ppt on endo

1. Methods And Biopsy Protocols
IN
Upper Gastrointestinal Endoscopy
Dr. DINESH THAPA
3rd
year MDGP and EM Resident

2. Introduction
 Performed by passing a flexible endoscope
through the mouth into the esophagus,
stomach and duodenum
 Best method for examining the upper
gastrointestinal mucosa
 Superior for detection of gastric ulcers and
flat mucosal lesions, such as Barrett’s
esophagus and it permits directed biopsy
and endoscopic therapy

3. Language of the Wheels/Buttons
 Superior button-
 Suction
 Inferior button
 Insufflation of air
 Insufflation of water
 Big Wheel
 Towards you
 Upwards
 Small wheel
 Away from you
 To the right side

4. Endoscope Handling
Ambidextrous
 Left hand on control head
 Right hand on endoscopy shaft
The endoscopist controls the shaft
 Clockwise twist
 Anticlockwise twist
Navigate using
 Wheel movement
 Shaft movement
 Your body movement

5. Endoscopic Biopsy Forceps
 2 cup shaped jaws
 Round/ elliptical, serrated/ non
serrated
 Best to use forcep with
needle spike at the center
- to fix the mucosa
- Provide deeper biopsies

6. Cleaning and Disinfection
 Low-level disinfection
 Non-critical accessories Come in contact with intact skin
 Cameras and endoscopic furniture
 Sterilization
 Critical reusable accessories
 Which enters body cavities and vasculature or penetrate mucous membranes
 Biopsy forceps, sclerotherapy needles and sphincterotomes
 High- level disinfection
 Semi-critical accessories  which come into contact with mucous
membranes
 Endoscopes and esophageal dilators

7. Cleaning and Disinfection
 Manual disinfection
Soak the instrument and accessories in the chosen disinfectant
Glutaraldehyde – most popular disinfectant
The length of contact time needed for disinfection- 20 minutes
is commonly recommended
More prolonged soaking  known or suspected mycobacterial
disease
Peracetic acid, chlorine dioxide, sterox – have also been used

8. Golden Rules for Endoscopic Safety
• Do not push if you cannot see
• If in doubt, inflate and pull back

9. Esophagus
 Cervical esophagus
- from the upper esophageal sphincter/cricopharyngeal
sphincter (16 cm from incisors) to entry of the
esophagus into the chest
- Lower boundary not visible at endoscopy
 Intrathoracic part
- almost 20 cm long and ends when the esophagus
enters the abdominal cavity through diaphragm
- Approximately 38-40 cm from incisors
 Intra-abdominal part
- Ends at esophagogastric junction and the lower
esophageal sphincters
 Aortic constriction- at 25cm, the aorta crosses the
esophagus and appears as an external compression

10. Esophagus
 Esophagogastric junction
- defined endoscopically as the distal ends
of esophageal that meet the proximal
ends of gastric longitudinal mucosal folds
 Squamocolumnar junction ( Z-line)
- The junction of the squamous mucosa
and columnar mucosa
 Hiatus
- Opening in the diaphragm through
which esophagus passes from the
thoracic to the abdominal cavity

11. Stomach

12. Steps of Endoscopy

13. Steps of Endoscopy

14. Steps of Endoscopy
Cervical Esophagus

15. Steps of Endoscopy
Thoracic Esophagus

16. Steps of Endoscopy
Esophagogastric Junction

17. Steps of Endoscopy

18. Steps of Endoscopy

19. Steps of Endoscopy

20. Steps of Endoscopy
To advance through the body and into antrum
 Big wheel towards you (UP)
 Clockwise twist of shaft
 Push the scope

21. Steps of Endoscopy

22. Steps of Endoscopy

23. Steps of Endoscopy

24. Steps of Endoscopy

25. Steps of Endoscopy
J Maneuver
Big wheel fully towards you and Pull back

26. Steps of Endoscopy
Big wheel fully towards you along with shaft movement and
your body movement
360 degree panoramic view of cardia

27. Steps of Endoscopy
Enter the pylorus when it is at the centre and wide open
and scope is straight

28. Steps of Endoscopy
Enter 2nd
part: Do 3 maneuvers
Big wheel: towards U
Small wheel: away from U
Turn your body to right

29. Removing the instrument
Mucosal views are often optimal during instrument withdrawal
The proximal lesser curve, a potential “blind spot” merits
particular attention
Aspirate air from the stomach completely on withdrawal

30. Upper GI Endoscopy
Pathological Lesions

31. Mallory-Weiss Lesion and Boerhaave Syndrome
 Longitudinal superficial mucosal laceration
 Occurs primarily at the gastroesophageal
junction and may extend proximally to involve
the lower to mid-esophagus or distally to
involve the proximal portion of the stomach
 Frequently posterior
 Complete rupture of the esophagus is known
as Boerhaave syndrome

32. Eosinophilic esophagitis
 Endoscopic finding
- multiple esophageal rings, linear furrows,
white punctate exudate and strictures
 Biopsy
- 2 to 4 biopsies of the proximal
esophagus
- 2 to 4 biopsies of the distal esophagus
 Biopsies of the gastric antrum and
duodenum if there is suspicion of
eosinophilic gastroenteritis

33. Infectious esophagitis
 Endoscopic finding
- Ulcerations are numerous, punctate
and diffuse
 CMV infection – biopsies from the
base of the ulcers
 HSV infection - biopsies from the
base of the ulcers
 Esophageal candidiasis – biopsies
from affected areas + exfoliative
cytology

34. Gastroesophageal Reflux and Reflux Esophagitis
Endoscopic findings
 Erosions and ulcerations are usually few and distal
Indications for endoscopy
 For patients with GERD symptoms who also have alarm symptoms such as
• Dysphagia
• Weight loss
• Bleeding
• Vomiting
• Anemia
Diagnostic endoscopy should ideally be performed after PPIs have been
stopped for 2 weeks and perhaps as long as 4 weeks if possible

35. Gastroesophageal Reflux and Reflux Esophagitis
Esophageal biopsy should be taken to exclude other diagnosis, including
infectious etiologies and malignancy under the following condition
 Immunocompromised patients
 Irregular and deep ulceration
 Presence of mass lesion or nodularity
 Irregular or malignant appearing stricture
Biopsy
 Targeted biopsies of irregular mucosa

36. Modified Los Angeles Classification of GERD
Grade Description
A 1or more mucosal break no longer than 5
mm without continuation between mucosal
folds
B 1or more mucosal break longer than 5 mm
without continuation between mucosal fold
C 1 or more mucosal break that is continuous
between the tops of two or more mucosal
folds but that involves less that 75% of the
circumference
D 1or more mucosal break that involves at
least 75% of the esophageal circumference

37. Hiatial Hernia
 Persistent or recurrent herniation of
portion of the stomach through the
esophageal hiatus into the chest cavity
 Forward view
 Double-ring configuration
 Proximal ring is formed by the lower
esophageal sphincter(LES), the distal
ring by the esophageal hiatus
 The Z-line is within the dilated
segment, several centimeters above
the esophageal hiatus

38.  Retroflexed view
 Cardia does not close around
the endoscope
 Bell-shaped dilatation over the
cardia
 Folds radiating into the hernia

39. Barrett’s Esophagus
 Condition in which the squamous
epithelium of the distal esophagus is
substituted with columnar epithelium
 Prague classification of barrett’s esophagus-
both the maximal length (M) and the length
of the circumferential barrett segment (C)
are measured during endoscopy
 These numbers can then be used to track
the length of the barrett segment over time

40. Barrett’s Esophagus
 Protocol of seattle
 Barrett’s esophagus without dysplasia-
biopsies of 4 quadrants every 2 cm
 Barrett’s esophagus with low grade
dysplasia- biopsies of 4 quadrants every 1-2
cm
 Barrett’s esophagus with high grade
dysplasia- biopsies of 4 quadrants every 1 cm

41. Esophageal Varices
 Esophageal varices are
distended submucosal veins
that protrude into the
esophageal lumen
 Baveno classification of
esophageal varices
Size Description
Small Minimally elevated varices above
the esophageal mucosa surface
Medium Tortuous varices occupying less
than one third of the esophageal
surface
Large Varices that occupy more than
one third of the esophageal
surface

42. Esophageal Varices
Dagradi classification
Grade I : Variceal diameter less than 2 mm ,
disappear with esophageal lumen insufflation
Grade II: Varices of similar diameter, clearly visible in
the esophageal lumen
Grade III: Varices of 3-4 mm , prominent in the
esophageal lumen
Grade IV: Variceal diameter 5 mm or more , tortuous
Grade V: Red color signs

43. Gastritis
 Endoscopic features:
- Edema
- Exudate
- Erythema
- Erosion
- Hemorrhage
 Type A (Autoimmune gastritis)- Body
predominant
 Type B ( Bacterial gastritis)- Antral
predominant

44. Urease test
 1-2 biopsies: 5 cm proximal to the pylorus on
the lesser curvature near the angularis or on
the greater curve opposite the angularis
 Gastric biopsy material is tested for urease
activity by placing tissue in a medium
containing urea and pH reagent such as
phenolphthalein
 H pylori urease hydrolyzes urea liberating
ammonia  which produces an alkaline pH
resultant color change of the phenolphthalein
test medium

45. Urease test
 Sensitivity and specificity of tests are 90% to 95% and 95% to 100%
 Accuracy can be negatively affected by the blood in the stomach or
by the use of antibiotics, bismuth-containing compounds or acid
antisecretory drugs, especially PPIs.
 Negative urease test does not exclude Hp infection in an individual
taking antisecretory medication
 To improve sensitivity, stopping the potentially problematic
medication and delaying endoscopy for 2 weeks if possible
 H. pylori eradication should be documented 4 weeks after
completing antibiotics and atleast 7 days off antisecretory agents

46. Potential indication for gastroscopic biopsies
 Gastric erosions or ulcer
 Thick gastric folds
 Gastric polyp or mass
 For diagnosis of Hp infection

47. Sydney Protocol Biopsy
 5 biopsies
 1 from antrum 2-3 cm from pylorus lesser
curvature
 1 from antrum 2-3 cm from pylorus greater
curvature
 1 from the corpus 8 cm from the cardia less
curvature
 1 from the corpus 8 cm from the cardia greater
curvature
 1 biopsy from angular incisure, as atrophic
gastritis and intestinal metaplasia are related to
the development of gastric cancer and occur
most commonly at the incisure

48. Chronic atrophic gastritis
 Endoscopic findings
 Antral mucosal thinning
 Color and context change of the mucosa to red and
white( white colored mucosa with increased visibility of a
vascular pattern)
 Loss of rugal folds
 Atrophy caused by H. pylori infection tens to start from
antrum and extends to the body
 Tissue sampling
 7-12 biopsies: 4 quadrants biopsies from antrum(2-3 cm
proximal to pylorus), 2 from angularis, 4 from the mid corpus (
2 lesser curvature, 2 greater curvature), 2 from cardia

49. Gastric ulcer
 Repeat endoscopy to document healing at 8-
12 weeks should be performed for gastric
ulcer especially if present in body and fundus
 Multiple biopsies (>8) from the base and
edges if there is suspicion of malignancy

50. Forrest Classification
Sta
ge
Characteristi
cs
Re-
bleeding
Ia Active
bleeding
90%
Ib Oozing
hemorrhage
50%
IIa Nonbleeding
visible vessel
25-30%
IIb Adherent clot 10-20%
IIc Flat
pigmentation
7-10%
III Clean-based
ulcer
3-5%

51. Portal hypertensive gastropathy
Degree Portal hypertensive gastropathy
Mild Mosaic pattern without red spots
Moderate Typical mosaic pattern and infrequent red spots
Severe Numerous red spots

52. Gave syndrome
 Patchy, streaky, or reticular pattern of
erythema
 Mucosal hemorrhage
 Streaks radiating toward the antrum
( watermelon stripes)
 Fragile mucosa

53. Gastric Varices
 Convoluted vessels
protruding into the
lumen, sometimes with a
“ cluster of grapes”
appearance
 Encircling the cardia or
fundus, sometimes
found in the body and
antrum

54. Gastric Varices
 Most commonly used classification is Sarin’s
classification
 Gastric varices are categorized based on the
relationship with esophageal varices, as well
as by their location in the stomach

55. Duodenal ulcers
 more than 5 mm disruption of the
mucosal integrity of the duodenum
leading to a submucosal exposure
 Usually located at the duodenal
bulb
 Malignant duodenal ulcers are
extremely are
 Repeat endoscopy is warranted in
patients with duodenal ulcers if
symptoms persist despite medical
therapy or a complication is
suspected

56. Duodenal Biopsies
 Chronic diarrhea, iron deficiency anemia  suspicion of celiac
disease
 Tissue Sampling- 4-6 biopsies in the total from duodenal bulb
and distal duodenum

58. References
 Clinical Gastrointestinal Endoscopy, 2nd
edition
 Cotton and William’s Practical Gastrointestinal Endoscopy, 7th
edition
 Endoscopic mucosal tissue sampling, American society for
gastrointestinal endoscopy, 2013

59. Thank you