FES Flashcards
No light at distal end
- Light source plug - Plugged in & on.
- Not in stand by mode.
- Clean scope tip.
- Burnt out Bulb.
- Dirty distal lens.
Irrigation solution
Sterile water
Saline crystallizes in channel
Out of focus
- White balance
- Clean lens
No irrigation
- Bottle contains water
- Bottle connected to umbilical cord
- Connection too tight
- Bottle lid too tight
- Power on
- Occluded/stuck valve
No insufflation
- Umbilical cord seated in light source. Needs to be screwed in
- Power turned on
- Stuck/Occluded valve
Clogged valve/nozzle
- Clean valve
- Flush channel with cleaning solution, followed by clean water
Unable to pass instrument
- Correct size selected
- Instrument tip closed
- Decrease tip deflection
Routine “high level disinfection”
Gluteraldehyde
Disinfection doe not work with foreign materials
Sterile “Overnight” cycle
Ethylene Oxide Gas
Location of suction port
5 - 7 O’Clock
Cart
- Monitor
- Video processor
- Light source
- Water bottle
- Image printer/recorder
Umbilical cable
Air & water valve
Umbilical cable - Partial depress
Air
Umbilical cable - Complete depress
Cleans lens
Withdraws air to force water into camera
Light cord
Coherent stacks of optic fibers
Positioning: ERCP
Prone with head to right
Left lateral decubitus if difficulty intubating duodenum
Supine: Associated with higher difficulty in intubating the papilla
Positioning: Colonoscopy
Left lateral decubitus
Positioning: APR
Supine
Fiber optic endoscope
Fragile
Fibers break = Dark spots on screen
Bronch and choledocoscopes only
Video endoscopes
Contraindication: Stricture (Can test with dummy pill)
Pregnancy
MRI
Dysphagia (Can endoscopically be placed in stomach)
Prep: NPO x 8hrs
Simethicone, Reglan, PEG
Timing of endoscopy in ESRD
Day after HD
Risk during Colonoscopy
Minor: Hypoxia (5.6%), hypotension, bradycardia, arrhythmia
Preprocedural labs
None
Cardiac Hx: EKG
Respiratory Hx: CXR
Coags: Hypocoaguability
General anesthesia: Pregnancy screen
Iso-osmotic (Polyethlene glycol PEG)
Safe in CHF, ESRD, Elecrolyte abnormaities, Liver disease
Hyperosmolar (Magnesium Citrate)
Better tolerated
Induces CCK release
Sodium Phosphate
Adverse effect: Hyperphosphatemia, Hypokalemia
Contraindication: CKD, AKI, CHF, ACS, lleus, Ascites, Pediatrics
Indication for antibiotics
Endocarditis risk (Prosthetic valve, prior endocarditis, surgical shunt, Tetrology of fallot, congenital heart disease, MVP, HOCM, valvular disease)
Esophageal dilation
Variceal sclerotherapy
ERCP (w/ ductal obstruction)
Pancreatic lesions
Percutaneous gastrostomy tubes
Safe INR
<1.5
ASA/NSAIDs
No contraindication for endoscopy
Post Colonoscopy
Major: Perforation, Bleeding, Post scope syndrome, Bronchospasm (0.07%)
Mortality: Colonoscopy
0.007%-0.001%
Mortality: EGD
0.0001% (1:10,000)
Procedural monitoring
Pulse Ox
Verbal stimulation
End tidal CO2
Vitals q 5 min
Telemetry
Risk factors for ERCP desaturation
Age >60
ASA >3
Procedural length
Monitoring: COPD
Use capnography to detect CO2 retention
Prior to each drug administration
Always check BP
Propofol
Preferred
Continuous End tidal and EKG
Midazolam
Shorter duration
Less venous irritation
Water soluble
Anterograde amnesia
Flumazenil
Risk of seizures with chronic benzodiazepine use
Remifentanyl
Better than propofol
Better HD stability
Better patient satisfaction
Shorter recovery time
Same respiratory depresssion
Half life of Narcan
60-90 minutes
Nitric oxide
Not tolerated well
Precedex
HD instability
Required analgesic
Longer recovery
Difficult administration
Contraindications: Small caliber endoscopy
Coagulopathy
Prior naso/oro/hypopharynx surgery
Complications: Small caliber endoscopy
Vagal stimulation
(Hypotension, hypoxia, epistaxis)
Anesthesia: Small caliber endoscopy
Lidocaine + Benzocaine + Oxymetazoline
Side effect of Lidocaine + Benzocaine + Oxymetazoline
Aspiration
Methemoglobinemia
Anaphylaxis
Complication rate: EGD
1.4%
Complication rate: Colonoscopy
0.42%
Most common: Missed polyps
Conscious sedation
Higher rate of mortality and morbidity
Bispectral index (BIS) monitoring
Score 0-100
0 = Coma
82 = Endoscopy
100 = Awake
Low accuracy in detecting deep sedation
Discharge criteria
Alert
Ambulating
Tolerating Clears
Surveillance: FAP
Q 1-2 years
Age: 10
Rule out duodenal neoplasm with EGD
Surveillance: Barretts (Low
Risk)
< 3 cm
Q 2 years (No dysplasia)
Surveillance: Barretts (Medium risk)
> 3 cm
Q1 year
Surveillance: Barretts (High risk)
Low grade dysplasia
Q 6 months
Surveillance: Varices w/ sclerotherapy
Q 6-8 weeks
Surveillance: Gastric or esophageal ulcer
Q6 weeks
Until ulcer healed w/ biopsy/brushing
Surveillance: Pernicious anemia
Single endoscopy
No follow up
Contraindications: EGD
HD unstable
Cannot tolerate sedation
Positioning: EGD
LLD
Head elevated
Turn to right for fundus bleeding
Technique: EGD scope introduction
Insert to posterior pharyngeal wall
Tip up to epiglottis
Deflect down to aretynoids
Marker: 15 cm
Technique: Passing duodenal superior angle
90 Right
Angle up
Dial right
Avoiding aspiration on EGD
Bite block reverses jaw thrust
Monitor
- Gastric distention
- Sedation level
- Head elevation
- Fluid removal from gastric fundus
- Decompression prior to scope withdrawal
Areas of perforation: EGD
Cricopharyngeus
Pharynx
Superior duodenum
Morbidity (Most common): EGD
Respiratory depression (drug induced) - 70%
Airway obstruction
Biopsy: EGD
Only biopsy mucosal lesions
Submucosal lesions = EUS/ FNA
Surveillance: Colonoscopy
Age: 45 - q10 years
First degree relative with colorectal cancer at 40 yrs or 10 yrs before youngest relative
< 60 years onset : q 5 years
> 60 years onset: q 10 years
Surveillance: HNPCC
Age: 20 - 25 years
Q 1-2 years colonoscopy
10 years prior to family member diagnosis
Proctoscope
Cannot assess posterior wall of rectum
Contraindications: Colonoscopy
Absolute: Peritonitis
Relative: Anal fissure, recent MI, PE, SBO
Scope size that reaches cecum
160 cm
Scope size for flex sigmoidoscopy
70 cm
Technique: Rectosigmoid junction
Tip deflection
Counterclockwise torque
Clockwise torque
Technique: Colonic loops
Withdraw/ jiggle scope
Apply external pressure on sigmoid to hold loop in place and prevent formation
Location of torque removal
Descending colon/sigmoid (circular muscle) junction
Techniques: Splenic flexure
Slit or fold
Down + Left
Place patient on back or to the right to open slit
Shorten scope once traversed (<50 cm)
Transverse colon
Triangular
Evacuate air to lessen difficulty of traversing hepatic flexure
Apply abdominal pressure/ place patient on back
Hepatic flexure
Straight up
Blue hue of liver
Technique: Ascending colon
Clockwise torque
Tip down + right
Loop reduction
Suction
Place patient to right/ back
70 cm
Anatomy: Ascending colon
Green mucus
Large diameter
Cecum
Crow’s feet (confluence of tenias and ICV) —> Appendiceal orifice
Technique: Terminal Ileum
ICV at bottom of screen
Tip down to valve
Insufflate to open valve
80/90 cm
Can retroflex into cecum = high risk of perforation
Scope withdrawal time
6 minutes
Adenoma detection rate: Men 30%, WOmen 20%
Poor prep
Can abandon colonoscopy
Stool balls in large diverticulum will be present despite repeat preps
Mucosa stuck in port
Remove cap on instrument
Rigid endoscopy
Most accurate way of localizing rectal lesions and measurement
Localizing lesion for removal
Tattooing with carbon microparticles
Circumferential (4 times) 1mL into submucosa
Distal to lesion
Vagal response to colonoscopy
Cessation of scope movement
IVF
Lipoma
No need for resection
Yellow bulge into lumen with mucosal covering
Colitis?
Biopsy
Angiodysplasia
Most common in right colon
If no bleeding no therapy needed
Perforation: Colonoscopy
Scope torquing
High air pressure
Blow out of diverticulum
Location: Rectosigmoid
Trend in mucosal ischemia
White -> Green -> Black
Scope with side view
Duodenoscope
Allows for visualization of duodenal strictures
Must loop along greater curvature of stomach to enter pylorus
Blind advancement into esophagus (Maintain center to avoid injury)
External source of illumination
Xenon arc
Halogen filled tungsten filament lamp
LED
Combination of button and scope channel
Blue: Air (Hover)/Water (Press)
Red: Suction & Biopsy
If no irrigation channel
Use suction/biopsy
How many wheels does a scope have
Two wheels
Brush biopsy detection rate
30-60%
Higher than FNA
Indications for biopsy in ERCP
Ductal pathology: Ampulla/ductal biopsy
Chronic pancreatitis
Pancreas divisum
Malignany
Strictures
Ductal Injury
Jaundice
Cholangiitis
Gallstone pancreatitis
Ductal dilation
FNA detection rate
6-30%
Technique: Sphincterotomy
11 O’clock on ampulla
Blend setting
15-20 J
Higher risk of post procedural pancreatitis
3-5%
Endoscopic balloon dilation
Stone removal: Balloon
Good: Multiple stone removal
Bad: Small stones in large duct, sharp stones
Adverse effect: Post procedural pancreatitis
Stone removal: Basket
Good: Large stone
Intrahepatic stones
Small stones in large ducts.
Large stone
Stent (plastic) and repeat ERCP
Biliary stent
Patency: 3-6 months
Replace if clogged (Higher pancreatitis rate 3-6 months)
Placed across ampulla
Pancreatic stent
Patency: 3 weeks
Risk of damage to pancreatic duct
Self expanding metal stents
Longest patency rates (Especially if covered)
Palliation/Malignant obstruction
Nasobiliary tube
Good: Does not need repeat endoscopy for removal
Contraindication: ERCP
Absolute: None
Relative: Coagulopathy
HD instability
Pregnancy
Severe gastritis
Duodenal strictures
Antiplatelets
Hold 10 days prior
Hold 5-7 days post procedure
Warfarin
Hold 5 days before procedure
Transition to Lovenox
Hold Lovenox 1 day prior to procedure
Technique: Intubating duodenum with Duodenoscope (side viewing scope)
Turn tip to right
Location of major papilla in D2
1-2 O’clock
Pancreatic duct cannulation in ampulla
1-3 O’clock
CBD cannulation in ampulla
11-12 O’clock
Post ERCP Risk reduction
Indocin 100 mg
Selective cannulation with guidewire prior to contrast
Stent pancreatic duct if CBD cannulation was difficult
Limit contrast in pancreatic duct
Risk factors for post ERCP cholangitis
Manipulation
Contrast in the biliary tree that was not fully decompressed
Duodenal stricture preventing ERCP
Dilate with forward viewing scope —> repeat ERCP
Perforation of Biliary tree
0.5%
Transpapillary & Transbadominal drainage
Avoid surgery in the acute period
Duration of post procedure bleeding
2 Weeks
Most common: Immediately or when eschar sloughs (7-8 days)
Snare cautery
Repeat thermal therapy is not advised
Risk factor for rebleeds
Active bleed
Visible vessel
Red/Dark/White maturing clot
Ulcer >2 cm
Age >60
Comorbidities
Shock
Coagulopathy
Anemia
Bleeding risk factors mandating endoscopic intervention
Active bleed
Visible vessel
Risk factor for perforation when achieving hemostasis
Repeated use of Thermal energy
Can occur up to 2 weeks post procedure.
Delayed recognition leads to heightened morbidity & mortality
Improve visualization during bleeding by
Lavage
Irrigation
Clot removal via position change
Warm fluid
Prevents hypothermia and cogulopathy
Larger caliber evacuation tubes
Edwald - Used for lavage
Gastric motility agents to allow for blood passage
UGI Bleed: Erythromycin, Reglan
LGIB: Polyethylene glycol
Nonthermal Technique for hemostasis
Submucosal injection
Band ligation
Endoscopic clips
Endoloop
Balloon tamponade
Band ligation complication (Esophageal varices, internal hemorrhoids)
Esophageal ulceration
Stricture formation
Less complications than sclerotherapy, same level of success
Poor visualization during banding
Submucosal injection
Epinephrine (1:10,000) +/- Sclerosant solution
Endoscopic clip
When thermal energy use is dangerous or has been unsuccessful.
Lower rate of success
Difficult in post pyloric bulb or requiring retroflexion (fundus, cardia)
Location: Thin walled areas
Balloon Tamponade
Endoscopic sphincterotomy
Risk of overinflation and tearing
Coaptive Hemostasis
Probe - Tamponade + Thermal energy
Occluding vessel via pressure from multipolar probe and applying energy
Decreases heat sink effect
Better visualization
Size limit: 2 mm
Bipolar & Heater probe
Most common
Allow use of irrigation
Sizes: 2.3 mm & 3.2 mm – Larger sizes require therapeutic channel
Deeper areas
Monopolar cautery
Higher risk of full thickness injury
Deeper areas
Variables in probe success
Probe size
Force of application
Power setting
Duration of energy delivery
Argon plasma coagulation (APC)
Advantage: Does not dislodge clot
Superficial (Palliative, Cleaning up)
Broad areas [Gatric antral vascular extasis (GAVE)]
Thin areas [Cecum]
Disadvantage: High perforation risk
No tamponade effect
Cannot reach deeper
Cold biopsy
Spiked forcep - Allows for multiple specimens in a single pass without tissue loss
Colonic gas
Replace colonic gas with air to decrease amount of flammable gas
Resective Technique
- Snare polypectomy
- Transection
Snare polypectomy
Pedunculated polyp
Pull polyp away from bowel, broad contact
Transection
Short monopolar bursts -> Tighten snare
Polyp retrieval
Small: Suction into trap
Large: Suction into tip w/ scope withdrawal
Retrieval net
Lost polyp: Stool straining
Sessile Polyp
- Elevate submucosa w/ saline/hyaluronic acid
- Place snare around lesion
- Suction polyp into port to raise it
*Need two-channel therapeutic endoscopes
Failure of sessile lesion to rise with saline injection
Involvement of submucosa
Endoscopic resection not advisable
Safe excision needed for (raised base with saline)
- Larger sessile polyps
- Angulated portions of intestinal tract
- Thin walled areas of colon (cecum)
Piecemeal Excision
- Polyp stalk >2-2.5 cm
- Polyp base >1-1.5 cm
Safe areas to perform multiple snare excisions
Thicker or extraperitoneal areas
(Rectum)
Periampullary duodenal adenoma excision
Consider biliary & pancreatic duct stenting
Post polypectomy syndrome
Focal pain and tenderness without free air or exravasation on imaging
Treatment: Bowel rest & antibiotics
Sampling technique
- Cold biopsy
- Spiked biopsy forcep
- Hot biopsy
- Brush cytology
- Repetitive biopsy (Required therapeutic endoscopy with 3.7 mm port)
Submucosal Pathology
Requires endoscopic ultrasound (EUS) and dual channel therapeutic endoscopy to delineate bowel wall depth
Enhanced visualization
Chromoscopic, spectroscopic, and magnification techniques
Lugol solution (1-2%)
Stains glycogen containing normal esophageal squamous mucosal cells
Methylene Blue (0.5-1%)
Stains intestinal absorptive epithelium
Identifies areas of intestinal metaplasia and focal carcinoma
Spectroscopy
Distinguishes dysplastic and malignant cells from benign epithelium
Narrow bandwidth imaging defines differences in tissue vascularity
Magnifying Endoscope/ Chromoscopes
Delineates mucosal crypt architecture
Risk of more advanced colonic neoplasia (delayed diagnosis)
Nd:YAG
Deep areas of hemostasis
Alcohol injection
Inexpensive ablative therapy
Unpredictable depth of infiltration
Photodymanic therapy
Protoporphyrin derivative (porfimer sodium) compound injected IV and concentrates within neoplastic tissue
Wavelength laser light deployed causing photochemical reaction to porfimer sodium leading to production of singlet oxygen and targeted cell death
Advantage: Barrett’s ablation (Dysplastic)
Palliative therapy (esophageal carcinoma)
Percutaneous Endoscopic Gastrostomy (PEG)
Indications:
1. Functioning GI tract but cannot take enteral feeds
2. Gastric decompression
3. Gastropexy for volvulus reduction
Contraindication:
1. Massive ascites
2. Diffuse gastric cancer
3. Distal obstruction
Relative: Threat to pulling out tube
Percutaneous Endoscopic Jejunostomy (PEJ)
- Gastroparesis
- Atony
- Functional GOO
- Reflux/aspiration
Pull Technique (PEG)
Attach pull PEG at oral end of guidewire
Pull retrograde through mouth
Secure PEG with bumper
Replacing PEG & PEJ
When no longer functional
PEG leaks
Loosen PEG, prevent movement
GC fistula
If early, operative closure
PEG dislodged w/ peritonitis
OR
Closure of track
Place tube elsewhere
Push Technique (PEG)
Advance PEG over stiff nonlooped wire
Secure external bumper
Russel Approach (PEG)
Patients with laryngeal/esophageal carcinoma
Avoids seeding cancer
Stomach held up by T fasteners
Needle -> Dialator -> Balloon tipped catheter
PEJ Placement
Pediatric colonoscope
Small G tube
Fluouroscopy
Dilations
Do not dilate beyond 3 sequential bougie sizes
Dyphagia relieved at what bougie size
40F
Where can objects not be retrieved endoscopically
Treitz to Treves (IC valve)
Stones in common hepatic duct proximal to cystic duct
Choledocotomy
Stone removal on IOC
- Saline flush
- Glucagon to flush through Oddi
- Basket or forcep
Foreign body amenable for removal
- In esophagus
- Irregular and in stomach
- Rectum or sigmoid
https://img.medscapestatic.com/pi/meds/ckb/43/35343tn.jpg
Barrett’s Esophagus
https://www.researchgate.net/publication/319412550/figure/fig1/AS:533599172923392@1504231364579/Endoscopy-revealed-an-esophageal-perforation-in-the-left-side-of-the-upper-thoracic.png
Perforation
https://img.medscapestatic.com/pi/meds/ckb/88/35688tn.jpg
Gastric ulcer
https://www.gastrotraining.com/wp-content/uploads/2010/07/image00110.jpg
Zenker Diverticulum
https://journal.medizzy.com/wp-content/uploads/2022/06/imageXml-2.png
Hiatal Hernia
https://www.endoscopy-campus.com/wp-content/uploads/2016/07/Grad_II_Bild1.jpghttps://www.endoscopy-campus.com/wp-content/uploads/2016/07/Grad_II_Bild1.jpg
Esophageal varices
https://f6publishing.blob.core.windows.net/cdc8fdfa-78d9-4514-b143-bf5b514b534d/WJGE-2-252-g003.jpghttps://f6publishing.blob.core.windows.net/cdc8fdfa-78d9-4514-b143-bf5b514b534d/WJGE-2-252-g003.jpg
Esophagitis
http://3.bp.blogspot.com/-lMaa7zKBbIk/Teqb96ej_gI/AAAAAAAACkY/8JdM77nHCvs/w1200-h630-p-k-no-nu/schatzki_ring.jpg
Schatzki Ring
https://upload.wikimedia.org/wikipedia/commons/4/49/Endoscopic_view_of_fundic_gland_polyps.jpg
Fundic gastric polyp
https://img.medscapestatic.com/pi/meds/ckb/65/291065tn.jpg
Gastric adenocarcinoma
https://www.researchgate.net/publication/283184318/figure/fig4/AS:614032855797775@1523408249679/Colonoscopic-images-of-hypertrophic-Peyers-patches-in-the-terminal-ileum_Q640.jpg
Peyer’s patches in terminal ileum
https://upload.wikimedia.org/wikipedia/commons/thumb/a/a5/Argon_plasma_coagulation.jpg/300px-Argon_plasma_coagulation.jpg
Angiodysplasia
https://study.com/cimages/multimages/16/cc463b5c-0d7e-4127-8929-116b6776fc4d_intestinal_ulcer.jpeghttps://study.com/cimages/multimages/16/cc463b5c-0d7e-4127-8929-116b6776fc4d_intestinal_ulcer.jpeg
Sterocoral ulcer
https://media.sciencephoto.com/c0/16/67/21/c0166721-800px-wm.jpg
Crohn’s Colitis
https://www.gastrointestinalatlas.com/imagenes/UlcerativePseudoPolipois4.jpg
Ulcerative colitis
https://static-02.hindawi.com/articles/grp/volume-2013/192794/figures/192794.fig.001d.jpg
Radiation enteritis
https://www.bmj.com/content/bmj/355/bmj.i6600/F3.large.jpg
Ischemic colitis
https://healthjade.com/wp-content/uploads/2018/03/Pseudomembranous-colitis.jpg
C diff
https://www.researchgate.net/publication/346919088/figure/fig5/AS:1022616718540809@1620822233607/Endoscopic-signs-of-colonic-lipoma-including-A-pillow-sign-and-B-naked-fat-sign-with.jpg
Lipoma
https://www.frontiersin.org/files/MyHome%20Article%20Library/973883/973883_Thumb_400.jpg
Melanosis coli
Forrest Classification
Bleeding ulcers
Hill Grade
Hiatal hernia
I: Ring of tissue around scope
II: Widening of angle of his
III: Lumen does not close around scope
IV: Hiatal hernia present at all times, sphincter axial
Los Angeles
Reflux esophagitis
A-D
Prague
Barrettes’ Esophagus
Right combination of button and channel
Suction + Biopsy
No channel for irrigation
Suction + Biopsy channel
Point to discuss in informed consent
Complications
Preparation: Sigmoidoscopy
Enema
High bleeding risk procedure
Esophageal dilation
Request anesthesiologist specialist
Increased risk of complications due to comorbidities
Boston bowel prep classification
Bowel prep classification
Enteroscopy
Double balloon - Gold standard
Scope: Proximal jejunum
Pediatric scope
Complication: Billroth II
Pancreatitis
Perforation
Retrograde access via distal duodenum
ERCP: Billroth II
Retrograde access from distal duodenum
Indication: Sphincterotomy
Leaks
Obstruction
Stent placement
Post sphincterotomy bleeding
Thermal & Endoclips
ERCP Anatomy
CBD = Parallel to duodenum
Pancreatic duct = Perpendicular to duodenum
Minor papilla: Proximal to major papilla. Harder to intubate
Cytology
When tissue removal is not needed
Esophageal candidiasis
EUS Probe type
Curvilinear
Biopsy on EUS can be taken up to the
3rd level of mucosa
1st: Superficial mucosa
2nd: Deep mucosa
3rd: Submucosa
EUS/FNA Post procedure pancreatitis
<2%
Lymph node anatomy
Benign: Triangular
Malignant: Hypoechoic
Size > 1cm
Irregular borders
Magnification on standard high resolution endoscope
30x
Magnification of zoom endoscope
150x
High definition scope detects dysplasia
3 fold
NICE classification
Hyperplastic: Lighter/Same as background
Adenoma: Browner than background
Invasive cancer: Dark brown, patchy white
NBI zoom detects dyplasia in Barrett’s: sensitivity & specificity
95%
DISCARD Trial
If NBI used, pathology is not needed for polyps <10 mm
Technique: Distal duodenum
Torque clockwise
Technique: Incisura
Torque ounterlockwise
Withdraw - See body & Cardia
Rotate endoscope 360 at GE junction
Technique: Rectum
Flex tip
Bypass canals
20 cm
Rockball Score
Likelihood of death with GIB