Upper Digestive Endoscopy: What is it? Medical Uses, Complications, Preparation, Procedure and Results

It is an endoscopic procedure in which a long, thin, flexible tube or “endoscope” is placed in the mouth and advanced into the duodenum (the beginning of the small intestine).

Esophagogastroduodenoscopy (EGD), also called by other names, is an endoscopic diagnostic and treatment procedure that views the upper part of the gastrointestinal tract to the duodenum for the prevention of many diseases of the digestive tract.

It is considered a minimally invasive procedure as it does not require an incision in one of the main body cavities and does not require significant recovery after the procedure (unless sedation or anesthesia has been used). However, a sore throat is common.

The endoscope has a light and a camera on the end that allows the doctor to examine the lining of the esophagus, stomach, and the first portion of the small intestine.

Alternative names for upper gastrointestinal endoscopy

Esophagogastroduodenoscopy (EGD or OGD) is also called panendoscopy (PES) and upper gastrointestinal endoscopy.

It is also often called upper endoscopy only, upper gastrointestinal or even endoscopy only; Because upper gastrointestinal endoscopy is the most commonly performed type of endoscopy, the ambiguous term endoscopy is sometimes used informally to refer to the default esophagogastroduodenoscopy.

The term gastroscopy literally focuses on the stomach alone, but in practice the use overlaps.

Medical uses

Diagnosis

Unexplained anemia (usually in conjunction with a colonoscopy ), upper gastrointestinal bleeding as evidenced by hematemesis or melena, and persistent dyspepsia in patients older than 45 years.

Heartburn and chronic acid reflux: This can lead to a precancerous lesion called Barrett’s esophagus and persistent vomiting.

Dysphagia (difficulty swallowing), odynophagia (pain when swallowing), persistent nausea, and inflammatory bowel diseases (IBD).

Surveillance

Barrett’s esophagus surveillance, gastric ulcer or duodenal ulcer surveillance, and occasionally after gastric surgery.

Confirmation of diagnosis / biopsy

Abnormal barium swallow or barium meal and confirmation of celiac disease (via biopsy).

Therapeutic

Treatment (banding / sclerotherapy) of esophageal varices, injection therapy (eg, epinephrine in hemorrhagic lesions), and cutting of larger pieces of tissue with a trap device (eg, polyps , endoscopic mucosal resection).

Application of cautery to tissues, removal of foreign bodies (eg, food) that have been ingested, plugging of bleeding, esophageal varices with a balloon, and application of photodynamic therapy for the treatment of esophageal malignancies.

Also endoscopic drainage of the pancreatic pseudocyst, squeezing the lower esophageal sphincter, dilation or stenting in stenosis or achalasia, and percutaneous endoscopic gastrostomy (feeding tube placement).

Endoscopic retrograde cholangiopancreatography (ERCP) combines upper gastrointestinal endoscopy with fluoroscopy, and endoscopic ultrasound (EUS) combines esophagogastroduodenoscopy with 5-12 MHz ultrasound.

Newer interventions

Endoscopic transgastric laparoscopy and gastric balloon placement in bariatric surgery.

Complications of upper gastrointestinal endoscopy

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

  • Aspiration, causing aspiration pneumonia .
  • Bleeding
  • Drilling.
  • Cardiopulmonary problems.

Limitations

Gastrointestinal function problems are generally not well diagnosed by endoscopy as movement or discharge from the gastrointestinal tract is not easily inspected by upper gastrointestinal endoscopy.

However, findings such as excess fluid or poor bowel movement during endoscopy may suggest impaired function.

Irritable bowel syndrome and functional dyspepsia are not diagnosed with esophagogastroduodenoscopy, but esophagogastroduodenoscopy may be helpful in excluding other diseases that mimic these common disorders.

Process

The endoscope tip should be lubricated and checked for critical functions including: tip angles, air and water suction, and image quality.

The patient is kept CVO (zero by mouth) or NPB (nothing by mouth), that is, he is instructed not to eat, at least 4 hours before the procedure. Most patients tolerate the procedure with only topical anesthesia of the oropharynx using aerosolized lidocaine.

However, some patients may need sedation and the very anxious / agitated patient may even need general anesthesia. Informed consent is obtained before the procedure. The main risks are bleeding and perforation. The risk increases when a biopsy or other intervention is performed.

The patient lies on his left side with the head resting comfortably on a pillow. A mouth guard is placed between the teeth to prevent the patient from chewing on the endoscope. The scope then passes over the tongue and into the oropharynx.

This is the most uncomfortable stage for the patient. Quick and gentle manipulation under view guides the scope into the esophagus. The endoscope is gradually advanced through the esophagus, taking note of any pathology.

Excessive inflation of the stomach is avoided at this stage. The endoscope passes quickly 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 to the stomach and a more thorough examination is performed including a J maneuver.

This involves retroflexing the tip of the endoscope to resemble a ‘J’ shape in order to examine the fundus and the gastroesophageal junction. Any additional procedures are done at this stage.

The air in the stomach is aspirated before the endoscope is removed. Still photographs can be taken during the procedure and then 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. Inspection alone is often sufficient, but biopsy is a valuable adjunct to endoscopy.

How to prepare for your upper gastrointestinal endoscopy test

There should be no food or fluids (this includes water) for at least 6 hours before the procedure. You may also have diet and / or medication restrictions the week before the exam. Please consult your physician for detailed instructions.

Plan to take the day off work for the test, and have someone you know drive you home. Since the procedure is usually done with IV sedation, you will be instructed not to drive a car or return to work until the next day.

Contact your doctor and inform them of any special needs, medical conditions, latex allergies, or current medications you are taking.

The gastrointestinal laboratory staff will attempt to contact you the night before the procedure to answer any questions you may have about the upper endoscopy procedure.

Team

Endoscope

Non-coaxial fiber optic system : to bring light to the tip of the endoscope.

A microprocessor camera at the tip of the endoscope – Coaxial optical fibers from previous scopes that were prone to damage and consequent loss of image quality have now been replaced.

Air / water channel : to clean the lens with the water and the air channel to dry the lens and inflate the esophagus and stomach during the operation to avoid collapsing the pathway and improve vision in the procedure.

Suction / Working Channels : These can be in the form of one or more channels.

Control Handle – This houses the controls.

Umbilical cords : which connect to the light source and video processor to supply the endoscope with suction and pressure of air and water for (suction and irrigation process) and light to transmit on the body to deliver the video signal to the processor to display the live image on the monitor.

Supply
  • Light source.
  • Suction.
  • Electrosurgical unit.
  • Video recorder / photo printer.
Instruments
  • Biopsy forceps.
  • Ties.
  • Injection needles.
Chemical agents
  • Dimethicone
  • Acetate.
  • Indigo carmine.

What to Expect Once You Get Your Upper GI Endoscopy Test

You are expected to arrive 30 minutes before the scheduled exam time. You may have an IV, as the upper endoscopy procedure is usually done with IV sedation.

You will be asked if there is a responsible person to drive you home after the exam. The procedure generally takes around 15-20 minutes. During the exam, there is often a feeling of pressure in the abdominal area.

Your doctor may give you medicine to help you relax and better tolerate the test, such as an intravenous (IV) catheter in your arm to administer sedation.

You will be connected to equipment that allows the doctor and staff to monitor your heart rate, blood pressure, pulse, EKG , breathing, and oxygen level during and after the exam.

Once in the exam room, you will be asked to lie on your left side on the table. Intravenous sedation will begin. Small amounts are given at a time to ensure that you don’t have any reaction to the medication and that you only provide the amount you need individually.

Once an adequate level of sedation is achieved, the scope will be gently inserted into the mouth. The scope will be carefully advanced through the esophagus, stomach, and first portion of the small intestine or duodenum.

A small amount of air is injected through the endoscope into the gastrointestinal (GI) tract to help the doctor see. Any fluid that remains in the upper gastrointestinal tract is suctioned out through the endoscope.

Depending on the findings of the exam, several things can be done during the procedure, the doctor can take biopsies (small samples of tissue) or remove polyps (growths on the lining of the stomach).

The numbing spray makes it difficult to swallow. This goes away shortly after the procedure. The team can make you want to throw up.

You can feel gas and the movement of the scope in your abdomen.

You will not be able to feel the biopsy, due to the sedation, you may not feel any discomfort and have no memory of the test.

You may feel bloated from the air that got into your body, this feeling soon goes away.

Depending on the findings, the exam takes approximately 10-20 minutes.

What to expect after the test

After completing the procedure, you will recover for approximately 30 to 45 minutes. You may experience a sore throat after the procedure.

Once you have met the discharge criteria, your doctor will discuss the preliminary findings with you. After the recovery period, patients can go home and usually eat right away.

Diet and / or medication restrictions may be given to certain patients depending on the examination findings. Patients receive discharge instructions to take home.

When will I get my results?

After the exam, the doctor and / or nurse will review the findings of the procedure with you. Most patients will not remember what they are told after the exam due to the effects of sedation.

It is recommended, if possible, to bring someone with you so that the results can also be discussed. The patient will also go home with a typed report.

The patient will be informed of the biopsy results usually within a week.

What are the risks of the exam?

In general, upper endoscopy is a very safe procedure. In general, complications occur in less than 1% of patients.

Most complications are not life threatening, however if a complication occurs it may require hospitalization and surgery. Before the exam, the nursing staff will review a consent form with the patient.

Should any questions or concerns arise, they can be discussed with your doctor before starting the procedure.

Medication reactions associated with sedation can occur. These may include, but are not limited to, allergic reactions, difficulty breathing, effects on the heart and blood pressure, and irritation of the vein used to administer the medicine.

Bleeding can occur with biopsies, removal of polyps, and with dilated strictures. Again, major bleeding that might require a blood transfusion or hospitalization is very rare.

The esophagus, stomach, or small intestine can be punctured. This may be recognized at the time of the exam, or it may not be apparent until later in the day. In most cases, a piercing will require surgery and hospitalization.

This remains a rare complication, even when biopsies are taken or a dilation is performed.

It is very important that the patient contact the doctor’s office immediately if symptoms appear after the procedure, such as worsening abdominal pain, bleeding, or fever.

Like any other test, an upper endoscopy is not perfect. There is a small accepted risk that abnormalities, including cancer, may be missed at the time of the exam.

It is important to continue to follow up with your doctors as instructed and to inform them of any new or persistent symptoms.

What are the alternatives to an upper endoscopy?

To some extent, the alternatives to the test will depend on why you need to undergo upper endoscopy in the first place.

In most cases, upper gastrointestinal endoscopy is the best method for evaluating and treating abnormalities in the upper gastrointestinal tract. However, an X-ray called an upper GI / barium swallow can also evaluate the upper GI tract.

However, this is only a diagnostic test. Treatment of abnormalities will require an upper gastrointestinal endoscopy or surgery

Upper gastrointestinal endoscopy in children

Since its inception in the 1960s, the field of pediatric gastroenterology has seen rapid growth.

Pediatric gastroenterology is now an American Board of Pediatrics certified subspecialty that grew out of previous training of pediatricians in adult gastroenterology units and increased recognition of gastrointestinal disorders that are unique to children.

In the last 30 years, the number of pediatric gastroenterologists has increased dramatically.

While there used to be only a few specialists based in select centers around the world, pediatric gastroenterology is now an ever-growing specialty with approximately one pediatric gastroenterologist for every 100,000 children in the United States.

With the development of a subspecialty focused on pediatric gastrointestinal tract disorders, new technologies were also developed to aid in diagnoses such as pediatric upper gastrointestinal endoscopy.

Pediatric upper gastrointestinal endoscopy was first introduced in the 1970s.

Over the past 30 years, pediatric upper gastrointestinal endoscopy has evolved from an infrequent procedure performed in the operating room with a monocular visualization of the intestinal lining to a routine outpatient procedure using intravenous sedation and large viewing screens.

With the increased use of pediatric upper gastrointestinal endoscopy procedures, the incidence of diseases requiring esophagogastroduodenoscopy for diagnosis in children has also increased.

Franciosi et al . showed that the characteristics of the children undergoing upper gastrointestinal endoscopy, as well as the endoscopy practices, changed in the 20-year period from 1985 to 2005.

During this time, there was a 12-fold increase in the number of esophagogastroduodenoscopies performed for the first time. This may also have led to an increase in disease incidence rates.

However, an increase in disease rates may reflect increasing rates of disease diagnosis rather than a true increase in disease incidence.

The inclusion of children with less severe clinical presentations and the collection of a greater number of biopsies per procedure could have played a role in increasing the rates of diagnosis of the disease.

During this 20-year interval, the number of patients referred for upper gastrointestinal endoscopy due to gastrointestinal bleeding decreased from 34% to 5%, while the number of patients with abdominal pain increased from 23% to 43%.

In addition, the rate of complete upper gastrointestinal endoscopy (in which biopsies of the esophagus, stomach, and duodenum were taken) increased from 18% in 1985 to 95% in 2005.

Studies report positive results in more than 50% of endoscopies performed in children. Complication rates associated with these procedures are 1.3% for esophagogastroduodenoscopy and less than 1% for colonoscopy.

However, these procedures are invasive as they require IV sedation or general anesthesia.

Concerns about neurobehavioral disorders and abnormalities in brain function caused by environmental chemical exposure during early brain development have recently extended to anesthetics and sedatives, which are administered to millions of young children around the world.

They are also associated with significant anxiety for both the patient and the patient’s family.

Given the invasiveness and anxiety associated with upper gastrointestinal endoscopy, predictors that could accurately identify children with diseases that would otherwise only be diagnosable by esophagogastroduodenoscopy would be helpful; however, there is little existing knowledge of such predictors.

The ability to perform diagnostic upper gastrointestinal endoscopy in adults and children has been one of the defining characteristics of the current era of gastroenterology.

Without a doubt, it has broadened our understanding of the pathophysiology of common gastrointestinal disorders in children and has been a tremendous tool in treating patients.

As the availability and usefulness of upper gastrointestinal endoscopy in the pediatric population has increased in the last three decades, the volume of procedures performed has paralleled this increase.

Consequently, decisions regarding the appropriate indications and timing for upper gastrointestinal endoscopy in children have evolved over time and arguably remain more of an art than a science.

A more critical review of the use of this tool is needed to maximize effectiveness and minimize risk.