8/22/2016

GastroenterologyEducationandCPDfortraineesandspecialistsGastroduodenoscopy(OGD)Print

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Gastroduodenoscopy(OGD)
1.Checkyourendoscopetoensurethatitissuckingandblowingandtakethewheellockoffand
ensurepictureiscomingwithcorrectnameofthepatientonthescreenandproceed.
2.EnsurecorrectPPE(personalprotectionequipment)arewornplasticgownanddisposablegloves
mustbewornatalltimes.Useadditionalprotectionwithfullsleevegownandeyegoggleswhen
appropriate.

3.Warnthepatientthatthelocalanaestheticspraytastesstrangebutdoesnotlastlong.Spraythe
backofthethroatapprox810times(eachsprayis10mg)45spraysintwogos.

4.Getthepatientintopositionleftlateral
5.Theheadendnursewillplaceasecretionholderaroundtheneck,attachtheoxygenprongs,get
readywiththeYankauersuctionprobeandplaceamouthguard

6.Ifpatientoptsforsedationensurethatobservations(BP,pulseandoxygensaturation)areok
beforeyouadministersedation

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7.Thesedationisnormallyivmidazolam25mg.Waitfor2minutesbeforeyoustart

8.Oncethepatientisreadyandsedated,smearthetipofthescope(upto10cm)withKYjellybut
avoidingthelensesandtakeupthescopeholdingtheendoscope20cmfromthetip.
9.Ensureyouareholdingthescopewithaxisaligningwiththepatientsoesophagusotherwise
whenyouenteryouwillseeonlyteethononeside

CorrectentrybothrightandleftsideareseenTongueattop,shinypalateatbottom

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Incorrectentryonlyonesideisseen
10.Onthescreenyouwillseethetongueontopandpalateonthebottom

Tongueattop,shinypalateatbottom
11.RememberThumbdownonthebigwheelmakesthetiptogouponthescreen(imaginethe

handpicture)butin3Dactuallythetipgoesdown

Thumbdownonbigwheelmakethescopetip(littlefinger)gouponthescreen(notinreal3D

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inreal3Dthetipgoesdown)

12.Bendthetipofthescopesoastomatchthecurvatureofthetongue.
13.Assoonthetipreachesthebackoftheoropharynxunbendthetiptowardstheposteriorwallof
thepharynx.

Vocalcordvisibledistaltoepiglottisinthesecondpicturebutnotinthefirst

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14.Nextyouseetheepiglottishidingtheentrancetothelarynxandoesophagus

15.Onceyoupasstheepiglottisyouwillseetheentrytothetrachea(laryngealinlet)guardedbythe
vocalcords
16.Oncehere,chooseeitherleftorrightsidebehindthearyepiglotticfold
17.Atthisstagetherewillberedoutifyouwaityouwillseethecricopharyngeusopening.Bewareof
pharyngealpouchanddontpushhard,justgentlyglide
18.Inflatewhileinoesophagusandgodown

19.NextcomestheGOJnotethedistancefromtheincisorfromthemarkingonthescopehere
thepearlwhitesquamousmucosameetswithpinkcolumnarmucosaattheZline

20.NormallytheZlineandtheGOJandthediaphragmatichiatusallwillbeatthesamelevel
21.IfthereisaslidinghiatalherniaGOJslipsupinthethoraxsotheGOJlookswideandpatent.So
youwillseeproximaltodistaltheZlineafterthatyouwillseethegastricrugaeinsidethe
hiatalherniaandthenafurthernarrowingthediaphragmaticgap(whichcontractsandrelaxes
onbreathing)

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Differentdegreesofslidinghiatalherniasmall,mediumandlonglengthhiatushernia
22.Familiariseyourselfwithconceptofrollingandslidinghiatalhernia(readmoduleonhiatushernia)
23.BarrettsepitheliumpinkcolumnarepitheliumabovetheGOjunction(i.e.proximaltothegastric
rugalfolds)

24.SometimeBarrettandhiatalherniacancoexistremembergastricrugaearenotvisualizedinthe
Barrettssegmentbutisvisualizedinhiatalsegment.Alsotheapparentnarrowingofstartof
stomachinthebeginningofthehiatalsegmentdoesnotcontractandrelaxwithrespirationbut
thediaphragmaticopeningdoes.(readtheBarrettsoesophagusmodule)
25.Inthefundusseerugaeblowairsufficientlytodistendstomach
26.Fortheverybeginnertroubletofinddirectionforpylorusfollowtheconvergenceofthe
rughaenormallydownandtotheright

27.BewareofrollinghiatalherniaifyoujustenteredthestomachbeyondGOJandcantseeanyway
forwardyoumaybeinarollinghiatalhernia,justwithdrawandstartagain.
28.Understandtheareasofthestomachifneededfromananatomytextbookroughlygreater
curveatthebottom,lessercurveattopthepostsurfaceisbetweengreatercurveandlesser
curveandontherightside,anteriorstomachisontheleftside
29.Thetechniqueofpyloricintubationwaitpatientlyforthepylorustoopenupsometimeyouwill
havetodeflatethestomachalittle

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30.Minoradjusmentwithsmallandlargewheelusuallyleadstopyloricintubation.Diaphagmatic
movementandpyloricperistalsiscansometimemakepyloricintubationdifficult.
31.OnceintheD1withdrawtogetabirdseyeviewofD1(duodenalcap)

DuodenalcapD1/D2junctionontheright
32.Beawareoftheanatomicalareasfordescriptionoflesionintheduodenum
33.TechniqueofgoingtoD2tipdown(thumbup)andrightturn(smallwheelawayfromyou)and
thenrighttorquewithyourshoulder
34.Controlbigwheelbythumboflefthandbutcontrolsmallwheelbythumbandotherfingersofthe
dominanthand(forbeginners)

SecondpartofDuodenumD2
35.Ampullawillbeontheleft

AmpullajustvisibleinD2at7oclock
36.InD2withdrawingthescopewillallowyoutomoveforward(becausetheloopinthegreater
curvatureisstraightenedup)
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37.WithdrawcarefullyintoD1theblindspotisthejunctionandsuperiorandposteriorwall
38.Withdrawbackinstomachanddoacarefulexaminationofthemucosalessercurveistheblind
spotbecarefulnottomissanylesionhere
39.DoingtheJmanoeuvreonceyouseetheincisuraatthetopofthescreentipup(bythumb
downonthebigwheel)

Incisura(semilunarfold)atthetop
40.Thenpullthescopeoutslightlyyoumighthavetorotatethescope

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41.Nowyoucanseethefundusfrombelow

42.Ifthereishiatalherniathediaphragmaticdefectwillnotgraspthescopetightlyleavingagap
(comparewiththepicturejustabove)

BothslidingandrollingherniavisibleonJmanoeuvre
43.D2biopsiesnomallytakeninirondeficiencyanaemiaorhistoryofweightlossfourpiecesof
tissueisneeded.Biopsiesaretakeninformalinpot(colonicbiopsiesaresometimetakeninastrip
asshownontherighthandpicture)

44.HPylorirapidureasetest(CLO/ProntoDry)youneedtwopiecesoftissue.IfpatientisonPPI
takethesamplefromfundusasHPylorimigratesup.Rememberformalininthebiopsypotcankill
it.Soeitherdothistestbeforeyoutakeotherbiopsiesorwashthebiopsytipwell

45.Takingoesophagealbiopsiescanbedifficultforthebeginnersasthebiopsyforcepscomeout
tangentiallytothemucosa.Tip:Goabovethelesionslightlyandusethewheelstoangulatethe
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tipmighthavetousewheellock.ForBarrettsoesophagusquadranticbiopsieseverytwo
centimetres.

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