A SEMIN AR ON PRINCIP LES AND PRA CTI CE OF GI ENDOSCOPY

Guide; Dr. M.Singh (M.S.) Associate professor Dept of Surgery Presented by Dr.K.Ravi

History o f Endoscopy

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Kussmaul in 1869 introduced silver tube successfully into the stomach of the sword-swallower and became the first person in medical history to visualize the stomach. In 1957 first prototype fiber optic endoscope was introduced In 1968 ERCP was introduced In 1974 Endoscopic sphincterotomy In 1979 PEG In 1980 Endoscopic injection sclerotherapy In 1980 Endoscopic ultrasonography In 1983 Electronic (charge coupled device) endoscope

Two types

EN DOSC OPY
a. Rigid endoscope b. Flexible endoscope
Now a days rigid type is virtually obsolete though some surgeons still use this traditional instrument It needs skill to introduce though there is significant risk of perforation Probably better for examination of the lower pharynx and cricopharyngeal area

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Function buttons, e.g., video recorder remote control Freeze button Suction button Air/water button Instrument channel Locking device Angling wheel (right/left) Angling wheel (up/down)

Vide o proc ess or (a bo ve) a nd l igh t so urce ( be lo w)

Ti p of Endoscope

Handl ing the Endoscope
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The control head of the endoscope is held in the left hand. The index and middle fingers activate the suction and air/water valves. Many examiners operate the angulation control wheels with the right hand, but an endoscopist with large hands can also manage these controls with the left hand. This leaves the right hand free to manipulate the insertion tube, which is advantageous in some situations.

PRINC IPLES OF ENDOSCOPY

In all flexible endoscopic system light is transmitted down the endoscope shaft to illuminate the surface to be examined. The reflected image is conveyed back to the endoscopist via one of two different modalities A. Fiber optics B. Electronics

Fi ber o pti c Endoscopy

In the fiber optics, a fixed lens at the end of the instrument shaft focuses the image on internal fiber optic bundle. The fiber optic bundle is 2-3mm wide &is composed of 20,000-40,000 individual fine glass fibers, each approximately 10mm in diameter. The image undergoes a series of internal reflection with in each fiber as it is transmitted up the bundle.

El ectro ni c Endoscopy

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Most endoscopes currently produced are electronic. In these system the image is reflected onto a charge coupled device [CCD] chip mounted on the end of instrument shaft. These chips contain thousands of light sensitive points [ “Pixels”]. The greater the number of pixels, the better the resolution. Current chips contain 100,000 to 300,000 pixels. The image is then transmitted through wires instead of light bundles to additional electronics in the instrument head.

Advantages endoscope

of vi deo

The endoscopist can stand erect and watch the television monitor without any interruption The intraluminal view and the lesions present within can be seen with more clarity by more than one person in the endoscopy room Therapeutic procedures are easier with a video endoscope The video endoscopes are water tight instruments and can be immersed in cleaning solutions Endoscopic pictures can be made readily available with the help of printer In video endoscope the images of tumors, ulcers & polyps can be faithfully transferred to the television monitor in their natural colors.

Gastrointestinal Endoscopy
Types of Gastrointestinal Endoscopy

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Esophagogastroduodenoscopy (Upper GI Endoscopy) Small Bowel Enteroscopy (Jejunoscopy) Colonoscopy (Lower GI Endoscopy) Sigmoidoscopy Endoscopic Retrograde Cholangiopancreatogram (ERCP)

Upper Gastrointestinal Endoscopy
Diagnostic Indications
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Therapeutic Indications
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Heartburn Dysphagia or odynophagia Hematemesis or melena Dyspepsia or upper abdominal pain Unexplained weight loss or anemia Evaluation of abnormal Barium meal X-ray Suspected

Control of bleeding Dilation of stricture Removal of foreign bodies Removal of polyps Tumor ablation

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Upper Gastrointestinal Endoscopy
Contraindications to Upper GI Endoscopy
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Uncooperative patient Hemodynamically unstable patient Suspected perforation cervical spine disorders Soon after a myocardial infarction

Upper Gastrointestinal Endoscopy

Cl eani ng a nd Di si nf ect ion

Meticulous cleaning of the endoscope with clean and filtered water immediately after use, is necessary to keep the instrument clean of organic debris like blood, dried gastric juice and food particles. It is scrubbed with a sponge or soft brush. After a thorough cleaning, the next step is to disinfect the scope against cross infection. The commonly used disinfectants are a. 2% Glutarldehyde (CIDEX) b. Iodophor (Betadine-providone Iodine) c. 70% ethyl or isopropyl alcohol d. Ethylene oxide (ETO) e. Formaldehyde vapour

Pati ent preparatio n

Fasted for at least 4 – 6 hrs more time for GOO. Before the study dentures & eye glasses should be removed. If intervention is anticipated, a recent coagulation profile &platelet count should be within safe ranges. Prophylactic antibiotics indicated in a. Sclerotherapy. b. Previous endocarditis. c. Recent vascular prosthesis. d. For PEG tube placements. e. Patients with prosthetic heart valves.

Meth od Two squirts of lidocaine sprayed into the pharynx or lidocaine viscus can be used.

Check List

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24 hours before the examination
Confirm indication Check contraindications Necessary lab tests ordered? (blood count, coagulation) Antibiotic prophylaxis? Informed consent obtained? Patient instructed about fasting? Cardiac pacemaker? Risk factors? (heart, lung, coagulation, general health)

Immediately before the examination
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Patient welcomed to the unit, greeted by name Signed consent form? Dentures removed? Defoaming agent administered? Coagulation tested? If necessary: peripheral venous access? (especially with sedation and for interventions) Equipment check? (air, suction) Endoscope tip lubricated Pharyngeal anesthesia (if desired) Contact with patient: “Here we go.”


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During the examination
Talk to the patient, explain what is happening. Keep the patient in a left lateral position. Observe the patient (sweating, restlessness, facial expression, gestures, pain manifestations, breathing, skin color). If in doubt: pulse oximetry, echocardiogram (ECG) monitoring.

Inserting the Endoscope
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Blind Insertion Direct-Vision Insertion
In the blind insertion method, the endoscope is first passed over the base of the tongue toward the hypopharynx under external visual control. With proper technique, the instrument tip can be advanced just to the introitus of the upper esophageal sphincter, at which time the patient is instructed to swallow. Endoscope insertion is contraindicated while the patient is coughing or taking a deep breath, as this will inevitably lead to tracheal intubation

Dia gnostic technique
inspection is often easier during withdrawal, when the viscera are well distended with air. -the endoscope is advanced to the esophagogastric junction. Noting the ‘Z’ LINE, where the white sqammous esophageal mucosa meets red columnar gastric epithelium. Importance of ‘Z’ Line in a. ph probe placement. b. Endoscopic Anti-reflux procedures. c. determine if a GE Junction lesion is gastric or esophageal in origin.

-entry into the duodenal bulb is recognized by the typical granular, pale mucosa. -finally, the second portion of the duodenal is entered by advancing to the superior duodenal angle. -when scope in the antrum either prior to entering or after with drawing from the duodenal bulb tip can be rotated through 180 degree in either direction to visualize fundus &cardia.

Upper Gastrointestinal Endoscopy
Normal Esophagus Normal Stomach Normal Duodenum

Esophagitis

Gastric Ulcer

Duodenal Ulcer

Gastric ulcer

Gastric ulcer

Bleeding gastric ulcers

Esophageal Varices

Esophageal Varices

Bleeding esophageal varices

Angiodysplasia of the stomach

Gastric varices

Mallory Weiss Tear

Esophagitis

Di agnosti c procedures

GI- Endoscopy

Can remove polyps, coagulate active bleeding sites, sclerotherapy of esophageal varices, dilate strictures & obtain biopsy samples Often guided by ultrasound

Therapeutic

Endoscopy

Endoscopic treatment
 

Upper Endoscopy is the procedure of choice in majority of patients with an acute upper gastrointestinal bleeding, for the following reasons:
– It can define the source of bleeding in the majority of patients with an upper gastrointestinal bleeding. – It can stratify the patients risk of rebleeding. – It can provide endoscopic therapy for esophageal and gastric varices, peptic ulcer disease, Dieulafoy's lesion, vascular malformations and tumors.

Therapeutic

opti ons

For Non variceal bleeding 1. Injection therapy 2. Thermal energy 3. Endoscopic clipping For Variceal bleeding 1. Sclerotherapy 2. Band ligation

Inj ection Therapy

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Materials
Endoscope Suction pumps Water jet Single-lumen injection needles for epinephrine and polidocanol, double-lumen needles for fibrin glue Epinephrine 1:10 000 in physiological saline solution, 1% polidocanol, fibrin glue

Duodenal ulcer (Clipping)

Argon plasm a co agu lati on

Esophageal Varices (Band ligation)

Band ligation of esophageal varices

Therapeut ic opt ions

Percutaneous endoscopic Gastrostomy & jejunostomy
for PEJ ; paediatric colonoscope with 160 cm flexible scope is used.

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Foreign body extraction. Dilation of stricture

Instr um ents used for forei gn body removal

Therapeutic

Endoscopy

Small bowel enteroscopy
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Capsule endoscopy Double baloon endoscopy Paediatric colonoscope

Capsule Endoscopy

Capsule Endoscopy

Capsule Endoscopy is a new technology that allows the doctor to see the middle part of the intestinal tract, the jejunum where no scope can currently go. especially helpful in finding the source of unexplained intestinal bleeding and Crohn’s disease. Patient swallows a wireless video camera about the size of a large vitamin Patient goes normally about their day while the capsule records images throughout the digestive tract.

Capsule Endoscopy

Capsule Endoscopy
Diagnostic Indications

Capsule endoscopy is intended for visualization of the small bowel mucosa It may be used as a tool in the detection of abnormalities of the small bowel in adults and children from 10 years of age and up

Capsule Endoscopy
Contraindications

Capsule endoscopy is contraindicated for use under the following conditions: In patients with known or suspected gastrointestinal obstruction, strictures, or fistulas based on the clinical picture or pre-procedure testing and profile In patients with cardiac pacemakers or other implanted electro medical devices In patients with swallowing disorders Severe gastro paresis Pseudo obstruction

Disa dva nta ges
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No therapeutic facility Long duration of procedure It does not localize the exact site of the pathology

Doubl e bal loon enteroscopy
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In 2000 it was introduced It consists of thin endoscope with 200cm length and over tube 145cm length. Soft latex balloon is attached at the tip of both the tubes which can be inflated & deflated. It can be inserted through duodenum or anus

Advantages
a. Tremendous diagnostic & therapeutic purpose in small bowel. b. Altered small bowel anatomy (patients who require ERCP after Roux-en-y gastric by pass)

Disadvantages a. Long duration; 1-3 hrs to complete b. Needs expertise c. Patient discomfort d. Needs general anesthesia

Endoscopic Retrograde Cholangiopancreatogram

William mckune a surgeon introduced ERCP IN I968

Endoscopic Retrograde Cholangiopancreatogram
Indications
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Conversly, the availability of ERCP should not be an indication for its liberal use.

Obstructive jaundice (benign or malignant) Ascending cholangitis Gallstone pancreatitis Unexplained jaundice or elevated LFT’s Bile duct injury or leak after cholecystectomy Chronic pancreatitis Pancreatic cancer Suspected Sphincter of Oddi dysfunction

Pati ent preparatio n

Normal coagulation profiles are more relevant in ERCP, especially if sphincterotomy or endoprosthesis insertion is contemplated. Prophylactic antibiotics are usually administered. Oropharynx is anaesthetized with local anesthesia. I.V. sedation and glucagon (0.5-1.0 mg) administered to decrease duodenal motility. Position of the patient most commonly in “ PRONE POSITION”. The I.V. access is preferred in the Right hand.

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Di agnosti c techni que of ERCP
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90 degree side viewing scope is used. Scope rides along the greater curvature towards the pylorus 7F cathetar with radio opaque tip is used for diagnostic purpose. Endoscopic spincterotomy Indications; a. Choledocholithiasis b. Sphincter of oddi dysfunction c. Acute cholangitis d. Stent placement e. Acute gall stone pancreatitis

Endoscopic Retrograde Cholangiopancreatogram

Pancreatic cancer with dilated bile duct and pancreatic duct (Double Duct sign)

Endoscopic Retrograde Cholangiopancreatogram

Gallstone impacted at ampulla, sphincterotomy being done and stones removed

Compl icati ons of Endoscopy

Perforation, more in therapeutic endoscopy Aspiration Pancreatitis, cholangitis, perforation & bleeding after ERCP.

Lower Gastrointestinal Endoscopy
Diagnostic Indications
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Therapeutic Indications
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Chronic diarrhea Rectal bleeding Iron deficiency anemia Unexplained abdominal pain Constipation, change in bowel habits or stool caliber Unexplained weight loss Evaluation of abnormal Barium enema x-ray Personal or family history of colon cancer Personal history of IBD

Control of bleeding Removal of polyps Tumor ablation Dilation of stricture Colonic decompression Reduction of sigmoid volvulus

Lower Gastrointestinal Endoscopy
Contraindications to Lower GI Endoscopy
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Uncooperative patient Hemodynamically unstable patient Suspected perforation Suspected colonic obstruction Suspected diverticulitis Soon after a myocardial infarction Deep ulcerations Severe ischemic necroses Fulminant colitis

The sigmoidoscope measures only 60 cm in total length. Because of its high degree of maneuverability, it is sometimes used in patients where the indications for examination are limited to the sigmoid colon and rectum.

Lower Gastrointestinal Endoscopy

(Lower GI endoscopy)

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Preprocedure
Consent form Laxative evening before & enema or suppository 1 hr before Full liquid diet 1-3 days before PEGLEC

Lower Gastrointestinal Endoscopy
Normal Colon Colon Cancer

Therapeutic

col onoscopy

Polyp

Colon Polyp and Polypectomy

a Colonoscope with suction cap and asymmetrical snare. b Submucosal injection with NaCl solution and epinephrine. c Lifting the flat lesion after submucosal injection. d Suctioning the flat lesion into the cap and resection with a snare. e Recovering the resected lesion by suction into the cap.

Sc he ma tic ill us tratio n o f en do scop ic mu cos al rese ctio n us in g suct ion c ap tech ni qu e

Future Endosc opy
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Chromoendoscopy Narrow band imaging High resolution magnification endoscopy GOALS; a. Recognition of early gastric and colorectal cancer b. To allow accurate discrimination of dysplasia grade in areas of Barrett’s esophagus or quiescent ulcerative colitis c. To aid polyp detection

Chromoendoscopy

The most widely available technique Chromoendoscopy refers to the intravital staining of epithelial structures during the endoscopic examination It involves the topical application of stains or pigments to improve tissue localization, characterization or diagnosis

Stains used in chromoendoscopy
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Absorptive stains
− Lugol solution − Methylene blue − Toluidine blue

Contrast stains
− Indigo carmine

Reactive stains
− Congo red − Phenol red

Absorptive stains are taken up by special epithelial cells and can differentiate cells according to whether they are stained or unstained. Contrast stains cause relatively marked enhancement of intestinal mucosa and are often used in magnification endoscopy. Reactive stains are used to identify certain secretions in which the stain induces a color reaction

Magnification Endoscopy

Principle.

Magnification endoscopy, known also as zoom endoscopy, can be used for the detailed endoscopic evaluation of suspicious areas, especially after staining

Endoscopic Ultrasound

The ultrasound probe is placed at the tip of the endoscope Allows ultrasonography of organs from a close distance Individual layers of the GI wall are visualized as five distinct layers of alternating hyper and hypo ecogenicity Can be used to take fine needle aspiration

Endoscopic Ultrasound
A T3 Rectal Tumor on EUS

Indications of EUS

PANCREATIC a. FNAC of malignancy b. Drainage of fluid collections c. Lymph node sampling d. Assess portal venous system e. Intraductal ultrasound HEPATOBILIARY a. Detect stones b. Periportal lymph nodesampling c. Biopsy of liver mass ESOPHAGEAL a. Esophageal cancer staging Gastric a. Gastric cancer staging b. Evaluation of submucosal masses

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