6. INDICATIONS OF UPPER GI ENDOSCOPY AND PATIENT PREPARATIONS.pptx

INDICATIONS OF UPPER GI
ENDOSCOPYAND PATIENT
PREPARATIONS
Prepared by :Dr.Sirili
Facilitator:Dr. Ringo
1 June 2023 Upper GI Endoscopy@Dr Sirili 1

INTRODUCTION
• Gastrointestinal (GI) endoscopy allows direct
visualization of the interior of the GI tract
• Frequently performed to:
–Investigate symptoms
–Confirm diagnosis
–Offer treatment.

Introduction cont…
• In the past, the realm of GI tract for
endoscopists has chiefly been limited to the
upper and lower GI tract, and the small bowel
has largely been considered a “no man’s land”
until the advent of enteroscopy.
• The introduction of (ERCP) has provided an
invaluable tool to evaluate and manage diverse
problems of the biliary and pancreatic ductal
systems.

Background
• 1958 Development of fibreoptic gastroscope
• 1968 Endoscopic retrograde pancreatography
• 1969 Colonoscopic polypectomy
• 1970 Endoscopic retrograde cholangiography
• 1974 Endoscopic sphincterotomy (with bile duct stone extraction)
• 1979 Percutaneous endoscopic gastrostomy
• 1980 Endoscopic injection sclerotherapy
• 1980 Endoscopic ultrasonography
• 1983 Electronic (charge coupled device) endoscope
• 1985 Endoscopic control of upper gastrointestinal bleeding
• 1990 Endoscopic variceal ligation
• 1996 Introduction of self-expanding metal stents
• 2008 Endomicroscopy delivers histological mucosal definition

ENDOSCOPY
Endoscopy is a nonsurgical procedure used to examine a
Gastrointestinal tract using an endoscope, a flexible tube
with a light and camera attached to it

UPPER GI ENDOSCOPY

PARTS OF ENDOSCOPE

ENDOSCOPY PRINCIPLE
• Endoscopy minimally invasive
diagnostic medical procedure
• used to evaluate interior surface
of an organ.
• Endoscope may have rigid or
flexible tube inserted into body.
• It has ability to looking inside
the body using a variety of very
small cameras attached to
flexible or rigid tube.
• It facilitates direct viewing the
interior of an organ is often very
helpful in determining the cause
of a problem.

Endoscopy principle cont..
• An endoscope is a flexible
tube equipped with lenses
and a light source.
• Illumination is done by the
help of a number of optical
fibers.
• Video endoscopy performed
by attaching in microchip
camera at the insertion tube,
setup image is viewed on a
video monitor.

ENDOSCOPE ASSEMBLY

HOLDING

Risk Factors and High Risk Patient
I. Advanced age
II. NYHA class III-IV heat failure
III. Severe aortic stenosis
IV. Severe pulmonary disease
V. Bleeding tendency, platelet count < 50,000 and
markedly prolonged
VI.Prothrombin time
VII.Anaemia (hemoglobin < 8g/dl)
VIII.Emergency Procedures

PREPARATIONS
• There are many factors that need to be taken
into account in order to perform safe
endoscopy.
• Each endoscopic procedure has its own
necessary preparation and precautions, many
are common to all and can be divided into
three procedural steps:
– Pre-procedure
– Intra-procedure
– Post-procedure.

Preparations cont..
• The components of pre-procedural preparation
includes:
– Identification of patient, procedure type, and indication
– Informed consent
– History taking and physical examination
– Risk stratification and sedation planning
– Antibiotic prophylaxis
– Antithrombotics: anticoagulants and antiplatelet agents
– Patient monitoring devices
– Preparation for emergency situations
– Time-out

Risk stratification and sedation
• The most commonly adopted risk stratification
system is the ASA physical status
classification.
• There are several limitations to this
stratification system.
–It does not provide specific examples for
each class or present additional information
to further define these categories

Risk stratification cont…
• When sedation/analgesia is intended level of
sedation to be planned includes:
–minimal sedation (anxiolysis)
–moderate sedation/analgesia (conscious
sedation)
–deep sedation/analgesia and general
anesthesia.

Risk stratification cont…
• Moderate sedation/analgesia is sufficient for
most endoscopic procedures
• deeper sedation/analgesia could be necessary
for procedures that take longer:
–ERCP
–EUS±FNAC
–Endoscopic mucosal resection (EMR)
–Endoscopic sub-mucosal dissection (ESD).

Antibiotics in endoscopy
• Antibiotic prophylaxis is necessary in high-
risk patients and for high-risk procedures :
• High-risk patients needing antibiotic
prophylaxis
–Cirrhosis and acute GI bleeding
–Pancreatic fluid collection communicating
with pancreatic duct (only for ERCP and
transmural drainage

Antibiotic and endoscopy cont…
• High-risk procedures needing antibiotic
prophylaxis
– Transmural drainage for sterile pancreatic fluid col-
lection
– EUS-FNA for cystic lesions along GI tract
– ERCP to relieve obstructed bile duct in patients with-
out cholangitis
– Percutaneous endoscopic gastrostomy (PEG)
– Natural orifice transluminal endoscopic surgery (NO-
TES)

Preparation for emergency
situations
• All equipment and medications necessary to
perform emergency resuscitation should be
available at any time during endoscopic
procedure.
• Adequate accessories and devices (injector,
coagulator, hemoclips, etc.)
• Should be prepared to manage procedure related
complication such as bleeding and perforation.

Time-out
• Before inserting the endoscope or
administering sedatives, the endoscopy team
should gather together and perform “time-out”
or “team pause” to verify that correct indicated
procedure is to be performed on the right
patient with appropriate apparatus

Time- out cont…
• Patient should be confirmed by using at least two
of the identifiable parameters.
• When time-out has been carried out, the patient is
now ready to undergo endoscopic procedure.
• If the endoscopist, endoscopy nurses, and
assistants have washed their hands before the
procedure and put on their protective gown and
gloves, the endoscopy team is also ready to begin
the exam.

Patient monitoring devices
• If a patient is to undergo endoscopic procedures with
moderate or deep sedation, patient status should be
monitored
• The standard parameters of patient status that need to
be periodically checked before, during, and after the
procedure include:
– Blood pressure
– Oxygen saturation, pulse rate (heart rate)
– Level of consciousness.
• Oxygen supplementation is recommended for both
moderate and deep sedation to reduce the degree of
oxygen desaturation.

Patients monitoring cont…
• ECG monitoring important when the
procedure time is expected to be prolonged
–For patient with significant cardiopulmonary
disease, arrhythmia, and advanced age.
• Level of consciousness should be monitored
directly by evaluating the patient

Recovery and discharge
• After the completion of endoscopy, patients
receiving intravenous sedation require observation
and monitoring.
• Standardized discharge criteria should be used to
assess recovering from sedation.
• Several recovery scales have been developed.
• Eg Aldrete scoring system, which evaluates 5
physiological parameters:
– Respiration and oxygen saturation
– blood pressure
– Consciousness and activity.

Aldrete scoring system

Indications For Upper GI
Endoscopy
I:DIAGNOSTIC
• Superior to Radiology
–Except for motility disorders
• Take Biopsies
• Explain cause of pain
–Reflux Oesophagitis
–Ulcer disease
–Oesophagus to jejunum
• Malignancy

Indications cont…
II:THERAPEAUTICS
• Upper GI endoscopy:
–Variceal bleed
–Nonvariceal bleed
• Therapeutic endoscopy in non-variceal
bleeding
–Stabilization first and then endoscopy.
–UGIE sensitive in 80-95% of cases
–Spontaneously stop in 70-85% (without
coagulopathy) without further intervention

Therapeautics cont..
• Variceal bleeding
• Endoscpic options
–Vasopressin
infusion
–Sengstaken
Blackmore tube
(12-24 hours
before sclerothery
–Sclerotherapy
–EVBL
Grade 3 esophageal
varices

VARICEAL BLEEDING
• Endoscopic
treatment options:
–Injection therapy
–Thermal therapy
–Endoscopic
clipping
–Endoscopic band
ligation
• Injection therapy:
• Sclerosants:
– Epinephrine (alone or
with saline)
– Absolute alcohol
– Thrombin in NS
– Sodium tetradecyl
sulfate
– Polidocanal

ENDOSCOPIC MANAGEMENT
OF PUD
• Endoscopy is essential for the diagnosis of the
cause of bleeding and endoscopic treatment
can reduce:
– Re-bleeding
– Surgery
– Mortality
• Early endoscopy within 24 hour is safe and can
reduce transfusion requirements and LOS

Bleeding PUD
Pre-endoscopic period:
• A clear endoscopic field is essential for the
success of endoscopic hemostasis.
• Prokinetic drugs such as erythromycin and
metoclopramide given before endoscopy to
improve visualization.
• Prokinetic drugs reduced the need for a second
endoscopic examination
• NGT decompression
• Pt stabilisation-fluids,blood transfusion

Endoscopic Treatment options
–Mechanical eg
clips
–Thermal-
contact/non
contact
–Injection therapies
consists :
• Epinephrine-widely used
for hemostasis
• Sclerosants (absolute
ethanol, polidocanol)
• Tissue adhesives
(thrombin/fibrin glues).

Esophageal Stricture dilatation
• Barium swallow is done before endoscopy
–structure and length and stricture
• Endoscopy
–to identify lesion and biopsy
• Benign peptic ulcer stricture

Esophageal stricture dilatation cont..
• 90% of peptic and
radiation strictures-
amenable to
dilatation
–Goal- dilate up to
14-15mm (45F)
–Dilatation done in
multiple sessions

STENTING
Self expanding
metalic stent(SEMS)
• Permanent
• Passed through working
channel of colonoscope
• over delivery cathether
• Over fluroscopically
placed guidewire

Stenting cont…
Silicone stent:
• Removable
• Used for benign
strictures

Endoluminal treatment of GERD
• Available options
i. Endoclinch:
–Sutures placed intra-mucosaly only at GE
junction (circumferentially)
–Overtube placement with 2 gastroscopes
• 1st gastroscope -suction
• 2nd gastroscope –knot tying

Endoluminal treatment of GERD
ii .Plicator:
–a suture based technique to create a full
thickness flap at GE junction.
– Serves as a barrier against reflux
iii. Stretta:
–Blindly performed after localisation of LES
–endoscopically
• Delivery of radiofrequency ablation into LES
and inducing collagen deposition to LES
• Thus adding more bulk and reducing
compliance of LES.

Role Of UGI Endoscopy In Baretts
Esophagus
• Endoscopic
– Ablation
– resection
• To remove the neoplastic
mucosa to prevent cancer and
cure mucosal cancer
• Surveillance every 3 months
with 4-quadrant biopsies every 1
cm.

Endoscopic Mucosal
Resection(EMR)
• EMR is an endoscopic technique developed for
removal of sessile or flat neoplasm confined to
the superficial layers (mucosa and submucosa)
of the GI tract.
• EMR can be used for treatment for Squamous
cell carcinoma esophagus
• When used for Barrett’s esophagus 30%
develop recurrence within 2 years.
• EMR is widely used for resection of flat
benign colon lesions.

EMR-Duodenal duplication cyst

Endoscopic Submucosal
Dissection(ESD)
• ESD has been developed for en bloc removal
of large (usually more than 2 cm), flat GI tract
lesions.
• Use less established for colonic lesions
• Use justified in stomach and esophageal
cancers when restricted to mucosa. (around 3%
lymph node positivity)

ESD

Endoscopic Biliary Stents
Metallic stents
• Self expanding
• Long lived
• Less prone to sludge
• Danger of becoming
irremovable
Plastic stents
• Straight flaps at each
end for easy insertion
• Short lived ,require
change every 3-6
months
• Removal easy

Indications Of Biliary Stenting:
• Malignant strictures
of CBD –favorable
for lesion below
bifurcation
• Benign strictures
• Sclerosing
cholangitis
• Choledochocoele

Pancreatic Endoscopic Therapy
• The goal of endoscopic therapy
is decompression of the main pancreatic duct
• There is a 75% success rate for endoscopic
therapy.
• The advantage of endoscopic therapy is that it
is a relatively noninvasive procedure.
• Effective in short-term pain relief.

Indications For Pancreatic Therapy
–Endoscopic sphinc
terotomy
–Stent placement
–Stricture dilation
–Stone extraction

Indications for pancreatic stenting
• By pass ductal leaks and strictures
• Pancreatic divisum-for minor papilla stenting
• Pancreatic fistula
• Pancreatic pseudocyst – when cyst in
connection with main pancreatic duct

Pancreatic stenting

References
• Joon Sung Kim, Sung Min Park ; Endoscopic
Management of Peptic Ulcer Bleeding;Clin
Endosc 2015;48:106-111
• Guideline;The role of endoscopy in the
management of variceal hemorrhage; Vol 80,
No. 2 : 2014 Gastrointestinal Endoscopy
• Basic Skills in Gastrointestinal
Endoscopy(Training Mnnual);2007
• The SAGES Manual:Perioperative Care in
Minimally Invasive Surgery ;2006
• Slide share

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