Esophagogastroduodenoscopy

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Definition

An endoscope as used in the field of gastroenterology (the medical study of the stomach and intestines) is a thin, flexible tube that uses a lens or miniature camera to view various areas of the gastrointestinal tract. When the procedure is limited to the examination of the inside of the gastrointestinal tract's upper portion, it is called upper endoscopy or esphagogastroduodenoscopy (EGD). With the endoscope, the esophagus (swallowing tube), stomach, and duodenum (first portion of the small intestine) can be easily examined, and abnormalities frequently treated. Patients are usually sedated during the exam.

Description

First, a "topical" (local) medication to numb the gag reflex is given either by spray or is gargled. Patients are usually sedated for the procedure (though not always) by injection of medications into a vein. The endoscopist then has the patient swallow the scope, which is passed through the upper gastrointestinal tract. The lens or camera at the end of the instrument allows the endoscopist to examine each portion of the upper gastrointestinal tract; photos can be taken for reference. Air is pumped in through the instrument to allow proper observation. Biopsies and other procedures can be performed without any significant discomfort.

— David Kaminstein, MD

Definition

An esophagogastroduodenoscopy (EGD), which is also known as an upper endoscopy or upper gastrointestinal endoscopy, is a diagnostic procedure that is performed to view the esophagus, stomach, and duodenum (part of the small intestine). In an EGD, the doctor uses an endoscope, a flexible, tube-like, telescopic instrument with a tiny camera mounted at its tip, to examine images of the upper digestive tract displayed on a monitor in the examination room. Small instruments may also be passed through the tube to treat certain disorders or to perform biopsies (remove small samples of tissue).

Purpose

An EGD is performed to evaluate, and sometimes to treat, such symptoms relating to the upper gastrointestinal tract as:

• pain in the chest or upper abdomen
• nausea or vomiting
• gastroesophageal reflux disease (GERD)
• difficulty swallowing (dysphagia)
• bleeding from the upper intestinal tract and related anemias

In addition, an EGD may be performed to confirm abnormalities indicated by such other diagnostic procedures as an upper gastrointestinal (upper GI) x-ray series or a CT scan. It may be used to treat certain conditions, such as an area of narrowing (stricture) or bleeding in the upper gastrointestinal tract.

Description

Upper endoscopy is considered to be more accurate than x-ray studies for detecting inflammation, ulcers, or tumors. It is used to diagnose early-stage cancer and can frequently help determine whether a growth is benign or malignant. The doctor can obtain biopsies of inflamed or suspicious tissue for examination in the laboratory by a pathologist or cytologist. Cell scrapings can also be taken by introducing a small brush through the endoscope; this technique is especially helpful in diagnosing cancer or an infection.

Besides its function as an examining tool, an endoscope has channels that permit the passage of instruments. This feature gives the physician an opportunity to treat on the spot many conditions that may be seen in the esophagus, stomach, or duodenum. These treatments may include:

• removal of polyps and other noncancerous (benign) tissue growths
• stretching narrowed areas (strictures) in the esophagus
• stopping bleeding from ulcers or blood vessels
• removing foreign objects that have been swallowed, such as coins, pins, buttons, small nails, and similar items

Some of the diseases and conditions that are investigated, identified, or treated using EGD include:

• abdominal pain
• achalasia, a defect in the muscular opening between the esophagus and the stomach
• Barrett's esophagus, a precancerous condition of the cells lining the esophagus
• Crohn's disease and inflammatory disease of the small intestine
• esophageal cancer
• gastroesophageal reflux disease (GERD), a condition caused by excess stomach acid
• hiatal hernia
• irritable bowel syndrome
• rectal bleeding
• stomach cancer
• stomach ulcers
• swallowing problems

An EGD procedure is usually performed by a gastroenterologist, who is a physician specializing in the diagnosis and treatment of disorders of the digestive tract. GI (gastrointestinal) assistants, operating room nurses, or technicians may be involved in the collection of samples and care of the patient. Patients will be asked to either gargle using a local anesthetic or will have an anesthetic sprayed into their mouths onto the back of the throat to numb the gag reflex. Then the endoscopist will guide the endoscope through the mouth into the upper gastrointestinal tract while the patient is lying on his or her left side. The lens or camera at the end of the instrument allows the endoscopist to examine each portion of the upper gastrointestinal tract by observing images on a monitor. Photographs are usually taken for reference. During the procedure, air is pumped in through the instrument to expand the structure that is being studied and allow better viewing. Biopsies and other procedures will be performed as needed. The patient's breathing will not be disturbed and there will be little if any discomfort. Many patients fall asleep during all or part of the procedure.

Some patients should not have an EGD. This examination is contraindicated in patients who have:

• severe upper gastrointestinal (UGI) bleeding
• a history of such bleeding disorders as platelet dysfunction or hemophilia
• esophageal diverticula, which are small pouches in the esophagus that can trap food or pills and become infected
• a suspected perforation (puncture or rupture) of the esophagus or stomach
• recent surgery of the upper gastrointestinal tract (throat, esophagus, stomach, pyloric valve, duodenum)

An EGD is also contraindicated for those patients who are unable to cooperate fully with the procedure or whose overall condition includes a severe underlying illness that increases the risk of complications.

Diagnosis/Preparation

Certain medications (such as aspirin and the anti-inflammatory drugs called NSAIDs) should be discontinued at least seven days before an EGD to reduce the risk of bleeding. Patients will be asked not to eat or drink anything for at least six to 12 hours before the procedure to ensure that the upper intestinal tract will be empty. Before the procedure, patients may be given a sedative and/or pain medication, usually by intravenous injection.

Aftercare

After the procedure, the patient will be observed in the endoscopy suite or in a separate recovery area for an hour, or until the sedative or pain medication has worn off. Someone should be available to take the patient home and stay with them for a while. Eating and drinking should be avoided until the local anesthetic has worn off in the throat and the gag reflex has returned, which may take two to four hours. To test if the gag reflex has returned, a spoon can be placed on the back of the tongue for a few seconds with light pressure to see if the patient gags. Hoarseness and a mild sore throat are normal after the procedure; the patient can drink cool fluids or gargle to relieve the soreness.

The patient may experience some bloating, belching, and flatulence after an EGD because air is introduced into the digestive tract during the procedure. To prevent any injury to the esophagus from taking medications by mouth, patients should drink at least 4 or more ounces of liquid with any pill, and remain sitting upright for 30 minutes after taking pills that are likely to cause injury. The doctor should be notified if the patient develops a fever; difficult or painful swallowing (dysphagia); breathing difficulties; or pain in the throat, chest, or abdomen.

Risks

Endoscopy is considered a safe procedure when performed by a gastroenterologist or other medical professional with special training and experience in endoscopy. The overall complication rate of EGD performance is less than 2%; many of these complications are minor, such as inflammation of the vein through which medication is given. Serious complications can and do occur, however, with almost half being related to the heart or lungs. Bleeding or perforations are also reported, especially when tumors or strictures have been treated or biopsied. Infections have been reported, though rarely; careful attention to cleaning the instrument should prevent this complication. Perforation, which is the puncture of an organ, is very rare and can be surgically repaired if it occurs during an EGD.

Normal Results

The results of the procedure or probable findings are often available to the patient prior to discharge from the endoscopy suite or the recovery area. The results of tissue biopsies or cell tests (cytology) will take from 72–96 hours. Normal results will show that the esophagus, stomach and duodenum are free of strictures, ulcers or erosions, diverticula, tumors, or bleeding. Abnormal results include the presence of any of these problems, as well as esophageal infections, fissures, or tears. An increasingly common finding is medication-induced esophageal injury, caused by tablets and capsules that have lodged in the esophagus. These injuries are thought to be associated with damage to the esophageal tissue from gastrointestinal reflux disease (GERD) and the related exposure of the esophagus to large amounts of stomach acid.

Resources

Books

Edmundowicz, Steven. "Endoscopy." In The Esophagus, 3rd ed., edited by Donald O. Castell and Joel E. Richter. Philadelphia, PA: Lippincott, 1999.

Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications, 5th ed. St. Louis, MO: Mosby, 1999.

Organizations

American Society for Gastrointestinal Endoscopy (ASGE). 13 Elm Street, Manchester, MA 01944-1314. (978) 526-8330. www.asge.org.

Society for Gastroenterology Nurses and Associates (SGNA). 401 North Michigan Avenue, Chicago, IL 60611-4267. (800) 245-7462. www.sgna.org.

Other

Johns Hopkins Consumer Guide to Medical Tests. Upper Gastrointestinal Endoscopy. www.hopkinsafter50.com.

— Maggie Boleyn, RN, BSN L. Lee Culvert

Endoscopic examination of the esophagus, stomach and duodenum.

"EGD" redirects here. For the computer software Entropy Gathering Daemon, see /dev/random.

"OGD" redirects here. For the IATA airport code, see Ogden-Hinckley Airport.

Intervention: Esophagogastroduodenoscopy
Endoscopic still of esophageal ulcers seen after banding of esophageal varices, at time of esophagogastroduodenosocopy
ICD-10 code:
ICD-9 code:	45.13
MeSH	D016145
Other codes:

In medicine (gastroenterology), esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure (unless sedation or anaesthesia has been used). A sore throat is also common.^[1][2][3]

Contents 1 Alternative names 2 Indications 2.1 Diagnostic 2.2 Surveillance 2.3 Confirmation of diagnosis/biopsy 2.4 Therapeutic 2.5 Newer interventions 3 Equipment 4 Procedure 5 Complications 6 Limitations 7 Additional images 8 References

Alternative names

Esophagogastroduodenoscopy may be abbreviated EGD, or OGD if one uses the British spelling 'oesophago-'. It is also called upper GI endoscopy (UGIE), gastroscopy or simply endoscopy (since it is the most commonly performed type of endoscopy, the ambiguous term 'endoscopy' refers to EGD by default).

Indications

Diagnostic

• Unexplained anemia (usually along with a colonoscopy)
• Upper gastrointestinal bleeding as evidenced by hematemesis or melena
• Persistent dyspepsia in patients over the age of 40-45 years
• Heartburn and chronic acid reflux - this can lead to a precancerous lesion called Barrett's esophagus
• Persistent vomiting
• Dysphagia - difficulty in swallowing
• Odynophagia - painful swallowing

Surveillance

• Surveillance of Barrett's esophagus
• Surveillance of gastric ulcer or duodenal ulcer
• Occasionally after gastric surgery

Confirmation of diagnosis/biopsy

• Abnormal barium swallow or barium meal
• Confirmation of celiac disease (via biopsy)

Therapeutic

• Treatment (banding/sclerotherapy) of esophageal varices
• Injection therapy (e.g. epinephrine in bleeding lesions)
• Cutting off of larger pieces of tissue with a snare device (e.g. polyps, endoscopic mucosal resection)
• Application of cautery to tissues
• Removal of foreign bodies (e.g. food) that have been ingested
• Tamponade of bleeding esophageal varices with a balloon
• Application of photodynamic therapy for treatment of esophageal malignancies
• Endoscopic drainage of pancreatic pseudocyst
• Tightening the lower esophageal sphincter
• Dilating or stenting of stenosis or achalasia
• Percutaneous endoscopic gastrostomy (feeding tube placement)
• Endoscopic retrograde cholangiopancreatography (ERCP) combines EGD with fluoroscopy
• Endoscopic ultrasound (EUS) combines EGD with 5-12 MHz ultrasound imaging

Newer interventions

• Endoscopic trans-gastric laparoscopy
• Placement of gastric balloons in bariatric surgery

Equipment

• Endoscope
  • Non-coaxial optic fibre system to carry light to the tip of the endoscope
  • A chip camera at the tip of the endoscope - this has now replaced the coaxial optic fibres of older scopes that were prone to damage and consequent loss of picture quality
  • Irrigation channel to clean the lens
  • Suction/Insufflation/Working channels - these may be in the form of one or more channels
  • Control handle - this houses the controls
• Stack
  • Light source
  • Insufflator
  • Suction
  • Electrosurgical unit
  • Video recorder/photo printer
• Instruments
  • Biopsy forceps
  • Snares
  • Injecting needles

Procedure

The patient is kept NPO (Nil per os) or NBM (Nothing By Mouth) that is, told not to eat, for at least 4-6 hours before the procedure. Most patients tolerate the procedure with only topical anaesthesia of the oropharynx using lidocaine spray. However, some patients may need sedation and the very anxious/agitated patient may even need a general anaesthetic. Informed consent is obtained before the procedure. The main risks are bleeding and perforation. The risk is increased when a biopsy or other intervention is performed.

The patient lies on his/her left side with the head resting comfortably on a pillow. A mouth-guard is placed between the teeth to prevent the patient from biting on the endoscope. The endoscope is then passed over the tongue and into the oropharynx. This is the most uncomfortable stage for the patient. Quick and gentle manipulation under vision guides the endoscope into the esophagus. The endoscope is gradually advanced down the esophagus making note of any pathology. Excessive insufflation of the stomach is avoided at this stage. The endoscope is quickly passed through the stomach and through the pylorus to examine the first and second parts of the duodenum. Once this has been completed, the endoscope is withdrawn into the stomach and a more thorough examination is performed including a J-maneuver. This involves retroflexing the tip of the scope so it resembles a 'J' shape in order to examine the fundus and gastroesophageal junction. Any additional procedures are performed at this stage. The air in the stomach is aspirated before removing the endoscope. Still photographs can be made during the procedure and later shown to the patient to help explain any findings.

In its most basic use, the endoscope is used to inspect the internal anatomy of the digestive tract. Often inspection alone is sufficient, but biopsy is a very valuable adjunct to endoscopy. Small biopsies can be made with a pincer (biopsy forceps) which is passed through the scope and allows sampling of 1 to 3 mm pieces of tissue under direct vision. The intestinal mucosa heals quickly from such biopsies.

Biopsy allows the pathologist to render an opinion on later histologic examination of the biopsy tissue with light microscopy and/or immunohistochemistry. Biopsied material can also be tested on urease to identify Helicobacter pylori.

Complications

The complication rate is about 1 in 1000. They include:

• aspiration, causing aspiration pneumonia
• bleeding
• perforation
• cardiopulmonary problems

Limitations

Problems of gastrointestinal function are usually not well diagnosed by endoscopy since motion or secretion of the gastrointestinal tract are not easily inspected by EGD. Nonetheless, findings such as excess fluid or poor motion of gut during endoscopy can be suggestive of disorders of function. Irritable bowel syndrome and functional dyspepsia is not diagnosed with EGD, but EGD may be helpful in excluding other diseases that mimic these common disorders.

Additional images

Endoscopic image of adenocarcinoma of duodenum seen in the post-bulbar duodenum.	Endoscopic image of gastric antral vascular ectasia seen as a radial pattern around the pylorus before (top) and after (bottom) treatment with argon plasma coagulation	Endoscopic image of Barrett's esophagus, which is the area of red mucosa projecting like a tongue.	Deep gastric ulcer
Endoscopic still of duodenum of patient with coeliac disease showing scalloping of folds.	Gastric ulcer in antrum of stomach with overlying clot due to gastric lymphoma.	Endoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.

References

1. ^ "Gastroscopy - examination of oesophagus and stomach by endoscope". BUPA. December 2006. http://hcd2.bupa.co.uk/fact_sheets/html/Gastrointestinal.html. Retrieved 2007-10-07. 
2. ^ National Digestive Diseases Information Clearinghouse (November 2004). "Upper Endoscopy". National Institutes of Health. http://digestive.niddk.nih.gov/ddiseases/pubs/upperendoscopy/index.htm. Retrieved 2007-10-07. 
3. ^ "What is Upper GI Endoscopy?". Patient Center -- Procedures. American Gastroenterological Association. http://www.gastro.org/wmspage.cfm?parm1=859. Retrieved 2007-10-07. 

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