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Upper Endoscopy

Editor: Joseph Sung

1. Upper Endoscopy: Overview

Joseph Sung & Peter Cotton

Young endoscopists may be surprised to hear that the first commercial gastroscopes of the modern (fiber-optic) era, in the late 1960s, were indeed gastroscopes. They had side-viewing optics and were designed to examine only the stomach, using appropriate rotation, and some up–down tip deflection.

This design grew out of the preoccupation of the Japanese with their burden of gastric cancer (and followed the widespread use of side-aimed gastro-cameras).

Western doctors wanted also to be able to examine the esophagus and duodenum, because of the prevalence of reflux disease, esophageal cancer, and duodenal ulcers. An American company developed the first forward-viewing 'panendoscope' in the late 1960s, and esophago-gastro-duodenoscopy (EGD) was born. Through the 1970s, instruments were refined progressively, and the images gradually improved.

The next major technical breakthrough (in the early 1980s) was the introduction of video-endoscopy. This converted a rather 'private' experience into a team event, with something for all to see (including the patients).

Video-endoscopy completely revolutionized teaching. Previously the endoscopic view could be shared only through a clumsy side-arm fiber-optic 'teaching attachment', but this (at least initially) degraded the quality of both images considerably. Movie and TV cameras were bulky and were used only rarely and with difficulty. Digital capture opened a new world of image recording, manipulation, storage, and transmission.

The next two decades saw considerable changes in the details of endoscope design (e.g. immersibility, minituarization, and control mechanisms), but not in the basics—that is until the recent extraordinary development of the capsule endoscope. This is indeed the start of a new era.

The evolution of endoscopy as a clinical tool has been a fascinating journey (at least to those who lived through it), and certainly dramatic. The ability to take target biopsies proved to be a watershed. Before that, endoscopists were scarce animals, and their enthusiasms and opinions were largely ignored, and sometimes ridiculed, by mainstream medicine and gastroenterology.

Biopsy brought almost instant respectability, since pathological reports were and are somehow sancrosanct. This is a little curious, since pathologists are really only endoscopists looking down rigid instruments, but perhaps our trust in their reports speaks to the quality of their training and experience. (There is a message here for endoscopists, who have, at least in the West, paid too little attention to the subtleties of image interpretation, relying on biopsy to sort out anything that looks odd.)

Through the 1970s we gradually accumulated the data (much of it rather biased) to show the superiority of endoscopy over the standard tool of the day — the barium meal. But, sceptics continued to argue—'so what'? For example, an NIH conference in 1980 questioned the value of endoscoping bleeders, since studies did not appear to show any outcome benefit.

One of us argued rather strongly at the time that the failure to show benefit with a more accurate diagnostic tool showed simply that the treatments were inadequate, and needed to be improved. Fortunately this call was answered quickly with the development of endoscopic techniques for hemostasis (and the NIH got the message).

Without question it was the development of effective therapeutic methods that guaranteed the place of digestive endoscopy in the mainstream of clinical practice.

The late 1970s and 1980s saw the establishment of many endoscopic therapies, for the management of dysphagia, foreign bodies, strictures, polyps, and enteral nutrition (in parallel with the exciting developments in other areas, such as colonoscopic polypectomy and biliary sphincterotomy for stone removal). All of these largely replaced more expensive and dangerous surgical procedures, a fact which led sadly to complex 'turf' issues, which are still being resolved. The boundary between surgery and interventional endoscopy is artificial and unhelpful. The leaders of our professions must redraw the traditional structures for training and practice- for our patients benefit.

The undoubted success of digestive endoscopy brings significant responsibilities. We have to ensure that these techniques are widely available when needed, and to high quality standards. Training issues are important, and are being addressed thoughtfully. Keeping up to date in practice is an even bigger challenge, since our field continues to expand. We are all busy people, and the literature proliferates. While there is no substitute for reading all of the source data, who has the time?

This ebook/annual series on 'Advanced Endoscopy' seeks to help by providing current and authoritative reviews of key areas of interest, concern, and controversy. We are indeed fortunate that so many international authorities have agreed to share their wisdom, and to make sure that it is updated regularly. This section focuses on aspects of Upper Endoscopy. Several related general issues (e.g. disinfection, sedation, and teaching) are covered in the section on 'Practice'.

Copyright © Blackwell Publishing, 2003

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Diagnostic upper endoscopy
  Normal esophagus
   Hiatus and Z-line
   Glycogenic acanthosis
   GEJ variants
  Abnormal esophagus
   Erythematous areas and erosions
   Hiatal hernia
Endoscopy in esophagitis
  Endoscopic staging of esophagitis
   Savary–Miller classification
   Hetzel–Dent classification
   MUSE classification
   Los Angeles classification
  Other lesions associated with GERD
   Schatzki's ring
   Mallory–Weiss tear
  Postoperative changes after fundoplication
  Endoscopic biopsy
  Chromoendoscopy in GERD
Endoscopic management of esophageal strictures
  Esophageal dilation
   Principles of esophageal dilation
   Mechanical dilation
   Pneumatic (balloon) dilation
   Techniques of dilation
   Dilation of distal esophageal (Schatzki's) rings
  Concomitant medical therapy for strictures
  Refractory strictures
   Intralesional injection of corticosteroids
   Other endoscopic methods for strictures
  Complications of esophageal stricture dilation
Endoscopic therapies for GERD
  Radiofrequency energy delivery (Stretta®)
   Stretta® technique
   Mechanisms of action
  Endoscopic implantation of bulking agents
   Inert polymer microspheres
   Expandable hydrogel prosthesis (Gatekeeper™)
  Endoscopic plication systems
   Endoluminal gastric plication (ELGP)
   Boston Scientific device
Outstanding issues and future trends
  Barrett's esophagus
  Esophageal cancer
Barrett's esophagus
  Definition of Barrett's esophagus
   Long-segment Barrett's esophagus (LSBE)
   Short-segment BE (SSBE)
   Ultra-short BE (SSBE)
  Risk factors for Barrett's esophagus
   Gastroesophageal reflux disease (GERD)
   H.pylori and GERD
   Age, sex, and race
   Other risk factors
  Epidemiology of Barrett's esophagus
  Natural history of Barrett's esophagus
  Pathogenesis of Barrett's esophagus
   Helicobacter pylori
  Novel diagnostic techniques for Barrett's esophagus
   Magnification/high-resolution endoscopy
   Other investigational techniques
   Endoscopic ultrasonography (EUS)
   Light induced fluorescence (LIF)
   Optical coherence tomography (OCT)
   Reflectance and elastic light scattering spectroscopy
   Confocal microscopy
   Raman spectroscopy (RS)
  Screening for Barrett's esophagus
   Esophagogastroduodenoscopy (EGD)
  Diagnosis of Barrett's esophagus
  Management of Barrett's esophagus
   Utility of surveillance
   Chemoprevention of Barrett's esopahgus
   Medical reduction of acid load
   Endoscopic therapy for Barrett's esophagus
   Thermal ablation: Monopolar/bipolar/heater probe electrocoagulation
   Photodynamic therapy (PDT)
   Endoscopic mucosal resection (EMR)
   Surgery for Barrett's esophagus
  Barrett's esophagus conclusion
Esophageal cancer
  Risk factors for esophageal cancer
  Epidemiology of esophageal cancer
  Natural history of esophageal cancer
  Diagnosis of esophageal cancer
   Clinical features
   Laboratory data
  Management of esophageal cancer
   Ablative techniques
   Endoscopic mucosal resection (EMR)
   Endoscopic dilation
   Injection therapy (EIT)
   Esophageal endoprosthesis (EE)
   Surgery for esophageal cancer
   Radiation therapy for esphageal cancer
   Chemotherapy for esophageal cancer
  Esophageal cancer conclusion
  Outstanding issue and future trends
  Diagnostic methods
   Endoscopy, when and where?
   Lavage before endoscopy?
   Ulcer stigmata
   Removing clots?
Endoscopic hemostasis
  Available techniques
  Injection hemostasis
  Thermal methods
  Combination methods
Care after bleeding
  Acid suppression
  Aspirin and NSAIDs
  Early rebleeding
  Predictors of rebleeding
   Ulcer stigmata
  Prevention of rebleeding
  Treatment of rebleeding
  Late rebleeding
   NSAIDs and aspirin
   Acid suppression
Non-ulcer bleeding
Issues and future trends
  New suturing devices, clips, and bands
  Visualization (scope size)
  Airway protection/anesthesia
National history of variceal bleeding
  Mechanism of bleeding
   Variceal stigmata
  Risk of bleeding
  Prognostic indices
Endoscopy: general
Endoscopic treatments
  Endoscopic injection sclerotherapy (EST)
  EST technique
   Accessory devices
   Post-EST care
   EST—proof of value?
  Endoscopic variceal ligation (EVL)
   Multi-fire devices
  Comparing EST and EVL
   Cyanoacrylate (Histoacryl®) injection
  Complications of EST and EVL
  Detachable mini-snare
Treatment of ACUTE variceal hemorrhage
  Pharmacological treatments
  Combined endoscopic and pharmacological therapy
   Comparing TIPSS with endoscopic treatments
  Consensus approach to acute bleeding
  Combined endoscopic therapies vs. single therapy
   Synchronous combinations
   Metachronous combinations
Prophylactic treatment of esophageal varices
  Detection and surveillance
  Endoscopic prophylaxis
Gastric varices
Endoscopic ultrasonography in variceal hemorrhage
  EUS and gastric varices
Outstanding issues and future trends
  H.pylori-associated gastritis
  Gastritis: clinical manifestations and symptoms
Ulcer disease
  H.pylori and ulcers
  H.pylori: the pathogenetic pathway
   Pattern and phenotype of gastritis in association with H. pylori
   Alterations in the homeostasis of gastric hormones and acid secretion related to H. pylori
   Gastric metaplasia in the duodenum is a prerequisite for H. pylori colonization
   Interaction of H. pylori with the mucosal barrier
   Ulcerogenic strains of H. pylori
   Genetic factors and H. pylori
   The therapeutic proof of causality: H. pylori and ulcers
  Ulcers: clinical features and diagnosis
   Test and treat
   Endoscopic diagnosis
Treatment of peptic ulcers
  Acid suppression
  H.pylori eradication
NSAIDs and gastrointestinal pathology
  Clinical and histological characteristics of NSAID-related injury
  Epidemiology of NSAIDs and gastric injury
  Risk modifiers of injury with NSAIDs
   Dosage and type of NSAID
   Prior ulcer
   H.pylori infection and NSAIDs combined
  Management of NSAID-associated gastrointestinal toxicity
   Selective COX-2 inhibitors
   Prophylaxis against NSAID injury
Outstanding issues and future trends
  Gastric carcinoma
  Premalignant gastric lesions
  Gastric polyps as premalignant lesions
   Adenomatous polyps
   Cystic fundic polyps
   Hyperplastic or hyperplasiogenic polyps
   Fibro-inflammatory polyps
   Hamartomas and juvenile polyps
   Other polyps
  Premalignant conditions in the gastric mucosa
   Chronic atrophic gastritis
Histopathological classification of gastric neoplasia
  TNM classification
  Vienna classification
  Geographical variations of risk
  Proximal and distal gastric cancer
  Causal factors
   Cancer at the EG junction
   Cancer in the distal or non-cardia stomach
  Time trends in incidence and mortality from gastric cancer
   A generalized decline of the disease
   Time trends in Japan
Gastric carcinogenesis
  From inflammation to cancer
  The APC mutation in gastric carcinogenesis
  Mutagenesis in the Lauren classification
  Hereditary gastric cancer
Symptoms of gastric cancer
Endoscopy in the diagnosis of gastric cancer
   At the EG junction
   In the non-cardia stomach
  Technological advances in equipment
   Digitization of the image
   Spectroscopic techniques
  Macroscopic appearance of digestive neoplastic lesions
  Endoscopic classification of superficial neoplastic gastric lesions
   At the EG junction
   In the non-cardia stomach
Non-endoscopic procedures in the diagnosis of gastric cancer
  Radiological imaging and ultrasound
  Molecular biology
   Proliferative indices
   P53 protein and TP53 mutations
  Staging of gastric cancer
Clinical relevance of early diagnosis of gastric cancer
Treatment decisions for gastric cancer
  The role of tumor staging
  Treatment with curative intent
  Other therapeutic options
Endoscopic treatment with curative intent
  Technique of endoscopic mucosal resection (EMR)
   EMR with a cap [97]: EMR-C (aspiration method)
   EMR with a ligating cap [102]: EMR-L (aspiration method)
   EMR with tissue incision [103,105,107,108]
   EMR grasp-method [100,103]
  Indications for EMR
  Results and complications of EMR
Surgery for gastric cancer
  Extent of the resection
  Palliative gastrectomy
Chemoradiation in advanced gastric cancer
  Chemoradiation protocols (palliation)
  Adjuvant chemoradiation protocols
Endoscopic palliation with Nd:YAG laser
Endoscopic palliation with stents
  Types of stents
  Placement of the stent and indications
  Results and complications of stenting
   Results at the EG junction
   Results at the gastric outlet
Guidelines in surveillance
Prevention of gastric cancer
  Prevention and H. pylori infection
  Prevention through dietary intervention
  Unplanned prevention
Secondary prevention of gastric cancer
  Gastroscopy and opportunistic screening
  Mass screening
   In Japan
   In other countries
   Strategy of detection worldwide
  Benefits of nutrition support
  Enteral access
Gastric or enteric feeding?
Nasogastric (NG) feeding
  NG tube placement
  NG tube management
  NG tube complications
Nasojejunal (NJ) feeding
   Different tubes
   Fluoroscopy or endoscopic assistance
   The drag technique
   Through the scope passage
  NJ tube management
  NJ tube feeding complications
   Bronchial misplacement
Percutaneous endoscopic gastrostomy (PEG)
   Cancer patients
  PEG technique
  PEG tube management
  Complications of PEG
   Tube dislodgement
Percutaneous endoscopy gastrostomy/jejunostomy (PEG/J)
  J tube placement through a PEG (PEG/J)
  PEG/J tube management
  Complications of PEG/J tubes
Direct percutaneous endoscopic jejunostomy (DPEJ)
  DPEJ technique
  DPEJ tube management
  DPEJ tube complications
Enteral formulations
  Blenderized formulations
  Lactose-containing formulations
  Lactose-free formulations
  Elemental formulations
  Specialty formulations
  Modular feedings
  Supplemental regimes
  Immune enhancing diets (IED)
Outstanding issues and future trends
  Sonde enteroscopy
  Push enteroscopy
   Depth of insertion
   Routine biopsy?
  Intraoperative enteroscopy
   Laparoscopic-assisted enteroscopy [32]
   Combined techniques
  Capsule enteroscopy
Clinical applications of enteroscopy and capsule endoscopy
  Obscure gastrointestinal bleeding
   Definitions and prevalence
   Alternative diagnostic procedures in obscure bleeding
   When to use enteroscopy in obscure bleeding
   Pathology of obscure bleeding
   Medical therapy for angiodysplasia
   Diagnostic yield and outcomes of enteroscopic techniques in bleeding
   Comparing capsule and push enteroscopy
   Repeat standard endoscopies before enteroscopy?
   Unusual causes of obscure bleeding
   Enteroscopic therapy for bleeding
   Intraoperative enteroscopy for obscure bleeding
   Push enteroscopy or capsule endoscopy for bleeding?
  Small intestinal mucosal diseases
   Celiac disease
   Crohn's disease
  Small bowel tumors
  Novel indications
Outstanding issues and future trends

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