Overview
Definition:
Upper gastrointestinal endoscopy (EGD or esophagogastroduodenoscopy) is a diagnostic and therapeutic procedure that involves the use of a flexible endoscope to visualize the lining of the esophagus, stomach, and duodenum
It allows for direct inspection, biopsy, and interventions within the upper GI tract
Sedation is crucial for patient comfort and procedural success, aiming to reduce anxiety and facilitate the examination.
Epidemiology:
Upper GI endoscopy is one of the most commonly performed endoscopic procedures worldwide
Millions of procedures are performed annually
Indications vary globally but commonly include evaluation of dyspepsia, reflux symptoms, suspected bleeding, and screening for malignancy
Age and comorbidities influence sedation choices.
Clinical Significance:
EGD is indispensable in diagnosing and managing a wide spectrum of upper gastrointestinal diseases
It provides definitive diagnosis for conditions like peptic ulcers, gastritis, esophagitis, celiac disease, and malignancy
Its therapeutic applications, such as variceal banding, polypectomy, and foreign body removal, are vital for surgical and medical management, directly impacting patient outcomes and reducing morbidity.
Indications
Diagnostic Indications:
Persistent or alarm symptoms of the upper GI tract, including dysphagia, odynophagia, persistent vomiting, unexplained weight loss, early satiety, and significant dyspepsia unresponsive to empirical therapy
Evaluation of suspected gastrointestinal bleeding (hematemesis, melena), anemia, or iron deficiency
Diagnosis of Helicobacter pylori infection
Screening for esophageal cancer in high-risk individuals (e.g., Barrett's esophagus)
Investigation of chronic diarrhea with suspected small bowel involvement
Assessment of patients with known GI malignancy for extent or recurrence.
Therapeutic Indications:
Management of acute upper GI bleeding, including varix ligation, injection sclerotherapy, and hemostatic clipping
Dilatation of benign esophageal strictures (e.g., peptic, post-radiation)
Removal of foreign bodies
Polypectomy of gastric or duodenal polyps
Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for early GI cancers
Gastrostomy tube placement
Palliative stenting for malignant obstructions.
Surveillance Indications:
Surveillance for dysplasia or malignancy in patients with Barrett's esophagus
Follow-up after treatment of esophageal varices
Monitoring of patients with a history of gastric cancer or polyps
Surveillance in patients with familial adenomatous polyposis (FAP) or Lynch syndrome.
Sedation And Anesthesia
Goals Of Sedation:
To ensure patient comfort and cooperation
To reduce patient anxiety and memory of the procedure
To minimize patient movement, facilitating optimal visualization and safe instrumentation
To suppress gag reflex and improve tolerance
To ensure patient safety through appropriate monitoring and management of potential complications.
Types Of Sedation:
Minimal sedation (anxiolysis): Patient can respond to verbal commands
Moderate sedation (conscious sedation): Patient can respond purposefully to tactile stimulation or verbal command
spontaneous ventilation is maintained
Deep sedation: Patient cannot be easily aroused but responds purposefully following repeated or painful stimulation
spontaneous ventilation may be inadequate
General anesthesia: Patient is not arousable, even by painful stimulation
airway support may be required.
Pharmacological Agents:
Benzodiazepines: Midazolam is commonly used for its anxiolytic, amnesic, and sedative properties
Opioids: Fentanyl is often used for analgesia and to potentiate sedation
Propofol: A potent intravenous anesthetic agent providing rapid induction and short recovery, often used for deeper sedation or by experienced endoscopists
Ketamine: May be used for dissociative anesthesia, especially in patients with difficult airways or hemodynamic instability
Local anesthetics: Topical lignocaine spray for pharyngeal anesthesia.
Monitoring And Safety:
Continuous monitoring of vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation)
Pulse oximetry is mandatory
Capnography may be used for deeper sedation
Adequate intravenous access is essential
A trained assistant should be present to monitor the patient
Emergency resuscitation equipment and medications must be readily available
Patient selection based on American Society of Anesthesiologists (ASA) physical status classification is crucial
Evaluation of airway, cardiac, and pulmonary status prior to sedation.
Procedure Steps
Patient Preparation:
Nil by mouth for at least 6-8 hours for solids and 2-4 hours for clear liquids
Review of medical history, allergies, medications (especially anticoagulants and antiplatelets)
Informed consent obtained
Establishment of intravenous access
Administration of prophylactic antibiotics if indicated (e.g., prosthetic heart valves, recent endocarditis).
Endoscope Insertion And Advancement:
After adequate sedation and topical pharyngeal anesthesia, the endoscope is carefully inserted into the mouth and advanced gently through the pharynx, esophagus, stomach, and into the duodenum
Air is insuffused to distend the lumen for better visualization
The scope is manipulated using controls on the handle to navigate the GI tract.
Examination Technique:
Systematic inspection of the esophageal mucosa, looking for inflammation, erosions, ulcers, strictures, varices, or masses
Examination of the stomach, including the cardia, fundus, body, and antrum, noting gastritis, ulcers, polyps, or tumors
Inspection of the duodenal bulb and post-bulbar duodenum for ulcers, inflammation, or masses
Biopsies are taken judiciously from suspicious lesions or for specific diagnostic purposes (e.g., H
pylori, celiac disease).
Interventions And Withdrawal:
Therapeutic interventions are performed as indicated
Once the examination is complete and any necessary interventions are done, the endoscope is slowly withdrawn under direct vision, allowing for a final inspection of the mucosa
The endoscope is cleaned and disinfected according to protocol.
Complications Of Endoscopy
Immediate Complications:
Perforation of the esophagus, stomach, or duodenum, occurring most commonly during difficult intubations, balloon dilatations, or tumor resections
Bleeding, usually minor, from biopsy sites or polypectomy
Aspiration pneumonitis, particularly with inadequate sedation or airway protection
Cardiopulmonary events, such as arrhythmias, myocardial infarction, or respiratory depression, related to sedation and patient's underlying comorbidities
Allergic reactions to medications.
Delayed Complications:
Bleeding from a biopsy site or post-polypectomy site occurring hours to days after the procedure
Infection, including post-ERCP cholangitis or sepsis, though less common with diagnostic EGD
Stricture formation at the site of intervention
Persistent dysphagia or pain.
Prevention And Management:
Careful patient selection and optimization of sedation
Thorough training of endoscopists
Use of appropriate equipment and technique
Meticulous post-procedure monitoring
Prompt recognition and management of complications, including urgent surgical consultation for perforations or significant bleeding
Adequate resuscitation and supportive care.
Key Points
Exam Focus:
DNB/NEET SS candidates must know common indications for EGD, contraindications to sedation, preferred sedation agents for different patient profiles, and immediate management of complications like perforation and bleeding
Understanding the steps of a diagnostic EGD and common therapeutic interventions is crucial.
Clinical Pearls:
Always assess airway, breathing, and circulation before administering sedation
Titrate sedative agents carefully to achieve desired effect while maintaining adequate spontaneous respiration
Have resuscitation drugs and equipment readily available
Consider patient comorbidities when choosing sedation agents and monitoring
Biopsy suspicious lesions liberally during diagnostic EGD to avoid missed diagnoses.
Common Mistakes:
Over-sedation leading to respiratory compromise
Under-sedation resulting in patient discomfort and poor cooperation
Failure to recognize or manage early signs of complications
Inadequate preparation of the patient leading to procedure cancellation or increased risk
Incomplete examination of the upper GI tract
Insufficient biopsy sampling.