cardiac arrhythmia
• Esophageal perforation
Precaution
• Patients with unstable airway or respiratory
failure need tracheal intubation before
endoscopy
• Check for hypoxia during the procedure and
titrate the supplemental oxygen to avoid
hypoxia
• Patients with massive bleeding with risk of
aspiration need tracheal intubation before
endoscopy
Precaution
• Patients with cardiac instability need proper
management before endoscopy
• Check for arrhythmia during the procedure and
terminate the procedure immediately if
significant tachy or brady arrhythmias arise
• Patients suspected for esophageal perforation
(with foreign body swallowing or corrosive
esophagitis) need CXR and contrast radiography
for detection of possible perforation before
endoscopy
Timing of endoscopy
• Emergent endoscopy is preferred in patients
with ongoing (active) severe bleeding
– Fresh blood on gastric washing
– Orthostatic hypotension in spite of proper
resuscitation
– Melena perse or coffee ground in gastric washing
is not a sign of active bleeding
• Elective endoscopy is preferred when no sign
of ongoing bleeding exist
Preparing the patient
• The risks and benefits of the procedure should be
offered to the patient and written informed
consent should be taken before the procedure
• The patient should be examined before the
procedure for the evaluation of:
– Vital signs
– Existence of wheezing in lungs that need
bronchodilator before the procedure
– Signs of esophageal perforation (pnumothorax and
subcutaneous emphysema)
Preparing the patient
• Check for hypoxia by pulse oximetery
• Use supplemental nasal oxygen for patient with
O2 saturation < 90%
• Check for false teeth or any foreign body in
mouth and remove them before the procedure
– Secretions in mouth should be suctioned and loose
teeth should be removed to reduce the risk of
aspiration
• Insert appropriate airway device
Preparing the patient
• Check for the I.V. lines
• Position the patient on left lateral decubitus
• Sedate the patient with midazolame infusion
Checking the endoscopy unit
• Check the light source of scope
• Perform white balance for getting the optimal
light
• Check for the air pump for appropriate air
insufflation
• Check the water tank and appropriate water
spray
• Check for the power of suction
Endoscopy procedure
• Check for the locks on endoscope and ensure that
the tip of scope can move freely
• Lubricate the end of scope with appropriate gel
to facilitate the passage of scope through the
pharynx
• To reduce the risk of aspiration of the gel, the
amount of gel should not be too much to
suspense from the tip of scope
• Do not insert gel near to the end of scope to
avoid covering the lens
Endoscopy procedure
• Insert the scope in the mouth and move it
toward the uvula watching the palate
• Find the pyriform recess and insert the scope
carefully to the esophagus
• Do not use the blind approach to reduce the
risk of perforation
• Move the scope down and air insufflate to
open the esophagus
Endoscopy procedure
• Mention to any mucosal abnormality or strictures and
obtain biopsy for the evaluation of malignancy
• Identify glycogenic acanthosis and inlet patch that do
not have risk of malignancy
• Watch for white plaques that indicate candidiasis
• The possible web or ring in esophagus should be
mentioned
• Check for the possible esophageal varices in distal part
– Describe the size
– Notice to the signs of bleeding tendency (red wale sign)
Endoscopy procedure
• Observe the Z line in distal esophagus
• Pay special attention to the possible mucosal breaks in
distal esophagus before entering the stomach, since
traumatizing the mucosa by the scope might cause
false breaks
• Observe for the length of salmon color appearance in
distal esophagus
• The salmon color appearance in distal esophagus is
indicative of columnar epithelium
• If the length of salmon color appearing part is > 3 cm,
obtain 4 quadrant biopsies from it for the detection of
possible Barrett's esophagus
Endoscopy procedure
• Move the scope upward and right to reach the
pylorus
• Insufflate air to inflate the stomach and watch
for mucosal abnormalities carefully
• To observe the cardia and the lesser
curvature, retroflex the scope and withdraw
the scope to reach the cardia
• Check for the hiatal hernia in retroflexion
maneuver
Endoscopy procedure
• Check for any evidence of mucosal edema (snake
skin appearance, cobble stoning) in stomach
• Check for the erosions and ulcers
– Define the location
– Define the size
– Stigmata of bleeding
• Check for submucosal lesions and polyps
• Check for any evidence of vascular malformations
suspicious as a source of bleeding
Endoscopy procedure
• It is better to approach from the base of antrum for passing through
the pylorus and entering the duodenum
• Check the bulb for the signs of duodenitis (snake skin appearance)
or ulcer
• The scope should move upward and right for reaching to the second
part of duodenum
• Check for any signs of malabsorption in D2 (scalloping)
• Obtain biopsy from any suspicious lesion in D2 for evaluation of
malabsorption
• If the mucosa seemed normal, Obtain 4 quadrant biopsy for
evaluation of malabsorption
• Check for Periampullary diverticula
• Check for Hemobilia
Check for the possible complications
• Check for chest pain, diaphoresis, and fatigue
after the procedure that might indicate
ischemic heart disease
• In case of dyspnea, examine the lungs to
check for aspiration
• Check for chest pain, subcutaneous,
emphysema and respiratory distress after the
procedure that might indicate perforation
Endoscopy report
• Report should include:
– Patient identification
– Date of endoscopy
– The reason for endoscopy
– Sedation details
– Endoscopic findings
– Name of the endoscopist and the endoscopy team
Endoscopy report
• The abnormalities in larynx and vocal cords
should be mentioned (vocal cord nodule,
laryngitis, vocal cord paralysis)
• The description of mucosal, submucosal,
vascular abnormalities, and extrinsic
compression in the esophagus should be
reported.
Endoscopy report
• The description of mucosal abnormality consists of:
– Size
– Location
– Stigmata of bleeding (active bleeding, cloth, or visible
vessel)
– Shape (depressed, elevated, or flat)
– Causing obstruction (could the scope pass through or not)
• An easy way to define the size of lesion, you should
compare the size of the lesion with the tip of biopsy
forceps
• To localize the lesions in esophagus, the distance of the
lesion is reported from the incisor teeth
Endoscopy report
• The description of submucosal abnormality consists of:
– Size
– Location
– Stigmata of bleeding (active bleeding, cloth, or visible
vessel)
– Causing obstruction (could the scope pass through or not)
• The description of extrinsic compression consists of:
– Size
– Location
– Causing obstruction (could the scope pass through or not)
Endoscopy report
• Vascular abnormalities in esophagus consist of:
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–
–
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Varices
Arteriovenous malformation
Angiodysplasia
Hemangioma
• The description of vascular abnormality consists
of:
– Size
– Location
– Stigmata of bleeding (active bleeding, clot, or visible
vessel)
Z line and salmon color appearance
mucosa in distal esophagus
Submucosal lesion
ESOPHAGEAL STRICTURE
Endoscopy report
• Describe the mucosal breaks in distal esophagus
according to “Los angles classification”:
– If the mucosal break is < 5 mm (GERD A)
– If the mucosal break is > 5 mm (GERD B)
– If the mucosal break is > 5 mm and invading more than
75% of the esophageal circumference (GERD C)
– If ulcer exists (GERD D)
• Describe the length of salmon color appearance part in
distal esophagus
• Report that biopsy was taken if the length of salmon
color appearance part in distal esophagus was > 3 cm
GERD
GERD A
GERD C
GERD B
GERD D
Endoscopy report
• Report the size of hiatal hernia:
– Small size hiatal hernia exists if there is free space
between the scope and esophagogastric junction with
inspiration and disappearance of the free space with
expiration
– Medium size hiatal hernia exists if there is fixed free
space between the scope and esophagogastric
junction that do not change with respiration
– large size hiatal hernia exists if there is fixed free
space between the scope and esophagogastric
junction that do not change with respiration and the
scope can freely enter the esophagus by withdrawing
the scope in retroversion maneuver
Hiatal hernia
Large size hiatal hernia with cameron
ulcer
Endoscopy report
• The description of mucosal, submucosal,
vascular abnormalities, and extrinsic
compression in the stomach should be reported
with the details mentioned previously.
• Report the mucosal edema or nodularity in
stomach
• Check for the erosions and ulcers
– Define the location
– Define the size
– Stigmata of bleeding
Nodularity (above)
Snake skin appearance (below)
Erosions
(active bleeding in right and without bleeding in left)
Stigmata of rebleeding in ulcer
Gastric polyp
Gastric tumor
Submucosal lesion
Submucosal lesion in stomach
Angiodysplasia
Blue rubber nevus syndrome
Varice in fundus
Watermelon stomach
Hypertrophied gastric folds
Endoscopy report
• To localize the lesions in stomach you should find
the incisura angularis as an important marker.
• If the lesions are between the incisura angularis
and pylorus they are located in antrum.
• If the lesions are above the incisura angularis
they are located in body.
• The area about 2-3 cm around the
esophagogastric junction is cardia.
• The fundus is considered as the portion of the
stomach that lies above the cardiac notch.
Endoscopy report
• The description of mucosal, submucosal,
vascular abnormalities, and extrinsic
compression in the duodenum should be
reported with the details mentioned previously.
• Report the mucosal edema
• Check for the erosions and ulcers
– Define the location
– Define the size
– Stigmata of bleeding
Submucoal lesion in second part of
duodenum
Scalloping in second part of duodenum
hemobilia