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Panendoscopy
EsophagoGastroDuodenoscopy, EGD; upper endoscopy

Most of the gastrointestinal (G.I.) tract from the esophagus to the anus can be examined by endoscopy (endo, inside; scope, see; to see inside the body). Panendoscopy is a procedure that allows the physician to examine the lining of the upper part of the gastrointestinal tract (i.e. the esophagus, stomach and duodenum). This involves the passage of a tube by mouth through the esophagus into the stomach and duodenum. The tube is long and flexible and contains a light source, lens system for focusing and fiber optics. The fiber optics conduct light to within these organs and an image back to a video camera that is connected to a monitor. The tube also contains a channel through which small instruments can be passed for various different uses.

Anatomy and Physiology

  • Esophagus, sometimes called the gullet, is a tube-like structure that connects the back of the throat, the pharynx, to the stomach (Figure 1) (See Esophagectomy)
    1. It is about 22 - 27 centimeters (9 to 11 inches) long and is composed mostly of muscle
    2. It serves as the passage for food and saliva to get from the mouth to the stomach.
    3. A few inches of the esophagus are in the neck (called the cervical esophagus)
    4. Most of the esophagus is located in the chest. It passes into the abdomen through the diaphragm, the broad muscular and fibrous structure that separates the chest from the abdominal cavity. Only an inch or so of the esophagus is located in the abdominal cavity where it attaches to the stomach
    5. The upper and lower ends of the esophagus are not wide open at all times, but rather have a mechanism that functions like a valve. These are called the upper and lower esophageal sphincters.
    6. The inner lining of the esophagus is made up of a tissue called epithelium. Most of the epithelium resembles skin in many respects and is of a cell type called squamous (flat) cell
  • Stomach is a reverse C-shaped organ that lies under the left lower ribs and left upper part of the abdomen (Figure 1) (See Gastrectomy)
    1. Food entering the mouth is passed into the esophagus and then goes into the upper end of the stomach. The stomach holds and mixes the food with gastric juices that aid in digestion and then passes the mixture through the pylorus, a muscular sphincter or gate, that controls the passage of the stomach contents into the duodenum, which is the beginning of the small bowel
    2. Glands in the wall of the stomach produce the gastric juices. After three to four hours, food entering the stomach is reduced by these juices to a liquid and ready to enter the small bowel to continue digestion
    3. The stomach is divided into three parts (Figure 1):
    • The cardia is the part of the stomach that is adjacent to the esophagus
    • The body of the stomach is the largest part and has two curvatures, the lesser curvature, which lies on the inside of the C, and the greater curvature, which lies on the outside of the C
    • The pylorus is the part of the stomach that lies at the end of the stomach and is demarcated from the body by a difference in the type of glands from those in the body
    1. The stomach is mobile and changes shape depending on whether it is full or empty or whether the person is standing or lying down. It is relatively fixed at the cardia, the part of the stomach near the esophagus
  • Duodenum connects the stomach to the jejunum (the second part of the small bowel) (Figure 1) (See Surgery of the Duodenum)
    1. It is 20 cm (8 inches) in length and divided into four parts
    2. The duodenum is retroperitoneal (has peritoneum, the thin layer of tissue that lines the abdominal cavity) only on the anterior (front) side; fixed in location; wraps around the head, neck and body of the pancreas; and the superior mesenteric artery and vein (major blood vessels for the bowel) pass anterior to the 3rd portion.
    3. The ampulla of Vater (entrance site into duodenum of joined common bile duct and pancreatic duct) enters the medial (towards the midline) side of the 2nd portion of the duodenum.
    4. The accessory pancreatic duct enters slightly higher in the medial wall of the duodenum
    5. The ligament of Treitz (a supporting band of peritoneum and muscle fibers) marks the point between the fourth part of the duodenum and jejunum
    6. The duodenum produces many hormones that help regulate digestion. Liver bile and pancreatic secretions are added to the bowel through the ampulla of Vater. The actual passage and presence of food in the duodenum triggers the flow of hormones, bile and pancreatic secretions. By the time food leaves the duodenum most of the ingredients necessary for digestion have been added. Little digestion and absorption (passage of nutrients from the bowel into the blood) take place in the duodenum
Figure 1 - Anatomy of the esophagus, stomach and duodenum. © N. Gordon

Pathology

The most common abnormalities for which panendoscopy are performed are:

  • Diseases of the esophagus including inflammation, ulcers, tumors, strictures (narrowing) and infection (Figure 2, 3 and 4)
  • Diseases of the stomach including bleeding, ulcers, tumors (benign and cancerous) and hiatal hernia (herniation of the stomach through the diaphragm into the chest) (Figure 5)
  • Diseases of the duodenum including bleeding, ulcers, strictures and tumors. (Figure 6)
Figure 2 - Cancer of the esophagus. Courtesy M. Takriti, MD Figure 3 - Barrett's Esophagus. Arrows point to patches of esophageal change. Courtesy M. Takriti, MD
Figure 4 - Erosive esophagitis. Arrows point to areas of erosion. Courtesy M. Takriti, MD
Figure 5 - Gastric ulcer with an exposed blood vessel. Courtesy M. Takriti, MD
Figure 6 - Tumor of the ampulla of Vater. Ampullary tumor. Courtesy M. Takriti, MD

Indications

  • Upper endoscopy is usually performed to evaluate symptoms of:
    1. Persistent upper abdominal pain
    2. Nausea or vomiting
    3. Difficulty in swallowing
  • It is the best test for finding the cause of bleeding from the upper gastrointestinal tract and providing the treatment to stop it
  • Detection and diagnose several conditions like ulcers or tumors. During the procedure biopsies can be obtained (small tissue sampling) and can be sent for pathological analysis. Biopsies are taken for many reasons and do not necessarily mean that cancer is suspected
  • Upper endoscopy is also used to treat a variety of conditions. Various instruments can be passed through the endoscope to allow many abnormalities to be treated directly with little or no discomfort. For example, stretching narrowed areas in the esophagus, removing polyps (protruding growth) or management of swallowed objects or impacted food in the esophagus

Preparation

  • For the best and safest examination the stomach and duodenum (See Surgery of the Duodenum) must be completely empty. The patient should not have anything to eat or drink, including water, for six hours prior to the examination. The doctor will be more specific about the time to begin fasting depending on the time of the day that the test is scheduled
  • The physician should be informed of any medical conditions, allergies or required antibiotics that should be given prior to the endoscopy. The antibiotics are usually given intravenously (by vein) prior to the procedure
  • The doctor should be informed of any major disease such as a heart or lung condition that might require special attention during the procedure

The Procedure

  • The procedure is usually done under sedation (See Anesthesia), therefore, the patient should experience very little or no discomfort. Most of the sedatives are given intravenously. Many patients fall asleep during the procedure and when they awake do not remember the procedure
  • The patient lies in a comfortable position on the left side. The throat may be sprayed with a local anesthetic before the test begins. The endoscope does not interfere with breathing. Saliva is suctioned through a suction device (like the one used by a dentist)
  • The endoscope is passed through the mouth and then, in turn, through the esophagus, stomach and duodenum with little discomfort
  • The surface of each of these organs is carefully viewed for any lesion (abnormality) and photographs may be taken
  • If necessary, a biopsy (small piece of the lesion) is removed and sent to the pathologist for review under the microscope. Polyps can be biopsied or totally removed at the time of the procedure. Any bleeding can be cauterized
  • The endoscope is removed after the procedure
  • The results of the visual part of the endoscopy is known immediately, however, if any specimen is obtained (biopsies or polyps) the results often take several days

Complications

  • Bleeding may occur from a biopsy site or where a polyp was removed. It is usually minimal and rarely requires further treatment
  • Localized irritation of the vein where the medication was injected may rarely cause a tender lump lasting for several weeks, but will eventually go away. Applying heat packs or hot moist towels may help relieve the discomfort.
  • Occasionally there may be a reaction to the sedatives
  • Patients with heart or lung disease may experience problems with these underlying diseases
  • Major complications such as perforation of the wall of the organ (a tear that might require surgery for repair) and persistent or marked bleeding can occur but are uncommon. Sometimes the endoscope must be inserted again and the area of bleeding cauterized
  • It is very important that the patient recognize these early signs of possible complications and report them to the doctor:
    1. Fever
    2. Trouble swallowing different from before the procedure
    3. Increasing throat, chest or abdominal pain

Post-Operative Care

  • After the test patients are monitored in the recovery area for 30 - 45 minutes, until the effects of sedation have worn off. They will need to make arrangements for somebody to drive them home (not a taxi) and to stay with them for the remainder of the day because the sedation affects judgment and reflexes for the rest of the day. No driving or working is allowed until the next day
  • The throat may be a sore for a while and can be soothed with throat lozenges
  • The patient might feel bloated after the procedure because of the air introduced into the stomach during the test
  • The patient should be able to resume a normal diet after the procedure unless instructed otherwise
  • The doctor will discuss with the patient or designated companion any further instructions or need for follow up