Esophagogastroduodenoscopy (EGD) is an endoscopic diagnostic and therapeutic procedure that provides clinicians with excellent views of the mucosal surfaces of the upper gastrointestinal tract. EGD is advocated for the evaluation of a variety of abdominal and chest complaints, and it can be safely performed in an office setting. The technique is diagnostically superior to diagnostic gastrointestinal radiographic procedures and affords added benefits of diagnostic biopsies or testing for Helicobacter pylori infection.
Many benefits have been suggested for the performance of EGD in primary care practices. Performance of EGD in an office setting can provide rapid assessment of patients' complaints, avoid lengthy referral delays, improve access to the procedure, increase patients' comfort by performance of the procedure in a familiar setting, reduce costs compared with referral to specialized settings, and improve the physician's understanding of the involved pathology. All of these benefits may translate into improved health care quality for the patient.
Most procedures historically have been performed using conscious sedation. The intravenous benzodiazepines diazepam or midazolam can be combined with the intravenous narcotic meperidine to provide good patient relaxation for the procedure. Midazolam provides a degree of amnesia, a desirable effect if initial intubation is difficult. Guidelines for monitoring the patient receiving conscious sedation for gastrointestinal endoscopy are included in Appendix F. Topical anesthesia of the oral cavity can be achieved with a viscous 2% lidocaine solution and with 20% benzocaine (Hurricaine) spray. Use of thin (7.9 or 9.0 mm outer diameter) pediatric endoscopes can improve safety, because the thin endoscopes reduce oxygen desaturation during the procedure. Ultrathin scopes have been developed that can be inserted intranasally for evaluation of the esophagus, but these scopes appear to have limitations for viewing the distal stomach and duodenum.
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
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sedation are monitored similar 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.
Because of the cost and invasive nature of EGD, many experts recommend that the procedure be performed for the evaluation of acid-peptic disorders only after a trial of medication therapy. Patients with signs of serious organic disease (e.g., weight loss, anorexia) or with severe upper abdominal distress should be evaluated promptly. Gastrointestinal bleeding should be evaluated in the controlled environment of a hospital gastrointestinal laboratory. Some practitioners prefer to perform studies on patients with acquired immunodeficiency syndrome (AIDS) or hepatitis in hospital settings to use automated cleaning systems for the endoscopes. Recommendations for endoscope disinfection are included in Appendix E. 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 produces 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. It is advocated that two biopsies be obtained for H. pylori, one from the antral lesser curvature (at or near the incisura) and the other from the antral greater curvature. These two biopsies yield nearly 100% sensitivity for the infection.
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 recording of procedures can help with documentation and learning. Although referral may be required for unusual or uncertain pathology, EGD is appropriately performed in primary care practices because of the large percentage of normal study results for patients with appropriate indications for the procedure.
INDICATIONS
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RELATIVE CONTRAINDICATIONS
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PROCEDURE
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 depresses the tongue, exposing the pharynx for two 2- to 5-second sprays. Avoid touching the patient's tissues (contaminating) the extension spray tubing from the multiuse spray bottle.
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(1) Benzocaine spray is applied to the posterior pharyngeal wall to blunt the gag reflex. |
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.
The patient is positioned in the left lateral position, with the patient's left side down on the table. A pillow is placed beneath the patient's head, and the head tilted forward. Disposable absorbant 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.
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(2) The patient is positioned in the left lateral position, with the patient's left side down on the table and with a pillow beneath the patient's head, which is tilted forward. |
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If nonintravenous anesthesia is administered, the patient can receive one or two sprays of butorphanol. Use the nondominant hand to open the nares, and administer the spray with the tip of the applicator bottle kept outside of the nose. Do not touch (contaminate) the multiuse applicator tip to the patient. If intravenous anesthesia is used, the medications can be administered (25 to 75 mg of meperidine and 2 to 8 mg of midazolam) after obtaining intravenous access.
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(3) Open the patient's nares, and administer one or two sprays of butorphanol without touching the tip of the applicator bottle to the patient. |
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The endoscope is shown (Figure 4A), and the components of the endoscope head (Figure 4B) and the endoscope tip (Figure 4C) are depicted.
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(4) The endoscope. |
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The mouthpiece is placed, and the patient is asked to gently but firmly place the teeth around the mouthpiece. The patient's neck is flexed (chin to the chest), and the lubricated distal endoscope is inserted through the mouthpiece. The endoscope is slid over the posterior tongue and angled downward to view the larynx. The scope is inserted slowly and kept off the side walls of the hypopharynx to limit gagging. The scope tip is inserted to the posterior larynx, away from the vocal cords, just proximal to the closed cricopharyngeus muscle (scope inserted about 18 cm from the incisors) (Figure 5A). Ask the patient to swallow, which opens the muscle and allows access to the esophagus (Figure 5B). 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 (Figure 5C).
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(5) After the scope tip is inserted to the posterior larynx, the patient is asked to swallow, which opens the muscle and allows access to the esophagus. |
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. Verbal anesthesia assists the patient at this time; talk 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 produces distress from the inability to breath and possibly from laryngospasm. The scope should be completely withdrawn if tracheal intubation occurs (i.e., tracheal rings are visualized) or is suspected.
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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 (about 40 cm from the incisors).
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(6) Examine the distal esophagus and gastroesophageal junction. |
Passage into the stomach reveals the characteristic gastric folds (Figure 7A). Turn the scope tip to encounter the gastric lake (i.e., gastric secretion pool). Suction the pool immediately to facilitate complete examination of the stomach and to make the examination safer (i.e., empty the stomach to prevent possible aspiration if vomiting develops) (Figure 7B).
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(7) Suction the gastric secretion pool immediately to completely examine the stomach and to prevent possible aspiration if vomiting develops. |
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Pass the endoscope to the pylorus. Angulation of the scope tip may be required, and the contractions of the stomach can be followed to reveal the pylorus. Position the scope tip just proximal to the pylorus, insufflate air, and insert the scope as the pylorus opens with a contraction.
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(8) Pass the endoscope to the pylorus. |
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.
Examine the entire duodenal bulb. This requires moving the scope tip up (anterior wall), down (posterior wall), left (inferior wall), and right (superior wall).
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(9) Examine the entire duodenal bulb. |
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Intubate the second portion of the duodenum. In 30% of individuals, this is accomplished with straight insertion of the scope. In 70% of individuals, there is a sharp downward turn to the right. The instrument tip is positioned just distal to the proximal duodenal fold and then turned sharply to the right as it is inserted.
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(10) Intubate the second portion of the duodenum. |
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After thorough examination of the duodenum, the scope is brought back into the stomach. Two biopsies are obtained in the antrum for H. pylori testing (CLOtest). Because of the risk of malignancy, multiple biopsies are performed on all gastric ulcers, in contrast to duodenal ulcers that do not require biopsy. Biopsy also is performed on abnormal growths, polyps, or other pathologic changes.
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(11) After thorough examination of the duodenum, the scope is brought back into the stomach, where two biopsies are obtained in the antrum for H. pylori testing. |
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.
The endoscope is retroflexed within the stomach to examine the fundus and cardia. Examination of the gastroesophageal junction is important to look for possible gastric malignancy at this site. To view the GE junction, maximally deflect the tip of the scope with the inner knob while inserting the endoscope.
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(12) Examine the fundus and cardia. |
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The air in the stomach is suctioned out, and the scope withdrawn into the esophagus. Examination of the distal esophagus is performed again. Hiatal hernias may be identified by asking the patient to sniff, contracting the diaphragm, and noting the distance between the diaphragmatic indention and the gastroesophageal junction (i.e., Z-line).
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(13) Examine the distal esophagus again, checking for hiatal hernias. |
Withdraw the scope, examining the esophagus and larynx on removal. 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.
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(14) Examine the esophagus and larynx on removal of scope, and wipe off any secretions that have drained from the mouth after removal of the mouthpiece. |
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CODING INFORMATION
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.
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INSTRUMENT AND MATERIALS ORDERING
Complete endoscopy equipment such as endoscopes, light sources, video endoscopy monitors, cleaning and disinfection aids, and mouthpieces are available from Olympus Corporation, Melville, NY (http://www.olympusamerica.com) and from Pentax Precision Instrument Corporation, Orangeburg, NY (http://www.pentaxmedical.com). A viscous 2% lidocaine topical solution is available from Alpharma USPD, Owings Mills, MD (http://www.alpharma.com). Benzocaine 20% spray (Hurricaine topical anesthetic) is available in several flavors from Beutlich Pharmaceuticals, Waukegan, IL (http://www.beutlich.com). CLOtest kits can be obtained from Tri-Med Specialties, Lenexa, KS (http://www.trimed.com). Butorphanol tartrate (Stadol) nasal spray is available from Bristol-Myers Squibb (http://www.bms.com). Intravenous materials (e.g., Intracaths, normal saline solution, intravenous tubing) can be obtained from local hospitals or surgical supply houses.
Redcommendations for endoscope cleaning appear in Appendix E. Guidelines for monitoring patients receiving conscious sedation appear inAppendix F.
Training is available in residency or fellowship programs or by attending one or more postgraduate continuing education courses. Self-study can also enhance skills, using atlases, videotapes, or computer-assisted programs. Preceptor-guided training is highly recommended under the supervision of experienced physicians. Discrimination between pathologic conditions and normal anatomy is an important skill to acquire. Complete information on training methodology is available from the American Academy of Family Physicians (http://www.aafp.org/practicemgt.xml).
Computer-based training is an emerging technology. New units such as the GI Mentor II from Simbionix (http://www.simbionix.com/GI_Mentor.html) can provide experience in repetitive endoscope manipulation, feedback on technique, and various clinical scenarios and pathology exposure for the trainees.
Recommended atlases: Keeffe EB, Jeffrey RB, Lee RG. Atlas of gastrointestinal endoscopy. Philadelphia: Appleton & Lange, 1998.
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Martin DM, Lyons RC. The atlas of gastrointestinal endoscopy. Available at http://www.mindspring.com/:dmmmd/atlas_1.html
Murra-Saca J. El Salvador atlas of gastrointestinal videoendoscopy. Available at 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, 1986.
Silverstein FE, Tytgat Guido NJ. Atlas of gastrointestinal endoscopy. St. Louis: Mosby, 1996.
Tadataka Y. Atlas of gastroenterology. Philadelphia: Lippincott-Raven, 1999.
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