In tutorials this week, we covered on the gastrointestinal problems.

During the discussion we were

given a learning issue on endoscopy and how the Rockall’s criteria and Glascow Blatchford score
relate to endoscopy. This essay will discuss on these learning issues and how it is applied in our
clinical settings.

To begin with, according to the American Society of Gastrointestinal describes endoscopy as “A

procedure using an endoscope to diagnose or treat a condition. There are several types of
endoscopy. Those using natural body openings include esophagogastroduodenoscopy (EGD) which is
often called upper endoscopy, gastroscopy, enteroscopy, endoscopic ultrasound (EUS), endoscopic
retrograde cholangiopancreatography (ERCP), colonoscopy, and sigmoidoscopy. Percutaneous
endoscopic gastrostomy (PEG) is a procedure that utilizes endoscopy to help placement of a tube
into the stomach; a small incision in the skin is also required. Endoscopies are usually performed
under sedation to assure maximal patient comfort”. Upon further reading I found out that
sigmoidoscopy and anoscopy generally don’t require any sedation.

Furthermore, the esophagogastrodudenoscopy (EGD) is the mainstay procedure for diagnosing and
providing therapeutic intervention for upper gastrointestinal bleeding. It is introduced through the
mouth (or with smaller caliber endoscopes, through the nose) and advanced through the pharynx,
esophagus, stomach, and duodenum up till the ligament of Treitz. It helps us to locate the source
and site of bleeding. It also helps us to determine and visualise presence of ulcers. Some of the
common indications where we use diagnostic EGD is when there is active or recent GIT bleed,
dysphagia , odonphagia, patient is unresponsive to empirical therapy and has alarm symptoms.

To add on, there are some contraindications of EGD and these are Acute myocardial infarction,
peritonitis, patient taking anticoagulants and acute perforation to name a few. I was curious to the
know the reasons behind the contraindication in MI and so upon further reading I found that in
acute MI, patient is already hemodynamically unstable, the risk of GIT bleed is high. The patient may
also be given anti-platelet therapy which further increases risk of bleed if biopsy is also taken. As
according to NCBI “Increased EGD complication and death rates were estimated from studies
reporting the performance of EGD in patients who had suffered AMI within 30 days prior to EGD”.

And also, in any procedure whether surgical or medical has inherent risk. However in dealing with
high risk patients, the benefit must always outweigh the risk. The risks associated with endoscopy
are perforation of oesophagus, respiratory distress and adverse reaction to conscious sedation as
sedation can lead to cardio respiratory distress. Thus it is important to consider elective intubation
before EGD in patients with active bleeding, altered respiratory or mental status to avoid
complications.

Moving on, it is important to do an early risk assessment for effective timing of endoscopy and for
determining if other interventions need to be taken. In order to do this we have scoring system and
the most frequent cited ones are the Rockall score and Glasgow Blatchford score ( GBS). As
mentioned before, it is used for early assessment of patient who has upper gastrointestinal bleed
and helps us to distinguish the high risk patients who may need clinical interventions from the low
risk patient who have a lower chance of developing any complication. The GBS score helps us to
identify patient who need hospital based intervention like endoscopy or surgery. The components
used to assess in GBS scoring system were blood urea, hemoglobin, systolic blood pressure, pulse
and any history or comobility. Hence this criterion does not require any endoscopic result to assess
the patient’s risk of upper GIT bleeding. A score of zero means that the patient can be safely seen as
an outpatient however in recent studies the score has been shifted to <1. The Rockall score,
however, uses both clinical criteria and endoscopic results to predict the risk of upper GIT bleed. The
clinical criteria include age, systolic blood pressure, co mobility and pulse rate whereas the
endoscopy finding includes the diagnosis and stigmata of acute bleeding. a score of <3 has a good
prognosis whereas >3 carries a higher risk of mortality. Interestingly, I found out that the GBS
criteria is more sensitive in predicting re-bleeds and need for endoscopic intervention whereas the
Rockall system is sensitive in predicting mortality.

To conclude, I have learnt on the importance of endoscopy and how in the future I must keep in
mind the risk and complications of endoscopy in order to effectively manage patients. I have also
learnt on GBS and RS criteria and how sensitive they are in predicting re-bleeding in upper git.