PREPARATION OF PATIENT PRIOR

UPPER AND LOWER GI ENDOSCOPY

PRESENTED BY
RN MUSABENDE VESTINE
 GASTRO INTESTINAL ENDOSCOPY
DEFINITION:
Gastrointestinal endoscopy is a diagnostic and
therapeutic procedure that allows one to image,
assess, and treat GI illnesses. Gastrointestinal
endoscopy can be categorized as upper or lower
endoscopy depending on whether the upper GI
tract (esophagus, stomach, duodenum, jejunum)
or lower GI tract (rectum, colon, and terminal
ileum) is examined
 CONT’’’
• With the procedure known as gastrointestinal
endoscopy, a doctor is able to see the inside lining
of your digestive tract. This examination is
performed using an endoscope-a flexible fiber-
optic tube with a tiny TV camera at the end. The
camera is connected to either an eyepiece for
direct viewing or a video screen that displays the
images on a color TV. The endoscope not only
allows diagnosis of gastrointestinal (GI) disease but
treatment as well.
 CONT’’’
• Current endoscopes are derived from a primitive
system created in 1806-a tiny tube with a mirror
and a wax candle. Although crude, this early
instrument allowed the first view into a living body.
• The GI endoscopy procedure may be performed in
either an outpatient or inpatient setting. Through
the endoscope, a doctor can evaluate several
problems, such as ulcers or muscle spasms. These
concerns are not always seen on other imaging
tests.
 ESOPHAGOGASTRODUODENOSCOPY (EGD)

• An esophagogastroduodenoscopy (also called

EGD or upper endoscopy
• An upper endoscopy is used to diagnose and,
sometimes, treat conditions that affect the
upper part of your digestive system, including
the esophagus, stomach and beginning of the
small intestine (duodenum).
CONT’’’
CONT’’’
CONT’’’
Your doctor may recommend an endoscopy procedure to:

• Investigate symptoms. An endoscopy may help

your doctor determine what's causing digestive
signs and symptoms, such as nausea, vomiting,
abdominal pain, difficulty swallowing and
gastrointestinal bleeding.
• Diagnose. Your doctor may use an endoscopy to
collect tissue samples (biopsy) to test for diseases
and conditions, such as anemia, bleeding,
inflammation, diarrhea or cancers of the digestive
system.
 CONT’’’
• Treat. Your doctor can pass special tools through the
endoscope to treat problems in your digestive system,
such as burning a bleeding vessel to stop bleeding,
widening a narrow esophagus, clipping off a polyp or
removing a foreign object.
• An endoscopy is sometimes combined with other
procedures, such as an ultrasound. An ultrasound probe
may be attached to the endoscope to create specialized
images of the wall of your esophagus or stomach. An
endoscopic ultrasound may also help your doctor create
images of hard-to-reach organs, such as your pancreas.
HOW YOU PREPARE THE PATIENT FOR THE PROCEDURE
UPPER ENDOSCOPY:

• Fast before the endoscopy. You will need to stop drinking and eating four to eight hours
before your endoscopy to ensure your stomach is empty for the procedure.

• Stop taking certain medications. You will need to stop taking certain blood-thinning
medications in the days before your endoscopy. Blood thinners may increase your risk of
bleeding if certain procedures are performed during the endoscopy. If you have chronic
conditions, such as diabetes, heart disease or high blood pressure, your doctor will give
you specific instructions regarding your medications.

• Ensure informed consent is signed.

• Remove dentures and partial plates to facilitate passing the scope and preventing
injury
 CONT’’’
• A randomized controlled trial of gastric lavage prior to endoscopy for
acute upper gastrointestinal bleeding: hypothesis that large volume
gastric lavage prior to endoscopy for acute upper gastrointestinal
bleeding would improve the quality of endoscopic examination
• Anesthetist visit: Anesthesia is one of the important components of
gastrointestinal endoscopic (GIE) procedures. The aim of anesthesia for
these procedures is to improve patient’s comfort and endoscopic
practice as well as patient and endoscopist satisfaction. The
requirement for anesthesia is dependent on the type and duration of
endoscopy, experience of endoscopist, and patient’s physical status.
• Intravenous fluids are routinely given empirically to the patients
undergoing colonoscopy or upper endoscopy: This common
practice will depend on patient’s physical status.
 DURING AN UPPER GI ENDOSCOPY:

• During an upper endoscopy procedure, you'll be

asked to lie down on a table on your back or on
your side:
• Monitors often will be attached to your body. This
will allow your health care team to monitor your
breathing, blood pressure and heart rate.
• You may receive a sedative medication. This
medication, given through a vein in your forearm,
helps you relax during the endoscopy.
 CONT’’’
• Your endoscopist may spray an anesthetic in your
mouth. This medication will numb your throat in
preparation for insertion of the long, flexible tube
(endoscope). You may be asked to wear a plastic
mouth guard to hold your mouth open.
• Then the endoscope is inserted in your
mouth. Your endoscopist may ask you to swallow
as the scope passes down your throat. You may feel
some pressure in your throat, but you shouldn't
feel pain.
 CONT’’’
• As your endoscopist passes the endoscope
down your esophagus:
• A tiny camera at the tip transmits images to a
video monitor in the exam room. Your doctor
watches this monitor to look for abnormalities
in your upper digestive tract. If abnormalities
are found in your digestive tract, your doctor
may record images for later examination.
 CONT’’’
• Gentle air pressure may be fed into your
esophagus to inflate your digestive tract. This
allows the endoscope to move freely. And it allows
your doctor to more easily examine the folds of
your digestive tract. You may feel pressure or
fullness from the added air.
• Your endoscopist will pass special surgical tools
through the endoscope to collect a tissue sample
or remove a polyp. Your doctor watches the video
monitor to guide the tools.
 CONT’’’
• When your doctor has finished the exam, the
endoscope is slowly retracted through your mouth.
An endoscopy typically takes 15 to 30 minutes,
depending on your situation.

• After the endoscopy:

You'll be taken to a recovery area to sit or lie quietly
after your endoscopy. You may stay for an hour or so.
This allows your health care team to monitor you as
the sedative begins to wear off.
 CONT’’’
Once you're at home, you may experience some
mildly uncomfortable signs and symptoms after
endoscopy, such as:
• Bloating and gas
• Cramping
• Sore throat
These signs and symptoms will improve with
time
 RISKS

An endoscopy is a very safe procedure. Rare complications

include:
• Bleeding. Your risk of bleeding complications after an
endoscopy is increased if the procedure involves removing a
piece of tissue for testing (biopsy) or treating a digestive
system problem. In rare cases, such bleeding may require a
blood transfusion.
• Infection. Most endoscopies consist of an examination and
biopsy, and risk of infection is low. The risk of infection
increases when additional procedures are performed as part
of your endoscopy. Most infections are minor and can be
treated with antibiotics
 CONT’’’
Your doctor may give you preventive antibiotics before
your procedure if you are at higher risk of infection.
• Tearing of the gastrointestinal tract. A tear in your
esophagus or another part of your upper digestive tract
may require hospitalization, and sometimes surgery to
repair it. The risk of this complication is very low.
• You can reduce your risk of complications by carefully
following your doctor's instructions for preparing for an
endoscopy, such as fasting and stopping certain
medications.
 Nursing management after upper GI
endoscopy
After the procedure:
 Monitoring of patients’ vital signs
 Reprocessing of endoscopic instruments and
devices
 Transfer patient to recovery room
 Handover to recovery nurse
 to stay at the hospital or outpatient center for 1
to 2 hours after the procedure so the sedative
can wear off
 Preparation prior Colonoscopy

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 Functions of Lower GIT
• Small Intestine. The two primary functions of the small
intestine are digestion and absorption (uptake of nutrients
from the gut lumen to the bloodstream).
• It extends from the pylorus to the ileocecal valve.
• The small intestine is composed of the duodenum, jejunum,
and ileum.
• The ileocecal valve prevents reflux of large intestine contents
into the small intestine.
• Absorption is the transfer of the end products of digestion
across the intestinal wall to the circulation. Most absorption
occurs in the small intestine.
• Monosaccharides (from carbohydrates),fatty acids (from fats),
amino acids (from proteins), water, electrolytes, vitamins, and
minerals are absorbed from small intestines.
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• The four parts of the large intestine are transverse
colon, ascending colon, descending colon, sigmoid
colon.

• The most important function of the large intestine

is the absorption of water and electrolytes.

• The large intestine also forms feces and serves as a

reservoir for the fecal mass until defecation occurs
(Elimination role)

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 Basic info about Colonoscopy

• Directly visualizes entire colon up to ileocecal

valve with flexible scope.
• Patient’s position is changed frequently during
procedure to assist with advancement of
scope to cecum.
• Used to diagnose or detect inflammatory
bowel disease, polyps, tumors, and
diverticulosis and dilated structures.
• It also allows for biopsy and removal of polyps
without laparotomy.
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 Before procedure:
• Bowel preparation must be done and is a crucial
step for successful examination.

• This varies depending on physician’ preferences or

probable diagnosis; For example, patients may be
kept on clear liquids 1-2 days before procedure.

• Nurses play an important role in guiding and monitor

patients for adequate bowel preparation and these
must be done using evidence-based practice.
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• During bowel preparation, patients are required to
cooperate actively with respect to the prescribed laxatives
and diet instructions.
• Many patients, however, often misunderstand these
complicated requirements, and as a result, it is a great
challenge for them to complete their bowel preparation
successfully.
• Therefore, several studies have suggested that facility
needs to develop standardized educational Tools for
patients and all health care providers that can be provided
as hand out/protocols,
• And this is our next step as CHUB, because studies have
shown that education to nurses and patients influences
the Quality of patient’s Bowel Preparation for Colonoscopy.
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• The diagnostic accuracy of colonoscopy largely depends
on the quality of bowel preparation, effective bowel
preparation is essential.
• Studies revealed that the quality of bowel preparation
among inpatients is poorer than that among outpatients.
• One study revealed that the rate of adequate bowel
preparation was only 50% in hospitalized patients.
• Consequently, the economic burden of inadequate
bowel preparation for inpatients is considerable because
of failed colonoscopy and incomplete examination,
ultimately leading to repeated colonoscopies;
• Which in turn, decreases the already limited endoscopic
resources and increases health care expenditures.
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 What must be done when preparing for
colonoscopy?
Several authors have different suggestions:
• One day before your colonoscopy:
• Breakfast – clear liquids only, no solid foods
• Lunch – clear liquids only, no solid foods
• Dinner – clear liquids only, no solid foods
• Drink plenty of clear liquids throughout the day.
• You may not drink alcoholic beverages within 24 hours of your procedure.
• Take one‐half of the bowel preparations starting at 5pm as instructed

• Day of colonoscopy:
• Do not eat any solid food until after your colonoscopy.
• Take the second part of bowel preparation as instructed, starting 6 hours before
and finishing at least 4 hours before your colonoscopy appointment.
• After you complete the preparation do not eat or drink any other liquid or food.
• Arrive 1 hour before the scheduled time with an adult who will be available to
accompany you home.
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• A large number of bowel preparations are currently available
• The timing of administration is very important in determining the quality of bowel
preparation for colonoscopy.
• One report found that consumption of the purgative/laxative solution shortly before
undergoing colonoscopy had superior results than when larger intervals were used.
• Studies suggest that preparation must begin with dietary changes, and these
regimens generally incorporate clear liquids and low-residue foods for a period of 1
or more days prior to the procedure.
• These bowel preparations solutions work by drawing water into the intestine, which
in turn causes bowel distention and stimulates evacuation.
• The routine use of these agents has also fallen out of favor because of the risk of
explosion during electrosurgical procedures.
• Hydrogen gas is produced by bacterial fermentation of the nonabsorbed
carbohydrates in the colon, which in turn causes the risk of explosion.
• Stimulant laxatives, such as castor oil and senna, were once widely used in bowel
preparation but were not very effective and considered to be harsh.
• Their mechanism of action is to increase peristalsis, which then leads to the
secretion of fluid into the intestinal lumen. These products have by and large been
abandoned by most endoscopists.
• Hyperosmotic laxatives prepared with non-absorbable carbohydrates (mannitol,
sorbitol, lactulose), were also in use.
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• Oral gastrointestinal lavage preparations that use balanced
electrolyte solutions with polyethylene glycol (example of PEKOL in
our setting) have become one of the preferred methods of bowel
cleansing.
• Pekol is a nonabsorbable solution that will normally pass through the
intestines without net absorption or secretion.
• There are no or minimal fluids shifts although large volumes of Pekol
solutions must be consumed to have an effect, which can create
hemodynamic instability in susceptible patients.
• A number of studies have shown that Pekol solutions are effective and
reasonably tolerated by patients, and several commercial preparations
are available.
• Pekol has certain advantages compared with some older methods of
bowel preparation like not cause damage to the colonic mucosa.
• Major disadvantages of Pekol is patient tolerance, as large volumes
must be ingested to have an effect.
• Many individuals also find the taste to be rather unpleasant, even with
flavoring added.
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 Assessing the quality of a bowel preparation

• The importance of a high-quality colonoscopy ensures that the patient

is adequately prepared for the procedure, and that the correct and
clinically relevant diagnoses are made or excluded.
• The American Society for Gastrointestinal Endoscopy (ASGE) Taskforce
on Quality in Endoscopy notes that effectiveness of colonoscopy in
reducing cancer incidence is dependent on “adequate visualization of
the entire colon, diligence in examining the mucosa, and patient
acceptance of the procedure.”
• For each colonoscopy, according to the ASGE, the colonoscopist must
document the quality of bowel preparation.
• Terms used to characterize quality of bowel preparation in clinical
trials, such as excellent, good, fair, and poor, do not have standardized
definitions in practice.
• Tools are available but not utilized in our settings while reports
regarding poor preparations are increasing (at least 3 per month).
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 How do I know when my bowel prep is complete?

The stool coming out should look like the stuff you are eating and drinking -
clear, without many particles. You know you’re done when the stool coming
out is yellow, light, liquid and clear - like urine.

Yellow and
Light orange
clear, like
and mostly
urine
clear
11/10/2023 You’re Ready
Almost There
 Practices at CHUB,

• Day before Colonoscopy:

• 10am: Eat clear food and liquids (clear, soft)
• We recommend to use Pekol.
• 3pm: take 1 bag (sachet), dilute it in 2 liters of water, then
take 200 ml (1 tasse) every 15-20 mins.
• Once the feces are not clear yet, take the second bag
(sachet) as the first one until feces are very clear.
• Day of Colonoscopy:
• Do not take any solid or liquid food/fluids until after your
colonoscopy.
• Monitoring of patients’ vital signs pre, during and post
colonoscopy.
• Ensure informed consent is signed
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 After procedure:
• Patient may experience abdominal cramps
caused by stimulation of peristalsis because
the bowel is constantly inflated with air during
procedure.
• Carefully observe for rectal bleeding and
manifestations of perforation (e.g., malaise,
abdominal distention, tenesmus).
• We must also check for vital signs.

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 Consequences of poor colonoscopy preparation

• Inadequate preparation can result in incomplete visualization of

the colon, a missed pathologic lesion, and procedural difficulties,
as it limits the ability of the endoscopist to visualize the colonic
mucosa.
• Colonoscopy in poorly prepared patients takes longer, is more
difficult, and more often incomplete.
• It leads to a substantial economic impact by prolonging the
procedure time and increasing the chance that a repeat
colonoscopy will be required at an interval sooner than what is
currently recommended by evidence-based guidelines.
• Studies found that suboptimal bowel preparation is estimated to
increase the cost of colonoscopy by 12% to 22%, and detecting
lesions of any size is dependent on the quality of bowel cleansing.
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 What are the risks of a colonoscopy?
• Complications include:

 Bleeding. Most cases of bleeding occur in patients who have polyps

removed. A tear or a hole in the colon or rectum wall (perforation).
 Infection.
 Aspiration that may lead to a lung infection (pneumonia), when the patient is
sedated.
 A reaction to the sedating medication, including breathing or heart
problems.
 Hemodynamic instability, and poor tolerance
 Patient may experience abdominal cramps caused by stimulation of
peristalsis because the bowel is constantly inflated with air during procedure.
• Therefore, we as Nurses:
 Must Carefully observe for rectal bleeding and manifestations of perforation
(e.g., malaise, abdominal distention, tenesmus), monitor patient for
hemodynamic instability.
 Must also check for vital signs.
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 Conclusion
• Colonoscopy is the most commonly used technique for
visualizing the colon, but its safety and effectiveness are
impacted by the quality of the bowel preparation.
• Optimal patient compliance with the preparation regimen will
achieve the best results.
• Improvements in bowel preparations, or measures to improve
patient compliance with bowel preparation, could significantly
improve adherence.
• Educational interventions and tools must be developed to ensure
good preparation prior colonoscopy.
• Nurses are key providers of counseling and education prior to
colonoscopies, and therefore, it is crucial that they understand
how important is to prepare well the patient, as well as being
able to effectively disseminate the information to their patients.
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• THANKS!