Esophagogastroduodenoscopy

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Esophagogastroduodenoscopy

Introduction

Equipment

endoscopic procedure that allows clinicians to diagnose and treat

multiple problems in the upper gastrointestinal tract. EGD is indicated

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

There are several potential benefits

when primary care providers perform EGD, especially if it is done in the

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

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

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

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

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

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.

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

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

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

stomach, one along the greater curvature and the other near the cardia.

This approach yields nearly 100% sensitivity for the infection in

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.

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

Step 1 View Original Step 1 View Original

Covering the air/water button

introduces air and can be checked by placing the tip into water and

watching for bubbles to be produced.

way down ejects a small amount of water to clean the lens. Check

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

shown with the components labeled.

depicted in the figure.

for pulse oximetry and blood pressure is attached to the patient,

and baseline measurements are taken.

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

anesthesia and rely solely on conscious sedation for the

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

throughout the procedure. The mouthpiece is placed, and the patient

is asked to gently but firmly place the teeth around the

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

procedure and intranasal butorphanol tartrate immediately prior to the procedure as described previously.

Lubricate the distal end of the endoscope.

the mouthpiece. The endoscope should slide easily over the posterior

view the larynx. The scope is inserted slowly and kept off the side

walls of the hypopharynx to limit gagging.

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

intubated, the characteristic appearance of the upper esophagus can

direct visualization. Insufflate air, and advance the endoscope only

gastroesophageal junction (35 to 40 cm from the incisors) prior to

reveals the characteristic gastric folds. Insufflate enough air to

antrum. The longitudinal folds of the body can be used to determine

the long axis and assist in finding the antrum and pylorus.

opens after a contraction. You may need to insufflate more air

duodenum, examine the mucosa for duodenitis before scope passage.

The lumen will typically be seen down and right. By moving the scope

Intubate the second portion

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

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

allow examination of the duodenal bulb if it was not thoroughly seen

thorough examination of the duodenum, the scope is brought back into

by deflecting the tip fully upward while the shaft is rotated 90

this maneuver. Withdraw the scope to examine the fundus and cardia.

make the examination safer (i.e., empty the stomach to prevent

possible aspiration if vomiting develops).

gastroesophageal junction is important to look for a hiatal hernia

suspected. This is performed by asking the patient to sniff and

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.

hernias may be also identified in this position by the "sniff

test " and noting the distance between the diaphragmatic

strictures because these can be caused by malignancy.

the esophagus and larynx on removal. Pay special attention to the

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.

procedure, begin the cleaning process by suctioning an enzyme

recommendations for disinfection. Recommendations for endoscope

disinfection are included in Appendix K: Recommendations for

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

A standard adult gastroscope

correspondingly smaller biopsy forceps with a reduced bite appropriate

Refer to the anesthesia chapter for

Some important considerations involve airway safety and anesthesia

selection. The necessary equipment and training for definitive airway

protection should be readily available.

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

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

commonly reported. In the office setting, a surgery tray charge may be

billed in addition (99070 or A4550) to cover some of the administrative

View Large CPT Code Description 2008 AVERAGE 50th Percentile Fee Global Period 43200 Esophagoscopy with or without brushings $729.00 0 43202 Esophagoscopy with biopsies $772.00 0 43234 Simple primary upper GI endoscopy $720.00 0 43235 Upper GI endoscopy, including duodenum with brushings $779.00 0 43239 Upper GI endoscopy, including duodenum with biopsies $879.00 0 CPT is a registered trademark of the American

Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008

MMH-SI 's copyrighted Physicians ' Fees and

View Large Abdominal mass 789.3 Anemia, unexplained 280.9 GI bleeding, acute 578.9 GI bleeding, occult 578.1 X-ray abnormality 793.4 Dyspepsia, severe 536.8 Dysphagia/odynophagia 787.2 Early satiety 789.0 Epigastric pain 789.0 Food slicking 787.2 Heartburn, meal related 787.1 Indigestion, severe 787.3 Nausea, chronic (vomiting) 787.0 Pain (substernal/paraxiphold) 786.5 Reflux of food (regurgitation) 787.0 Weight loss, severe 783.2 Cancer surveillance in high risk patients V 67.9 Esophageal stricture 564.2 Gastric retention 782.0 History of duodenitis 535.6 History of esophagitis 530.1 History of gastritis 535.4 History of hiatal hernia 553.3 Monitoring a gastric ulcer 531.9 Peptic ulcer disease 533.0 Pyloroduodenal stenosis 537.0 Varices 456.0

cleaning and disinfection aids, and mouthpieces are available from

(e.g., Intracaths, normal saline solution, intravenous tubing) can

be obtained from local hospitals or surgical supply houses.

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Fee and Coding Guide. Duluth,

• 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

• 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.

• Pearl: The advantage of using a downward deflection is the tip cannot be overly deflected (it will bend only 90 degrees downward).

• 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).

• 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.

• 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.

• PITFALL: Lesions in the proximal esophagus may be missed upon initial insertion of the endoscope. Examine this area carefully.

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

• Respiratory depression
• Apnea
• Hypotension
• Excessive sweating
• Bradycardia
• Laryngospasm

Pediatric Considerations

Postprocedure Instructions

Coding Information and Supply Sources

• Olympus Corporation, Center Valley, PA. Web site: http://www.olympusamerica.com.
• Pentax Precision Instrument Corporation, Montvale, NJ. Web site: http://www.pentaxmedical.com
• A viscous 2% " ‚lidocaine topical solution is available from Alpharma USPD, Bridgewater, NJ. Web site: http://www.alpharma.com.
• Benzocaine 20% spray (Hurricaine topical anesthetic) is available in several flavors from Beutlich Pharmaceuticals, Waukegan, IL. Web site: http://www.beutlich.com
• CLOtest kits can be obtained from Tri-Med Specialties, Roswell, GA. Web site: http://www.kchealthcare.com/global/index.asp.
• Butorphanol tartrate (Stadol) nasal spray is available from Bristol-Myers Squibb. Web site: http://www.bms.com.

Bibliography