Esophagogastroduodenoscopy

Michael B. Harper, MD, DABFM and Albert L. Smith, III, MD
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Introduction

Esophagogastroduodenoscopy (EGD) is an endoscopic procedure that allows clinicians to diagnose and treat multiple problems in the upper gastrointestinal tract. EGD is indicated for the evaluation of a variety of abdominal and chest symptoms. It can be safely performed in an office setting. When compared to radiographic procedures, EGD has greater sensitivity and specificity for diagnosis of mucosal abnormalities and allows biopsies for histology and testing for Helicobacter pylori infection. Radiographic studies are superior to EGD in evaluating motility of the esophagus and stomach. 
There are several potential benefits when primary care providers perform EGD, especially if it is done in the office setting. These benefits include rapid assessment of patients’ complaints, improved access to the procedure, increased patient comfort, reduced costs, improved provider understanding of the involved pathology, and improved health-care quality for the patient. 
In the United States, procedural (conscious) sedation is typically used during EGD. Intravenous benzodiazepine, diazepam or midazolam, is often combined with an intravenous narcotic, meperidine or fentanyl, to improve patient comfort. Midazolam causes amnesia in most patients. Guidelines for monitoring the patient receiving conscious sedation for gastrointestinal endoscopy are included in Procedural (Conscious) Sedation. Topical anesthesia of the oral cavity can be achieved by gargling with a viscous 2% lidocaine solution or by spraying the posterior pharynx with 20% benzocaine (Hurricaine spray), but this latter method can cause methemoglobinemia. A public health advisory warning of this complication has been issued by the U.S. Food and Drug Administration. Patients who smoke and patients who have asthma, bronchitis, or chronic obstructive pulmonary disease (COPD) are at higher risk of methemoglobinemia. 
Nonintravenous methods of sedation have been used successfully for EGD. Practitioners may be more comfortable with administering similar medications by nonintravenous routes in an office setting. Patients can take the benzodiazepine triazolam (Halcion, 0.25 or 0.5 mg) orally 1 hour before the procedure. Butorphanol tartrate nasal spray (Stadol) can be administered (one or two sprays) immediately before the procedure if additional anesthesia is required. Good results from this regimen were reported in a pilot study, but this regimen has not been compared with intravenous regimens. Patients undergoing nonintravenous sedation are monitored similarly to those undergoing intravenous sedation. Cost savings can be achieved by avoiding the placement of an intravenous line for the procedure. Consent must be obtained before any anesthesia is administered. 
In many countries (Asia and Europe), patients commonly do not receive sedation for EGD. Smaller diameter endoscopes make this approach more feasible. Pediatric endoscopes (7.9 or 9.0 mm outer diameter) and ultrathin endoscopes (<6 mm) are available. The later can be inserted intranasally. 
EGD is most commonly performed to evaluate patients with signs or symptoms of acid-peptic disorders who do not respond to appropriate medical therapy. Patients >50 years of age, as well as those with signs or symptoms of serious organic disease, should be evaluated promptly. Alarm features for serious disease include weight loss, refractory vomiting, early satiety, dysphagia, and gastrointestinal bleeding. If active bleeding is suspected, the patient should be evaluated in the controlled environment of a hospital endoscopy suite. Good patient outcomes often follow proper patient selection, and specialty referral of medically unstable or high-risk patients appears prudent. 
Testing for H. pylori, the bacteria highly associated with antral gastritis and peptic ulcer disease, is an important component of the EGD examination. H. pylori produce urease, the enzyme involved in breakdown of urea to ammonia. Ammonia can be evaluated colorimetrically, and a red color change is seen in the gel testing medium when urease activity is present in the biopsy specimen. If patients are treated with antibiotics or proton pump inhibitors prior to the EGD, the test is less sensitive because of the suppression of the bacteria. To maximize sensitivity, take four biopsy specimens. Two biopsies should be from the antrum, one from the lesser curvature (at or near the incisura), and the other from the greater curvature. Take two additional biopsies from the body of the stomach, one along the greater curvature and the other near the cardia. This approach yields nearly 100% sensitivity for the infection in patients who have not been on antibiotics or a proton pump inhibitor for the previous 3 to 4 weeks. 
Correct identification of pathology is a major challenge in learning EGD. Experience helps, but even seasoned endoscopists consult books and atlases to review their visual observations. Photographic or videotape recordings of procedures can help with documentation and learning. When nonvascular abnormalities are seen, biopsy is particularly useful to help identify the pathology. Although referral may be required for unusual or uncertain pathology, EGD is appropriately performed in primary care practices. 

Equipment

  • Video endoscopes are available in a variety of pediatric to adult sizes.

  • Supporting equipment includes the instrument stack containing a light source, insufflator, suction, and video recorder/photo printer.

  • Instruments include biopsy forceps, snares, and injecting needles.

Recommended Atlases

  • Keeffe EB, Jeffrey RB, Lee RG. Atlas of Gastrointestinal Endoscopy. Philadelphia: Appleton & Lange; 1998.

  • Martin DM, Lyons RC. The Atlas of Gastrointestinal Endoscopy. http://www.endoatlas.com/atlas_1.html

  • Murra-Saca J. El Salvador Atlas of Gastrointestinal Videoendoscopy. http://www.gastrointestinalatlas.com

  • Owen DA, Kelly JK. Atlas of Gastrointestinal Pathology. Philadelphia: WB Saunders; 1994.

  • Schiller KF, Cockel R, Hunt RH, et al. A Colour Atlas of Gastrointestinal Endoscopy. Philadelphia: WB Saunders; 1987.

  • Silverstein FE, Tytgat Guido NJ. Atlas of Gastrointestinal Endoscopy. St. Louis: Mosby; 1997.

  • Tadataka Y. Atlas of Gastroenterology. Philadelphia: Lippincott Williams & Wilkins; 2004.

Indications

  • Dyspepsia unresponsive to medical therapy

  • Periodic surveillance of patients with biopsy-proven Barrett esophagus

  • Dysphagia or odynophagia

  • Persistent vomiting of unknown origin

  • Documentation of H. pylori

  • Persistent regurgitation of undigested food

  • Suspected malabsorption

  • Periodic monitoring of patients with gastric polyps or Gardner syndrome

  • Documentation of clearance of gastric ulcers

  • Iron-deficiency anemia

  • Atypical chest pain with negative cardiac workup

  • Esophageal reflux symptoms unresponsive to medical therapy

  • Evaluation of upper gastrointestinal bleeding

  • Suspected bezoar

  • Suspected Zenker diverticulum

  • Suspected upper intestinal or gastric obstruction

  • Dyspepsia associated with serious signs such as weight loss

  • Evaluation of abnormal radiographic findings

  • Screening for gastric cancer (especially in high-risk populations such as the Japanese)

Contraindications (Relative)

  • Known or suspected perforated viscus

  • Acute, severe, or unstable cardiopulmonary disease

  • Uncooperative patient

  • Coagulopathy or bleeding diathesis

  • Severe or active upper gastrointestinal bleeding

  • Patients requiring therapeutic EGD that cannot be performed by the practitioner in that setting

  • Hemodynamically unstable patient

The Procedure

Step 1

The first step in any endoscopic procedure is to determine that all functions of the endoscope are working properly. Turn on the light source, and confirm the image is clear. If using a videoendoscope, perform the white balance maneuver. 

Step 2

Covering the air/water button introduces air and can be checked by placing the tip into water and watching for bubbles to be produced. 

Step 3

Pushing this button all the way down ejects a small amount of water to clean the lens. Check suction by suctioning a small amount of water through the endoscope. 

Step 4

Be sure the tip will fully deflect by rotating both control wheels fully in both directions while observing and feeling for free movement. Remember the tip will deflect upward 170 degrees and deflect only 90 degrees in the other directions. 
The tip of the endoscope is shown with the components labeled. 
The head of the endoscope is depicted in the figure. 

Step 5

Intravenous access is obtained if intravenous sedation is to be used. Monitoring equipment for pulse oximetry and blood pressure is attached to the patient, and baseline measurements are taken. 

Step 6

Dentures are removed, and oral topical anesthesia is administered. The patient can swish, gargle, and swallow 5 to 10 mL of 2% viscous lidocaine. Benzocaine spray is then applied to the posterior pharyngeal wall to blunt the gag reflex. The examiner’s gloved left index finger or tongue depressor is used to depress the tongue, exposing the pharynx for two 2- to 5-second sprays. Avoid touching the patient’s tissues, which would contaminate the extension spray tubing from the multiuse spray bottle, or use replacement tubing with each procedure. Some endoscopists do not use topical anesthesia and rely solely on conscious sedation for the procedure. 
  • PITFALL: The benzocaine spray has a pungent taste, even with flavoring added. Warn the patient about the taste, and allow time for a brief respite before the second spray.

Step 7

The patient is positioned in the left lateral decubitus position. A pillow is placed beneath the patient’s head, and the head is tilted with the chin to the chest. Disposable absorbent pads are placed beneath the patient’s head and neck for secretions that may drain during the procedure. The assistant may need to hold the head during insertion of the endoscope and should have suction readily available throughout the procedure. The mouthpiece is placed, and the patient is asked to gently but firmly place the teeth around the mouthpiece. 

Step 8

Anesthesia is then administered. Intravenous fentanyl (50 to 100 μg) or meperidine (25 to 75 mg) along with midazolam (1 to 2 mg) or diazepam (1 to 5 mg) is administered to achieve sedation. The proper level of sedation is recognized when the patient has slurred speech and dozes off but is still able to respond to questions and commands. Additional sedation may be used during the procedure to keep the patient comfortable as long as oxygen saturation and blood pressure are satisfactory. This step can be replaced with oral triazolam 1 hour before the procedure and intranasal butorphanol tartrate immediately prior to the procedure as described previously. Lubricate the distal end of the endoscope. 

Step 9

Insert the endoscope through the mouthpiece. The endoscope should slide easily over the posterior tongue. At about 8 cm from the incisors, deflect the tip downward to view the larynx. The scope is inserted slowly and kept off the side walls of the hypopharynx to limit gagging. 

Step 10

The scope tip is inserted to the posterior larynx, away from the vocal cords, just proximal to the closed cricopharyngeus muscle (scope inserted 15 to 18 cm from the incisors). This photo shows the view with an upward deflection in the endoscope tip. 
Alternatively, this photo shows the view with a downward deflection in the endoscope tip. 
  • Pearl: The advantage of using a downward deflection is the tip cannot be overly deflected (it will bend only 90 degrees downward).

Step 10
Step 10

Step 11

Ask the patient to swallow, which opens the muscle and allows access to the esophagus. The scope tip is inserted as the patient swallows, and if the esophagus is intubated, the characteristic appearance of the upper esophagus can be seen. 
  • PITFALL: The patient often gags when the scope is inserted. As soon as intubation is accomplished, stop and prevent movement of the scope tip. This allows the patient to resume normal respiratory pattern and become accustomed to the sensation created by the tube. Calm verbal encouragement should be used to assist the patient through this most difficult aspect of the procedure.

  • PITFALL: Tracheal intubation can happen if the tube is forcibly inserted with the scope tip positioned over the vocal cords. The endoscope usually produces gagging and distress from the inability to breath and possibly from laryngospasm. The scope should be completely withdrawn if tracheal intubation is suspected or occurs (i.e., tracheal rings are visualized).

Step 11
Step 11

Step 12

The scope is inserted under direct visualization. Insufflate air, and advance the endoscope only when lumen is visualized. Examine the distal esophagus and gastroesophageal junction (35 to 40 cm from the incisors) prior to passage of the endoscope. 
Step 12
Step 12

Step 13

Passage into the stomach reveals the characteristic gastric folds. Insufflate enough air to visualize the stomach. 
Step 13
Step 13

Step 14

Pass the endoscope to the antrum. The longitudinal folds of the body can be used to determine the long axis and assist in finding the antrum and pylorus. Angulation of the scope tip may be required. Position the scope tip just proximal to the pylorus, and insert the scope as the pylorus opens after a contraction. You may need to insufflate more air during this step, but do not use excessive amounts. 
  • PITFALL: The longer the scope is in the stomach, the greater is the degree of pylorospasm. Rapid intubation of the duodenum is advocated to reduce difficulty in passing through the pylorus.

  • PITFALL: Often, the scope tip slips back into the stomach, and the scope must be reinserted into the duodenum.

Step 14
Step 14

Step 15

As the endoscope enters the duodenum, examine the mucosa for duodenitis before scope passage. The lumen will typically be seen down and right. By moving the scope tip up, examine the anterior wall, down to examine the posterior wall, left for the inferior wall, and right to see the superior wall. 
Step 15
Step 15

Step 16

Intubate the second portion of the duodenum. In 30% of individuals, this is accomplished with insertion of the scope under direct visualization. In 70% of individuals, intubation of the sharp downward turn to the right requires a blind maneuver. The instrument tip is positioned just distal to the proximal duodenal fold and then turned to the right and downward. Insert a few centimeters blindly (while watching for mucosa sliding by) then deflect the tip gently upward while torquing the shaft counterclockwise to maneuver around the “C-loop.” When you see concentric rings (folds of Kerckring), you know that the scope is in the descending duodenum and further insertion is not needed for most cases. The papilla (ampulla of Vater) may be seen in some patients but is not necessary for a complete EGD. A sideviewing endoscope is needed for complete evaluation of this structure as used for endoscopic retrograde cholangiopancreatography (ERCP). 
Step 16
Step 16

Step 17

Withdraw the scope slowly to allow examination of the duodenal bulb if it was not thoroughly seen upon insertion. Often the endoscope comes out of the pylorus and must be reinserted to fully evaluate the duodenal bulb. After thorough examination of the duodenum, the scope is brought back into the stomach. 
  • PITFALL: Do not biopsy pulsatile or vascular lesions, because the resulting bleeding can be extensive and difficult to control.

  • PITFALL: Esophageal ulcerations or erosions may be better assessed by brushing or washing. The esophagus is much thinner than the stomach, and risk of perforation from biopsy is greater at this location. Beware of biopsying the base of a deep gastric ulcer, because perforation can occur in this situation.

Step 17
Step 17

Step 18

The endoscope is retroflexed by deflecting the tip fully upward while the shaft is rotated 90 degrees counterclockwise. Leftward deflection may also assist in this maneuver. Withdraw the scope to examine the fundus and cardia. Suction any gastric secretions to fully examine this area and to make the examination safer (i.e., empty the stomach to prevent possible aspiration if vomiting develops). 
Step 18
Step 18

Step 19

Examination of the gastroesophageal junction is important to look for a hiatal hernia and other lesions at this site. A “sniff test” can be used to confirm the level of the diaphragm if a hiatal hernia is suspected. This is performed by asking the patient to sniff and watching for contraction of the diaphragm. 
Step 19
Step 19

Step 20

Biopsies are then obtained for H. pylori testing (CLOtest). Because of the risk of malignancy, multiple biopsies are performed on all gastric ulcers along the raised edges. In contrast, duodenal ulcers do not require biopsy. Biopsy also is performed on abnormal growths, polyps, or other nonvascular pathologic changes. 
Step 20
Step 20

Step 21

The air in the stomach is suctioned out, and the scope is withdrawn into the esophagus. Examination of the distal esophagus is performed again. Hiatal hernias may be also identified in this position by the “sniff test” and noting the distance between the diaphragmatic indention and the gastroesophageal junction (i.e., Z-line). Biopsy any abnormal mucosa or nonvascular abnormalities, and biopsy any strictures because these can be caused by malignancy. 
Step 21
Step 21

Step 22

Withdraw the scope, examining the esophagus and larynx on removal. Pay special attention to the proximal esophagus because this may have been passed blindly upon initial insertion of the scope. Remove the mouthpiece. Wipe off any oral secretions that have drained from the mouth. Observe the patient until the sedation wears off or the patient is stable for discharge with a family member or caregiver. 
  • PITFALL: Lesions in the proximal esophagus may be missed upon initial insertion of the endoscope. Examine this area carefully.

Step 22
Step 22

Step 23

Immediately following the procedure, begin the cleaning process by suctioning an enzyme solution through the endoscope, and follow manufacturer’s recommendations for disinfection. Recommendations for endoscope disinfection are included in Appendix K: Recommendations for Endo-scope Disinfection. 
Step 23
Step 23

Complications

  • Perforation of stomach, esophagus, or duodenum

  • Bleeding at biopsy site

  • Adverse reaction to anesthesia or medication, including

    • Respiratory depression

    • Apnea

    • Hypotension

    • Excessive sweating

    • Bradycardia

    • Laryngospasm

Pediatric Considerations

Pediatric indications for EGD are similar to adult indications. Ingestions of foreign objects and caustic materials are more common in the pediatric population. Caustic items such as watch batteries should be retrieved from the esophagus urgently. Oral mucosa damage should be useful in determining the need for further evaluation of questionable liquid ingestion. Most coins will advance to the stomach within 24 hours, but a foreign body impacted in the esophagus should be removed within 24 hours. Size and shape of a foreign object is another important consideration. Objects >3 cm in length young children and 5 cm in length in ages up to adolescence should be promptly removed. Sharp or pointed objects should be urgently recovered. 
A standard adult gastroscope (≥9.7 mm) is appropriate for most children weighing >25 kg. A smaller gastroscope (7.9 or 9.0 mm outer diameter) is recommended for infants and smaller children. Also, pediatric endoscopes have correspondingly smaller biopsy forceps with a reduced bite appropriate for thinner small bowel. 
Refer to the anesthesia chapter for pediatric anesthesia (see Pediatric Sedation). Some important considerations involve airway safety and anesthesia selection. The necessary equipment and training for definitive airway protection should be readily available. 

Postprocedure Instructions

Someone should be available to take the patient home after the procedure and stay with the patient for a while. Patients should not be allowed to drive themselves because of the sedation. 
Patients should call their health-care provider if any of these conditions arise after endoscopy: chest pain, severe abdominal pain, fever, black stools, or hematemesis. Patients might find relief from a transitory sore throat with warm saltwater gargling or throat lozenges. 

Coding Information and Supply Sources

For comprehensive upper gastrointestinal (GI) endoscopic procedures, 43239 is the code most commonly reported. In the office setting, a surgery tray charge may be billed in addition (99070 or A4550) to cover some of the administrative costs. 

ICD-9 Codes

Suppliers

Complete endoscopy equipment such as endoscopes, light sources, video endoscopy monitors, cleaning and disinfection aids, and mouthpieces are available from these suppliers: 
Intravenous materials (e.g., Intracaths, normal saline solution, intravenous tubing) can be obtained from local hospitals or surgical supply houses. 
Recommendations for endoscope cleaning appear in Appendix K

Bibliography

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