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.
View OriginalView Original
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 1 View Original Step 1 View Original
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 2 View Original Step 2 View Original
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 3 View Original Step 3 View Original
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 4 View Original Step 4 View Original
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 5 View Original Step 5 View Original
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 6 View Original Step 6 View Original
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 7 View Original Step 7 View Original
Step 8
Anesthesia is then
administered. Intravenous fentanyl (50 to 100 Όg) 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 8 View Original Step 8 View Original
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 9 View Original Step 9 View Original
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 View Original Step 10 View Original
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 View Original Step 11 View Original
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 View Original Step 12 View Original
Step 13
Passage into the stomach
reveals the characteristic gastric folds. Insufflate enough air to
visualize the stomach.
Step 13 View Original Step 13 View Original
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 View Original Step 14 View Original
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 View Original Step 15 View Original
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 View Original Step 16 View Original
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 View Original Step 17 View Original
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 View Original Step 18 View Original
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 View Original Step 19 View Original
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 View Original Step 20 View Original
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 View Original Step 21 View Original
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 View Original Step 22 View Original
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 View Original Step 23 View Original
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.
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
Coding Guide.
ICD-9 Codes
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
Suppliers
Complete endoscopy equipment
such as endoscopes, light sources, video endoscopy monitors,
cleaning and disinfection aids, and mouthpieces are available from
these suppliers:
- 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.
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.
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