Esophagogastroduodenoscopy

Definition

An esophagogastroduodenoscopy (EGD), which is also known as an upper endoscopy or upper gastrointestinal endoscopy, is a diagnostic procedure that is performed to view the esophagus, stomach, and duodenum (part of the small intestine). In an EGD, the doctor uses an endoscope, a flexible, tube-like, telescopic instrument with a tiny camera mounted at its tip, to examine images of the upper digestive tract displayed on a monitor in the examination room. Small instruments may also be passed through the tube to treat certain disorders or to perform biopsies (remove small samples of tissue).

Purpose

An EGD is performed to evaluate, and sometimes to treat, such symptoms relating to the upper gastrointestinal tract as:

• pain in the chest or upper abdomen
• nausea or vomiting
• gastroesophageal reflux disease (GERD)
• difficulty swallowing (dysphagia)
• bleeding from the upper intestinal tract and related anemias

In addition, an EGD may be performed to confirm abnormalities indicated by such other diagnostic procedures as an upper gastrointestinal (upper GI) x-ray series or a CT scan. It may be used to treat certain conditions, such as an area of narrowing (stricture) or bleeding in the upper gastrointestinal tract.

Description

Upper endoscopy is considered to be more accurate than x-ray studies for detecting inflammation, ulcers, or tumors. It is used to diagnose early-stage cancer and can frequently help determine whether a growth is benign or malignant. The doctor can obtain biopsies of inflamed or suspicious tissue for examination in the laboratory by a pathologist or cytologist. Cell scrapings can also be taken by introducing a small brush through the endoscope; this technique is especially helpful in diagnosing cancer or an infection.

Besides its function as an examining tool, an endoscope has channels that permit the passage of instruments. This feature gives the physician an opportunity to treat on the spot many conditions that may be seen in the esophagus, stomach, or duodenum. These treatments may include:

• removal of polyps and other noncancerous (benign) tissue growths
• stretching narrowed areas (strictures) in the esophagus
• stopping bleeding from ulcers or blood vessels
• removing foreign objects that have been swallowed, such as coins, pins, buttons, small nails, and similar items

Some of the diseases and conditions that are investigated, identified, or treated using EGD include:

• abdominal pain
• achalasia, a defect in the muscular opening between the esophagus and the stomach
• Barrett's esophagus, a precancerous condition of the cells lining the esophagus
• Crohn's disease and inflammatory disease of the small intestine
• esophageal cancer
• gastroesophageal reflux disease (GERD), a condition caused by excess stomach acid
• hiatal hernia
• irritable bowel syndrome
• rectal bleeding
• stomach cancer
• stomach ulcers
• swallowing problems

An EGD procedure is usually performed by a gastroenterologist, who is a physician specializing in the diagnosis and treatment of disorders of the digestive tract. GI (gastrointestinal) assistants, operating room nurses, or technicians may be involved in the collection of samples and care of the patient. Patients will be asked to either gargle using a local anesthetic or will have an anesthetic sprayed into their mouths onto the back of the throat to numb the gag reflex. Then the endoscopist will guide the endoscope through the mouth into the upper gastrointestinal tract while the patient is lying on his or her left side. The lens or camera at the end of the instrument allows the endoscopist to examine each portion of the upper gastrointestinal tract by observing images on a monitor. Photographs are usually taken for reference. During the procedure, air is pumped in through the instrument to expand the structure that is being studied and allow better viewing. Biopsies and other procedures will be performed as needed. The patient's breathing will not be disturbed and there will be little if any discomfort. Many patients fall asleep during all or part of the procedure.

Some patients should not have an EGD. This examination is contraindicated in patients who have:

• severe upper gastrointestinal (UGI) bleeding
• a history of such bleeding disorders as platelet dysfunction or hemophilia
• esophageal diverticula, which are small pouches in the esophagus that can trap food or pills and become infected
• a suspected perforation (puncture or rupture) of the esophagus or stomach
• recent surgery of the upper gastrointestinal tract (throat, esophagus, stomach, pyloric valve, duodenum)

An EGD is also contraindicated for those patients who are unable to cooperate fully with the procedure or whose overall condition includes a severe underlying illness that increases the risk of complications.

Diagnosis/Preparation

Certain medications (such as aspirin and the anti-inflammatory drugs called NSAIDs) should be discontinued at least seven days before an EGD to reduce the risk of bleeding. Patients will be asked not to eat or drink anything for at least six to 12 hours before the procedure to ensure that the upper intestinal tract will be empty. Before the procedure, patients may be given a sedative and/or pain medication, usually by intravenous injection.

Aftercare

After the procedure, the patient will be observed in the endoscopy suite or in a separate recovery area for an hour, or until the sedative or pain medication has worn off. Someone should be available to take the patient home and stay with them for a while. Eating and drinking should be avoided until the local anesthetic has worn off in the throat and the gag reflex has returned, which may take two to four hours. To test if the gag reflex has returned, a spoon can be placed on the back of the tongue for a few seconds with light pressure to see if the patient gags. Hoarseness and a mild sore throat are normal after the procedure; the patient can drink cool fluids or gargle to relieve the soreness.

The patient may experience some bloating, belching, and flatulence after an EGD because air is introduced into the digestive tract during the procedure. To prevent any injury to the esophagus from taking medications by mouth, patients should drink at least 4 or more ounces of liquid with any pill, and remain sitting upright for 30 minutes after taking pills that are likely to cause injury. The doctor should be notified if the patient develops a fever; difficult or painful swallowing (dysphagia); breathing difficulties; or pain in the throat, chest, or abdomen.

Risks

Endoscopy is considered a safe procedure when performed by a gastroenterologist or other medical professional with special training and experience in endoscopy. The overall complication rate of EGD performance is less than 2%; many of these complications are minor, such as inflammation of the vein through which medication is given. Serious complications can and do occur, however, with almost half being related to the heart or lungs. Bleeding or perforations are also reported, especially when tumors or strictures have been treated or biopsied. Infections have been reported, though rarely; careful attention to cleaning the instrument should prevent this complication. Perforation, which is the puncture of an organ, is very rare and can be surgically repaired if it occurs during an EGD.

Normal results

The results of the procedure or probable findings are often available to the patient prior to discharge from the endoscopy suite or the recovery area. The results of tissue biopsies or cell tests (cytology) will take from 72–96 hours. Normal results will show that the esophagus, stomach and duodenum are free of strictures, ulcers or erosions, diverticula, tumors, or bleeding. Abnormal results include the presence of any of these problems, as well as esophageal infections, fissures, or tears. An increasingly common finding is medication-induced esophageal injury, caused by tablets and capsules that have lodged in the esophagus. These injuries are thought to be associated with damage to the esophageal tissue from gastrointestinal reflux disease (GERD) and the related exposure of the esophagus to large amounts of stomach acid.

BOOKS

Edmundowicz, Steven. "Endoscopy." In The Esophagus, 3rd ed., edited by Donald O. Castell and Joel E. Richter. Philadelphia, PA: Lippincott, 1999.

Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications, 5th ed. St. Louis, MO: Mosby, 1999.

ORGANIZATIONS

American Society for Gastrointestinal Endoscopy (ASGE). 13 Elm Street, Manchester, MA 01944-1314. (978) 526-8330. <www.asge.org>.

Society for Gastroenterology Nurses and Associates (SGNA). 401 North Michigan Avenue, Chicago, IL 60611-4267. (800) 245-7462. <www.sgna.org>.

OTHER

Johns Hopkins Consumer Guide to Medical Tests. Upper Gastrointestinal Endoscopy. <www.hopkinsafter50.com>.

Maggie Boleyn, RN, BSN L. Lee Culvert