A SEMIN AR ON

PRINCIP LES AND

PRA CTI CE OF GI
ENDOSCOPY

Guide; Dr. M.Singh (M.S.)

Associate professor
Dept of Surgery

Presented by

Dr.K.Ravi
History o f Endoscopy

 Kussmaul in 1869 introduced silver tube successfully

into the stomach of the sword-swallower and became
the first person in medical history to visualize the
stomach.
 In 1957 first prototype fiber optic endoscope was
introduced
 In 1968 ERCP was introduced
 In 1974 Endoscopic sphincterotomy
 In 1979 PEG
 In 1980 Endoscopic injection sclerotherapy
 In 1980 Endoscopic ultrasonography
 In 1983 Electronic (charge coupled device) endoscope
EN DOSC OPY
Two types
a. Rigid endoscope
b. Flexible endoscope

 Now a days rigid type is virtually obsolete

though some surgeons still use this traditional
instrument
 It needs skill to introduce though there is
significant risk of perforation
 Probably better for examination of the lower
pharynx and cricopharyngeal area
1 Function buttons, e.g., video recorder remote control
2 Freeze button
3 Suction button
4 Air/water button
5 Instrument channel
6 Locking device
7 Angling wheel (right/left)
8 Angling wheel (up/down)
Vide o proc ess or (a bo ve) a nd l igh t so urce ( be lo w)
Ti p of
Endoscope
Handl ing the Endoscope

 The control head of the endoscope is held in

the left hand.
 The index and middle fingers activate the
suction and air/water valves.
 Many examiners operate the angulation
control wheels with the right hand, but an
endoscopist with large hands can also
manage these controls with the left hand.
 This leaves the right hand free to manipulate
the insertion tube, which is advantageous in
some situations.
PRINC IPLES OF ENDOSCOPY

 In all flexible endoscopic system light is

transmitted down the endoscope shaft to
illuminate the surface to be examined.
 The reflected image is conveyed back to
the endoscopist via one of two different
modalities
A. Fiber optics
B. Electronics
Fi ber o pti c Endoscopy

 In the fiber optics, a fixed lens at the end

of the instrument shaft focuses the image
on internal fiber optic bundle.

 The fiber optic bundle is 2-3mm wide &is

composed of 20,000-40,000 individual fine
glass fibers, each approximately 10mm in
diameter.

 The image undergoes a series of internal

reflection with in each fiber as it is
transmitted up the bundle.
El ectro ni c Endoscopy

 Most endoscopes currently produced are

electronic.
 In these system the image is reflected onto a
charge coupled device [CCD] chip mounted on the
end of instrument shaft.
 These chips contain thousands of light sensitive
points [ “Pixels”].
 The greater the number of pixels, the better the
resolution.
 Current chips contain 100,000 to 300,000 pixels.
 The image is then transmitted through wires
instead of light bundles to additional electronics
in the instrument head.
Advantages of vi deo
endoscope

 The endoscopist can stand erect and watch the

television monitor without any interruption
 The intraluminal view and the lesions present within
can be seen with more clarity by more than one
person in the endoscopy room
 Therapeutic procedures are easier with a video
endoscope
 The video endoscopes are water tight instruments and
can be immersed in cleaning solutions
 Endoscopic pictures can be made readily available
with the help of printer
 In video endoscope the images of tumors, ulcers &
polyps can be faithfully transferred to the television
monitor in their natural colors.
Gastrointestinal Endoscopy

Types of Gastrointestinal
Endoscopy

 Esophagogastroduodenoscopy (Upper GI
Endoscopy)
 Small Bowel Enteroscopy (Jejunoscopy)
 Colonoscopy (Lower GI Endoscopy)
 Sigmoidoscopy
 Endoscopic Retrograde
Cholangiopancreatogram (ERCP)
 Upper Gastrointestinal
Endoscopy

Diagnostic Indications Therapeutic Indications

 Heartburn  Control of bleeding
 Dysphagia or  Dilation of stricture
odynophagia
 Removal of foreign
 Hematemesis or melena bodies
 Dyspepsia or upper  Removal of polyps
abdominal pain
 Unexplained weight loss
 Tumor ablation
or anemia
 Evaluation of abnormal
Barium meal X-ray
 Suspected
Upper Gastrointestinal
Endoscopy

Contraindications to Upper GI Endoscopy

 Uncooperative patient
 Hemodynamically unstable patient
 Suspected perforation
 cervical spine disorders
 Soon after a myocardial infarction
Upper Gastrointestinal
Endoscopy
Cl eani ng a nd Di si nf ect ion
 Meticulous cleaning of the endoscope with clean
and filtered water immediately after use, is
necessary to keep the instrument clean of organic
debris like blood, dried gastric juice and food
particles. It is scrubbed with a sponge or soft
brush.
 After a thorough cleaning, the next step is to
disinfect the scope against cross infection.
 The commonly used disinfectants are
a. 2% Glutarldehyde (CIDEX)
b. Iodophor (Betadine-providone Iodine)
c. 70% ethyl or isopropyl alcohol
d. Ethylene oxide (ETO)
e. Formaldehyde vapour
Pati ent preparatio n

 Fasted for at least 4 – 6 hrs more time for

GOO.
 Before the study dentures & eye glasses should be
removed.
 If intervention is anticipated, a recent coagulation
profile &platelet count should be within safe ranges.
 Prophylactic antibiotics indicated in
a. Sclerotherapy.
b. Previous endocarditis.
c. Recent vascular prosthesis.
d. For PEG tube placements.
e. Patients with prosthetic heart valves.
Meth od
Two squirts of lidocaine sprayed into
the pharynx or lidocaine viscus can be
used.
Check List
 24 hours before the
examination
 Confirm indication
 Check contraindications
 Necessary lab tests ordered? (blood count,
coagulation)
 Antibiotic prophylaxis?
 Informed consent obtained?
 Patient instructed about fasting?
 Cardiac pacemaker?
 Risk factors? (heart, lung, coagulation,
general health)
Immediately before the
examination
 Patient welcomed to the unit, greeted by
name
 Signed consent form?
 Dentures removed?
 Defoaming agent administered?
 Coagulation tested?
 If necessary: peripheral venous access?
(especially with sedation and for
interventions)
 Equipment check? (air, suction)
 Endoscope tip lubricated
 Pharyngeal anesthesia (if desired)
 Contact with patient: “Here we go.”
 During the examination
 Talk to the patient, explain what is
happening.
 Keep the patient in a left lateral
position.
 Observe the patient (sweating,
restlessness, facial expression,
gestures, pain manifestations,
breathing, skin color).
 If in doubt: pulse oximetry,
echocardiogram (ECG) monitoring.
Inserting the Endoscope
 Blind Insertion
 Direct-Vision Insertion
 In the blind insertion method, the endoscope
is first passed over the base of the tongue
toward the hypopharynx under external
visual control.
 With proper technique, the instrument tip
can be advanced just to the introitus of the
upper esophageal sphincter, at which time
the patient is instructed to swallow.
 Endoscope insertion is contraindicated while
the patient is coughing or taking a deep
breath, as this will inevitably lead to tracheal
intubation
Dia gnostic technique

inspection is often easier during withdrawal,

when the viscera are well distended with air.

-the endoscope is advanced to the esophago-

gastric junction. Noting the ‘Z’ LINE, where the
white sqammous esophageal mucosa meets red
columnar gastric epithelium.

Importance of ‘Z’ Line in

a. ph probe placement.
b. Endoscopic Anti-reflux procedures.
c. determine if a GE Junction lesion is gastric or

esophageal in origin.
-entry into the duodenal bulb is recognized by the
typical granular, pale mucosa.

-finally, the second portion of the duodenal is

entered by advancing to the superior duodenal
angle.

-when scope in the antrum either prior to entering

or after with drawing from the duodenal bulb tip
can be rotated through 180 degree in either
direction to visualize fundus &cardia.
Upper Gastrointestinal
Endoscopy
Normal Esophagus Normal Stomach Normal Duodenum

Esophagitis Gastric Ulcer Duodenal Ulcer

Gastric ulcer

Gastric ulcer Bleeding gastric ulcers

 Esophageal Varices

Esophageal Varices Bleeding esophageal varices

 Angiodysplasia of the stomach
Gastric varices
Mallory Weiss Tear Esophagitis
Di agnosti c procedures
 GI- Endoscopy
 Can remove
polyps, coagulate
active bleeding
sites,
sclerotherapy of
esophageal
varices, dilate
strictures & obtain
biopsy samples
 Often guided by
ultrasound
Therapeutic Endoscopy

Endoscopic treatment
 
 Upper Endoscopy is the procedure of choice
in majority of patients with an acute upper
gastrointestinal bleeding, for the following
reasons:

– It can define the source of bleeding in the majority

of patients with an upper gastrointestinal bleeding.
– It can stratify the patients risk of rebleeding.
– It can provide endoscopic therapy for esophageal
and gastric varices, peptic ulcer disease,
Dieulafoy's lesion, vascular malformations and
tumors.
Therapeutic opti ons

 For Non variceal bleeding

1. Injection therapy
2. Thermal energy
3. Endoscopic clipping

For Variceal bleeding

1. Sclerotherapy
2. Band ligation
Inj ection Therapy

 Materials
 Endoscope
 Suction pumps
 Water jet
 Single-lumen injection needles for
epinephrine and polidocanol,
 double-lumen needles for fibrin glue
 Epinephrine 1:10 000 in physiological saline
solution, 1%
 polidocanol, fibrin glue
 Duodenal ulcer (Clipping)
Argon plasm a co agu lati on
 Esophageal Varices (Band
ligation)

Band ligation of esophageal varices

Therapeut ic opt ions

 Percutaneous endoscopic Gastrostomy &

jejunostomy
for PEJ ; paediatric colonoscope with 160 cm
flexible scope is used.
 Foreign body extraction.
 Dilation of stricture
Instr um ents used for forei gn
body removal
Therapeutic Endoscopy
Small bowel enteroscopy

 Capsule endoscopy
 Double baloon endoscopy
 Paediatric colonoscope
Capsule Endoscopy
Capsule Endoscopy
 Capsule Endoscopy is a new technology that allows
the doctor to see the middle part of the intestinal
tract, the jejunum where no scope can currently go.

 especially helpful in finding the source of unexplained

intestinal bleeding and Crohn’s disease.

 Patient swallows a wireless video camera about the

size of a large vitamin

 Patient goes normally about their day while the

capsule records images throughout the digestive
tract.
Capsule Endoscopy
 Capsule Endoscopy

Diagnostic Indications
 Capsule endoscopy is intended for visualization of
the small bowel mucosa
 It may be used as a tool in the detection of
abnormalities of the small bowel in adults and
children from 10 years of age and up
 Capsule Endoscopy

Contraindications
 Capsule endoscopy is contraindicated for use under the
following conditions:

In patients with known or suspected gastrointestinal

obstruction, strictures, or fistulas based on the
clinical picture or pre-procedure testing and profile

In patients with cardiac pacemakers or other

implanted electro medical devices

In patients with swallowing disorders

Severe gastro paresis
Pseudo obstruction
Disa dva nta ges

 No therapeutic facility
 Long duration of procedure
 It does not localize the exact site of the pathology
Doubl e bal loon enteroscopy
 In 2000 it was introduced
 It consists of thin endoscope with 200cm length
and over tube 145cm length.
 Soft latex balloon is attached at the tip of both
the tubes which can be inflated & deflated.
 It can be inserted through duodenum or anus

 Advantages
a. Tremendous diagnostic & therapeutic purpose
in small bowel.
b. Altered small bowel anatomy (patients who
require ERCP after Roux-en-y gastric by pass)
 Disadvantages
a. Long duration; 1-3 hrs to complete
b. Needs expertise
c. Patient discomfort
d. Needs general anesthesia
Endoscopic Retrograde
Cholangiopancreatogram
 William mckune a surgeon introduced ERCP IN
I968
Endoscopic Retrograde
Cholangiopancreatogram
Indications
 Obstructive jaundice
(benign or malignant)
 Ascending cholangitis
 Gallstone pancreatitis
 Unexplained jaundice or
elevated LFT’s
 Bile duct injury or leak
after cholecystectomy
 Chronic pancreatitis
 Pancreatic cancer
 Suspected Sphincter of
Oddi dysfunction
Conversly, the availability
of ERCP should not be an
indication for its liberal
use.
Pati ent preparatio n
 Normal coagulation profiles are more relevant in
ERCP, especially if sphincterotomy or
endoprosthesis insertion is contemplated.

 Prophylactic antibiotics are usually administered.

 Oropharynx is anaesthetized with local
anesthesia.

 I.V. sedation and glucagon (0.5-1.0 mg)

administered to decrease duodenal motility.

 Position of the patient most commonly in “ PRONE

POSITION”.
 The I.V. access is preferred in the Right hand.
Di agnosti c techni que of
ERCP
 90 degree side viewing scope is used.
 Scope rides along the greater curvature towards
the pylorus
 7F cathetar with radio opaque tip is used for
diagnostic purpose.
 Endoscopic spincterotomy
Indications; a. Choledocholithiasis
b. Sphincter of oddi dysfunction
c. Acute cholangitis
d. Stent placement
e. Acute gall stone pancreatitis
 Endoscopic Retrograde
Cholangiopancreatogram

Pancreatic cancer with dilated bile duct and pancreatic duct (Double Duct sign)
 Endoscopic Retrograde
Cholangiopancreatogram

Gallstone impacted at ampulla, sphincterotomy being done and stones removed

Compl icati ons of Endoscopy
 Perforation, more in therapeutic endoscopy

 Aspiration

 Pancreatitis, cholangitis, perforation & bleeding

after ERCP.
 Lower Gastrointestinal
Endoscopy
Diagnostic Indications Therapeutic Indications
 Chronic diarrhea  Control of bleeding
 Rectal bleeding  Removal of polyps
 Iron deficiency anemia  Tumor ablation
 Unexplained abdominal  Dilation of stricture
pain
 Constipation, change in
 Colonic decompression
bowel habits or stool  Reduction of sigmoid
caliber volvulus
 Unexplained weight loss
 Evaluation of abnormal
Barium enema x-ray
 Personal or family history
of colon cancer
 Personal history of IBD
Lower Gastrointestinal
Endoscopy

Contraindications to Lower GI Endoscopy

 Uncooperative patient
 Hemodynamically unstable patient
 Suspected perforation
 Suspected colonic obstruction
 Suspected diverticulitis
 Soon after a myocardial infarction
 Deep ulcerations
 Severe ischemic necroses
 Fulminant colitis
 The sigmoidoscope measures
only 60 cm in total length.
Because of its high degree of
maneuverability, it is sometimes
used in patients where the
indications for examination are
limited to the sigmoid colon and
rectum.
Lower Gastrointestinal
Endoscopy
 (Lower GI endoscopy)
 Preprocedure
 Consent form
 Laxative
evening before
& enema or
suppository 1 hr
before Full liquid
diet 1-3 days
before
 PEGLEC
Lower Gastrointestinal
Endoscopy
Normal Colon Colon Cancer
Therapeutic col onoscopy

Polyp

Colon Polyp and Polypectomy

 a Colonoscope with
suction cap and
asymmetrical snare.
b Submucosal injection
with NaCl solution and
epinephrine.
c Lifting the flat lesion
after submucosal
injection.
d Suctioning the flat
lesion into the cap and
resection with a snare.
e Recovering the
resected lesion by
suction into the cap.

Sc he ma tic ill us tratio n o f en do scop ic mu cos al rese ctio n

us in g suct ion c ap tech ni qu e
Future Endosc opy
 Chromoendoscopy
 Narrow band imaging
 High resolution magnification endoscopy

 GOALS;
a. Recognition of early gastric and colorectal
cancer
b. To allow accurate discrimination of dysplasia
grade in areas of Barrett’s esophagus or
quiescent ulcerative colitis
c. To aid polyp detection
Chromoendoscopy

 The most widely available technique

 Chromoendoscopy refers to the intravital

staining of epithelial structures during
the endoscopic examination

 It involves the topical application of

stains or pigments to improve tissue
localization, characterization or diagnosis
 Stains used in
chromoendoscopy
Absorptive stains are taken up by special
 Absorptive stains epithelial cells and can differentiate cells
 − Lugol solution according to whether
 − Methylene blue they are stained or unstained. Contrast
 − Toluidine blue stains cause relatively
 Contrast stains marked enhancement of intestinal
mucosa and are often used in
 − Indigo carmine
magnification endoscopy. Reactive stains
 Reactive stains are used to identify
 − Congo red certain secretions in which the stain
 − Phenol red induces a color reaction
 Magnification Endoscopy

Principle. Magnification endoscopy, known also

as zoom endoscopy, can be used for the detailed
endoscopic evaluation of suspicious
areas, especially after staining
Endoscopic Ultrasound

 The ultrasound probe is

placed at the tip of the
endoscope
 Allows ultrasonography
of organs from a close
distance
 Individual layers of the
GI wall are visualized as
five distinct layers of
alternating hyper and
hypo ecogenicity
 Can be used to take fine
needle aspiration
Endoscopic Ultrasound

A T3 Rectal Tumor on EUS

Indications of EUS
PANCREATIC
a. FNAC of malignancy
b. Drainage of fluid collections
c. Lymph node sampling
d. Assess portal venous system
e. Intraductal ultrasound
HEPATOBILIARY
a. Detect stones
b. Periportal lymph nodesampling
c. Biopsy of liver mass
ESOPHAGEAL
a. Esophageal cancer staging
Gastric
a. Gastric cancer staging
b. Evaluation of submucosal masses