Endoscopy

Endoscopy

Upper GI Endoscopy

Contraindications

Contraindications for UGI scopy include the following:

• Possible perforation
• Medically unstable patients
• Unwilling patients
• Anticoagulation, pharyngeal diverticulum, or head and neck surgery (relative contraindications)

Diagnostic UGI scopy is considered a low-risk procedure for bleeding in patients on anticoagulants and therefore can be performed without adjustment of anticoagulants before the procedure. However, if polypectomy or any therapeutic intervention is contemplated or conceivable, then the patient’s coagulation profile should be normalized. A risk of retropharyngeal hematoma also may be present in patients with severe coagulation abnormalities.

Certain therapeutic procedures ( dilations, percutaneous endoscopic gastrostomy [PEG], polypectomy, endoscopic sphincterotomy, ERCP, EUS-guided fine-needle aspiration [FNA], laser ablation, and coagulation) are considered high-risk procedures for bleeding, and adjustment of anticoagulation may be necessary.

PRE-PROCEDURE TESTS AND FORMALITIES:

Preprocedural testing in selected cases might include,

• Complete blood count (CBC),
• Triple H,
• INR
• Chest xray PA view
• Electrocardiography (ECG) / 2Decho as per patients profile if necessary
• Anesthetist fitness/Cardiologist fitness/Physician fitness – only as per patient profile if necessary
• Appointment with Procedure room-through an assistant
• Clearance from the reception
• Willful consent from patient & relative after understanding all terms, procedure, indication, need, alternative options, outcome, and prognosis risk & related counselling.

PATIENT PREPARATION

Topical anesthesia (eg, with lidocaine) is administered.
Advantages of topical anaesthesia

• Eliminating the risk of sedation,
• Decreasing the cost of the procedure
• Less recovery time

PROCEDURE

Topical anesthesia (eg, with lidocaine) is administered.
Advantages of topical anaesthesia

1. The patient is usually placed in the left lateral position. Administer topical and/or IV sedation to minimize gagging and to facilitate the procedure.
2. An antispasmodic agent (eg, hyoscine,etc) may be given to suppress gastrointestinal (GI) peristalsis.
3. Bite block is placed to prevent damage to the endoscope and to ease its passage through the mouth.
4. Under direct vision, pass the endoscope through the pharynx, esophagus, and stomach and into the duodenum, with careful inspection upon both insertion and slow withdrawal.
5. Insufflation of air is done to distend the lumen so as to facilitate viewing. Liquid and particulate matter can be aspirated through the suction channel.

Complications

Complications are very less common in diagnostic procedures if patients health profile is good, also if endotherapy or emergency situation arises, based on the underlying disease profile of patient and the indication and patients hemodynamic condition, the complications vary.

The major complications of UGI scopy /LGI scopy/Endotherapyare as follows:

• Bleeding
• Infection
• Perforation
• Cardiopulmonary problems

COLONOSCOPY / Lower GI Scopy

Colonoscopy enables visual inspection of the entire large bowel from the distal rectum to the cecum. The procedure is a relatively safe and effective means of evaluating the large bowel. The technology for colonoscopy provides clear mucosal imaging through a video camera attached to the end of the scope. The computer connects, stores and can print color images selected during the procedure.

Triaging the patients and following appropriate treatment protocols leads to best possible outcome for that patient. If necessary, higher intervention at same centre or different centre may be suggested if facilities deem so.

Indications for colonoscopy

1. Lower GI bleeding
2. Screening and surveillance of colorectal polyps and cancers:
• Colon cancer
• Surveillance after polypectomy
• Colorectal cancer post-resection surveillance
• Inflammatory bowel diseases
3. Chronic diarrhoea
4. Therapeutic indications for colonoscopy:
• Excision and ablation of lesions
• Treatment of lower GI bleeding
• colonic decompression
• Dilation of colonic stenosis
• Foreign body removal
5. Miscellaneous indications:
• Isolated unexplained abdominal pain
• Chronic constipation
• Preoperative and intraoperative localization of colonic lesions.

Contraindications for colonoscopy

1. Patient refusal
2. Uncooperative patients
3. Inadequate sedation
4. Known or suspected colonic perforation.
5. Severe toxic megacolon and fulminant colitis
6. Clinically unstable patients
7. Recent myocardial infarction
8. Inadequate bowel preparation
9. Peritonism

Preparation

Peglec solution is given in water overnight for the next morning procedure, and overnight fasting after completion of oral preparation is advised, also anaesthesia support may be necessary to ensure smooth completion of the colonoscopy procedure.

Procedure

For LGI scopy, patient is placed in left lateral position ,and with slow insufflation of air, screening of the entire colon and terminal ileum is attempted., Biopsies can be obtained as per indication.

Complications

Complications are very less common in diagnostic procedures if patients health profile is good, also if endotherapy or emergency situation arises, based on the underlying disease profile of patient and the indication and patients hemodynamic condition, the complications vary.

The major complications of UGI scopy /LGI scopy/Endotherapyare as follows:

• Bleeding
• Infection
• Perforation
• Cardiopulmonary problems

GASTROINTESTINAL BLEEDING

For UGI/LGI bleeding , patient needs to be stabilised and after blood parameters are checked, patient can undergo intervention to stop bleed after appropriate counselling, consent, blood product transfusion as per necessary, IV infusion, and then the patient is taken up for procedure after appropriate risk stratification as per patients profile.

Causes

• Ulcer bleed
• Variceal bleed in cirrhosis patients
• Diverticular bleed
• Mallory Weiss tear bleed
• Dieulafoy’s lesion bleed
• Inflammatory bowel disease related bleed
• Cancer related bleed
• Coagulation disturbances and other co-existing diseases need to be ruled out.
• Other causes(as per patients comorbid condition)

PROCEDURE

1. The patient is usually placed in the left lateral position. Administer topical and/or IV sedation to minimize gagging and to facilitate the procedure.
2. An antispasmodic agent (eg, hyoscine,etc) may be given to suppress gastrointestinal (GI) peristalsis.
3. Bite block is placed to prevent damage to the endoscope and to ease its passage through the mouth.
4. Under direct vision, pass the endoscope through the pharynx, esophagus, and stomach and into the duodenum, with careful inspection upon both insertion and slow withdrawal.
5. Insufflation of air is done to distend the lumen so as to facilitate viewing. Liquid and particulate matter can be aspirated through the suction channel.
6. Cirrhosis patients may need Endoscopic variceal ligation or glue endotherapy as per findings on UGI scopy. Also nonvariceal bleed like ulcer or diverticular bleed needs sclerotherapy / hemoclipping as per patients findings on endoscopic examination

COMPLICATIONS

Ongoing bleed, rebleed despite best possible treatment measures, though less common, are possible and it may sometimes require re-endoscopy and /or re endotherapy with hemoclips, sclerotherapy etc.

Other Complications as mentioned above.

Triaging the patients, counselling the patients relatives and following appropriate treatment protocols leads to best possible outcome for that patient. If necessary, higher intervention at same centre or different centre may be suggested if facilities deem so. Despite all best measures taken by the managing team of ICU/Gastroenterologists/Physician, if the patients condition does not stabilise, they can be offered alternative treatment measures like BRTO/Surgery/as necessary.

Overall outcomes and risk to life is different for different patients and also different for the same patient in different situation, which depends on the age, comorbid conditions, co-existing other organ dysfunctions, cardio-respiratory status, neurological condition and other factors on a case-to-case basis especially in case of bleeding GI patients which are having more risk than the general population for organ dysfunction and risk to life.

Above all, trusting your doctor for the treatment is of prime importance at every step of patient care in this journey of doctor-patient relationship.