Esophagogastroduodenoscopy

The goal of esophagogastroduodenoscopy is to visualize the entire upper GI tract (to the second portion of the duodenum).

Indications

Diagnostic indications include obtaining fluid and tissue specimens and exploring upper GI symptoms or abnormalities seen on an upper GI x-ray series. Any pathologic process (eg, ulcer, mass, irregularity) can be characterized by inspection and biopsy. Brush cytology may aid diagnosis in malignant disease.

Esophagogastroduodenoscopy may be used to monitor the healing rate of a gastric ulcer but is usually unnecessary with a duodenal ulcer. Periodic endoscopy and biopsy in Barrett's syndrome, a premalignant process, can detect early evidence of cancer. Esophagogastroduodenoscopy can best identify the site of upper GI bleeding and should be performed as soon as the patient is stable.

Therapeutic indications include dilating esophageal strictures using a dilator threaded over an endoscopically placed guide wire or using a balloon catheter passed through the endoscope. Obstructive esophageal or gastric neoplasms may be vaporized endoscopically with a laser wave guide passed through the gastroscope or with photodynamic therapy in patients who are not surgical candidates. With a more extensive obstructive tumor, enteral nutrition can be reestablished by precisely locating the tumor endoscopically and placing an esophageal stent prosthesis using a guide wire.

The use of esophagogastroduodenoscopy to treat GI bleeding has markedly enhanced the value of this procedure. GI hemorrhage, which is not well tolerated by elderly persons, requires immediate attention; the endoscopic team should be alerted as soon as the patient is first seen. Almost all episodes of upper GI bleeding can be controlled by using endoscopic injection therapy with epinephrine or absolute alcohol or by using a thermal coagulation device. The mortality rate in elderly patients ranges from 6 to 10%.

Sclerotherapy for esophageal varices and injection therapy for bleeding vessels may be performed during the initial diagnostic examination by passing a long, flexible needle-tipped catheter through the endoscope. A new technique, rubber band ligation of varices, can be accomplished rapidly with relatively low morbidity in the elderly. Polyps may be resected using a wire snare loop and an electrocoagulation current to prevent bleeding.

Usually, submucosal lesions cannot be resected endoscopically. Removing foreign bodies such as dentures from the esophagus or stomach may require special maneuvers, including attaching to the tip of the endoscope a shield that folds over sharp objects to prevent esophageal injury during extraction. Foreign bodies smaller than a dime often pass spontaneously and may not require endoscopic removal. Food bezoars can sometimes be broken up with the snare, biopsy forceps, or a strong jet of water.

Percutaneous endoscopic gastrostomy (a nonoperative procedure in which a gastric feeding port is inserted) has largely replaced surgical creation of a feeding gastrostomy. This procedure can be accomplished at the bedside with little risk and is ideally suited for the elderly patient with deglutitive problems.

Contraindications

Absolute contraindications are a recent myocardial infarction and an acute perforated viscus. However, elderly patients with cardiorespiratory disease and dyspnea are at special risk for complications. Even without sedation, these patients have a lowered oxygen partial pressure; with sedation, some are particularly vulnerable to respiratory depression. In these patients, using a small-caliber endoscope and administering additional oxygen during the procedure may help.

Procedure and Complications

For most patients, restricting food and drink for 6 hours before the examination is the only preparation. Those with achalasia or gastric outlet obstruction may have retained food for days and may require lavage to empty the esophagus or stomach. Light sedation with an IV opioid and/or a benzodiazepine may be combined with a local anesthetic applied to the posterior pharynx. After removing the patient's dentures or nonpermanent bridges, the examiner passes the instrument under direct vision through the pharynx to examine the entire esophagus and stomach and the first two portions of the duodenum. An x-ray is not a prerequisite for esophagogastroduodenoscopy because the gastroscope can be passed safely under direct vision even in patients with dysphagia and a possible Zenker's diverticulum. The procedure can be performed in 15 to 30 minutes.

Perforation occurs in 0.03% of patients and death from complications in about 0.006%. Most complications are caused by sedative drugs and include arrhythmias, aspiration, and, rarely, cardiac arrest.